Unlike business, where the goal is to make money, the job of foundations is to give away money. While businesses try to earn a financial return on investment, the return on a foundation's investment is measured by contributions to the public good. The basic tools of business are products (which can be ideas or services); the basic tools of foundations are grants and the communication of information accumulated by their grantees. Investing for financial return is not the same as investing for social return. Thus, while business can offer models and ideas for foundations-particularly in matters of managerial efficiency-the most useful ideas and models come from foundations themselves and the work of their grantees.
With this in mind, we have scoured the seven volumes of The Robert Wood Johnson Foundation Anthology series to find out what its seventy-five chapters reveal about the craft of grantmaking: What distinguishes effective from ineffective grantmaking? What approaches have led to a strong social return on the Foundation's investments? and why? The following are our observations.

Catching the Wave

The Foundation has enjoyed singular successes by entering fields about to emerge and helping to guide their development. Back in the 1970s-a time when, because of their size, hearses doubled as ambulances-an underground of medical professionals began to appreciate the need for a better emergency medical system. The Foundation stepped in and, working with the federal government, played a critical role in providing direction for the new emergency medical response system¹ In the early 1990s, as the toxic effect of cigarettes was attracting the attention of health professionals and the media, the Foundation entered the tobacco field and helped shape one of the nation's more successful public health movements² Similarly, through its early recognition of the potential importance of nurse practitioners and physician assistants, the Foundation helped that field take off and guided its development³ The same can be said of the Foundation's end-of-life programs, which in the 1990s helped harness a movement that had been gathering steam since the 1980s⁴

One can never know, of course, which fields will take off and which won't. But the best program officers and foundation leaders will have a sense-through their conversations, reading, and travels-about emerging trends. (Sometimes, in fact, The Robert Wood Johnson Foundation's interest in an emerging field can give it attention that it otherwise might not have had.) Currently, for example, there is a lot of buzz around obesity, public health, and aging-three priority areas for the Foundation. If the past serves as prelude, the Foundation might be able to catch the wave and help guide the development of these areas.

Keeping Strategic Focus

In a large sense, The Robert Wood Johnson Foundation is focused. It awards grants only in the areas of health and health care, and it does not fund basic research or international projects. Its mission guides the Foundation's grantmaking⁵

Taking this sense of clear direction down a notch or two-to priority areas and to programs-has been a challenge. Even with a relatively limited focus on health and health care, there is a dizzying array of ideas from which to choose, and it is easy to jump from issue to issue.

Where the Foundation has been clear in establishing the directions it wants to go (that is, where it has set clear objectives and goals) and then stayed with them, it has increased its chances of having an impact. Take two areas where the Foundation has had an important influence. In the case of tobacco, the Foundation honed in on kids' tobacco use early on, giving its grantmaking a clear focus. In its end-of-life programs, the Foundation concentrated on palliative care-again giving it a relatively sharp focus. In contrast, where the approach has been less targeted-where the Foundation adopted a more scattershot approach-the results have not always been as solid. The strategies for improving the care of chronically ill people, for example, have not been cohesive, nor have the results of the Foundation's efforts been as impressive.

As Risa Lavizzo-Mourey writes in the Foreword, the Foundation is trying to come up with a limited number of measurable strategic objectives for each of its priority areas. If these prove effective, they will give the Foundation (and the public) a clearer idea of where the Foundation is going and whether it is achieving what it set out to⁶

Maintaining Tactical Flexibility

While it is certainly true that focus matters-that clear objectives and well-wrought implementation strategies are essential elements of success-it is equally, or even more, important to maintain flexibility in the tactics employed to attain long-term strategic goals.

