The burden of rising health care costs falls not just on individuals—half of all personal bankruptcies are at least partly due to medical expenses—but also on US companies. At General Motors, health care costs put the company at a $5 billion disadvantage against Toyota.¹ The same is true for federal, state, and local governments. In Massachusetts, for example, school employees’ health care costs rose $1 billion from 2000 to 2007, crowding out growth in nearly every other area of the state budget.²

Despite such spending, US health indicators are among the worst of high-income countries. Since 1960, the United States dropped from 12th to 46th in infant mortality rankings (below Cuba and Slovenia), and from 16th to 36th in life expectancy (below Cyprus and Chile), according to the CIA’s World Factbook. In certain neighborhoods in Baltimore, Chicago, and Los Angeles—and other communities across the country—life expectancy for subsets of the population is lower than in Bangladesh.

Such ineffective spending is bad enough. In the coming years, additional factors will keep our health care system from providing high-quality care to all those who need it. Two high on the list are a shortage of primary care doctors and rising poverty.

Primary care doctors are the key to improving value-based care: By focusing on preventive services, care coordination, and disease management, they can reduce unnecessary health care costs. In the 1960s, half of the doctors in the United States worked in primary care. Today, barely 30 percent do. And this trend is deepening: From 2000 to 2005, the percentage of US medical school graduates who chose to enter primary care dropped from 14 percent to 8 percent, creating a projected shortfall of up to 150,000 primary care physicians by 2025.³ More than 56 million Americans—greater than one-fifth of the US population—already live in areas with too few primary care physicians, according to the National Association of Community Health Centers.

There are many reasons doctors eschew primary care. The fee-for-service reimbursement system has incented tertiary care and episodic crisis management. Primary care providers are thus often paid less than specialists, with specialization acquiring particular cachet among medical students and residents. Moreover, for those who do choose primary care, the job is especially taxing because of the high demand for services and the absence of sufficient support to meet patients’ nonmedical needs—access to healthy food or heat in the winter, for example—which often thrust themselves into the doctor’s office, especially in a shaky economy. Few physicians have been trained to confront these social issues that often thwart conventional medical care. In a recent poll of 1,000 primary care physicians across the country, 80 percent said they were not confident in addressing their patients’ social needs, even though those needs undermined their patients’ health.⁴

Ironically, health care reform will make the problem worse, not better. Expanded insurance coverage will increase the number of patients seeking care, but from the same number of physicians. In Massachusetts, where universal coverage became law in 2006, there are critical shortages of primary care doctors—more than half do not accept new patients, and most report dissatisfaction with the practice environment, according to a 2011 Massachusetts Medical Society report.

With 21 million potential Medicaid patients poised to enter the health care system in 2014, primary care physicians will face a double burden: caseload constraints coupled with at-risk patients’ substantial social needs. Poverty seeps into emergency rooms and inpatient wards and pervades the health system. Half of the adults who will gain insurance eligibility in 2014 are very poor (with incomes below 50 percent of the federal poverty level), a third have a diagnosed chronic medical condition, and many are likely to have long-neglected health care needs due to years without coverage.

The links between poverty and poor health are well known: Foodinsecure children, now numbering 17 million in the United States, are 91 percent more likely to be in fair or poor health than their peers with adequate food, and 31 percent more likely to require hospitalization.⁵ Children under age 3 who lack adequate heat (another 12 million) are almost one-third more likely to require hospitalization.⁶ And families with difficulty paying rent and housing-related bills face increased acute care use and emergency room visits.⁷

Unfortunately, social workers and case managers—traditional first responders for patients’ social needs—are overloaded, too. New York-Presbyterian Washington Heights Family Health Center, for example, has only two social workers for the clinic’s 46,000 patients. This is sadly typical. Even if all the United States’ 24,750 licensed medical and public health social workers in clinic or hospital settings served only Medicaid patients—and many serve none at all—there would still be just one social worker for every 2,404 patients.

But it doesn’t have to be this way. Models of health care delivery that improve patient outcomes while cutting costs are cropping up with increasing frequency. Further, in the last 20 years, public, private, and philanthropic entities have invested billions of dollars learning how to build health care systems despite extreme resource constraints, too few doctors, and overwhelming poverty. Some of these models have been pioneered in the United States; many come from other countries. One characteristic they share is a broader conception of health care. Given the challenges facing the US health system, policymakers and others advocating health reform would do well to give a hard look at some of these alternative models.

Indeed, the innovation we need is right in front of us. In his 2009 best-seller The Checklist Manifesto, surgeon and journalist Atul Gawande eloquently argues that medical “innovation” is less about discovering new interventions than it is about properly executing the ones we already have. As Gawande explains, failure more often stems from ineptitude (not properly applying what we know works), rather than ignorance (not knowing what works). “The knowledge exists,” he writes, “yet we fail to apply it correctly.” As one example, Gawande cites a five-point checklist implemented in 2001 in the intensive care unit at Johns Hopkins Hospital. Although the checklist merely summarized wellknown best practices of administering drugs to a patient’s body through a “central-line” tube, its consistent use virtually eradicated central-line infections. A subsequent use of the checklist in intensive care units in Michigan caused infections to drop by 66 percent and saved more than 1,500 lives in a year and a half.

We contend that Gawande’s insight about the benefits that could be reaped by deploying existing innovations extends beyond the operating room and hospital to the very structure and orientation of health care itself. The depth and breadth of the US health care crisis has led some to throw up their hands. Others imagine grand reconstructions of health care roles, incentives, and behaviors. Between these extremes are concrete adjustments that will save lives and dollars—in short order. Drawing on lessons learned from high-quality health care delivered in resource-poor settings here and overseas, the US health system can finally shed the inefficiencies of habit and history.

Broaden Definitions of Product, Place, and Provider

In the developing world, health care providers must adapt to limited financial resources, scarce health care professionals, underdeveloped health infrastructure, and widespread poverty—all in settings with huge burdens of preventable and treatable diseases that too often go untreated. Some of the lessons that have emerged are well worth examining. Just as the United States sought advice about counterterrorism from Israel after 9/11, and about post-disaster reconstruction from Kosovo after Hurricane Katrina, we should look beyond US shores for new ideas about health reform.

Although the landscape of health risk and the systems charged with providing care differ by nation, resource-poor settings face common problems and have often devised similar solutions. Specifically, these solutions broaden conceptions of product, place, and provider in health care.

Product | What is being delivered when we say “health care”? In the United States, we usually mean medicines, diagnostic tests, and hospital services. We rarely include basic necessities, such as food, housing, or heat, even when their absence leads to ill health. In a 2007 study at Johns Hopkins Medical Center, 98 percent of pediatric residents said that referring well-child patients for help with basic needs could improve the children’s health. But how many of those residents routinely screened their patients for food sufficiency? Only 11 percent.⁸

In contrast, in resource-poor settings, health care providers have no choice but to design programs based on the stubborn relationship between poverty and ill health, and to start from the premise that health care must mean more than medicine.

The UN World Food Programme, for example, provides nutritional supplements alongside HIV drug therapy in recognition that “Food and nutrition support is essential for keeping people living with HIV healthy for longer and for improving the effectiveness of treatment.” A Haitian proverb is perhaps more to the point: “Giving drugs without food is like washing your hands and drying them in the dirt.”

In Brazil, Associação Saúde Criança (ASC) has operationalized this concept by routinely sending low-income children home after hospitalizations with resources for ongoing nutrition, sanitation, and psychological support. “Children cannot be discharged from hospital without first ascertaining what conditions await them at home,” notes ASC in its organizational overview. The idea is not to expand doctors’ work beyond medicine, but to improve the ability of health systems to address structural, nonclinical determinants of health, and therefore reduce recurring hospitalizations and associated costs.

Place | In addition to a broad conception of health care, resource-poor settings demand a more expansive view of the place in which care is delivered. Most care, in countries rich and poor, is delivered outside the formal health system—in homes and communities. In the words of medical anthropologist Arthur Kleinman, “for all the efforts of the helping professions, caregiving is for the most part the preserve of families and intimate friends, and of the afflicted person herself or himself.”⁹ Health providers can leverage such local networks of care by integrating health care into patients’ daily lives, and locating health resources where (and when) patients are most likely and able to access them. Moving health resources from clinics—often remote from patients in distance and culture—into homes and communities, or alternatively, bringing critical social resources—which are themselves instrumental to the efficacy of medical care—into hospitals and clinics, can improve access to and quality of health care.¹⁰

Locating health resources in homes and communities as well as putting them in clinical facilities recognizes the role of environmental interventions in improving health outcomes. In Nudge: Improving Decisions About Health, Wealth, and Happiness, Richard Thaler and Cass Sunstein describe how “altering the choice architecture” can, without coercion, adjust the placement, sequence, and context in which people make choices with an eye toward increasing the common good. A typical example is altering the choice architecture in a cafeteria by placing healthy snacks at eye level and sugary snacks on the top shelf, increasing the likelihood that people will choose the healthy ones.

