A Vision for the Field: Equitable Outcomes Funding
PRINCIPLES FOR EQUITABLE OUTCOMES FUNDING
This is the full version of an article co-written by Jen Lewis-Walden and Matthew Tinsley of Shift Health Accelerator, Jessica LaBarbera and Kristin Giantris of Nonprofit Finance Fund and Jeremy Cantor and Erin Shigekawa of JSI. Additional articles, blogs, and commentary will be published on Medium and other venues to gather insights, feedback, and ideas to further this vision in the field.
Imagine a world in which community leaders, government, healthcare, philanthropy and investors work together to address the priorities that communities identify for themselves. Imagine a world that addresses historical injustices and dismantles structural, historical and institutional barriers to create equitable systems for delivering services and resources to communities that need them.
Imagine a world where communities maximize their potential for health, well-being 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 achieve their unique vision of well-being. We define community broadly, encompassing local leaders who hold a vision for health equity. We came together at a convening hosted by the Federal Reserve Bank of San Francisco of cross-sector leaders in 2019 to initiate this vision for equitable outcomes funding. This article aims to carry those ideas forward. We propose testing and operationalizing a set of principles we articulate below, which center equity as a core value within the broad outcomes-based funding field, and by holding ourselves and others accountable to these principles.
We believe 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 now time to bring those threads together to provide community leaders with the resources they need to innovate. At the same time, we must also shift the interconnected systems of public and private funding that hold the status quo in place. We believe that reconceptualizing outcomes-based funding to center equity and community leadership provides a path to do both and will advance health and well-being efforts at a community level across the country.
Outcomes-based funding emerged from an interest in paying for what works and giving freedom to community providers to innovate toward an outcome. Outcomes-based funding promised to engage more private sector funding toward social good and achieve better results in a more integrated way. That promise has not been fully realized. Outcomes-based funding delivers billions of dollars to interventions that improve outcomes, but rarely support the kinds of community-led, local, cross-sector work necessary to shift the systems that stand in the way of 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. The field has grown tremendously in the last decade, yet much of outcomes funding -- encompassing Pay for Success or Social Impact Bonds, impact investing, philanthropic program related investments, healthcare investments in community health outcomes and government performance-based contracting -- perpetuates top down decision making models.
Of the billions of dollars currently allocated in outcomes-based funding projects, very few engage communities and smaller community-based organizations leading change at the local level.
This denies opportunities to define outcomes, priorities and what success would look like, to the people who stand to benefit most. The current, rapid growth in outcomes funding make it a critical time to establish more equitable approaches within this field.
What we are proposing is a broadly applicable approach to supporting communities on their own unique paths to health equity, de-emphasizing a focus on a specific set of recommendations or a “silver-bullet” approach to scaling one intervention just because it worked in one community context. For outcomes-based funding to be equitable, it must be directed by communities to meet their needs and support their aspirations. Without community leadership, there is no equity. 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 be following the lead of the community and building supports, structures and systems around their efforts so that resources flow towards needs and outcomes they identify.
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 serve. An equitable approach recognizes that these inequalities usually lead to inequities and that they must be intentionally counterbalanced within the structures and systems of funding. 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 and not the providers and communities they are trying to serve. This also means that funders have an opportunity to play a critical catalytic role in achieving equity in the United States, through modeling and supporting community power, resources and systems designed to acknowledge, leverage and support long histories and deep expertise rooted in local communities to address their needs. We believe the results will be equitable, powerful and hopeful, and in turn, more effective, efficient and sustainable.
Building a field of equitable outcomes funding requires creating a vision for the field to strive towards, a set of shared, 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, the projects run the risk of being a series of one-off pilots. This could both threaten lasting partnerships within and between communities, and limit the impact and sustainability of investments. Without the projects, the principles are words on paper, uninformed by the rigor of working with community.
PRINCIPLES OF EQUITABLE OUTCOMES FUNDING
We believe it is essential to co-create an equity-centered vision for the field of outcomes funding and to hold ourselves accountable to a set of principles that operationalize that vision. The principles center the vision and leadership of community in outcomes funding projects and establish opportunities to wrap support, resources, and networks around this leadership.
The list of principles below is a first draft. They represent our current best thinking. Our intent is to co-create future iterations of these principles with communities, funders and other partners through ongoing dialog and by testing the principles in practice. They will undoubtedly change as the field tests them, but our hope is that they will inform project design, help translate values into actions and support an accountability framework to advance equitable outcomes funding.
Local communities decide priorities, goals, and outcomes.
We support communities to identify key needs and priorities and to work toward their vision.
