Evolving Philanthropy with Kristy Klein Davis

G: Funders talk about needing to "to move at a systems level", but often struggle to define what that means. What does a systems approach mean to you?

KKD: When we see health inequities we can assume one of two things: people are less healthy because of their own individual choices OR people are less healthy because they are disadvantaged by the systems that influence our health. We believe the second is true, that the health system, our political system, our education system, our economic systems are fundamentally set up in a way that make it easier for some people to be successful. The belief that these are systems give equal access to success or to health is simply false. A systems approach means that we are looking critically at any and all of those systems and looking for ways to disrupt and change them so that they actually do act in service to equity.

G: How has Missouri Foundation for Health's work evolved over your ten years of work there?

KKD: The Center for Effective Philanthropy has put out a continuum of philanthropy, which is helpful. It runs from charitable to strategic — and philanthropies, foundations, and institutions can run anywhere along that continuum. When MFH started out we were much more at the charitable end of the continuum – a fairly traditional grant maker. It made sense. Only 20 years ago we were a new institution with an infusion of cash, and nobody internally knew a lot about the range of nonprofits and health needs across the state. So we started out with big open calls and just put money into the world to fund good programs. There's nothing wrong with that. The charitable realm of philanthropy is good, and it's important that it stays in place.

With that in place, what we've started to do is move across that continuum more toward the role of a more strategic funder. We've come to appreciate more that to forward our mission of improving health and wellbeing of people and communities we can't sit and accept the status quo. It calls for a different type of work. The nonprofit community is a huge conduit between us and the community on the ground, but at the same time there are ways to improve the health and wellbeing of the community and people that aren't through grants to nonprofits to implement programs. At the end of the day, we are accountable to the people so all our activities must be in service to improving the conditions people face.

G: What does accountability to the people mean to you?

KKD: It's our mission to improve health and well being for people in communities in need. I want to be careful and not be flippant about the role of nonprofits - that is not my intent - but there are ways to improve the health and wellbeing of the community that aren't through charitable support of a great program.

We are trying to fundamentally shift the environment that people are living and accessing services in. If you can change environmental policies then ultimately that will give people more opportunity. If we can change the rules by which people access fresh fruits and vegetables through SNAP rather than give a grant to a food pantry to buy more fruits and vegetables, we're going to have a broader, greater impact.

It may look like a contract for a researcher, funding a consultant to work with the state to make some rule changes, it might look like advocacy. The outcome is a more sustainable, longer-term version of which we all agree is important. Nonprofits are critical partners in the work. We need to support them and think about the other things we can do to drive the long-term change we are all looking for. That's what Missourians are looking for and deserve.


G: How do you see your relationship with government and other public entities?

KKD: Government is always going to have more money than philanthropy. Programs, policies, and services funded through the government will ultimately serve the most people, so doing work to increase effectiveness of those programs, policies, and services is critical. We have done policy work since the early 2000s, which we now do that a few different ways.

We have our own policy division that does policy research, legislative tracking, and legislator education. We have worked for 15 years to develop strong relationships with the state government. We're nonpartisan, but that doesn't mean we are agnostic. We have opinions on things, but it's not from a partisan lane. We also train and educate legislators on issues of health and health policy, which is one reason it's important for us to maintain that nonpartisan stance.

We don't care if you are Republican, or Democrat, neither, or something in between. We care that you use solid information about good health policy to benefit people in communities. We've worked hard to be the group that legislators and department and figure heads call upon when they are trying to understand something. And while we provide input to our partners, we make it clear that our focus is improving health and wellbeing for people in communities in need. We are going to be straight shooters about it.

G: What has motivated the shift to a more strategic role change? Why wasn't traditional charity enough?

KKD: These things always start with a board. There was frustration with the fact that we are putting out all of this money year after year, but what is really changing? What can we point to? People were hungry for real impact. That shift was hard. It meant organizations who have been our partners and grantees for years didn't get grants anymore. We tried to give plenty of notice, explain our rationale, but at the end of the day it was just a hard switch. And it wasn't because they weren't doing good, important work, but we had to take a hard look at how to prioritize $50M a year in Missouri.

G: Ten years from now, are you confident that you'll be in a better to position to show what was accomplished?

KKD: Yes. I think we are doing really good work, work that requires a long-view. For example, we have work in infant mortality that we launched in 2013, place-based work in St. Louis and the Bootheel - a six county rural region of the state. In both of these areas black babies were dying at 2 times the rate of white babies. It was unacceptable and due to inequities in the systems that support women before, during, and after pregnancy. It's directly tied to racism in our health systems and our communities. It's systems change. It's not about hiring more neonatologists in those hospitals, it's about fundamentally shifting how women experience care.

Our goal wasn't to provide all this support when an individual baby is born. We focused on building collaboration that could change the systems where women are experiencing pregnancy and prenatal/postnatal care. Our goal was to ensure that women can have healthy pregnancies, feel respected, be cared for, and that their babies thrive all in addition to dropping the infant mortality rate and closing the disparity gap between black and white babies. So success isn't just measured on infant mortality rate alone. It's harder to describe that impact than it is to say we gave $50,000 to this organization and they saw 50 patients (which I would argue isn't actually talking about impact).

G: So in that shift, it sounds like you're pushing beyond simple impact numbers toward a holistic assessment to see if people are included and cared for.