In Haiti’s Central Plateau, the challenge of place is not one of choice but of necessity: With just one doctor for every 50,000 people, Partners in Health (PIH), a medical nonprofit that has worked in Haiti for almost three decades, rejects the notion that the infrastructure gap makes it impossible to deliver high-quality health care to the poor. PIH trains patients and other community members to act as health care liaisons in their homes and communities, observing the ingestion of pills, responding to patient and family concerns—including structural barriers to care, such as high transport costs or shoddy housing—and spotting symptoms of illness or side effects of medication. Just as they have taken health to the community, PIH brings the community to the health care facility by, for example, operating farms adjacent to clinics to integrate anti-malnutrition efforts into medical care.¹¹

Provider | Widening conceptions of product and place demands also widening the definition of health care provider. Nontraditional medical workers are critical to health systems, especially those in resource-constrained environments. They are less encumbered by competing clinical care priorities, possess firsthand understanding of patient culture, community, and experience, and are often more aware of nonmedical local resources that may improve patient care. Acknowledging that licensed clinicians are not the only health care providers can help health systems become more efficient, effective, and equitable.

PIH, for example, relies on doctors and nurses to provide clinic-or hospital-level care and hires community health workers (CHWs) to distribute food, deliver medicine to patients in remote rural areas, and identify undiagnosed illnesses as well as social needs. CHWs can help health care systems overcome shortages of human and financial resources by providing high-quality, low-cost services to community members in their homes and by diagnosing diseases in their early stages, before they become more dangerous and expensive to treat.

Similarly, in sub-Saharan Africa, Mothers2Mothers trains and employs new mothers with HIV, who work side by side with doctors and nurses in health care facilities and are responsible for ensuring that patients understand and adhere to antiretroviral treatments and other prescribed interventions. These “Mentor Mothers” are a new tier of paid, professional, health care providers—drawn from, trained in, and working for local communities. Evaluations of the program have found that enrolled mothers are more likely to receive and take medications and to undergo tests to determine if they are eligible for antiretroviral treatment and if their babies are infected with HIV.

Broadening the health care workforce enables doctors, nurses, social workers, and other professionals to “practice at the top of their license”: They can spend more time doing what they are trained to do, while leaving critical tasks like coaching patients and connecting them to community resources to other health care workers. The World Health Organization summarized the utility of this “task shifting” in a 2008 report: “The rational redistribution of tasks among health workforce teams will maximize the efficient use of health workforce resources.”

US health professionals, in contrast, tend to take one of two (largely ineffective) approaches. Most often, as noted in the Johns Hopkins study mentioned earlier, health care providers bracket patients’ social needs, deeming issues like hunger, poor housing, and indebtedness beyond the scope of short patient-doctor visits. Some primary care clinicians do try to address patients’ basic social needs. But they quickly become overloaded, and addressing such needs crowds out other key modalities of their clinical practice. A June 2011 Health Leads survey at Bellevue Hospital in New York City discovered that doctors spend an average of 9.2 minutes of each 15-minute patient visit on social needs.

Practicing at the “bottom” of one’s license can be expensive for taxpayers, is draining (or demoralizing) for clinicians, and causes patients to wait longer to get timely and effective care. Task shifting—or task sharing, to be more precise—can reduce such inefficiencies. Although evolving financial incentives in the US health care system, including increased risk sharing between insurers and medical providers for patient outcomes, has begun to catalyze increased task sharing, there is ample room in the health system to broaden our conception of what it means to be a provider of health services.¹²

Approaches Already Under Way

In the last two decades, some health care organizations in the United States have developed delivery models based on more expansive definitions of product, place, and provider. The results have been promising.

The Prevention and Access to Care and Treatment (PACT) program, a domestic arm of PIH, serves the sickest and most marginalized HIV-positive and chronically ill patients in Greater Boston. Applying the principles described above—that health care means more than clinical care, that health-related resources must be located in patients’ communities, and that the health care workforce must leverage trained nonclinical personnel—PACT has helped raise the standard of care, while cutting costs in some of the poorest parts of Boston.

Specifically, PACT supplements comprehensive medical care with “wraparound” antipoverty services. Its model is built on accompaniment: CHWs are trained and paid to supplement clinical care and deliver social support services, health promotion, and harm reduction services within patient homes and communities. This model is an example of “reverse innovation” from a successful program in rural Haiti, adapted for use in an American city. By accompanying patients to important visits and communicating regularly with licensed clinicians, CHWs ensure that treatment recommendations are patient-centered. CHWs visit patients’ homes to provide directly observed therapy, supervising patients while medication is being administered, and to help them overcome structural and psychosocial hurdles to wellness. Their tasks range from motivating medication adherence to surveying patients’ pantries and helping them identify ways to make healthy, affordable meals. In so doing, CHWs help patients more effectively self-manage their illnesses.

The program has realized impressive results. Seventy percent of its AIDS patients show significant clinical improvement, whether measured by viral load, CD4 count, incident opportunistic infections, or emergency room visits.¹³ Costs to Medicaid have dropped significantly, thanks to a 60 percent decrease in hospitalization rates among enrolled patients: One analysis of Medicaid claims from PACT patients showed 16 percent net savings. Similar gains are being made among patients with multiple chronic diseases and behavioral health comorbidities. The PACT model is now being replicated in New York City, Miami, and the Navajo Nation.

Such “reverse innovation” often occurs when providers serving the poor in affluent countries travel to poorer countries struggling with access to care for the majority. In 1996, Dr. Rushika Fernandopulle went on a medical mission to the Dominican Republic. There he saw promotoras, community health workers who coached individual patients through medical compliance and recovery. When Fernandopulle was named to run the Special Care Center (SCC) in Atlantic City, N.J., which serves the 14,000 union employees of Atlantic City’s restaurants, hotels, and casinos, he adapted the promotoras model, expanding the health care product and provider.

Under the guidance of SCC doctors, “health coaches” see patients at least once every two weeks and regularly communicate by phone and e-mail, helping them achieve healthier lifestyles and manage chronic disease. Like PACT’s community health workers, the coaches are recruited from within the community and speak the patients’ language, often connecting more successfully than doctors might about patients’ true difficulties and helping them identify realistic solutions. The doctors, social workers, nurse practitioners, and health coaches meet as a team every morning to review the medical and nonmedical issues facing their patients.

A program evaluation found that after 12 months in the program, patients’ emergency room visits and hospital admissions dropped by more than 40 percent and surgical procedures fell by 25 percent. Among 503 patients with high blood pressure, only two were in poor control of it at the end of the study. Patients with high cholesterol experienced, on average, a 50-point drop in cholesterol level. And a remarkable 63 percent of smokers with heart and lung disease quit smoking, Gawande reported in a Jan. 17, 2011, New Yorker article. Meanwhile, the cost of care for these patients rose by only 4 percent per year, compared to 25 percent before they began participating.

Health Leads likewise widens the frame of health care, broadening the health care product to include connections to basic resources like food and housing; broadening the health care place by using hospital waiting rooms to make resource connections; and broadening the health care provider, by integrating college volunteers into the health care team.

Located in primary care and prenatal clinics in six US cities, Health Leads empowers doctors, nurses, and other health care providers to ask the previously un-askable questions: Are you running out of food at the end of month? Do you have safe housing? These providers can then write “prescriptions” for food, housing, heating assistance, or other basic resources, just as they would for medication. The patients take their prescriptions to the clinic waiting room, where Health Leads’ 1,000-member corps of college volunteers works side by side with them to secure these resources. The volunteers’ assistance is often as straightforward—but critical—as tracking down an agency phone number, completing a benefits application, or bridging language barriers.

Health Leads leverages providers’ scarce time, so that they can focus on activities that demand their training and experience. At Harlem Hospital Center, for example, an electronic medical record automatically refers all patients with an elevated body mass index—an indicator of obesity—to Health Leads for help in accessing healthy food, exercise programs, and other resources. A recent study at the Dimock Center, a Boston community health center, found that Health Leads increased the clinic social worker’s ability to provide reimbursable therapeutic services to children by 169 percent, improving the quality of care while generating additional revenue for the health center. This is just one example of the several ways in which the definition of provider might be expanded: promotoras, community health workers, and college volunteers each possess different competencies, but all can increase the efficiency and quality of care delivered to patients.

An Open Window

The United States is poised for a primary health care transformation. The health care system is in crisis, driven chiefly by escalating costs, suboptimal health outcomes, scarce primary care resources, and rising poverty. At the same time, thanks to grassroots innovation—and, in some cases, US-based funding—a growing number of health providers around the globe have learned to deliver high quality health care at low cost. Now we need to align our resources in the United States to bring this knowledge fully to bear in saving dollars and lives.

