A conversation with the Robert Wood Johnson Foundation's Health Group on September 23, 2013

Participants

• Dr. Jim Marks — Senior Vice President and Director, Health Group, Robert Wood Johnson Foundation
• Cari Tuna — Co-Founder, Good Ventures

Note: These notes give an overview of the major points made by Dr. Jim Marks.

Since this conversation took place last year, the Robert Wood Johnson Foundation has realigned many staff responsibilities. While the information in these notes is accurate, Dr. Marks has a new portfolio of responsibilities today.

Summary

Good Ventures spoke with Dr. Jim Marks to learn more about the Robert Wood Johnson Foundation’s (RWJF) Health Group. Conversation topics included an overview of the Health Group’s work, its major successes, and how it selects projects to fund.

Overview of Robert Wood Johnson Foundation’s Health Group

The RWJF Health Group works on issues of health by addressing problems outside of the healthcare system, in areas such as public health, agriculture, education, and transportation. For example, addressing child obesity involves improving access to healthy food, creating safe exercise spaces, and changing food marketing tactics that target children, among other things. The notion that areas beyond healthcare have implications for health is a somewhat underdeveloped concept.

There is some disagreement in the US as to whether health is the effect of personal decisions or the effect of social factors. RWJF believes that both are important. For example, in working on the County Health Rankings reports, a US county-level health scoring system based on measures of mortality and morbidity, RWJF found that—in addition to healthcare—both personal health behaviors, and environmental and social factors such as the education level and single parenthood were correlated with mortality and morbidity. Information provided by the health scoring system encouraged counties to address issues outside the realm of healthcare. For example, a county in Michigan learned that their bus lines were a barrier for some low-income women from receiving prenatal care at hospitals in neighboring counties because the buses stopped at the county line.

Five years ago, RWJF formed a commission to develop practical recommendations for improving health in America. The background and expertise of the commission was not limited to health and healthcare.

Generally speaking, RWJF looks for opportunities that are tractable, sustainable, and scalable. RWJF prioritizes vulnerable populations and tends to focus on early childhood, mental health, and populations whose health problems stem, at least in part,  from social circumstances. Policy work and advocacy are important parts of creating lasting, scalable change. Rather than solely funding interventions in multiple communities, RWJF often prefers to leverage its impact by evaluating a policy change, and if it is found effect, supporting efforts to educate for that policy to be adopted more widely.

RWJF reviews existing research to investigate questions such as, “what is the available science on a given topic,” and “what policies have grown out of research, and have these policies had an impact?” It also evaluates the impact of specific policy changes. For example, RWJF’s investigation of tobacco taxes addressed questions such as, “did tax increases lower initiation by youth?”

Currently, RWJF does not grant outside of the US. However, it hopes to learn more about global opportunities that could be usefully applied in the US in the future.

Non-legislative policy work

Roughly 20% of RWJF’s work is on policy change. In particular, the foundation does a lot of work to promote non-legislative policy change.  Changing policy through non-legislative channels often involves facilitating the sharing of information and best practices. Examples of RWJF’s policy-oriented work include:

• Funding a partnership between the Clinton Foundation and the American Heart Association to improve local school health policies. The group recommended policy changes that local schools could make, based on scientific literature from the NIH, CDC, and others. Recommended policies included instituting exercise periods before and after school and offering healthier food options. The group also created a system for recognizing schools that improved their health policies.
• Sponsoring local YMCAs to collectively advocate for municipal- and state-level policy changes to help make their communities healthier. It has also supported the YMCA in smaller-scale policy efforts.
• Creating a network to connect individuals working on public health law, e.g. legal advisors to city and state health departments. An example of the kind of work accomplished by this network was the creation of shared use agreements that allow the public (e.g. little leagues and city parks and recreation departments) to use school grounds for exercise and recreation during after-school hours while assuming liability for the time spent there.
• Creating the LawAtlas, which documents variations in public health laws across states. LawAtlas has provided, for example, information on new laws on concussions in schools.

Major successes

RWJF’s Health Group has had success in areas including:

