Investing In Policy And Advocacy: A Foundation Shares Lessons Learned

Working on advocacy and policy is challenging. Not only is it complex, fluid, and increasingly politicized, it is also challenging to measure progress and communicate success.

Some Background

Understanding this, in 2012, the Foundation for a Healthy Kentucky, a statewide foundation located in Louisville, launched Promoting Responsive Health Policy (PRHP)—a six-year, multifaceted initiative to address four broad health policy areas—increasing access to integrated health care; increasing the proportion of Kentuckians living in smoke-free jurisdictions; improving children's health; and strengthening local public health.

Building on past investments, the foundation engaged a variety of grantees and contractors as partners: legal, youth, and consumer advocates; researchers; and communications and media organizations. The Center for Community Health and Evaluation (CCHE), located in Seattle, Washington, and affiliated with Kaiser Permanente, was selected to serve as the external evaluation partner because of its experience evaluating policy work and its developmental approach to evaluation.

Halfway through PRHP, a change in state leadership prompted dramatic changes in the political climate and in policy positions coming from the governor. These changes meant that PRHP's policy goals, especially around the Affordable Care Act (ACA) and a comprehensive statewide smoke-free law, were at odds with the new governor's goals. These changes had profound impact on the foundation and its grantees, requiring all players to reassess their strategies and make substantive adjustments.

The foundation's approach, combined with the dynamic policy environment, provides a unique opportunity to examine and share lessons learned (addressed more fully in the final report on the PHRP evaluation.)

Strategies Used

Recognizing the complexity of the policy issues and taking a broad approach to policy change, the foundation approached PRHP using four key strategies:

1. Requiring use of the following characteristics of effective, high-quality grant making.

Trust: The foundation's partnership approach to grant making enabled it to provide the needed flexibility for grantees to be responsive to political changes. This approach depended on trust and long-term relationships with and among grantees.

Flexibility: An adaptive and multipronged approach allowed the foundation and its grantees to be agile in a rapidly changing policy environment.

Diverse strategies: Having a diverse cadre of partners made available to the foundation a variety of tools, and that was particularly useful when tactics had to be adapted to the changing political landscape.

Collaboration: As a result of the foundation's efforts to promote collaboration among partners, grantees reported increased connections with other partners.

Capacity building: Investing in organizations through multiyear grants, trainings, and technical assistance, in addition to sharing findings from foundation-funded research projects, deepened and strengthened the advocacy infrastructure in Kentucky.

2. Acting as a convener, which was consistently identified as one of the most effective ways the foundation informed policy. Evaluators found that "stakeholders described the valuable and unique role that the Foundation plays in informing health policy in Kentucky as a non-partisan, independent organization." The foundation brought local and national speakers to inform local health policy discussions and facilitate difficult conversations, guided by research and best practices, in a safe, neutral space.

3. Investing in data and research, which was the foundation's key contribution to health policy. Grantees and key stakeholders identified the annual Kentucky Health Issues Poll and the multiyear study on the impact of the ACA, which was conducted by the State Health Access Data Assistance Center (SHADAC), as integral and valuable in grounding advocacy efforts in facts. As noted by evaluators, "[I]nvestments in convenings and data were examples of how the Foundation could leverage its resources to be responsive to emerging policy issues and to bolster the capacity of advocates."

4. Using communication and messaging for effective policy and advocacy work. The foundation increased its own communications capacity to support grantees and highlight grantees' work. The foundation also offered media training and assistance with messaging around complex health policy issues, and its communication grantees translated policy issues for the mainstream media and diverse stakeholders without health policy expertise.

Challenges

While the foundation was in fact able to apply what it had learned from prior advocacy initiatives, working in a time of a rapidly changing policy landscape presented some challenges including the following:

• Lack of clarity on policy positions and the foundation role: Changes in state government leadership placed the foundation at odds with prevailing state policy directions, which uncovered a lack of clarity on specific policy positions among members of the foundation's staff and governance committees. This was compounded by an ongoing deliberation regarding the foundation's advocacy role. While the foundation made a decision to be an operating foundation as well as a grant-making foundation, it was less clear how public the foundation would be on increasingly politicized policy issues.
• Maintaining alignment with grantees: Organizations took different positions as to how oppositional they would be to the new state administration. This divergence created tensions between and among the foundation and its grantees, and in response, the foundation developed mechanisms to maintain connections and alignment with key partners. As an example, the foundation created and led a working group of grantees and other partners to identify opportunities and strategies for coordinating and collaborating efforts to sustain the health policy wins from the past few years (such as Kentucky's Medicaid expansion, state-based health insurance exchange, tobacco-free policy on state government property).
• Breadth versus depth: ACA implementation created unique policy opportunities for PRHP to contribute to Kentucky's success in outreach and enrollment. This focus, however, tilted foundation resources and staff capacity to one of its four policy priorities, thereby limiting the investments made in the other priorities. If the foundation had had a narrower policy focus, it might have had an even greater impact on state health policy.
• Differing definitions of success for the initiative: PRHP used a "policy spectrum" framework (see pages 7–8), which allowed for a broad understanding of policy and incorporated a wide array of strategies and tactics. While this was embraced by grantees and foundation staff, there was a "strong focus from the Foundation's board on judging impact primarily through policy enactment," the final PRHP evaluation report said. This divergence in how policy, and policy success, were defined became more pronounced as the initiative progressed.

Lessons Learned

The successes and challenges experienced throughout PRHP provided the foundation with lessons on how best to pursue policy change through investments by philanthropy and how funders can make policy more responsive to the needs of the communities they serve. Recommendations from the evaluation included the following:

1. Clearly identify policy priorities and understand potential trade-offs between a broad set of policy priorities and more focused policy goals.
2. Articulate the funder's role in the initiative, including the level of engagement in direct policy work and how policy positions will be developed. Depending on the legal structure of the foundation, funders will need to be clear on their ability to lobby and the extent to which they can engage in lobbying.
3. Align the focus and structure of grants with the necessary expertise and strategies, such as flexibility, needed to respond to the dynamic policy environment. For example, for a health policy initiative such as PRHP, both the foundation staff and the grantees should have expertise in health policy. And it is also important to contract with experienced researchers who can provide data and research findings to the foundation, grantees, and interested members of the general public.
4. Build awareness of the broad spectrum of strategies needed to develop, enact, and implement policy.
5. Consider long-term investments to build infrastructure in key partner organizations.

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