And the time is, indeed, now. The dual, market-driven imperatives to cut costs and improve outcomes—and the inevitable shift away from fee-for-service reimbursement to shared risk between payers and providers—create an unprecedented receptiveness to new approaches in care delivery. The United States has a window of opportunity to seize this fluidity in the sector to broaden the health care product, place, and provider and thereby expand access, improve outcomes, and cut costs. This approach demands, as Gawande says, that we innovate by properly executing the solutions we already have—and that the private, philanthropic, and public sectors invest in these evidence-based models of health care delivery.

Private Sector Creativity | Recognizing the opportunity for significant returns in a sector that currently comprises 17.6 percent of GDP, private sector groups have long invested in some components of the health care industry. Last year, US venture capital firms invested $2.38 billion in medical devices and $3.78 billion in biotech.¹⁴ Private equity dollars also increasingly are focused on the health care sector, as restructuring inefficient hospitals can be especially lucrative. The initial public offering in 2006 of the Hospital Corporation of America, a for-profit hospital chain backed by KKR & Co., Bain Capital, and Bank of America, was the biggest private equity-backed offering in history, raising $32 billion.¹⁵

Deployed strategically, even a fraction of these private sector dollars could accelerate a broadening of the definition of product, place, and provider to drive down overall costs and improve outcomes. One compelling, if unconventional, example is the so-called retail clinic. An alternative to lengthy waits in the emergency room or the challenge of getting to the doctor’s office during working hours, retail clinics typically offer brief visits with an advanced-practice provider (physician assistant or nurse practitioner) who can provide immunizations and care for simple illnesses in a retail store, such as CVS and Wal-Mart. The clinics are open evenings and weekends; they provide care that is roughly 30 to 40 percent less expensive than similar care at a doctor’s office and 80 percent less expensive than the cost of an emergency room visit.¹⁶

Retail clinics broaden the health care place from the doctor’s office to the shopping mall. They are, in a sense, a US analog of PIH’s accompagnateur-based service delivery model in rural Haiti. (The financing models, however, are divergent: PIH depends not on out-of-pocket financing but on philanthropic and public sector support.) Not surprisingly, 35 percent of patients visiting retail clinics are underinsured or have no coverage at all—according to Tine Hansen-Turton, executive director of the Convenient Care Association—and thus would almost certainly be using the emergency room or not receiving care at all in the absence of this care delivery model. Yet, as Julie Appleby reports in the Nov. 17, 2011, issue of Kaiser Health News, “The clinics see a pure business opportunity based on consumer convenience and cost savings, which they can market to the public, employers, insurers, and hospitals.”

We have an opportunity to leverage private sector investments in new care delivery models that generate revenue or cost savings and address the nonclinical needs of low-income patients, who are among the most “costly” consumers of health care. If the PACT model, for example, yields 16 percent savings for Medicaid, why isn’t it attracting private sector dollars to scale up regionally or even nationally? If the booming electronic health records market designed products that captured nonclinical data (such as whether a patient is living in a shelter or running out of food each month), health care providers would be far better positioned to negotiate bundled or capitated payments that reflect the true cost of delivering care for vulnerable patient populations.¹⁷ Given the size of the health care market—and the dollars spent delivering unnecessary health care—private sector players could likely sustain profits from scaling up cost-saving models of comprehensive, community-based care for the poorest.

Philanthropic Sector Investment | The philanthropic sector also should recognize the opportunity represented by domestic health care reform. In 2008, US foundations invested more than $2.5 billion in global health, according to the Foundation Center. The Bill & Melinda Gates Foundation alone has committed $15.3 billion to nondomestic global health efforts since 1994—more than twice as much as it has invested in all US-based programs combined. These investments have saved countless lives and untold suffering; they also have yielded critical insights into how to improve health outcomes amid severe resource constraints—and, in particular, how to do so by broadening the health care product, place, and provider.

The philanthropic sector now has the ability to secure the full return on investment from past grants by adapting lessons learned to the US context. Global health programs should also be continued, expanded, and bolstered with insights developed in poor communities in the United States.

The Center for High Impact Philanthropy, in its January 2012 report Women’s Health and the World’s Cities, cites the example of the Nurse-Family Partnership, funded by the Edna McConnell Clark Foundation and BRAC’s Manoshi Project in Bangladesh. The partnership’s programs achieved great value by applying shared principles: reaching women in their homes, providing links to referral systems, creating partnerships and networks that address the root causes of ill health, and developing a critical feedback loop to improve performance and generate data for others seeking to adopt a similar model.

Another example is the Gates Foundation’s $15 million award to the Last Ten Kilometers (L10K), a project that addresses health care provider shortages and lack of access to health care in remote areas of Ethiopia. L10K trains local volunteers to demonstrate healthy behaviors pertaining to prenatal care and maternal and child health in their own households, and thus serve as model families in their communities. But securing adequate prenatal care is also a significant challenge for low-income women in the United States, as evidenced by vivid disparities in infant mortality rates: African-American infants are twice as likely to die in the first year of life as Caucasian infants; in some cities, the infant mortality rate for African-American infants is five times higher.¹⁸ Basic prenatal care can significantly reduce infant mortality, but poor women in the United States often gain access to such care later in their pregnancies and have fewer prenatal visits.¹⁹ The Gates Foundation could secure the full return on its investment in the L10K project and accelerate improvements in health outcomes in the United States by leveraging L10K’s core elements, including a broader definition of provider (to include community health workers) and place (to include household- and community-based modeling of prenatal care).

Public Sector Funding | Philanthropic and private sector investment cannot by themselves shift the direction of health care delivery. Government funding streams will always drive decision making, especially with respect to health care provision to lowincome people. At long last, policymakers are reevaluating the incentive structure—often inefficient, sometimes perverse—of the US health care system. How will their decisions affect providers and patients? What are the corresponding implications for both costs and health outcomes?

Although the 2010 Patient Protection and Affordable Care Act makes significant strides toward expanding insurance coverage and improving quality of care, it leaves unchanged one of the most problematic aspects of Medicaid: It does not reimburse the activity of connecting patients to essential nonclinical resources they need to be healthy, or to any other services delivered by non-clinicians that address the underlying causes of poor health outcomes.

To the contrary, the Centers for Medicare & Medicaid Services’ State Medicaid Manual, which advises states on implementing Medicaid programs, explicitly forbids such reimbursement: “[C]ase management related to obtaining social services, Food Stamps, energy assistance, or housing cannot be considered a legitimate Medicaid administrative expense even though it may produce results which are in the best interest of the recipient.”²⁰

Nor are such services generally reimbursable as a nonadministrative expense. States may opt to provide through Medicaid “Targeted Case Management,” which reimburses efforts to connect patients to certain social services. But its scope is limited to care management for chronically ill and complex patients, such as foster youth and patients with AIDS, mental health conditions, and developmental disabilities. In short, Medicaid does not support nonclinical services as a pillar of primary care—even though it could bring substantial downstream cost savings.

The good news is that there are easy ways for the federal government to use Medicaid to incentivize health programs with more expansive conceptions of product, place, and provider: by broadening eligibility for Targeted Case Management to include patients whose socioeconomic status puts them at risk for poor health or by reimbursing community health workers, patient navigators, case managers, and other lay health care workers for a well-defined set of activities with documented health benefits. In doing so, Medicaid could scale up nonclinical services and health care workforces that have been shown to achieve better health outcomes and increase health care provider productivity, at minimal cost or with cost savings. These more expansive health care delivery models are almost certain to prove the highest standard of care for chronic diseases, whether in Haiti or in the shadow of Harvard’s teaching hospitals.

Realignment Is Within Our Grasp

It is by no means a new discovery that poverty and poor health are linked, or that health resources are more likely to be used if they are offered conveniently to the recipients, or that a goal as complex and ambitious as “health” can be effectively pursued only with a multidisciplinary team of workers. The challenge is implementing these insights effectively and on a large enough scale to reap the synergies they promise.

But what’s new is this: The US health care system has reached a tipping point. Reform is in the air across the sector, with primary care especially positioned for transformation. “Never let a good crisis go to waste,” said Winston Churchill. The practices of countries that have improved health despite scarce resources are ready for adoption and adaptation. And the US health care ecosystem, including public, private, and philanthropic resources, is ripe to leverage this crisis to implement solutions that will improve it.

“Health” is a bold, expansive aspiration. Let’s make sure that what we call “health care” is broad enough to get the job done.

Two randomized evaluations recently conducted by Innovations for Poverty Action (IPA) in Ghana (by Dean Karlan, Ryan Knight, and Chris Udry) and in Mexico (by Miriam Bruhn, Dean Karlan, and Antoinette Schoar) explore this question for small and medium enterprises (SMEs). We aim to shed light on when advice will help SMEs, so that policymakers can decide how best to support them. The evaluations also challenge our assumptions.

In February, we asked SSIR website readers to predict the results of the two studies. Most got the answer wrong. Granted, the online article was short, with little room to provide the full contexts from which readers could make their predictions. Nearly everyone expected the consulting advice to affect enterprise growth positively in at least one of the studies, and almost half expected positive impact in both studies. The consulting advice did positively impact enterprises in Mexico, but generated some adverse effects in Ghana.

