Imagine a world in which community leaders, government, health care, philanthropy, and investors work together to address the priorities that communities identify for themselves. Imagine a world that dismantles structural, historical, and institutional barriers and builds equitable systems for delivering services and resources to communities that need them.
Imagine a world in which communities maximize their potential for health and quality of life, and where dignity, hope, and self-determination are measures of well-being.
Our Vision is an Equitable, Healthy, and Just Society.
We propose working toward this vision by redirecting resources and power to communities so that each can meet its standards of well-being.
We came together in 2019 at a gathering of cross-sector leaders hosted by the Federal Reserve Bank of San Francisco. We propose testing and operationalizing principles, which place equity as a core value within the broad outcomes-based funding field.
A New Approach to Advancing Health Equity
A new approach is needed to advance health equity holistically and systemically. In the last decade, concurrent efforts have expanded investments in outcomes and investments in equity. It is time to bring those threads together to give community leaders the resources they need to innovate.
At the same time, we must shift the interconnected systems of public and private funding that maintain the status quo. We believe that reconceiving outcomes-based funding through equity and community leadership will advance community health and well-being efforts across the country.
Traditional Outcomes-based Funding
This type of funding emerged from an interest in paying for what works and letting community providers find innovative ways to achieve the desired outcome. Outcomes-based funding promised to avail more private-sector funding for social good and achieve better results in a more integrated way. That promise has not been fully realized. The funding delivers billions of dollars to interventions that improve outcomes, but rarely support the kinds of community-led cross-sector work necessary to shift the systems that thwart lasting health equity. Outcomes funding uses contracting and financing transactions to tie payments and funding to an achieved outcome(s), rather than to a set of prescribed steps, programs, or processes.
While the field has grown tremendously, much of outcomes funding — encompassing Pay for Success or social impact bonds, impact investing, philanthropic program-related investments, investments in community health outcomes, and government performance-based contracting — perpetuates top-down decision-making models. This denies people who stand to benefit most of the opportunity to define outcomes, priorities, and success.
The current rapid growth in outcomes funding makes it a critical time to establish more equitable approaches within this field. We propose a broadly applicable approach to supporting communities on their paths to health equity, de-emphasizing focus on a specific set of recommendations or a proscribed approach to scaling an intervention just because it worked in one community. Outcomes-based funding must be directed by communities to be equitable. While the field is showing some promise by including community engagement approaches in project design and implementation, we argue that this is a half measure. Instead, we should direct the flow resources toward community needs.
In the current environment, this may seem like a radical view, yet it is grounded in an understanding of the inherent power inequalities between funders, providers, and the communities they are supposed to serve. An equitable approach counterbalances these inequalities within funding structures and systems. This devolution of power may be uncomfortable, particularly given that communities have historically been held accountable to funder expectations, but this discomfort should be borne by funders, not the providers and communities they are trying to serve.
This also means that funders have an opportunity to play a critical role in achieving equity in the United States through modeling and supporting community power, resources, and systems to acknowledge, leverage, and support local history and expertise. We believe the results will be equitable and powerful, and in turn, more efficient and sustainable.
Building equitable outcomes funding requires creating a vision; a set of guiding principles that articulate how we can achieve that vision; and a portfolio of projects demonstrating these principles in action. Both the principles and projects are required to create a cycle of mutual refinement and reinforcement. Without the principles, projects run the risk of being a series of pilots. This could threaten partnerships within and between communities and limit the benefits and sustainability of investments.
Learn more about the principles for equitable outcome funding in part 2 of this series.
WHO WE ARE
This article was written by Jen Lewis-Walden & Matthew Tinsley, Shift Health Accelerator, Jessica LaBarbera & Kristin Giantris, Nonprofit Finance Fund, Jeremy Cantor & Erin Shigekawa, JSI.
Our organizations have come together based on our unique experiences in the field. We hold a point of view that we believe is valuable to the evolution of our work and the partnerships we cultivate. We also recognize that we come from a position of privilege and are committed to opening space to seed new ideas, challenge our assumptions and build these ideas collectively.
Founded in 1980, Nonprofit Finance Fund provides capital, strategic consulting, knowledge, and influence to transform the funding and financing landscape. We are committed to improving how money is given and used for social good.
Shift Health Accelerator was launched in 2018 by individuals in the Robert Wood Johnson Foundation Culture of Health Leaders program to help funders solve society’s toughest challenges, from lack of access to healthy food to unsafe and unaffordable housing.
Much of the JSI California Office’s work focuses on the alignment of health care and community-driven efforts to improve health. We support efforts to advance local and state policies that make equitable investment easier, more likely, and community-driven.
