For a Midwestern Funder, Improving Health Means Balancing Immediate Relief With Systems Change

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Remember that old saying about it being better to teach a person how to fish than to give them one? As many in the nonprofit sector are fully aware, teaching a person to fish (i.e., addressing underlying issues) will lead to longer-lasting positive outcomes. Then again, if someone’s already starving, you’d better feed them before expecting them to heft a rod and reel.

At 21 years old, the Missouri Foundation for Health (MFH) now mostly takes the strategic, systems-based approach. But it’s also ready and able to marshal truckloads of metaphorical fish when an emergency arises. 

During a recent interview, the foundation’s Kathleen Holmes and Courtney Stewart told me that when MFH was founded, their immediate focus was to move money as quickly as possible. Since then, the funder, which was endowed as part of a deal allowing Blue Cross and Blue Shield of Missouri to become a for-profit health insurer, has increasingly focused on strategy. 

“Particularly early on, I think the intent was really to get funding out the door,” said Holmes, MFH’s vice president of strategic initiatives. “You know, we were given the blessings of a lot of funds and wanted to get that out into the community on issues that were affecting community members at the time.”

There was definitely a lot of money to move. MFH still has roughly $1 billion in assets, and Holmes said the foundation moves around $45 million a year toward its goals.

These days, the bulk of those funds and of the foundation’s other work focuses mostly on strategies addressing the underlying causes of poor health outcomes—a shift, Holmes told me, that she has seen during her 14 years and counting at MFH. Over time, she said, the funder realized that throwing money at specific issues without attacking the underlying cause of those issues wasn’t the most effective approach. 

In addition, the foundation realized that systemic issues don’t lend themselves to quick fixes. “It wouldn’t be three years and you’re done,” she said.

Missouri Foundation for Health’s evolution from “grantmaker to changemaker” allowed the funder to build several partnerships that nurture and sustain its work, said Stewart, MFH vice president of strategic communications. 

Meeting emergency needs while also staying the course

As it turned out, building those partnerships allows MFH to move very quickly when necessary. Last year, the foundation spent more than $15 million to alleviate the damage being wrought by the COVID-19 pandemic. 

According to the foundation’s 2020 annual report, it took less than a week after the federal state of emergency declaration for MFH to create and share a mini-toolkit of accurate COVID messages with local public health agencies. The funder’s other COVID-related work included grants to two nonprofit hunger relief organizations, which then partnered with the St. Louis Regional Chamber to hire laid-off workers to keep up with the increased need for food assistance.

Missouri Foundation for Health didn’t let the immediate crisis distract it from the systemic problems that threaten the health of BIPOC and people otherwise living in poverty, whether or not a pandemic is in the air. In addition to its COVID work, MFH continued its MoCAP program (formerly known as Missouri Capture), which helps local nonprofits apply for and attract federal and national funding for health and prevention-related programs. In 2020 alone, more than $20 million was “captured” by this program. 

Other work included a virtual convening of health organizations to discuss ways to support more equitable healthcare for Black mothers and babies; the ongoing Healthy Schools Healthy Communities initiative; recruiting an additional six health centers to a program that offers free or low-cost birth control; funding a two-year project of the Kansas City Star to investigate gun violence in the state; and creating a public information campaign that helped lead to the expansion of Medicaid in Missouri.

Health in a broad sense

Even a quick look through the MFH website shows that this foundation takes an expansive view of its mission to support better health for Missourians. In addition to being an early supporter of the new Racial Healing + Justice Fund and focusing on gun violence, MFH supports WePower, which works to elevate the power of Black and Latino communities to address the effects of systemic racism in the economy, healthcare, education and the justice system. 

MFH also supports projects that work on issues that may seem at first glance to be tangential to health, like access to housing and transportation.