We ensure that decision-making is led by communities, those with lived experience, knowledge, and understanding of local priorities, and those that stand to benefit most by defining and investing in health and well-being.
We believe communities understand their needs and priorities and trust them to decide on outcomes that will address those needs. We do not “fix” communities, we do not “empower” communities. Communities have history and power that exists from long before our time with them and will endure long after. The relevance, sustainability and impact of our work is determined by its level of community ownership, during and after our time with the community.
Outcomes are defined by community needs and valued to reflect societal benefits.
Outcomes must encompass what really matters to people; center story, culture and history; and combine qualitative and quantitative measures to support the change the community wants for itself. Defining and measuring outcomes is about more than reliable, valid measurement.
We seek to measure what is important to communities, which requires flexible approaches to evaluation, learning and adaptation.
Further, we define the value of an outcome to include the long-term benefits to individuals, families and communities. Investments that aim to achieve long-term benefits must attempt to alleviate policy, institutional and systemic barriers creating inequities in our communities. To do this successfully, we define value beyond cost savings to a particular funder to reflect the global benefit accruing to the community and society over generations.
Benefits and risks are shared equitably.
We design strategies to ensure benefits, including the value of outcomes, savings and/or revenue, are shared equitably, that is, that the value of achieving the outcomes is shared by both funders and the community. This ensures that when communities and community-led efforts successfully achieve outcomes, the value of that success goes directly back to communities, providing resources to address additional priorities. Similarly, there are risks in outcomes-based funding models for communities as well as funders. However, current arrangements usually only mitigate risks for funders, through mechanisms like a risk premium, while those that hold the least power, communities and providers, are also exposed to the most risk. We aim to develop ways to share risks equitably by situating it with partners with the resources and ability to mitigate and manage them. This includes both finding creative ways to mitigate risk for communities and service providers as well as identifying opportunities to situate benefit, savings and value within communities to ensure reinvestment and resources for community-led efforts.
Pathways of community leadership are supported, cultivated and sustained.
We support pathways of community leadership by ensuring that communities can make meaningful decisions about their futures and have the power to implement those decisions. We build from a community’s strengths, assets and existing resources (defined broadly to include its people, history and culture) to support leaders in achieving community goals, rather than by assuming the community has deficits and that new structures must be created. Communities are unique but community leadership is everywhere. We are not proposing to scale a solution or discrete projects, but rather a broadly applicable approach to supporting diverse communities on their own path to health equity.
Institutional and systemic barriers to health equity are explicitly acknowledged
We acknowledge the challenges that communities face are rooted in inequities caused by systemic power inequality including systemic and institutional racism, white supremacy, systems of wealth accumulation and other aspects of the status quo that impact health equity.
To do so, we commit to identifying and addressing the root causes of historical injustice and the lasting impact on communities across the country and advancing investments to uproot the systemic causes of inequity.
As leaders, we must all understand, analyze, and responsibly hold power, justice, equity, diversity and inclusion principles. As such, we commit to conducting an internal power analysis of our organizations and holding our partners to the same standard so that all participating entities embed equity principles into operations, partnerships, and decisions. Further, we are responsible for vetting that everyone we bring into a community with us is a respectful partner and a good guest.
CHALLENGING EXISTING SYSTEMS
Current outcomes funding approaches are rooted in systems that reinforce existing power structures and will need to be changed to put these principles into action and achieve equitable outcomes. This is an opportunity to reflect on the evolving nature of outcomes funding, along with the assumptions and systems that have supported the development and implementation of projects in the field. In order for us to hold ourselves accountable to the principles, we believe it is critical to name and interrogate the barriers and challenges embedded in the state of current outcomes funding and then design creative solutions that place community at the center of the future direction of outcomes funding.
Expanding outcomes defining success
Proponents of outcomes-based funding view it as a tool that maximizes funding to pay for what is working well. In theory, the money that flows through these types of transactions serves the community. The strong focus on outcomes should also allow for a diversity of means to achieve those outcomes, theoretically increasing the range of interventions resourced by these financing tools.
However, existing outcomes funding tends to require strong causal evidence linking interventions to outcomes. These efforts traditionally require standards of proof, for example randomized control trials, which may not be available for the intervention or outcome, which may not be appropriate for evaluating complex, multi-part community strategies and may require resources beyond the capacity of community-led work. The diversity of approaches is further limited by the quantitative metrics available in existing systems. Success defined as proof of outcomes also limits qualitative lived experience and wisdom that might define success in terms of community dignity, hope, spirituality and holistic well-being. Additionally, expectations to prove causality between interventions and outcomes can also place focus back on the intervention instead of improving the outcome. This expectation can limit higher risk and innovative interventions by prioritizing tested, lower risk interventions. Funding a narrow range of interventions to address a limited range of issues - while minimizing risk for funders - will not move communities in the direction they want to go.