Why did we study these programs with randomized evaluations? For years, evaluations of such programs would follow participants over time, observing the change in their business afterward compared to beforehand. But countless outside factors influence the success, or failure, of a business. This fails to answer the question of impact: How have the businesses changed compared to how they would have changed had the training or consulting not taken place? Even if an analyst compares nonparticipants to participants, one must ask: Why are some participating and others not? Could it be that those participating are striving to improve their businesses? Random assignment to treatment and control addresses these factors.

In Accra, Ghana, IPA partnered with Ernst & Young to provide urban tailors and seamstresses with customized consulting advice on record keeping, customer service, and management of employees. Those offered the consulting services were randomly selected from a group of 160 tailors and seamstresses; we subsequently compared business outcomes for those selected to receive the consulting with those who got no consulting.

Our results showed that although the consulting intervention caused short-term changes in business practices, these impacts dissipated within a year after the consulting ended. On average, we found no long-term benefit from the consulting, and actually lower short-term profits. We believe some businesspeople hoped the advice would work and thus took it. But better bookkeeping and other business practices potentially took time away from the physical act of sewing clothes. Once profits took a hit, enterprise owners likely abandoned the practices and reverted to their previous methods.

If these tiny firms don’t benefit from consulting, would they benefit from more capital? To test this hypothesis, we handed out unconditional cash grants of $160—roughly equal to the businesses’ average monthly revenues—to a random subset of the tailors and seamstresses. The cash was generally invested in the businesses. As with the advice, the cash grants did not lead to increases in profits, but rather decreased profits. We see the capital infusion as not much different from the advice infusion: both represent a push from afar to expand operations, when these businesses were actually operating at their optimal scale. Following these interventions, the business owners made some changes, but they didn’t work out well. So they eventually reverted to former practices (which is good).

Note that 61 percent of respondents to our online survey assumed that the consulting in Ghana would raise firms’ profits. This corresponds with the common development practitioner and donor assumption that motivates advice-giving interventions for micro and small enterprises around the world. Our result does not mean, for the record, that no such program works. But it should make us think harder about the conditions necessary for success, and to test rigorously to see if we are right.

As for the Mexico study results, 77 percent of respondents to the SSIR online survey who thought we would find positive results from consulting in Mexico were right. We found an average 80 percent increase in sales and an average 120 percent increase in profits for firms receiving consulting advice, compared to the group that did not receive the intervention.

But the Mexico study was different from Ghana in that the program openly advertised to find interested firms. Those that responded were then entered into a lottery, and winners were matched with a local consultant who worked with the firm to define the scope of the consulting services. We must note, however, that we did not study the impact on firms that did not go out of their way to get consulting services (whereas in Ghana, we approached the businesses, not the other way around).

Thus a policy-relevant question remains: Would an expansion of this program have a similarly positive effect on those who did not self-identify as needing consulting advice? The effect could go up, or down, for those who do not seek the advice. In an earlier study on microenterprises in Peru, IPA found that the impact was higher on microentrepreneurs who expressed lower interest in business training. Thus the answer may not be as simple as providing the service to those who demand it the most.

We believe that economic development efforts are best served by testing and refining assumptions about what works, because despite the hopes and best intentions of smart people, not all interventions work. Finding different results in different contexts encourages us to look deeper into specific contexts and into the interventions themselves to determine which factors matter. Several of the differences in the chart on page 7 could explain the strikingly different results, but, in a sense, we have only two data points: one for Ghana and one for Mexico. In fighting poverty, simple questions typically have complex answers. This doesn’t mean the questions are unanswerable. It does mean that no one study, or in this case no two studies, will answer them all.

Let’s start with the definition he provides early in the book.

ZERONAUT, n. 1. An inventor, innovator, entrepreneur, intrapreneur, investor, manager, or educator who promotes wealth creation while driving adverse environmental, social, and economic impacts toward zero. 2. Someone who finds, investigates, and develops breakthrough, footprint-shrinking solutions for the growing tensions between demography, consumerist lifestyles, and sustainability. 3. Political leader or policymaker who helps to create the regulatory frameworks and incentives needed to drive related “1-Earth” solutions to scale.

Although Darth Vader would not aspire to join this club, many other people would like to be part of the solution. In a world of 7 billion people, there are a huge number of potential producers of game-changing ideas. Some work on discovering medical breakthroughs, while others focus on creating Facebook-like Internet startup companies. How do such ambitious, talented people choose which hard problems to work on? Put simply, when would the profit motive alone—without any virtuous Zeronauts—be sufficient to give us the “green capitalism” that Elkington argues is on the horizon?

Consider the challenge of male baldness. As a 46-year-old man without much hair, I have thought about this issue. If I were the only bald man in the world, then no for-profit drug company would spend a cent researching a solution to my problem. But when millions of people have this problem, there is huge aggregate demand and a jackpot for the company that can develop a solution (i.e., Rogaine). Old-fashioned capitalist price signals direct this entrepreneurial activity. Although some efforts will fail, some firm will succeed, and millions of men will smile again. This example highlights that anticipated desperation creates a profit opportunity and then triggers efforts to find a solution.

So what’s the difference between baldness cures and innovations that enhance sustainability? Elkington argues that status quo capitalism lacks imagination and ambition. Zeronauts, he writes, “aim to get our competitive juices fl owing with a ‘Race to Zero’ framing of their initiatives— whether it applies to toxics, greenhouse gases, or poverty. They start from the assumption that there is a fundamental design fault in capitalism—both in its prevailing paradigm and in the linked mindsets, behaviors, cultures, economic formulae, business models, and technologies.”

As a University of Chicago-trained economist, I see no “design fault” in capitalism. Instead, I see un-priced externalities. Despite the fact that the US House of Representatives passed in June 2009 the American Clean Energy and Security Act that would have introduced incentives and regulations for de-carbonizing the economy, the Senate chose not to vote on this legislation and President Obama did not resuscitate it. In the absence of federal legislation, auto manufacturers and power plants have little incentive to economize on greenhouse gas production. Higher fossil fuel prices would nudge them to do so, but the recent discovery of vast amounts of accessible natural gas in the United States and Canada suggests that “peak oil” may be far away. We would not need to celebrate the rise of the Zeronauts if the United States had introduced carbon pricing.

Elkington is 100 percent correct to focus on experimentation and to celebrate the power of game-changing ideas. The Zeronauts will succeed in achieving large-scale sustainability improvements in cases where there is a market price signaling scarcity. For example, if consumers face higher prices for resources such as water and electricity, this would stimulate more entrepreneurial activity focused on economizing on these resources. But I am pessimistic that the Zeronauts will succeed in de-carbonizing our economy. In the absence of carbon pricing and in a growing world economy, global greenhouse gas emissions will rise. Can the Zeronauts figure out how to convince China not to burn its coal endowment? Anticipating that the answer is “no,” I published my 2010 book, Climatopolis, in which I optimistically argue that profit-seeking entrepreneurs will figure out many new strategies to help us adapt to climate change.

Elkington’s book is a valuable contribution at the intersection of business and sustainability. He is right to emphasize that human ingenuity, passion, and experimentation will play a crucial role in helping us to avoid the nightmare scenarios predicted for the 21st century and beyond.

SocialCoding4Good (SC4G) aims to fill this gap by developing an online platform to match skilled employees from the technology sector with causes that need technical help. An initiative of Benetech, a nonprofit pioneer in leveraging technology for social good, SC4G focuses specifically on opensource projects that address humanitarian issues. Known as HFOSS for humanitarian free and open source software, such projects are proliferating to address causes ranging from human rights to global literacy.

“Open-source projects are perfectly suited to volunteers,” explains SC4G leader Gerardo Capiel, vice president of engineering for Benetech. The open-source Firefox browser, for instance, has been developed and improved by thousands of volunteers collaborating from around the world. Why not do the same, he reasoned, to speed the development of innovative tools to protect human rights workers, improve food supply chains in drought-stricken regions, or achieve other social benefits?

Seed funding from the Knight Foundation through the Silicon Valley Community Foundation has enabled SC4G to launch a pilot with HFOSS “sister organizations,” as Capiel describes them. Although not formally connected, organizations such as FrontlineSMS and Benetech are like-minded when it comes to using technological innovation to solve tricky social and environmental problems. They also need more extended volunteer engagement than a weekend-long burst of hackathon energy.

The Guardian Project, for example, is building tools on the Android mobile platform to ensure safer communication channels for those working under high-risk conditions. “These tools make secure communication possible in sensitive areas,” explains Guardian’s Derek Halliday. Having a safe way to gather and send information via mobile device, protect online contacts, or just keep your web browsing history private can be a lifesaver for human rights workers, journalists, health workers, and citizen activists in political hotspots.

