A person experiencing homelessness receives a COVID-19 vaccination in Los Angeles. Ringo Chiu/shutterstock
A person experiencing homelessness receives a COVID-19 vaccination in Los Angeles. Ringo Chiu/shutterstock

The pandemic has laid bare vast health inequities in California. Despite being the state with the largest economy in the nation—and indeed, the fifth-largest economy in the world—California’s low-income and communities of color have disproportionately borne the brunt of the public health crisis.

One example that’s still unfolding is its efforts to vaccinate residents against COVID-19. While the state has made significant strides in accomplishing this goal in recent months, numerous reports found that vaccinations lagged in vulnerable communities that were hit hardest by the pandemic. But the vaccine rollout is only the most recent example.

Starting long before the pandemic hit, The California Endowment (TCE) has been fighting to address deep-seated health disparities in the Golden State. Over the past 10 years, the endowment’s Building Healthy Communities initiative was a conduit for that work, but it also had a profound impact on how the grantmaker operates, prompting changes in its strategies and practice. The initiative came to a close in 2020, and has informed a new game plan for supporting greater progress on this front in the years to come.

At the core of the funder’s past and future work in this arena is the understanding that health extends far beyond a doctor’s office.

“When we started… health equity was always at the heart of what we did, but it was very traditional, like most philanthropy, where we thought about access to quality health services, coverage, culturally competent workforce and so on,” said Dr. Hanh Cao Yu, chief learning officer at TCE. “It was very much a model of serving one individual at a time in California.”

Through its work with Building Healthy Communities, the endowment—which was established in 1996 when Blue Cross of California acquired for-profit subsidiary WellPoint Health Networks—has since expanded its definition of health to include the wellbeing of communities as a whole.

“There’s a new health equity dialogue that’s happening, so that we have to think about health in all policies, in many ways—whether it’s in urban planning [or] nutrition in schools—that encompass every aspect of our lives,” she said.

Launched in 2010, BHC was a $1 billion, place-based, 10-year effort to advance statewide policy, change narratives and transform 14 vulnerable, high-poverty communities where disparities are the greatest. In total, BHC wound up exceeding its target with a whopping $1.75 billion in funding. TCE has more than 700 grantee partners, ranging from statewide organizations like Pico California and California Calls, to local coalitions like Bay Rising.

Now that BHC has wrapped up, the endowment is looking back on its legacy, “not as an initiative,” according to a recent report on the topic, “but as a way of work for TCE as a major driving force for achieving health equity and racial justice in California.”

Your ZIP code shouldn’t predict how long you’ll live”

As BHC came to a close, The California Endowment commissioned a report from the Center for the Study of Social Policy, titled “Toward Health and Racial Equity: Findings and Lessons from Building Healthy Communities.”

The authors found that the initiative was able to significantly advance health equity in the state over the past 10 years, directly impacting the lives of residents, helping to change the way the public and policymakers understand health equity, and building power among people and places that have been most marginalized.

This required advancing the central premise that health is not determined just by access to healthcare or even the quality of the healthcare, but by the historical, structural and systemic community conditions and the policies that shape them. This includes factors like educational and economic opportunities, levels of stress and trauma, and even simply being able to make ends meet.

One of BHC’s most impactful messages was: “Your ZIP code should not predict how long you’ll live, but it does.” In other words, an individual’s health is intrinsically tied to their community’s health. The report found that this message resonated in Sacramento and led to increased discussion on the concept among policymakers and advocates.

In addition to broadening the definition of health and raising awareness of the health inequities in the state, BHC also built public will for expanding healthcare coverage to all residents, created a richer approach to power-building, and grew youth organizing in the state, according to the report.

But these accomplishments came with some difficult lessons.

Early missteps

Perhaps one of the most painful—and arguably most impactful—lessons TCE learned was the importance of listening to its community partners and, by extension, the communities themselves.

“Early on, we stumbled,” Yu wrote in the report. “Like most foundations, we prescribed from within the foundation the outcomes that we thought California’s communities needed in order to be healthy and thriving.”

TCE’s community partners pushed back against this practice. In order to have a successful collaboration, TCE needed to be humble and listen to and support community priorities, rather than try to set them itself.

“We had our own notion of what we wanted to accomplish,” Yu told Inside Philanthropy, “but when we got the pushback a couple years into the work, we needed to change ourselves as a foundation.”

Rather than dictating from on high, TCE began building theories of change and action in partnership with communities, and around their priorities. Then it empowered the communities to pursue what they believed worked best. According to Yu, many wanted to focus on issues like gentrification, job availability and economic justice.