More broadly, this approach reinforces an orientation of accountability over learning, which limits testing of different outcomes to measure success. This also limits space for building community cohesion through projects even if successful outcomes are not achieved and continues to place power with funders and those defining the terms of funding and outcomes, rather than the communities that stand to benefit most from the resources.
Outcomes funding in its current form is also limited in the ways outcome are valued for funding commitments. To date, the predominant focus is on the opportunities to limit wasteful spending and increase cost savings. The value of outcomes is easier to measure for short-term evaluation using existing data systems, which limits understanding of value of multi-generational outcomes, long-term individual and societal benefits, and the opportunity to value elements of community well-being beyond what our existing systems currently measure.
Redefining readiness for outcomes funding
Outcomes funding is intended to be agnostic in terms of geography, population, community, organizations delivering interventions and types of outcomes that have the opportunities to be resourced through these funding mechanisms. Yet, the predominant paradigm within the field values larger, well-resourced organizations with an ability to prove readiness to achieve outcomes.
The concept of readiness inherently limits the types of organizations and communities that are able to engage in outcomes-based funding, and thus, reinforces inequities across place and organization.
Capacity within governments, nonprofits and communities is seen as a requirement for participation in outcomes funding efforts. The complexity of the financing tools and contracting often requires significant up-front time, resources, staff commitment and multi-layered teams even before a project is officially launched. Well-established and resourced governments and organizations with capacity and flexibility specifically for contracting, financial analysis, evaluation and fidelity to program delivery, position these entities with more opportunity than smaller, less resourced governments, organizations and communities. This has also led to more outcomes funding projects explored and launched in urban areas as compared to rural areas of the country.
The complexity of transactions has also led to a forced reliance on national experts and intermediaries within the outcomes funding field. This further reinforces selection of communities and organizations deemed ready to engage with intermediaries and research institutions, while simultaneously limiting local capacity and knowledge to drive efforts. Community expertise, lived experience and grassroots capacity are not valued in the design and implementation of outcomes funding projects.
Finally, the focus on scaling interventions also limits the accessibility of outcomes funding by diverse communities. The commitment to scale forces a lens of standardization of approaches, interventions and outcomes, and centralization of decision-making that is antithetical to a community-centered approach. It also leaves out consideration of local diversity and context that are critical to ensure commitment, leadership, locally relevant and sustainable results.
Outcomes funding focuses on investments in discrete projects and does not address the complexity of health and well-being in communities. The project-based approach focuses on one or a few outcomes that can be isolated in evaluations to assess the success of an intervention. This prioritizes causal pathways of intervention to outcome, to the detriment of understanding the larger context and multiple determinants affecting the health of communities. These priorities limit cross-sector efforts engaging diverse partners leveraging multidimensional approaches from accessing outcomes funding. This also limits evaluations focused on the important interplay of multiple interventions and outcomes.
These challenges are further reinforced by prioritizing short-term thinking and proving outcomes within a window of time typically based on funder needs, rather than community priorities. Assessing sustainable, multigenerational impact would require a long-term horizon for defining, funding and measuring success.
The tension of testing solutions to address critical needs in real time, while also viewing the long-term horizon of successful outcomes, is a challenge and opportunity for outcomes funding. The urgency to address critical, immediate needs is often a barrier that limits efforts to understand and prevent the kinds of challenges that result in poor health outcomes, inequities, and societal challenges. Outcomes funding lacks a lens that would help prioritize this type of prevention-focused, long-term thinking with systems change objectives.
Multidimensional approaches addressing the multiple determinants of health are critical to change the interconnected systems that are barriers to health equity. In this sense, opportunities need to be created to embrace complexity; to weave together the partnerships, networks, interventions, ideas, influence and resources to create systemic change.
Naming and Reorienting Power
Outcomes funding, like many other fields and sectors, has not reconciled the power, privilege and inequities that are built into the systems at work in the field today.
In current outcomes funding, oftentimes the communities are not identifying critical needs or provided with support to meet those needs. Funders and governments are driving the selection of sites, outcomes and testing of these tools. Outcomes are often selected by funders or lead service providers, instead of communities, leading to the selection of outcomes for payments that may or may not reflect community aspirations, lived experience and local wisdom. While community engagement is increasingly being incorporated into specific project components, decision-making across the lifespan of projects often limits community voice. This top down decision-making significantly limits the power, voice and ability for communities to access funding for their priorities and to define success.
Outcomes funding projects and approaches are situated within a society defined by structural and institutional racism, white supremacy and inequitable power structures.
