Investing in Communities to Create Health: The Colorado Trust
by Christopher Freeman Adams
Foundation News and Commentary, May/June 1999, and
Voices from America: Ten Healthy Communities Stories from Around the Nation,
Health Research and Educational Trust, 1998

Introduction

When the Colorado Trust embarked on The Colorado Healthy Communities Initiative (CHCI) in 1992, it did so under the impression that it would be funding community-based public health projects. After all, the core mission of The Trust was to support health promotion and disease prevention. But when the twelve communities which had received planning grants reported the results of their year-long planning processes, most of the projects the communities wanted to undertake did not look like traditional public health. The issues that the communities wanted to address included strengthening families, improving transportation, building community leadership capacities, planning regional land use, and creating sustainable economic development. Important issues, The Trust agreed, but not the public health projects The Trust's Board had in mind. They wanted projects that would correlate with Healthy People 2000, a national set of disease prevention goals that includes such objectives as increasing intake of fiber containing foods and reducing the incidence of fetal alcohol syndrome.

At a 1993 meeting between the staff of The Trust and representatives of the communities, the representatives challenged The Trust to reconsider its requirement that the implementation grants be used solely to support activities related to Healthy People 2000. The Trust had an obligation, the community representatives argued, to fund the most important aspects of their plans to make their communities healthier-whether they fell outside of Healthy People 2000 or not. The passion and commitment in this conversation convinced the staff to ask the Board to expand what was permissible under the implementation grants, including activities such as leadership development and ongoing community forums. After considerable deliberation among Board members, the funding guidelines were expanded.

The way in which the staff and subsequently the Board of The Trust responded to the communities demonstrated two of the essential characteristics that it would later recognize as fundamental to a foundation's role in building healthy communities: flexibility and allowing new information to influence both the process and the expected outcomes. This mid-course learning set the stage for a statewide effort to improve health and quality of life in Colorado by using a broad, locally defined definition of health. It also put Colorado, and The Colorado Trust, in the vanguard of one of the most promising, energetic movements for health improvement and community renewal in the country.

The Colorado Healthy Communities Initiative

In 1985 The Colorado Trust was established with the proceeds from the sale of Presbyterian/St. Luke's Medical Center in Denver. As one of the very first conversion foundations-philanthropies created from the sale of a healthcare system-it has had one overriding goal that has remained constant throughout its history: to improve the health of the people of Colorado. What has not remained constant, however, is the way in which health is defined and the best way to achieve it.

During the first five years of The Trust's existence it supported a number of traditional public health-related efforts, including nonprofit organizations providing services such as prenatal care, shelters for victims of domestic violence, and fitness programs on Native American reservations. While these efforts certainly provided beneficial services, the Board began to question whether providing operating support for existing programs was the best grantmaking strategy to improve health. Realizing the practical limitations of what it could do with its substantial yet limited resources, the Board sought a way to maximize the effect of its support by searching for and then funding leverage points that would be most likely to improve health.

Between 1990 and 1992 The Trust temporarily suspended its grantmaking while it undertook an environmental scan to identify those leverage points. The results, published in Choices for Colorado's Future, had two findings that would exert a strong influence over future grantmaking. The first was that Coloradans strongly believe in prevention to address health-related issues; and the second was that Coloradans want to participate in the decisions that affect their lives. Given these results, The Trust concluded that as a philanthropy, one of the most effective means to improve the health of Coloradans would be to fund efforts to engage local communities to promote health and prevent disease.

At the same time that The Trust had concluded that Colorado communities were promising leverage points to improve public health, a similar insight was fueling a national and international movement-the healthy cities/communities movement. In 1986 The World Health Organization began an effort in 34 European cities to focus on improving environments and moderating lifestyles in order to improve health. In 1989, The US Department of Health and Human Services began a domestic initiative in the US, asking the Denver-based National Civic League (NCL) to help launch the effort. Taking advantage of this Colorado asset, in 1992 The Trust engaged NCL to provide project management and direction.

In addition to its innovative approach to improving health, CHCI represented another innovation for The Trust. It was the first initiative in a new "initiative-based" approach to grantmaking. By taking this approach, The Trust assumed a more active role in the projects it would fund. Rather than being completely dependent on good ideas flowing up from non-profit groups in communities, in the initiative-based approach The Trust develops its own program ideas and works with the grantees to transform these ideas into effective activities. The CHCI was originally a five-year, $6.8 million effort to implement projects in 30 communities. By 1997 the project had been extended to eight years with the total expenditure approaching $9 million.