• Smoking: RWJF selected interventions with strong scientific evidence, such as increasing the price of cigarettes via taxation, instituting clean indoor air laws to protect workers and patrons, getting Medicaid and other insurers to cover cessation-related healthcare, and requiring physicians to ask patients about tobacco use.
• Obesity: RWJF was among the first organizations to address “food deserts” in the US. RWJF is also having a significant impact in schools. It funded the Alliance for a Healthier Generation, through which about 20,000 schools are now actively pursuing better policies. And the Alliance has engaged with industry on behalf of food and beverage school policies. For example, when individual schools began changing their policies around vending machines, the American Beverage Association requested and the Alliance helped negotiate nationwide standards. RWJF is optimistic about its work around obesity. In August 2013the CDC reported that obesity rates in children ages two to four attending WIC clinics have declined in 18 states; obesity rates in school-aged children have declined in a number of states as well.  And most recently CDC reported a nationwide decline in obesity among children age 2-5.
• Healthy habits: RWJF has funded a lot of research on effective ways to encourage healthy habits, such as exercising and eating well. This research has influenced policy discussions at the local and state level and occasionally at the national level.
• Public Health agency accreditation: RWJF helped establish a new voluntary program to accredit public health agencies after noticing a lack of agency-level quality standards and inconsistent practices across agencies. (RWJF found that there were quality standards for individual programs but not for agencies’ work overall.) Agencies representing over half of the US population have applied for accreditation since the program launched last year. The program has helped health agencies gain credibility on the local level and possibly the national level.

Selecting projects

Research often informs RWJF’s project selection. Research has led RWJF to the following conclusions:

• There is probably wider variability in public health funding than in any other public service sector and overall spending per person on public health is low. In the past, states have addressed wide (two to three-fold) variability in education funding. Variability in public health funding is much greater, at about 30-fold. The 80th percentile for public health investment is about a hundred dollars a year per person, whereas the 20th percentile is about eight dollars a year per person. These numbers are small relative to investments in clinical care, which average $8-10,000 a year per person.
• Having a Board of Health is associated with higher levels of investment in public health.
• Higher levels of investment in public health are associated with lower infant mortality, lower cancer and heart disease mortality, and lower Medicare costs.

Before committing to the project on health agency accreditation, RWJF sought a variety of perspectives; investigated the impact of accreditation programs in other social agencies and in the health agencies of particular states (for example, research in North Carolina found that accredited agencies responded more effectively to the flu pandemic); spoke to health officers who suggested that accreditation requirements help protect important programs during budget cuts; and compiled best practices with the CDC as its major partner.

Matching local funders

RWJF has matched funding for projects selected by local funders, such as the Early Detection, Intervention, and Prevention of Psychosis Program (EDIPPP). In several cases, it worked to scale-up these projects or compile more evidence on their behalf. For example, RWJF funded additional sites for EDIPPP and added an evaluative component to the program.

Service models

RWJF looks for opportunities to fund “service models” such as EDIPPP and Playworks (an elementary school program whose growth RWJF has helped fund) for which it can help strengthen evaluative capabilities, develop sustainable business models, and support efforts to spread the model. Before making a commitment, RWJF investigates questions of funding (e.g. “does this program need a government source of funding?”), scalability (e.g. “can this program be sold as a service to hospitals?”), and management (e.g. “does the program have a board structure with good fiscal management, evaluative capabilities, and strong networks?”).

Miscellaneous considerations

• Health Education campaigns are valuable but often require ongoing funding.
• It is important to engage other partners when tackling large problems. These partners may or may not be independently funded, but expertise, and their reach into communities are often crucial elements they can bring to the table.

Less successful projects

RWJF has been involved in some projects that did not achieve as much as expected. These include:

• The Urban Health Initiative (UHI). Through this initiative, RWJF made large grants on the order of $70-100 million in aggregate to a small number of cities to make system-level changes. Though there were successes in some cities, the initiative did not lead to fundamental change overall.
• RWJF’s work around substance abuse, which often involved working with colleges. (Though it did not achieve system-level change, RWJF made an important contribution by helping to change the narrative around substance abuse from one about personal failure to one about a chronic relapsing disease requiring treatment.

RWJF has published evaluations of some of its projects on its website, including its work on tobacco, substance abuse, and end-of-life care. These evaluations discuss the accomplishments, failures, and evolutions of its projects. For example, the evaluation on its work around end-of-life care discusses how the project was initially oriented more toward medical education than policy. After shifting the direction and strategy of the project, RWJF was able to make a larger contribution to the field.

Promising opportunities

Areas of great interest and potential for the future include:

• Mental wellness. The Adverse Childhood Experiences study, among others, has demonstrated that stress experienced early in life can cause long-lasting mental damage.
• The root causes of violence, which involve factors such as bullying, early-life stress, and issues of social and emotional learning in young children.
• Community development. Work in this area includes: improving public safety, providing quality housing, and ensuring access to parks.
• Early childhood education. The work of Nobel Prize-winning economist Jim Heckman suggests that strengthening self-command in young children may lead to success later in life.

Dr. Marks also recommends funding research around:

• Behavioral economics, i.e. how to structure choices so that people make the choices that are in their best interest. This work is important because corporations tend not to have consumers' best interests in mind.
• Empathy i.e. how people try to understand the perspectives of others and learn to use that to work well together, help each other out and avoid conflict.   This work is important as our society becomes more diverse and complex.    It is also important during times of stress whether economic, natural disaster or even day-to day interactions