These systems and structures define the landscape of funding decision-making, resource allocation and access to necessary levers of change in the United States. At its core, an equitable approach is one that addresses and redresses the misallocation of power with the goal of achieving better outcomes.
PUTTING THE PRINCIPLES TO WORK
The challenge we have set is not easy. We do not anticipate that the whole outcomes-based field will begin centering equity immediately. But, if we do not even ask the question of what is possible at the intersection of equity and outcomes, then we never will know what might be achieved. Outcomes funding holds the possibility of supporting a diversity of approaches, tailored to local needs, building on local expertise and providing the flexibility and motivation for continuous evolution and innovation in addressing community needs.
We want to know: what would it take to operationalize these concepts? What struggles are we facing or do we anticipate facing? What do these principles mean for our respective disciplines, sectors and geographies?
The intent of this piece is to invite additional contributions, critiques, and ideas; to learn together and to co-create future iterations of these principles. We are publishing this piece to prompt your reflection on the ideas, provoke critiques and new ways of seeing outcomes funding, solicit opportunities to apply these principles in work and hasten improvements on the ideas. We recognize this document may be missing perspectives, opportunities, and voices and we are asking you to bring them and advance new ideas in this space.
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 a space to seed new ideas, challenge our assumptions and build these ideas collectively.
Founded in 1980, Nonprofit Finance Fund (NFF) promotes the success of nonprofits by providing capital, strategic consulting, and using our knowledge and influence to transform the funding and financing landscape. We have been a leader in supporting innovative approaches to delivering services to communities, including our Pay for Success and Invest in Results work, which endeavours to free up community groups to focus on long-term impact instead of short-sighted metrics that can hamper meaningful change. We acknowledge that our access to financial and social capital—and that we have been white-led for 40 years—gives us a position of privilege that many organizations on the front lines fighting inequity do not have. We are committing to use this position to address decades of disinvestment in communities of color. Working with these communities hand in hand, our goal is for them to gain control of the resources they need– whether donations, contracts, or loans – and improve how money is given, gotten, and used for social good.
Shift Health Accelerator was launched in 2018 by community leaders in the Robert Wood Johnson Foundation Culture of Health Leaders program. Shift was created to solve a thorny problem. In years of work, we saw incredible leaders striving mightily to solve society’s toughest challenges: from lack of access to healthy food to unsafe and unaffordable housing, inadequate public transit that’s a barrier to keeping a job, or no parks for kids to play. At the same time, we knew funders who wanted to direct their investments to do good, but who lacked the local knowledge needed to support the organizations doing the best work. Shift was established to help them all do better at doing good. Our experiences in outcomes-based funding made us curious about the potential in the field, but it is the values that underpin our work that create our shared commitment to an equitable future.
Much of JSI California's work focuses on the intersection and alignment of healthcare and community-driven efforts to improve health. Through projects such as provision of financial sustainability technical assistance to the California Accountable Communities for Health Initiative and qualitative research on the perspectives of Medi-Cal plans on social determinants of health, we've seen a genuine interest in new ways to invest resources to improve health and equity. However, we've also witnessed the need for a better defined and consistently applied set of practices and robust and transparent dialogue about how to address issues such as existing power dynamics, fair risk taking, the wrong pockets problem, and inclusive governance and decision-making. We are partnering to support innovative local efforts to address those issues and advance local and state policies that make equitable investment easier, more likely, and community-driven.
Our intent is to hold ourselves accountable to living our values and the principles outlined in this piece. We are asking ourselves how we can move toward this vision, understand what is standing in the way that we need to reconcile and invite other voices to contribute to a more equitable future.
We hope that this ongoing dialogue will build trust, unveil what might be unseen, and unearth new and creative approaches to center equity in our decision-making as a society. An ongoing space for testing these concepts will help us understand barriers and opportunities, create new partnerships and celebrate successes. We invite both the dialogue and the testing, and commit to taking action within our own work. We invite conversation through a variety of venues. Please take advantage of the interactivity of online publishing and social media to provide your responses to this piece. We will continue to publish ideas so collectively we can create, resource and support a just, equitable future.
Please post your reactions to the article through this survey. We are partnering with the Federal Reserve Bank of San Francisco’s Community Development Department to collect feedback and promote cross-sector dialogue on the principles outlined above. Your comments will be helpful in shaping an upcoming issue of the Community Development Innovation Review, which will bring together perspectives, critiques, and fresh ideas from across the field that can help advance both the theory and practice of equitable outcomes funding. For additional background on the outcomes funding field, please check out the 4th volume in the San Francisco Fed’s “What” series: What Matters: Investing in Results to Build Strong, Vibrant Communities.