The Guardian Project’s work has attracted grant funding and government support, “but we don’t have the funds to really ramp up resources,” Halliday says. Developer headcount runs to “the tens,” he estimates, rather than hundreds. Through SC4G, Halliday is anticipating an influx of highly skilled technical innovators to advance the Guardian Project’s cutting-edge mobile tools on a limited budget.

On the other end of this equation, technology companies see SC4G as a way to offer employees new opportunities for skills-based volunteering. VMware, a global cloud virtualization company based in Palo Alto, Calif., is the first to commit to the initiative, giving each employee five paid days per year to devote to “causes they care about, things that are closest to their hearts,” says Nicola Acutt, director of the VMware Foundation.

Through SC4G, VMware’s global workforce of 12,000 “can leverage their specialized skills to have a bigger impact,” Acutt predicts, “and find opportunities that spark their passions.” What might software engineers gain in return? “Leadership experience, working in new situations— there’s a whole host of potential soft skills,” she adds.

SC4G is developing its own tools to fine-tune matching opportunities between HFOSS projects and interested volunteers. “We want to pair up the right developer with the right project,” Capiel says. “We’re breaking projects into small bits so that it’s easy for lots of people to collaborate.”

Well, my worries were misguided. Ghonim’s new book, Revolution 2.0, is a revelation. Go buy it, read it, and then share it with a friend. It is a careful and thoughtful retelling of the roots of Egypt’s uprising and the nuts and bolts of Ghonim’s online organizing, as well as an inspiring illustration of a trend. That is, how a new generation that is growing up networked keeps spawning “free radicals”—people who teach themselves how to use technology to build community, share powerful messages, and ultimately weave movements for social change. Ghonim is just the most famous of a list of net-native activists who have figured out how this Internet thing can tip the scales their way.

Ghonim is quick to admit that the Internet changed his life. In 1998, as he was starting his studies at Cairo University, he created a website called IslamWay.com, “to help Muslims network with one another.” It was a hub for sharing audio recordings of religious sermons, “featuring a complete range of moderate Islamic opinions.” Two years after its launch, the website had tens of thousands of daily users and was curated by more than 80 volunteers. Ghonim eventually donated it to an American Islamic foundation to maintain. I mention this bit of biographical history for only one reason: It shows that a full decade before Ghonim turned his challenging the Mubarak regime, he was already an online community organizer.

Ghonim’s first foray into Facebook organizing was to support Mohamed ElBaradei, a former top UN official who became an outspoken critic of Egyptian President Hosni Mubarak. Ghonim created a fan page for ElBaradei that grew to more than 150,000 members, but ElBaradei’s reliance on mainstream media and cautious approach to opposition politics also left Ghonim frustrated by the pace of change.

Then, on June 8, 2010, he writes, “while browsing on Facebook, I saw a shocking image that a friend of mine has posted on my wall.” It was an image of Khaled Said, a 28-year-old who two days earlier was pulled from an Internet cafe and beaten to death by the secret police. Ghonim found himself in tears and decided he could not “stand by passively in the face of such grave injustice.” Instead of publishing the news of Said’s killing on ElBaradei’s Facebook page, which he felt could be seen as exploiting the death for one politician’s gain, he decided to create a new Facebook page devoted to Said.

And here is where Ghonim’s tale starts to get really interesting for Net activists. He quickly discovered that there already was a page called “My Name is Khaled Mohamed Said,” but it was run by political activists whose discourse Ghonim found too confrontational to become mainstream. Instead, Ghonim called his page “We Are All Khaled Said” and started writing in colloquial Arabic, avoiding language that average Egyptians wouldn’t use. Within a single hour, the page had 3,000 followers. By its third day it had 100,000.

Ghonim details several strategies he employed to engage page members directly and convince them to become more active. One was to ask people to photograph themselves holding a paper sign saying “Kullena Khaled Said”; hundreds did so, helping personify the movement. Another was to rely on page members to promote protest events, like a series of “Silent Stand” rallies that were designed to be visual evocations, not provocations.

Ghonim’s story eventually moves from the virtual world of Facebook, to the tumultuous days of the Jan. 25 revolution, to his arrest by the secret police. The memoir culminates with the heady night in Tahrir Square when Mubarak finally stepped down from power, touching only glancingly on government efforts to trick and co-opt Ghonim and other members of Egypt’s youth movement, and saying little about the unfinished business that remains.

But even if Ghonim’s (and Egypt’s) story is unfinished, the value of online organizing seems conclusively settled by the events of last year. As he writes in an epilogue, “thanks to modern technology, participatory democracy is becoming a reality. Governments are finding it harder and harder to keep their people isolated from one another, to censor information, and to hide corruption and issue propaganda that goes unchallenged. Slowly but surely, the weapons of mass oppression are becoming extinct.”

At the same time, Ghonim is not a techno-utopian. After a recent talk at Harvard University, I asked him whether activists should trust Facebook, which shut down the Khaled Said page at a critical moment. “I don’t personally trust any tool,” he said. “I trust the people behind the tool.” And that remains the most important lesson of Revolution 2.0. Technology is just an enabler. It is what people decide to do with it that matters most.

Abundance is techno-utopianism at its worst. The outlook of the book can be summed up by a discussion of the advent of 3-D printers—machines that can form three-dimensional objects much as an inkjet printer forms words. Soon, the authors suggest, “everyone” will have one of these amazing machines. They approvingly quote an innovator of 3-D printing technology: “And once that happens it will change everything. … Instead of placing an order and waiting 24 hours for your FedEx package, just hit print and get it in minutes.” Although you may be wondering how solving a 1 percent problem will change the world of the billions of people without easy access to electricity, clearly the authors aren’t.

Why? Because no matter what the symptom, the authors see a technological Band-Aid. They describe a future in which something like Google is directly connected to our brains so that when we think of something we don’t know, the answers are instantly supplied to us. Clearly this technology innovation is not working yet, as the authors didn’t automagically learn that they have devastatingly mistaken symptoms for problems. In the few places where they begin to acknowledge that the problems that keep much of the world disenfranchised, impoverished, and unhealthy are not technological in origin, they quickly explain that we already “know” how to deal with those issues. For instance, we “know” that “community support is the most critical component for any water solution” and “maintenance workers need to be incentivized.” Now that we know these facts, a technology breakthrough is all that’s needed to fix global water problems. I wonder what technology will fi x global justice problems now that we know all people are created equal.

Abundance is meant to be an optimistic antidote to the world’s doomsayers, but it left me deeply depressed. If bright and innovative minds are still completely captured by technological fixes to social problems, we have much further to go in solving those problems than I believed.

After throwing Abundance across the room, I found Philip Auerswald’s The Coming Prosperity a breath of fresh air. Auerswald’s focus is on human beings and the way they solve problems. Technology matters only insofar as it enables the people solving their own problems to outpace the people creating them.

Auerswald’s term for people who solve problems is a familiar and dear one to readers of this magazine: entrepreneur. His main concern is that entrepreneurs, a term he uses quite expansively, are not receiving enough attention from policymakers, economists, political scientists, and philanthropists. These groups all come in for criticism for their habits of patting entrepreneurs on the head before getting back to the serious business of picking winners and driving policy from the top down.

Ultimately though, he argues, this habit is irrelevant. The world’s entrepreneurs are now numerous enough, free enough, and, yes, have access to sufficient technology, to innovate and succeed in spite of the powers that be. Auerswald writes not to convince the powerful and influential at the top of the pyramid to change as much as to inform them that they are no longer relevant—and that’s good news for everyone.

This is a message that needs to be delivered. Unfortunately, The Coming Prosperity doesn’t do the best job of delivering it. The book wavers between popular and academic modes, between personal anecdote and global sweep, between explaining the deficiencies of current elites and telling them they don’t matter. As a result, chapters tend to ramble and it’s easy to lose the plot. The best way to read the book is probably to read the last page of each chapter first. Then you’ll be in a better position to appreciate the many interesting anecdotes and data.

Despite its weaknesses in execution, Auerswald’s fundamentally humble message is both cheering and worth hearing. You and I don’t have the answers to the world’s problems, and we don’t need to. There are now enough smart people in every corner of the world with access to the ideas, tools, and resources necessary to ensure the coming of a new and truly global prosperity no matter what the 1 percent or anyone else does. I’m a skeptic by nature and by no means convinced by Auerswald, but I’m more hopeful than I was before picking up the book. Maybe the failures of Abundance’s authors to appreciate what it truly takes to solve problems simply don’t matter after all.

“We want to bend that curve back to where it needs to be,” says Julie Gerberding, president of Merck’s vaccines division, who serves on the steering committee of Merck for Mothers.

The scale of the new initiative “is certainly staggering—a positive signal to the whole field,” acknowledges Meg Wirth, founder of Maternova, a social enterprise that aims to improve maternal and neonatal health. “It adds to the growing recognition of how serious this problem is and how many different players it will take to overcome the issue of maternal mortality.” Wirth, who spent 15 years working on global maternal health policy issues, adds, “When the announcement was made, everyone gasped—and then asked, what will it be spent on?”