Nowhere is the need for flexibility more evident than in the programs, mounted in the 1990s, to improve access to care. The Reach Out program, for example, which encouraged physicians to volunteer to serve the uninsured, emerged just as managed care was forcing physicians to work longer hours and cut back the time they had to volunteer. Many Reach Out sites responded by coming up with innovative strategies that allowed doctors to serve uninsured patients⁷ Similarly, the Strengthening Hospital Nursing program, designed to give nurses more clout in hospitals, was rolled out as managed care was forcing hospitals to cut their nursing staffs. Some of the program's sites showed great ingenuity in finding ways to circumvent this difficult situation⁸

Nor are these the only examples. The National Program Office of Coming Home, a program set up to make loans to nonprofit development companies to build affordable assisted-living housing, discovered that borrowers needed money for up-front start-up costs, not the long-term permanent financing that had been originally planned. With the Foundation's approval, the National Program Office quickly changed the nature of the loans⁹ Similarly, when Join Together became the National Program Office for Fighting Back, which supported community anti-substance abuse coalitions, it revamped a plan that had looked good on paper but was not working in practice.¹⁰

Staying the Course

In general, the Foundation has had a good record of staying with programs over a period of years, particularly in areas that reflect its basic values. For example, in the 1970s, it funded programs designed to increase the attractiveness of generalist medicine, and it maintained its support in the 1980s and early 1990s, even though the concept remained unpopular within mainstream medical practice¹¹ Its work to advance minorities in the health professions has continued since the early 1970s,¹² as have its Clinical Scholars and Health Policy Fellowships programs¹³ and its efforts to expand health insurance coverage ¹⁴ The Foundation's commitment to these areas over a long period of time has given it an influence it might otherwise not have had.

The Foundation does, however, terminate its support for programs and, indeed, to entire fields of endeavor. After all, it doesn't make sense to stick with unworkable concepts-or to fund successful programs- forever. As former Foundation president and chief executive officer Steven Schroeder noted, "You've got to know when to hold 'em and when to fold 'em."¹⁵ In many cases, the timing of decisions to end support appeared to be appropriate-mental health, cost containment, and some areas of chronic care come to mind. In other cases, the exit was probably premature. There is a widespread feeling that the Foundation's support of nursing and dentistry in the 1970s and 1980s ended early and that staying the course would have increased the Foundation's effectiveness¹⁶ The Foundation began supporting both fields again in the late 1990s and early 2000s.

While the Foundation has not found the secret of how long to stay (nor has anybody, for that matter), it has learned that a few years is probably too short a time to have a meaningful impact. As Foundation president and chief executive officer Risa Lavizzo-Mourey notes in the Foreword, the Foundation has now established time periods for each of its strategic objectives¹⁷

Embracing Fields

The Foundation tends to take on big problems-like improving access to medical care, reducing substance abuse, getting people to exercise. One way it does so is by building the field.
When the Foundation does get involved in field building, it seems to be particularly effective when it embraces (in the sense of a bear hug) the problem by using all the tools at its disposal. Take, for example, the Foundation's work on smoking. It funded research, public policy dialogues, communications, demonstration projects, training, standard setting, advocacy groups, the Center for Tobacco-Free Kids, and the like¹⁸ A similar bear hug approach appears to have worked in the case of end-of-life care. As Ethan Bronner noted in his chapter in volume VI of the Anthology, the efforts of The Robert Wood Johnson Foundation and the Soros Foundation to legitimize palliative care demonstrated the power of foundations to nurture new fields¹⁹

The approach, however, hasn't worked yet to reduce the number of people without health insurance coverage-an issue of great concern to the Foundation. The difference may lie in the nature of the problems. Take tobacco, for example. Smoking is widely recognized as harmful; there is a villain (Big Tobacco), and there is a simple solution (stop-or don't start-smoking). In contrast, the uninsured are not yet a matter of national concern; great differences of opinion exist on potential solutions to the problem; and health insurance is highly charged politically.

Supporting Talented People

The payoff from supporting good people and promising leaders is a recurring theme throughout the pages of the Anthology series. The Foundation supports people in basically three ways.
One way is by developing the capacity of those in the health field-as in its fellowship programs such as Clinical Scholars, Health Policy Fellowships, Scholars in Health Policy Research, and the Minority Medical Education Program²⁰-or, as in the case of the Community Health Leadership Program,²¹ by recognizing and supporting the work of leaders at the local level. Within The Robert Wood Johnson Foundation, there is a widely shared feeling that these programs to develop human capital have been productive investments, even though it's hard to prove²²