In the report, Abraham Medina, director of California Alliance for Youth and Justice, noted that BHC was originally focused on issues related to health insurance and access to a responsive healthcare system.

Medina said, “Health equity is about how we’re impacted every day in our neighborhoods—if we’re undocumented, for example, or how being a young person of color in criminalized communities impacts our health. We’re getting killed in the street by the police and by violence in the community. So health equity has become a broader framework that is about life and death.”

A shift toward power-building

One major shift the foundation made as it carried out the Building Healthy Communities initiative was a move toward supporting power-building in the communities it was serving.

“It was really important to us to be thinking about how we not only promote the social determinants of health, in terms of broader understandings that health doesn’t happen in the medical offices, but we had to think about how we can go upstream more to really support people to build their power, their sense of agency, and their sense of belonging, and also change conditions in their lives,” Yu said.

This is one of the areas where TCE has evolved the most, she said. Power-building, which TCE refers to as “people power,” was initially a means to an end, a way to help pass policies that would lead to greater health equity. Eventually, it evolved into both a means and an end.

TCE recognized that this meant building a sense of voice among the most marginalized communities so that both adult and youth residents were empowered to define what the problems are and what solutions worked best for them.

“We’re going to support the grassroots leaders to really do the work, the organizing groups, and then make sure that they are the ones who are guiding the work of larger nonprofit organizations like advocacy groups that are usually quite well supported,” Yu added.

As previously reported by Inside Philanthropy, TCE announced it was committing $100 million over the next 10 years to support AAPI organizations in California in response to the uptick in anti-Asian attacks. The investment is geared toward providing resources to grassroots organizations to expand power that will advance both health and racial equity.

A focus on racial equity

Another major change for TCE has been “naming and centering” racial equity in its work, according to Yu.

“We came into BHC—and that’s a huge lesson learned for us—with not much of a trauma-explicit focus on race,” said Yu. “As you can tell from all that’s been happening in this last year with COVID and the disproportionate impacts on communities of color, as well as the racial reckoning moment we’re in, that we have to deepen our focus on race-based equity.”

In 2018, TCE’s board made a commitment to centering its racial equity work. In addition to its recent support for Asian Americans, Yu also highlighted its work against anti-Blackness, stating that many groups have been hurt and left behind when foundations work without an explicit racial equity lens.

She added that TCE has sought to remain consistent in funding not just services for individuals but thinking more broadly in terms of policy and systems changes that need to happen. These include working to change city governments’ policies and procedures and changing how school districts allocate funding for students who are most in need (such as foster youth or English language learners).

Crucially, TCE is willing to act as a shield for these organizations and advocates. As a powerful institution, TCE can throw its weight behind smaller, BIPOC-led groups that may face pushback from others. TCE can also risk being the first to make a sizable investment so others can see that their team has vetted and done their homework on the grantee—in turn, this could theoretically reassure others so that they, too, can invest.

Risk also means being willing to “stay the course” with organizations. This means that organizations can rely on TCE’s backing and resources and can therefore “plan and dream around a long-term, multi-issue agenda.”

What’s next?

While BHC has come to a close, The California Endowment has committed to taking the lessons it learned from the initiative and implementing them in its future work.

According to its report, TCE’s board has adopted three ideas that will set the direction of the foundation’s work for the next decade. These are: power-building to raise the voices of marginalized communities, reimagining public institutions to become significant investors in and champions of racial and social justice; and ensuring prevention, community wellness, and access to quality healthcare for all. One of the biggest changes is that the foundation is expanding its health focus from the original 14 communities to a regional focus, in order to scale up the work and reach more people.

The foundation has also been doing internal examinations of its grantmaking policies and procedures as it looks to maintain the flexibility it created in 2020 in response to the pandemic. Last year, TCE increased its general operating support to grantees from around 3% to nearly 20%, with a goal to double that this year. The team has also been looking at how it interacts with the people it aims to serve.

“In philanthropy, we tend to fund in ways that pit groups against each other, cause fragmentation, competition and so on,” said Yu. “We are now committed to a trust-based approach where we’re giving the power and removing the roadblocks for communities to really decide themselves how to allocate resources.”

The goal, Yu added, is to bring people together, to find like-minded individuals with shared values and shared root cause analyses of conditions that need to be addressed. Then, they need to be resourced.

“We as funders have a role to play within the ecosystem of all of the different players… but we have to be really humble about our role as a convener,” Yu said.

“The larger you are, I think the more responsibility you have to really honor community voices and have that continual feedback loop, to really listen to our communities and then to think about how we build power.”