To answer that question, Merck is investing first in active listening. Gerberding says the company’s initial step was to reach out to the United Nations, which under Secretary-General Ban Ki-moon’s leadership has started an ambitious maternal and child health campaign called Every Woman Every Child. “Rather than thinking up a project on our own,” says Gerberding, “we asked the UN how Merck could be most helpful in accomplishing its goals.”

Conversations with those on the front lines have helped Merck understand challenges in parts of the world where big pharma companies currently have little impact. “We want to reach that 80 percent of the world’s population that global health companies don’t currently reach,” Gerberding says. Merck for Mothers will focus on new product innovation, accelerating access to proven solutions for issues like preeclampsia and postpartum hemorrhage, and improving access to prenatal care and family planning services, along with ongoing advocacy efforts.

When it comes to product innovation, a team of research scientists is working to develop a heat-stable compound to treat hemorrhage during labor and delivery. A product that could be used in resource-poor conditions, without needing refrigeration, to treat one of the leading causes of maternal death “could be a game changer,” adds Wirth.

At the same time, the initiative is looking to leverage Merck’s expertise to speed the development and distribution of already existing products. One of the first grants awarded will enable PATH, a global health nonprofit, to evaluate more than 30 technologies that show promise for treating preeclampsia and postpartum hemorrhage. Merck researchers are collaborating with PATH on the $2.5 million project.

New public-private partnerships are likely to emerge around the globe. “We’re talking with heads of government, NGOs, and others to see if we can’t come up with ideas that would be relevant to their unique epidemiology,” says Gerberding. “Not everything is going through the UN or the US government. We’re trying a variety of models of engagement,” in countries as diverse as Zambia, Brazil, and India.

One nonprofit leader suggests transparency will be important as Merck for Mothers makes funding commitments and evaluates results. The initiative website (merckformothers.com) will be “a hub of information” as the program ramps up, Gerberding says. “Our full dashboard of metrics is being developed now.” Results in partner countries will be tracked closely, along with overall impact.

“It’s important not to gloss over how big this problem is,” Gerberding adds, “but fundamentally, we want to help achieve the Millennium Development Goals. That’s why we got started down this path.”

Dr. Bruce Lee, assistant professor of medicine, epidemiology, and biomedical informatics at the University of Pittsburgh, provided an unusual service during the last H1N1 outbreak. Embedded at the US Department of Health and Human Services, Lee was on call to model situations that had decision makers concerned. Using a high-powered computing platform that he compares to game worlds like SimCity, he was able to provide visualizations of different scenarios so that decision makers could better weigh their responses to changing information.

“People can get lost in numbers. But if you show them something with a striking visualization, they perk up. It gets their attention,” says Lee. Modeling also improves communication among specialists who may have different areas of expertise. When medical experts and policymakers have to reach decisions based on best available information, “a picture really is worth a thousand words.”

Using an approach called agent-based computational modeling, Lee and his colleagues work with a virtual population lab that can mimic actual population patterns in a specific part of the world or even globally. Using US census data, for instance, they can run simulations to show how different health scenarios would affect the nation’s 100 million households.

One project underscored the importance of treating low-income populations first to achieve benefits across society. Poor people tend to use public transportation and travel greater distances to work than more well-heeled populations, making them more likely transmitters. “Moral and ethical arguments are effective when you want to work for some type of social change,” Lee says, “but sometimes it’s even more effective to have a utilitarian argument.”

Lee, who has an MBA and an MD, leaves it to others to suggest which questions to analyze. “My interest is using modeling to address real-world questions. We work closely with decision makers to understand, what are the questions they need answered? What are the challenges to answering those questions?” He is also part of a network of modelers known as MIDAS, for Models of Infectious Disease Agent Study, started by the National Institute of General Medical Sciences (NIGMS) in response to 9/11 and associated health threats.

Agent-based modeling is an increasingly useful tool to analyze a range of public health issues, including bioterrorism threats. “The limitation is how quickly people can be trained to use these tools,” says Dr. James Anderson, program director of the Division of Biomedical Technology, Bioinformatics, and Computational Biology at NIGMS. Anderson says the greatest value for modeling comes at the planning stages, “when you can think about something that hasn’t happened yet.”

Still relatively new, agent-based modeling requires both powerful computers and specialized understanding. Lee credits his modeling skills to an interest in gaming that dates to his youth, followed by business school classes in modeling and business analysis, and then a stint at Quintiles, a clinical research organization, where he did economic modeling for big pharmaceutical companies.

Lee and his colleagues are currently studying vaccine supply chains in a project for the Bill & Melinda Gates Foundation, and also collaborating with UNICEF and the World Health Organization. “People who need vaccines the most are sometimes the last to get them,” Lee says, “especially if they’re in remote areas or underserved populations. Models can help inform decision making about the best way to get vaccines to people.”

The term “reverse innovation” was coined by Dartmouth College business professor Vijay Govindarajan and GE CEO Jeffrey Immelt to describe innovations that go in the opposite direction of what traditionally has been observed. Until recently, innovation seemed to be reserved for industrialized nations. Reverse Innovation, co-authored by Govindarajan and Dartmouth colleague Chris Trimble, digs deep into the work of corporations at the frontier of emerging markets and offers guidance and understanding of this rising phenomenon.

Govindarajan and Trimble could not have timed their book better. Tales of innovation from emerging markets are now reported daily—from Kenya’s mobile banking miracle M-Pesa to Tata Motors’ ultra low-cost Nano. We have transitioned from a time when emerging markets were ignored completely by multinational corporations, to a period when firms turned their attention toward the “bottom billion” as a group of potential consumers, to a new era in which innovation flows from these regions. The authors tell detailed stories that leave you convinced of a rising trend in innovation from this previously ignored market.

At the book’s core are the intricacies and struggles faced by Western firms that were the first to experiment in and successfully enter emerging markets. One example shows how GE realized that the electrocardiograms it was manufacturing were too expensive, were not portable enough, didn’t have batteries, and were too complicated to maintain. After turning the design process upside down, GE eventually produced the MAC400, whose product line has now been deployed in the rest of GE Healthcare markets. (This is a story Govindarajan knows intimately, as he spearheaded GE’s energy and health care innovation efforts from 2008 to 2010.)

The section on Deere & Company is just as captivating, detailing how an organization can learn that its high-quality products may be unsuited for new global markets. Deere’s high-end tractors have, in the authors’ words, “tires taller than an NBA center, loads of high-tech gadgetry, and fully enclosed air-conditioned cabins big enough to have friends in for lunch.” These specs were at odds with the tractors Indian farmers sought: ones that could clock 10 times as many hours and be used to “carry friends and family to the movies, markets, and other social events.” Deere’s team pressed the reset button and successfully applied smart design practices to produce a new utility tractor called Kish for the Indian market—and did so in record time.

Although some of the stories in Reverse Innovation may seem familiar, most were not widely reported and offer far more detail than the usual newspaper article. The book also provides a useful addendum in a “Reverse Innovation Playbook,” which spells out nine rules that enable successful innovation in emerging markets. The playbook is a first of its kind and the closest thing available to a 10 commandments for reverse innovation. Two examples of rules are “To capture growth in emerging markets, you must innovate, not simply export” and “Move people, power, and money to where the growth is—the developing world.” For those hungry for detailed steps to becoming practitioners, the authors also provide a “Reverse Innovation Toolkit.” It is an ideal diagnostic tool for those brave enough to seek out reverse innovation in their own organizations.

Although the book provides compelling evidence of innovation in emerging markets, it leaves one wondering about the role of local firms. The examples in Reverse Innovation are all large Western firms. Is the conclusion that these firms are learning how to interpret and act on the needs of poor consumers? Will innovation be truly reversed only when firms in India, China, or Mexico take the lead in innovation, as has happened with Tata or G-Cash in the Philippines? Maybe it is just a matter of time.

That said, Reverse Innovation is a must read for anyone seeking to participate in emerging markets, be they CEOs of multinationals, leaders of NGOs, or government policy makers.

Entrepreneurs are setting up shop in the nation’s urban food deserts, expanding options for a market that has been overlooked by traditional grocers. “We want to create a prototype that will serve multiple community needs,” says Boxcar co-founder Alison Cross, who started the store with her brother, Alphonzo Cross. Despite their social good aspirations, they have deliberately steered clear of the nonprofit model. “To create change,” she says, “we need to prove that this can be done for profit.”

My Street Grocery also operates as a for-profit social enterprise. Founder Amelia Pape says she started planning the business while earning an MBA from Portland State University. One of her first class assignments was to identify a market failure and devise a solution. She focused on food deserts, defined by the US Department of Agriculture as low-income neighborhoods where a substantial portion of the residents live more than a mile from a supermarket. Despite Portland’s reputation as a foodie haven, the city has its share of neighborhoods with few healthy food options.

