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A February 2021 article on the Health Affairs Forefront explored the increased emphasis on health equity among philanthropic organizations across the US. The piece, which shared findings from a survey of health care grantmakers, reported that more than four out of five foundations had changed or plan to change their health equity programming. Moreover, nearly half of those polled had created new initiatives during the pandemic focused primarily on access to care and racial justice.
For practitioners such as us who have spent our careers working to close gaps in access and opportunity for historically marginalized communities, this is welcome news. There is no question that events over the past three years have catalyzed long-overdue action on equity. From the growth of equity-focused corporate roles—with nearly 80 percent of companies pledging to increase equity budgets—to increased health equity programs and curricula in medical and health professions education, there is clearly momentum building to advance change.
And yet, as philanthropic budgets growso, too, does frustration within communities that are best positioned to deploy those resources. Most philanthropic dollars still seem to go toward short-term, deficit-based, and scope-limited projects—charitable donations rather than sustainable investments. Of particular concern is that funding models themselves tend to reinforce the same power dynamics they purportedly seek to dismantle.
That’s why a new approach to health care equity funding is desperately needed now to both change the system and model how to change the system.
Good Intentions, Unintended Outcomes
In 2012, the National Institutes of Health (NIH) released a seminal report on the lack of diversity in biomedical research. The study revealed that Black principal investigators accounted for just 1.1 percent of grantees at the world’s largest grantmaking body (the NIH has an annual operating budget of more than $45 billion). Laudably, their admission set into motion a range of actions designed to increase available monies to underrepresented groups.
Unfortunately, new money didn’t deconstruct old barriers.
While funding grew, conditions for eligibility were unchanged. These conditions included successful administration of prior grants, cash reserves, staffing requirements and salaries, lab infrastructure, and so on. Ironically, these necessary conditions were often the very requests from applicants seeking support. Because institutions and grantees had to prove a level of past accomplishment, this almost universally disqualified many historically Black colleges and universities, women, and other minorities who only recently had access to funding, employment, and enrollment.
This is exactly the catch-22 scenario that is similarly playing out in health philanthropy today. With increased awareness of health disparities, foundations may be offering new opportunities for communities historically barred from participation, but barriers remain. Too often, grantees must demonstrate a level of prior success, which, of course, they have been unable to access due to structural racism and inequities.
Philanthropy And Power
The unpleasant truth is that philanthropy is often an expression of privilege. Capitalism creates wealth, which creates inequality, and thus nurtures conditions for the rich to spend that excess wealth on helping the poor without ever shifting the power dynamics at the heart of inequality. Furthermore, the process of distributing that wealth is prone to perpetuating a system of need rather than dissolving it. In his 1932 publication on the relationship between ethics and politics, Moral Man and Immoral Society, Reinhold Niebuhr notes that, “Philanthropy combines genuine pity with the display of power [which] explains why the powerful are more inclined to be generous than to grant social justice.” In other words, rather than addressing deep and historic injustices, charity often reinforces the world as it is.
And yet, philanthropy still plays an essential role in our societal ecosystem. The challenge we now face is how to dismantle the biases embedded in the very solutions themselves and offer a new standard for grantmaking. In other words, how can philanthropic organizations partner with communities to co-create solutions that, as the expression goes, lift all boats?
Changing The Paradigm
Redesigning philanthropic health equity funding can itself provide a model for social justice. Our own experience leads us to offer the following recommendations to reshape a more just system of health equity philanthropy.
First, Stop Fixing
Too much funding is deficit-focusedmeaning that grants are designed to fix. For communities historically wronged, that “fixing” looks like correcting people and cultures. Rather than approaching philanthropy as solution-oriented giving, it’s essential to position our work as assets-based investments in what (and who) is already effectively advancing vibrant and just communities, such as the Black and Brown communities that have generations of experience resisting social injustice. We don’t need to “direct” these communities; indeed, we should follow their lead.
Furthermore, the trap of “fixing” compels many philanthropic endeavors to address symptoms rather than root causes of need. Thus, they fund projects to feed the hungry, create jobs, build housing, and improve services. While these efforts are worthwhile, that work can be wiped out by public spending cuts, predatory lending, or exploitatively low levels of pay. Progress is also likely to stall when the funding ceases.
Instead of framing funding as a “fix” or a “stopgap,” let’s start identifying the people and organizations operating well and use those examples to shape the work.
Second, Most Needs Are Not Time-Limited Or Narrowly Focused
Just as racism has taken centuries to intractably root, infrastructures to dismantle these constructs of bias take time and resources to build. Addressing health equity is long-term work. Disparities in health outcomes—especially the upstream social drivers of health—are embedded in persistent inequities and power structures. While we may be able to offer some short-term supports—such as vaccinations, food, or housing—these outputs only last as long as a particular program and do little to ensure that ownership and implementation is wholly centered in and sustained by the community.
Moreover, when we focus on short-term projects, we’re unable to build capacity and attract the kinds of people who best understand their own neighborhoods and the challenges they face. Without sustained funding, too many small organizations wind up with a collection of myopic initiatives that duplicate efforts, expend resources inefficiently, keep staff narrowly focused on outcomes, and fragment collective energy and impact.
Third, Ease Restrictions
There was a time when paying a patient’s rent was considered a radical, dubious intervention. Today, health care systems, payers, and practitioners all acknowledge the utility in housing as central to health. Likewise, we’ve seen health care magic happen by underwriting barbers as the trusted messengers of preventive health care information. From providing the overhead to cover salaries to the downstream, often iterative (or on the fly) support of unusual undertakings, grantees need to have the autonomy to be creative. In fact, it’s only with a level of autonomy that people can be truly creative.
Finally, And Most Importantly, Nurture Trust-Based Philanthropy
In medical education, trainees spend much of their time learning the art and science of trust; it’s the one non-negotiable, essential element in all patient care. If you haven’t earned patients’ trust nor demonstrated your own trust in them, progress cannot be made.
The same is true in philanthropy. Trusted relationships between grantors and grantees are essential to cultivating sustainable change that ultimately shifts the power away from those who have historically held it and into the spaces where power can be used to transform every measure of human progress.
If a foundation intends to support an organization, it must do so wholeheartedly and alongside; this signals value in the people leading the work and sustains them in their mission to uplift teams and communities. This also allows trust to transition to respect, which is ultimately the only way to truly reframe the relationship between those who hold resources and those who should have them.
Shaping A New Normal
Much has been written of the inflection point we now find ourselves in as we reflect on the experience of COVID-19 and scaffold a new normal. Among the most valuable lessons we believe we must carry forward is that sustainable change happens with, in, by, and for the very groups we strive to serve. So, let’s let our community partners drive that change with the resources they’ve long been owed—demonstrating that the mechanics of philanthropy can model the promise of equity.
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