As part of this initiative-based approach to grantmaking, each of the communities selected to take part in CHCI were given a number of services and resources. These included:

  • Professional assistance for the planning and implementation phases from the National Civic League, which had been engaged to provide management direction and technical expertise to the communities in the initiative;
  • $7,500 for local administrative costs;
  • $8,000 for consultants on particular issues;
  • Access to a pool of implementation grant seed funds (generally $100,000 per community); and
  • Access to a statewide network of healthy communities.

While each of CHCI projects is as different as the communities which gave them birth, The Piñon Project is a good illustration of a community that has benefited in ways it could not have without The Trust. The Piñon Project is based in Cortez, a small town in southwestern Colorado that is approximately a seven hour drive to Denver. The project covers Montezuma County and the Ute Mountain Ute Tribe. According to Dennis Prather, Executive Director of the Piñon Project, "The Trust and the facilitators from the National Civic League were first rate. They helped us to learn how to bring 150 community members together to collaborate, get along and make some decisions. They also taught us skills like how to facilitate a meeting, how to create an agenda and how to create a board of directors. They taught us about the concepts of healthy communities." This technical assistance, coupled with the $100,000 of funding The Trust provided, was instrumental in creating a number of projects that include four family centers, a leadership development project, a summer camp for "kids on the edge," and a trained group of Family Advocates who meet with families to review needs, strengths and to offer referrals where necessary.

One of the major successes of the project has been in building bridges between those who live in the county and the Native Americans who live on the Ute Reservation. Currently three Utes are on the board, and several serve as Family Advocates. According to Prather, "At first we made all kinds of special accommodations to ensure their participation. Now we have moved to a point where everyone is at the table and everyone realizes that they have a stake in this."

Outcomes

"I thought that after five years," said Doug Easterling, Director for Research and Evaluation at The Trust, "we would be measuring changes in health status. Instead we are measuring things like leadership and a community's capacity to identify and solve problems." When the Board of The Trust made its decision to fund the projects that the communities determined would make them healthier, the issue of evaluation became as broad as the definition of health. Rather than measuring progress on indicators that could be specified beforehand, evaluation became more of an open question to be answered as the groups progressed on their healthy communities journeys. Even the indicators themselves needed to be identified based on the situations in each community.

In a survey conducted by The Trust of participants in CHCI about what the most significant results of the initiative had been, few answers related to traditional health data and statistics (though improvements in these categories may have taken place as well.) Most responses focused on developing the capacities of the communities, such as learning to solve problems collaboratively and with broad participation from many stakeholders. Even where the results were tangible-such as the creation of a community foundation or the opening of five resource centers-there was still no readily identifiable cause-and-effect relationship with health.

This presented a troubling problem for The Trust. Leadership development and improving the ability to solve problems are desirable outcomes, but wasn't the purpose of the Colorado Healthy Communities Initiative to improve health? More generally, what relevance does a community-building initiative such as CHCI have for a conversion foundation dedicated to "health"? This tough question is taken up in, "Promoting Health by Building Community Capacity: An Effective Medicine?" In this thought-provoking paper by Easterling, Kaia Gallagher and Jodi Drisko, both of the University of Colorado Health Sciences Center, and Tracy Johnson, Colorado Department of Human Services, the authors group the types of outcomes CHCI has produced into the category of "community capacity".

In the author's use of the term, community capacity has five dimensions:

  • Skills and knowledge that allow for more effective actions and programs,
  • Leadership that allows a community to draw together and take advantage of the various talents and skills that are present among its residents,
  • A sense of efficacy and confidence that encourages residents to step forward and take the sorts of actions that will enhance the community's well-being,
  • Trusting relationships among residents that promote collective problem-solving, and reciprocal caregiving ("social capital"), and
  • A culture of learning that allows residents to feel comfortable exploring new ideas and learning from their experience.

Through a review of cutting edge social science and public health research, they demonstrate a link between improving community capacity and improving health status over the long-term. For example, a recent study has shown a link between the level of trust, civic engagement and helpfulness (all characteristics of "social capital") in a community and differences in mortality by state. Another study links low birth weight to neighborhood social and economic conditions. Easterling and the other co-authors conclude, "The research reviewed here shows that community capacity is a strong determinant of health. In other words, a healthy community leads to a healthy community."

While this link between community capacity and health continues to be built, for The Colorado Trust it provides evidence that the foundation's approach to improving health is a promising one. It also reinforces the rationale for The Trust to use its resources as it has. "No single organization," say Easterling, et. al., "including a foundation, controls all the resources, behaviors, knowledge and relationships that influence health, but a foundation is in a unique position to draw out the ideas and talents that too often lie dormant when a community confronts its health threats." By using a combination of innovation, hard work, intellectual insight and careful evaluation, The Colorado Trust is helping to make Colorado communities healthier over the long-term.