To reduce overhead and serve more neighborhoods, Pape and her two co-founders settled on the mobile grocery model. Another mobile grocer—Fresh Moves—delivers to Chicago’s Englewood neighborhood in a retrofitted city bus.

Pape and company tested their idea last fall by setting up temporary food stands in several low-income neighborhoods. The pilot demonstrated demand. Using Kickstarter, the online fundraising platform, they raised more than $10,000 in contributions to buy and refurbish their first truck.

Both enterprises make consumer education part of their business model. My Street Grocery works closely with Oregon State University Extension to connect customers with cooking classes and offers culturally appropriate recipes. Ready-made meal packs include recipes along with premeasured ingredients like whole wheat pasta, fresh green beans or spinach, and canned tomatoes. My Street Grocery is also seeking approval to accept food stamps. That means navigating regulatory challenges, Pape admits, “but it’s something our customers want.”

Boxcar Grocer has developed a network of urban farmers who rent six indoor market stalls to sell their produce directly to customers. The Boxcar brand is a nod to the neighborhood’s many railroad warehouses and also connects with cultural history. “Trains are great connectors. The store is an immediate way to make the connection between urban and rural land. We’re helping people realize that there are still black farmers,” says Cross, who is African American. “For many people in our generation, our parents left the farms and never looked back.”

Business has been growing faster than the brother-sister team expected. Their brick-walled store—which feels more like hip bistro than mini-mart— is appealing to a wider demographic than they envisioned. “Health food stores don’t cater to people who look like me,” Cross says. “We have an opportunity to market to people nobody’s marketing to.” Their biggest competitor, Cross adds, isn’t Walmart. “It’s McDonald’s, KFC, and Burger King. How do we change the mindset of a generation of upwardly mobile people who think that taking your kids to McDonald’s makes you a good parent?”

Food tastings are just one way they’re reaching out to new consumers. “Many people think healthy food is elitist, upper income, and white,” Cross says. With free samples of kale salad and other tasty snacks, she’s hoping to take a bite out of that misconception.

But for Scott Rozelle, a good idea isn’t good enough—it has to be backed by empirical evidence. So Rozelle, founder and co-director of the Rural Education Action Project (REAP) at Stanford University, designed an experiment: 300 of the poorest seventh-graders in an area of Shaanxi province in northern China were identified. Half of them were chosen at random to receive $75 if they stayed in school for another semester during the 2009-10 school year. Half were not; they served as the control group.

The results were better than Rozelle imagined. The dropout rate for the students who received money was 60 percent less than for those who didn’t.

The Chinese government was impressed, too. Thanks to long-established connections in the country, a policy brief written by REAP and its partners made its way to China’s State Council, the equivalent in the United States to the Cabinet. Soon afterward, China’s top education official directed $10 million to be spent on cash incentives for students.

For Rozelle, taking the time to do such experiments is the difference between helping 150 kids and affecting millions. “Our entire raison d’être is to change policy to help the poor,” says Rozelle, an agricultural economist. “When we’re implementing projects we’re always thinking, how would the government do it?”

Poverty in China is such an immense challenge, Rozelle says, that the government has to be involved to make substantial change. The canyon between rich and poor, urban and rural is wider in China than anywhere else.

China has the second-largest economy and the second-largest number of billionaires (after the United States)—and the second-largest number of people in poverty (after India). In China’s cities, 70 percent of children go to college. In the countryside, most children suffer from severe malnutrition, intestinal worms, and anemia, and fewer than 5 percent will continue their education past high school.

Against this inequity, REAP leverages research. Since its founding in 2007, REAP has conducted about 30 sets of experiments that have produced policy briefs read by top government officials. From there, the government has issued directives and money to improve nutrition among children and make education more affordable.

In 2008, China bestowed on Rozelle the Friendship Award, the highest honor available to a non-Chinese, for significantly contributing to the country’s economic and social advancement. REAP’s $2 million annual budget is funded by a wide range of donors, from foundations such as the Ford Foundation to corporations such as Nokia to individuals who had no previous interest in China.

Even as REAP enjoys such support, the work of putting the policy into practice remains a challenge—as it does for any social endeavor. Managing relationships and changing human behavior is much harder than crunching data.

In one province, REAP showed that most children were anemic and that teaching parents about nutrition wasn’t making a difference. A few more research trials later, local officials finally conceded that vitamins are the best solution. But they still hesitated to distribute vitamins that a company donated; they worried about liability.

Rozelle shakes his head over the bureaucratic absurdity, but he smiles with optimism. Convincing the officials to consider vitamins was a major step forward, and the rest will follow, eventually. “Policy change,” he says, “is a long haul.”

Rigor Plus Collaboration

Although REAP is only five years old, its roots reach back more than two decades. That’s how long Rozelle and Linxiu Zhang have been working together on research about rural China. Zhang, of the Chinese Academy of Sciences in Beijing, a national research institution, is REAP’s co-director.

Rozelle, who grew up in a middle-class Los Angeles suburb, became interested in learning Chinese on the recommendation of his father, whose military career included a stint in Shanghai. Zhang, the daughter of an illiterate farmer, was admitted to college in 1978, the first year that China allowed entrance strictly through test scores rather than family connections.

Although their backgrounds may be different, Rozelle and Zhang rely on each other’s contributions. The philosophy of shared learning became a part of REAP. “We know better about our country, but partners like Scott know better about the research methods,” Zhang says. “It’s mutually beneficial.”

That collaborative spirit has been crucial to REAP’s credibility, says Prashant Loyalka, a professor at Peking University who is part of an institute that advises the government about education policy. Loyalka says that some education nonprofits from overseas will send teachers and resources to China, but operate only within the confines of their program. REAP, however, has expanded its network and encouraged others to be invested in its outcomes.

At Northwest University in Xi’an, Loyalka says that REAP increased the capacity of researchers there to design and lead the work, rather than simply participate. During meetings, even local university students who serve as data collectors, usually the lowliest cog in a project, were asked for their input.

“I don’t think REAP sees itself as from the outside,” says Loyalka, who received his doctorate in education from Stanford. “I think REAP sees itself as being part of China and wanting to help China grow.”

Before REAP, China lacked rigorous, systematic research on its rural areas. Data collection often consisted of a person surveying a few schools picked because of connections with the principals. REAP’s methods involve random sampling, control trials, and repeated visits over the course of a school year. This type of research, sometimes called “poverty labs,” is similar to how drug companies test new products. Although randomized sampling had been increasingly used in other developing countries, it had not been introduced in China until REAP.

With the research, REAP is often able to push ahead of others trying to influence government policy. “There’s a natural proclivity to rely on evidence,” Rozelle says. “Lots of people say that they have the best sliced bread, but if you can come and give them evidence-based research, what we find is that they’ll always consider it. They don’t always act on it, but they’ll consider it.”

The research methods are controversial, however, among some NGOs and academics. Critics have asked why some people are given access to a resource, such as scholarships, while those in the control group are denied. Rozelle says researchers follow the medical edict of “do no harm.” “No one leaves worse off,” he says, adding that in a study involving scholarships, REAP distributed money to more students after research was completed. Although the subjects might not be worse off, the organization conducting the study may feel under attack. Many nonprofits aren’t eager to find out that a much touted program isn’t effective.

Economist Yaojiang Shi says that by saving face, the organizations are limiting their potential. As director of the Northwest Socioeconomic Development Research Center in Xi’an, Shi works with REAP as well as nonprofits that don’t use research methods. Some nonprofits have invested 10 times more money than REAP, Shi says, but they can’t identify what part of their efforts is working. Without that, he said, it’s hard to change broader policy.

For REAP, data are the real measure of progress, not anecdotes. “Storytelling is fine, but you need to have basic facts,” Zhang says. “What do you want to achieve? Do you want to know whether your efforts are worthwhile?”

Sometimes, the research results are surprising and revoke REAP’s strongest assumptions. Two years ago, REAP hosted an intensive training for English teachers in migrant schools. The three-week program was featured on REAP’s website, with photos of beaming teachers.

“The students and teachers and volunteers all agreed the goal of improving the English proficiency of the migrant teachers was achieved,” the press release trumpeted. Zhang was convinced that the teachers would go back to their villages and raise student performance. A semester later, REAP’s research showed that the training had no impact.

“It’s a failure, but it’s a good experience,” Zhang says. “We learned a lot.” REAP is now following up training with periodic text messages of reinforced lessons. If that doesn’t work, Zhang says, they’re still another step closer to the solution that will improve the lives of millions of children.

Across every sector of society, decision makers are struggling with the complexity and velocity of change in an increasingly interdependent world. The context of decision-making has evolved, and in many cases has been altered in revolutionary ways. In the decade ahead our lives will be more intensely shaped by transformative forces, including economic, environmental, geopolitical, societal, and technological seismic shifts.¹

As part of its response to this global dynamism, the Rockefeller Foundation has translated its 1913 mission of promoting the well-being of humanity into two overarching goals: expanding opportunity through more equitable growth, and strengthening resilience to acute crises and chronic stresses, whether man-made or ecological. Our vision is a world in which globalization’s benefits are more widely shared and the inevitable challenges that accompany a world that is fast changing, diverse, and complex are more easily weathered.