KKD: Yes there is an effort called the Equitable Evaluation Framework that is pushing for a paradigm shift in how we understand impact. It challenges who gets to say what works and who doesn't. For example, why would we rely on quantitative data alone to say whether or not something worked? Who gave the data that authority? Your number may say it is fine or good – infant mortality rates dropped but if in doing so women haven't felt respected, haven't felt heard haven't felt cared for, I wouldn't call that success. This shift is important, but it's harder. Boards want a dashboard that shows progress towards impact. Ina ten year effort to decrease infant mortality by 10% you don't see 1% per year, that's not how it works. So we need to be wiling to think more broadly as a culture about a different frame of what is success and who gets to make those calls. Why should I get to decide? It should be the person who is receiving services.

G: What are other things that you need to change in the ways philanthropy operates?

KKD: Trend hopping - it's harmful. New practices come on for a reason, and they're really good practices, but we should think about why we use them to support solving the problem. For example, collective impact was the big thing for a long time, and our infant mortality work was built on that model. But we don't use that same model for our Medicaid expansion work because it wouldn't make sense given our goals. So collective impact, general operating support, participatory grantmaking, and many other trends all have a really important role to play within social change, but hopping from trend to trend and going all is not as helpful as thinking about what tools are going to contribute to the desired outcome.

In a charitable model, grantmaking is your tool - you make grants. We've tried to broaden our tool box so we turn to policy and advocacy work, communications, research, business-engagement. We are starting to inch our way into impact investing tools and we have experimented with PRIs (program related investments). It's something we want to do more of. How do we use our endowment to further our mission and continue to maintain our spending power? Again, all these ways of working are tools in our tool box and our job is to deploy the right one at the right time to get to the change we want to see.

G: What are some of the trends in philanthropy we need to be aware of? What is changing in society that is changing your work?

KKD: There is no excuse to not be attuned to racial equity and the impact of race and racism on everything. If we aren't doing that, we are at fault. It has to change how you do your work. If you are forcing the issue and asking the questions it's going to change your strategy.

We also need to be paying attention to the intersection of place and health. They're different things, it's coded language. A lot of the issues that plague us are true no matter where you live geographically, though the history of how they got that way and the avenues to improve them are different. I think we've ignored rural health for a long time. Rural places are dwindling, but the need there is high and – through immigration - they are becoming increasingly diverse. So how do we think across places for solutions?

I also believe we need to pay attention to how a new generation of leadership is showing up and how they are choosing to lead.

G: What does leadership look like for this new generation?

KKD: Nonprofit leadership and grassroots advocacy movements are building and demanding a different future. They are powerful and important and we need to know how we not only support them, but also invest in the solutions they are putting forth.

G: What is an example of a new leader you are struggling to support or need to evolve?

KKD: Take the groups that stepped up after Michael Brown was killed and the uprising in Ferguson, it was a giant spark in the Black Lives Matter movement across the country. We wanted to support black-led advocacy but it was a challenge for us. Many of the groups that stepped up to lead efforts didn't want to form a 501c, didn't want to get a fiscal agent, they just wanted to do their work. Many were also wary of philanthropic money and the rules that come with it, because it represents everything that has contributed to where we are today.

But we also believe in the changes they are trying to make and want to support it, so we get stuck. We (and the IRS) have rules that dictate how we fund, and organizations have their own sets of rules about how they want to accept and receive money. The two don't always match up, so what do we do? It's on us, not on them, to find a different way to do this because its understandable that they don't want to conform to the conventional structures that have not helped them.

G: As a rising leader in systems work, how do you sustain perspective? What do you do to think creatively in this work?

KKD: I am a mom of young kids - it just grounds you to some extent in the why. It's not just that I want a different future for my kids, I do, but this experience helps you see the real issues that families face. I look at my family and recognize they've got every advantage that the world can give them. I have a white boy whose family has money and who has been in high quality early education. There are so many kids who don't have that and parents – really great parents - are struggling and it's just not fair. I think being a mom with young kids helps to give that perspective.

G: Let's talk about COVID. What's the most important thing you've learned from this experience so far?

KKD: How connected everything really is and how important it is to focus on those connections when we aren't in the midst of a crisis. One straw breaks and you see systems upon systems cracking globally. We have put $15M into the COVID response in Missouri to but some of the issues we are facing are issues that money cannot solve. I can send you $30,000 but good luck buying a mask. We are used to using money to solve problems and so much of this response so far isn't about money.

G: What has changed at MFH during the pandemic?

KKD: I think at first everybody scrambled but we've been fairly well situated. Some Foundations made decisions to convert all their grants to general operating support. We talked with our partners and agreed not to go that direction. The things we were working on pre-COVID are going to be just as relevant, or even more relevant, post-COVID.

For example, now is not the time that behavioral health organizations want to stop working on suicide prevention. We have reason to believe suicide rates will go up in these circumstance. So we need to stay the course on that work.

I'm happy to see that fifteen years of relationship building is coming to fruition. We can make phone calls and they are working. We were hearing from food banks, which are distribution systems for the state. They had food but no people to package it, so we needed to call the Chambers, who have people. That's not a complicated, innovative solution. Here's a problem, lets match it. I hope we can continue to on a trajectory to reinforce our connectedness - to recognize the ecosystem approach and improve the relationships between philanthropy, private, and public sectors. We should all be working together on these things because it hits us all.

Additional resources:

• Equitable Evaluation Framework
• Missouri Foundation for Health's Infant Mortality Reduction Initiative