Another way in which the Foundation supports talented people is by giving them a series of grants over a number of years, thus allowing their work to mature and develop. David Olds is a good example. The Foundation first supported his work to train nurses to provide home visits to low-income pregnant women back in 1978; more than twenty years later, the Foundation continues to support Olds's work²³ Olds is just one of a number of people whom the Foundation has supported year after year. The list includes Barbara Barlow, a physician at New York's Harlem Hospital, whose work to prevent childhood injuries the Foundation has been funding since 1988,²⁴ and Judith Miller Jones, the first and only director of the Washington, D.C.-based National Health Policy Forum, which the Foundation has supported since 1973²⁵
A third way the Foundation looks to support talented people is by awarding them (or, literally, their organizations) a grant based on a sense that they will get the job done. Former St. Louis Cardinals catcher Joe Garagiola, for example, almost single-handedly carried a program to reduce the use of chewing tobacco by enlisting major league baseball in the campaign²⁶ Martha Ryan, a San Francisco nurse practitioner, received an almost unheard-of two grants from The Robert Wood Johnson Foundation's Local Initiative Funding Partners program to work with homeless pregnant women and with women newly released from prison²⁷ Rhonda Roland Shearer, a New York City sculptor, received quick Foundation support for her efforts to bring supplies to rescue workers after September 11²⁸
At a time when carefully crafted objectives and measurable goals are given priority in the world of philanthropy, it is well to remember, too, that the Foundation's support of good people doing good things has reaped great dividends.

Thinking Small-Sometimes

The Foundation has long taken pride in-and to an extent earned its reputation through-its strategic grantmaking in large demonstration programs. Some demonstrations have been replicated widely;²⁹ others have been models for government programs or legislation;³⁰ and still others have catalyzed or guided the development of emerging fields³¹

But even though large strategic demonstration programs can be dazzling in scope and effect, the Foundation's programs that affect people directly form an important and often unappreciated part of its portfolio. Recovery High, for example, was an innovative New Mexico high school for substance-abusing high school students³² The awards made under the Faith in Action program support community volunteers who ferry elderly people to doctor's appointments and seniors' activities³³ The Foundation's Local Initiative Funding Partners program actively seeks small community-based projects³⁴ As one example, the Homeless Prenatal Program, which received funding under the Local Initiative program, provides needed services to women who often fall outside of the health care system³⁵
These programs and projects are not designed to change health or the health care system. They do, however, touch individuals directly, and this is important. Moreover, they win friends for the Foundation and keep its staff in touch with the reality of people's lives. Effective grantmaking balances the strategic with the charitable.

Exploiting Failure

Everybody loves success and to build on success. Indeed, The Robert Wood Johnson Foundation sometimes tries to replicate successful programs and to "take them to scale" nationally. However, it's also important to admit and learn from failure.

The Anthology series examines a number of programs that have failed and areas that have not taken hold in the consistent and coherent fashion they were expected to. In some cases, the Foundation simply accepted the outcomes and moved on to other things³⁶

In other cases, it learned from failure and found better approaches to the problem or issue. Perhaps the best example is the development of the Foundation's end-of-life programs. Between 1989 and 1994, The Robert Wood Johnson Foundation funded a study, whose acronym was SUPPORT, designed to improve the care of terminally ill hospitalized patients by improving communications between physicians, nurses, patients, and patients' families. At the time, it was the costliest program the Foundation had ever funded. SUPPORT was a failure. Care of the dying patients did not improve, even after specially trained nurses had made intensive efforts to see that patients' wishes were honored³⁷ Rather than hiding the failure or being discouraged by it, the Foundation took the opposite tack. Recognizing that the original problem still existed, it mounted a major and more diversified effort to improve care toward the end of life³⁸

Recognizing Messiness

The Foundation has made investments in communities and state and local governments that haven't panned out, largely because the Foundation has not appreciated the difficulty and the messiness of bringing about change at the local level.