As Stewart told me, MFH has always looked at health “in the broad sense. It’s never just focused on healthcare.” Citing “For The Sake of All,” a 2015 report by researchers at Washington University in St. Louis and St. Louis University, Stewart added that there aren’t many issues in the philanthropic universe that don’t impact people’s health. Among other findings, “For The Sake of All” reported that St. Louis residents living in zip codes just a few miles away from each other have an up to 18-year difference in life expectancy. 

“It would almost be impossible for us to look at health and achieving health equity if we didn’t explore those other aspects of health,” Stewart said. 

At the same time, Holmes added, “we also recognize that not one organization or one philanthropy institution is going to solve” all of the interlocking systems that contribute to poor health outcomes for BIPOC individuals and others living in poverty. 

When faced with large issues involving multiple factors, she said, any single organization would ask, “Well, what would you expect me to do about all of that?” 

MFH’s response? No single organization has to tackle the problems of systemic racism and other inequities that lead to bad health outcomes. Instead, Holmes said, funders and nonprofits need to bring the community to the table to work on these issues.

“That’s why we address these [challenges] at the system level, as opposed to at an organizational level, because an organization cannot address these huge problems in and of themselves,” Holmes said. 

“I never say ‘funder’”

Taken together, Missouri Foundation for Health’s systems-based approach, scope of work, willingness and ability to fund advocacy in addition to direct services, and focus on community partnerships all add up to a forward-thinking backer of public health. The foundation is part of a growing pool of health funders, such as the California Endowment and Robert Wood Johnson Foundation, that recognize the many social factors that are inseparable from their mission. Stewart also considers MFH to be much more than just a grantmaker. 

“When people ask who we are, I never say ‘funder,’” Stewart said, unless she’s in a setting with other funders. “I describe us as a statewide change-maker working on a number of issues, using a number of tools and resources to drive change.”

As the foundation evolved, Holmes said, “We wanted our partners to view us differently. We couldn’t continue to be seen as just a funder. I think that’s very limiting in our role as a change-maker.”

It’s true that MFH doesn’t limit itself to writing checks. The MoCAP program, for example, leverages the foundation’s expertise to help nonprofits attract federal money. MFH also makes extensive use of strategic communications campaigns to educate both the public and specific audiences about health and related issues, and serves as a “backbone” support to an effort to reduce Black infant mortality.

While other funders have been waking up (or not) to the idea of treating other community organizations as equal partners, Stewart said that “building trust and respect in communities is at the core of all that we do.” 

“While people look at us as this funding organization, and sitting on a bucket of money at the top of the rainbow, it’s really more complex than that,” Stewart said. 

MFH is also unique when it comes to transparency: The foundation’s board meetings are open to the public, including by live stream. When it was founded, MFH was governed by the state’s sunshine rule. When that requirement ended, Holmes said the organization decided to carry on the tradition of transparency. 

“Equity is in our DNA”

Both Holmes and Stewart told me, at different points in our discussion, that equity is in MFH’s DNA. This is expressed in several ways. 

For one, Holmes said, “Our office is located in St. Louis, but we are not in any way a St. Louis foundation. We are a Missouri foundation. And by that, I mean that we represent urban, rural, suburban, very rural, and everything in between.” 

“Everything we do is rooted in that equity lens, whether that’s racial, the foundation from which all inequity is happening, or gender or geographic inequities that we see within the 114 counties (and St. Louis, an independent city) that make up Missouri,” Stewart said. 

The foundation has always put a big focus on where people live as a determinant of health, something the funder made more explicit beginning in 2016 with its revised mission statement: “To improve the health and well-being of individuals and communities most in need.” Last year, when Dr. Dwayne Proctor came on board as MFH’s new CEO, he told a local paper that his goal is to do no less than to achieve health equity in Missouri during this decade.

The commitment to equity extends to how MFH does business internally. The organization has been examining its staff and hiring practices, job descriptions, and both the long-term contractors and short-term vendors it hires. 

“We are by far not experts on [equity], but it is a concept that we are biting big chunks off, and embracing every single day,” Stewart said.