Lessons

The CHCI was an especially significant undertaking for The Trust, not only because of the level of funding and project duration, but also because it was the first initiative in The Trust's then new initiative-based grantmaking strategy and because the healthy communities model led to projects that did not necessarily fit the Board's preconceptions of public health. As such, the project has received a great deal of assessment, which has led to a rich series of lessons that have implications for other healthy communities efforts and for other foundations contemplating similar projects.

In a recently published report, The Trust and the National Civic League have distilled ten lessons from their experience with CHCI after five years.

  • Lesson 1: Allowing communities to define their borders without regard to "traditional" jurisdictional boundaries encourages the establishment of boundaries as community members experience them, which in turn leads to improved deliberation and more effective solutions. The trust allowed communities to create a definition of community that was meaningful and appropriate to the problems to be addressed.
  • Lesson 2: The involvement of a neutral facilitator is central to success. As part of being a CHCI project, The Trust supplied the communities with a facilitator from outside the community. According to one participant, "That guy with the flipcharts and markers is OK!"
  • Lesson 3: Having a model to follow is very useful, but being flexible is a must. The healthy communities model developed by NCL proved to be a very useful place to begin, but the resources, needs and experiences in each of the communities is different enough that the model needs to be adaptable. For philanthropic organizations, a corollary to this is that flexible models need flexible funding.
  • Lesson 4: To involve representatives from the entire community, a significant focus on outreach must be built into the process. One of the axioms of former President Lyndon Johnson was that in order to get a complex task done, you had to look at who needed to be on board at landing and make sure that they are there for takeoff. This is as true with healthy communities work as it is with legislation. For a healthy communities initiative to be successful, the convenors must provide a variety of meaningful ways for people from all walks of life to become involved.
  • Lesson 5: The transition from planning to implementation doesn't "just happen;" it must be thoughtful and deliberate. Even the best of action plans is only a plan; if effective systems change is to actually occur, the community must establish an appropriate governing structure for the initiative. The formation of a new 501(c)(3) corporation may or may not be the best approach, depending upon the existing institutional landscape of the community.
  • Lesson 6: Dedicated people are the key to a successful project. Even though CHCI projects thrived from volunteer efforts, a dedicated staff person is essential, especially when it comes to implementing complex action plans and administering large grants.
  • Lesson 7: Offering implementation funding inevitably impacts the planning process. With the promise of funding after the planning phase, some communities had to overcome the temptation to use the new money for existing health and human services work rather than genuinely developing and implementing community-driven, consensus-based change projects.
  • Lesson 8: It is possible to feel and see tangible outcomes, but the actual effects on a community's health state are difficult to document. At least over the short-term, the principle effects of CHCI projects have more to do with creating new ways of organizing to solve problems than with immediate, measurable gains in health status.
  • Lesson 9: Establishing strong statewide networks plays an important role in supporting local initiatives. In 1994 The Trust established the Colorado Healthy Communities Council to reinforce the principles and values of the healthy communities movement. In addition, the Council offers support to CHCI projects by serving the functions of convening, networking, collaborating with and connecting members. From the perspective of The Trust, the Council is so effective that it vested it with nearly $1 million to re-grant to its members.
  • Lesson 10: Significant change takes time. This statement is as much a conviction as a lesson, but it is based on careful analysis of the results of an innovative project. One CHCI stakeholder rhetorically asks about the time and cost in money of this work, "What would be the cost if you didn't do it?"

Conclusion

"Several people have credited us with having a clear vision at the beginning of CHCI," said Jean Merrick, Vice President for Programs and Public Information, "but the reality is that we've learned tremendously what supports health in communities over the course of this initiative - as we have worked with the communities funded under CHCI." Whether The Trust knew exactly what it was getting itself into or not when it made the decision to fund CHCI-especially when the projects presented for funding looked quite different than what they originally had expected-the results are impressive. Across the state of Colorado cities and communities have a newly developed capacity to improve the places where they live. Measurable improvements in health status may remain several years down the road, but even if it were never possible to measure them, CHCI has had a tremendous impact. The CHCI provides a valuable model and a large-scale example of how a foundation can use the principles of healthy communities to multiply the good effects coming from its grantmaking. Though The Trust claims to have not known how it would all turn out, it deserves credit for placing its money and its resources where it would pay incalculable dividends: communities

Christopher Freeman Adams is president of Healthy Outcomes, and the general editor of this collection of case stories. He frequently writes and speaks about healthy communities, as well as providing meeting facilitation. His email is chris@chris-adams.com.

For Further Information Contact:

Susan Downs-Karkos
Program Officer
The Colorado Trust
1600 Sherman Street
Denver, CO 80203-1604
Phone: (303) 837-1200
Internet: www.coloradotrust.org