Foundation-supported programs that attempted to weave disparate, often competing, elements into community coalitions have not, as a general rule, met their objectives. Two examples are the Fighting Back program and the Community Programs for Affordable Health Care initiative. The authors of Anthology chapters examining these programs agree that one of the main reasons that they did not work was the Foundation's failure to appreciate the very real and practical difficulty of getting often-competing groups to work together for the common good³⁹

Similarly the Foundation's efforts to improve health policymaking at state levels foundered because of the Foundation's trying to impose order on a basically disorderly system. As Beth Stevens and Lawrence Brown observed in their chapter on the Foundation's efforts to improve health policy at the state level, "Foundations and those who evaluate their work should recognize that discussion, better staffing, technical aid, and diffusion of knowledge can tidy up the messiness of health politics only so far."⁴⁰

Utilizing Research and Communications

The Robert Wood Johnson Foundation devotes a substantial amount of its resources-both human and financial-to research and communications and to integrating them with program development⁴¹ Within the Foundation, there is an implicit belief in the power of research to provide knowledge that will lead to better policies and programs and the power of communications to put information in the hands of those who will use or benefit from it.

The investments in research and communications over many years have, in fact, given the Foundation-directly and through its grantees-a credibility, influence, and access that it might not otherwise have had. These investments have also provided a great deal of public information on many aspects of improving health and health care-everything from medical malpractice to workers' compensation and from tobacco policy to health insurance⁴²

Despite the value of the Foundation's use of research and communications, the Anthology series is replete with examples where research findings were ignored, where programs were developed without waiting for research or evaluation results, and where policymakers had the best information available but did not use it⁴³ In a system that is not wholly rational, even the best research and the most strategic communications efforts may produce limited results.

Perhaps the lesson is that the Foundation's large investments in research and communications have paid dividends by giving the Foundation credibility and access, by providing the public (including policymakers) with timely and reliable information, and by developing a network of highly skilled researchers and communications experts. However, to the extent that research and its dissemination are ignored or overtaken by events (which, not surprisingly, happens frequently in the politically charged arena of health and health care), the return on investment is diminished.

Taking Programs to Scale

An ideal for The Robert Wood Johnson Foundation is the small, well-evaluated, and widely publicized demonstration that is replicated at many sites and is ultimately adopted nationally. The ideal was reached in the cases of emergency medical services, nurse practitioners, training of dentists to serve disabled patients, regional perinatal networks, and, to an extent, palliative care and injury prevention programs⁴⁴ More often, the ideal is not reached-hardly surprising, since large-scale social change does not come easily. What accounts for the difference? Why can some programs be taken to scale and others not?
One explanation of the difference has to do, simply, with timing. It is not coincidental that many of the successes occurred in the 1970s, a time when the federal government looked for programs to adapt and expand nationally. In the first years of the new century, the federal government has devolved responsibility for social programs to financially strapped states, which, in turn, are trying to pass responsibility to localities. The model is not as likely to work today as it did yesterday. Insofar as it can be made to work, it requires catching the wave, bringing all the Foundation's resources to bear, and engaging other foundations and, to the extent possible, governments.

Another reason for the difference has to do with the clarity and appropriateness of the model to be replicated. In the case of nurse practitioners, for example, despite variations in training and deployment, the model was relatively simple and repeatable. The same was true of regionalized perinatal care. In the case of AIDS, however, the community-based model based on the successful San Francisco experience turned out to be inappropriate for other locations that didn't have San Francisco's unique population and resources⁴⁵ In the case of David Olds's nurse home visitation program, the original model using public health nurses to visit pregnant women in their homes was expensive, and the use of less-qualified personnel turned out to be less effective⁴⁶ Whether the pure or diluted model should be replicated wasn't clear. Thus, clarity, flexibility, and appreciation of local circumstances are important factors in taking seemingly successful models to scale.

Finally, there is the matter of collaboration. Since only the federal government has sufficient financial resources to fund programs on a large scale, collaboration among foundations is needed for programs to be widely replicated. Yet foundations have shown little ability to work together in the past and have few incentives to do so in the present⁴⁷ Taking programs to scale might require a change in the inner-directed culture of foundations.

Foundations play a unique role in American life. Yet little is known about how to develop effective grantmaking strategies. Business, as we noted earlier, offers an imperfect model; because their goals are different, what works in a corporate boardroom may be wrong for a foundation headquarters. While there is no single right way to practice the craft of philanthropy, we believe that much can be learned from the successes and failures of a foundation with more than thirty years' experience.

San Francisco Princeton, New Jersey August 2000

Stephen L. Isaacs James R. Knickman Editors

Notes