The Rockefeller Foundation structures its work around time-bound cross-sectoral initiatives that seek innovative solutions and support enabling environments to bring about change. The foundation’s structure reflects its view that today’s problems and solutions are multi-dimensional in scope and nature, and that they require multi-disciplinary responses at the intersection of fields.

Just as the Rockefeller Foundation’s approach to philanthropy has evolved, so too has its approach to evaluation. With its mission to improve the well-being of humankind, its focus on impact, and much of its grantmaking in developing countries, the Rockefeller Foundation is committed to evaluation practices that are rigorous, innovative, inclusive of stakeholders’ voices, and appropriate to the contexts in which the foundation works. This article discusses how the Rockefeller Foundation integrates the views of developing-region evaluators into its evaluation approaches, and highlights five key strategies:

1. Engaging stakeholders to develop shared outcomes.

2. Expanding capacity through use of non-staff monitoring and evaluation specialists to partner with grantees.

3. Sharing knowledge through learning forums and communities of practice.

4. Strengthening developing country evaluation practice and ownership of results.

5. Developing innovative methods and approaches to evaluation and learning.

Rethinking, Reshaping, and Reforming Evaluation

In November 2011, the Rockefeller Foundation brought together leaders from philanthropy and development at the Future of Philanthropy and Development forum, held at its conference center in Bellagio, Italy. In one of the keynote papers, Evaluating Development Philanthropy in a Changing World, Robert Picciotto, former vice president at the World Bank and now professor at King’s College London, squarely tackled the role of evaluation in philanthropy and development. “The changing context and thinking on development has profound implications for development evaluation itself, and for the contribution evaluation can bring to the empowerment of people; and the effectiveness of development interventions by national governments and international partners and, increasingly, by non-state actors—foundations, philanthropists, and agencies that promote investing for impact.”

Picciotto continued, “Pressing human needs are not being met by an official aid system that is short of resources, catering to multiple interests, and hobbled by massive coordination problems. By contrast, private giving for development is growing and has proven nimbler and more results-oriented than official aid. However, the philanthropic enterprise will not fulfill its potential unless it identifies and taps into its distinctive comparative advantage and coordinates its interventions with other development actors; embeds evaluation in its processes to achieve operational relevance, effectiveness, and efficiency; and demonstrates that it is accountable and responsive to its diverse stakeholders.”

Developing country evaluation leaders have also articulated the need for a new approach to evaluation and the role it plays in improving the wellbeing of humankind—in particular, the lives of the poor and vulnerable in developing countries. At the January 2012 gathering of the Africa Evaluation Association’s biannual conference in Accra, Ghana, African evaluation leaders and policy makers highlighted five steps foundations and development agencies must take if they aspire to play a meaningful role in social transformation.

1. Broaden the inclusion of key stakeholders in evaluation. Only when the voices of those whose lives we seek to improve are heard, respected, and internalized, will we be able to effectively evaluate what success should look like for the people we are most concerned about. Foundations and agencies need to take practical steps to include key stakeholders in the design of, conduct of, and learning from evaluation.

2. Regard evaluative knowledge as a public good and share it widely. Learning with our partners and stakeholders about what works and what doesn’t work should be seen as a global public good not limited to boards and program teams, but shared widely with grantees, partners, and peers.

3. Address evaluation asymmetries between developed and developing regions. The majority of human and financial resources for evaluation emanate from agencies and foundations based in the developed world. With evaluators from developing countries playing a minor role, if any, many of them do not get sufficient experience to move into leadership roles. Mentoring, coaching, and training can strengthen the role, capacity, and resources of developing-country evaluators so that they can play key roles in conducting and using evaluation results for social transformation and accountability in their own countries.

4. Broaden the objects of evaluation to learn more beyond the individual grant or project to a more strategic assessment of portfolios of investments, policy change, new financing mechanisms, and sector-wide approaches that tell us more about what works and what does not in different contexts. Framing evaluation to take into account the drivers of unsustainability and causes of the challenge being addressed provides greater learning than narrower evaluations that focus only on the funder's specific intervention.

5. Invest in the development and application of innovative new methods and tools for evaluation and monitoring that reflect multidisciplinary and systems approaches to problems and complexity; invest in methods that assess network effectiveness and policy change; and use and adapt new technology to enable stakeholders to provide close to real-time data and feedback.

The Rockefeller Foundation’s Approach

With its long history of supporting developing country institutions, the Rockefeller Foundation has responded to the call to action from developing-region evaluators by adopting the following approaches to planning, monitoring, and evaluating its work.

Shared Outcomes | An important underpinning of the Rockefeller Foundation’s initiative-based approach is a fundamental recognition that the world’s greatest challenges can’t be solved alone. These challenges involve a complex mix of actors that are often globally interdependent across sectors and geographies. Networks, alliances, and coalitions of diverse stakeholders from governments, foundations, civil society, and business are increasingly seen by the foundation as a more powerful way to mobilize the vast range of resources and actions required to bring about sustained and transformational change on a significant scale.

Increasingly, the Rockefeller Foundation brings together grantees and partners from developed and developing countries to establish a common vision of the problem, outcomes, and indicators for success. Grantee agreements now include reference to the common vision of results and shared outcomes to which the grantee contributes, and foundation teams are expected to manage portfolios of grants and relationships with grantees towards that common vision. This shared-outcomes approach forms the basis for ongoing monitoring, evaluation, and reporting, and for learning dialogues with grantees and partners. (See “Shared Results Framework.”)

Monitoring and Evaluation | Most foundations have capacity limitations on the amount of time that can be devoted to monitoring and learning with grantees and partners, visiting field projects, and working collaboratively—activities that we know contribute to greater collaborative learning and effective relationships. Recognizing these limitations, the foundation awards grants to monitoring and evaluation (M&E) groups and specialists in developing and developed countries who act as monitoring partners, or what we call “critical friends,” ² throughout the life of initiatives (typically, a five- to six-year period). They work with grantees to identify key learning questions, help to set up monitoring systems, and provide support in analyzing monitoring data. The most significant feature of the critical friends is that they build trust with grantees and partners to ask tough evaluative questions, and they support grantees in seeking and using feedback to make improvements throughout the life of the initiative. Periodic evaluations are conducted by independent teams to provide an objective assessment of progress toward outcomes and impact.

For example, the India-based nonprofit Participatory Research in Asia, in collaboration with the Ghana-based Institute for Policy Alternatives, works alongside Shack/Slum Dwellers International (SDI) which directly represents millions of urban poor slum dwellers in 33 countries. The aim of this critical friend partnership is to strengthen the participatory learning, monitoring, and evaluation systems and abilities of the urban poor networks to better capture and systematize learning and strengthen accountability with the goal of empowering the urban poor to achieve wider positive impacts. The critical friend role underpins a belief that federations of the urban poor are capable of changing their own situation for the better. As a result of this partnership, SDI has strengthened its ability to democratize learning, monitoring, and evaluation—continuing to place the tools, responsibility, and ability for change in the hands of its members.

This figure illustrates the framework around which Rockefeller Foundation staff, grantees, and partners develop a common vision of the results and impact that they seek to achieve collectively. The top frame represents the mission and strategy of the foundation—promoting the well-being of humanity in two overarching goals: expanding opportunity through more equitable growth, and strengthening resilience. The middle frame represents the medium-term outcomes that the foundation seeks to achieve during the life of the initiative (these change from initiative to initiative). The lower frame represents the work that grantees, partners, and staff do in their individual organizations to collectively bring about outcomes and ultimately improve the lives of beneficiaries. These shared results frameworks anchor the ongoing dialogue with grantees about progress toward achieving this vision and their contribution to the shared outcomes. It also serves as a framework for managing portfolios of grants and monitoring changes during the life of the initiative.

Learning Forums and Communities of Practice | Most of the Rockefeller Foundation’s initiative teams convene grantees and partners annually to review progress, highlight lessons and challenges, celebrate successes, and identify improvements needed. Through these forums grantees learn from others in the field, meet new resource people, and adjust their strategies going forward. Although this practice does not guarantee impact, it increases the likelihood of it by creating a greater sense of ownership and shared outcomes, and it increases leverage by connecting grantees with new resource people, funders, and mentors. Increasingly, M&E grantees produce high-quality knowledge products as a public evaluation good to highlight what works, what does not, for whom, and under what conditions. Our aim is to establish with grantees a body of collaborative knowledge, shared lessons, and a culture that values evaluation as a resource for learning as well as for accountability.

For example, the Rockefeller Foundation has aligned with the South East Asia Community of Practice in Evaluating Climate Change Resilience (SEA Change), facilitated by the nonprofit organization Pact, to work on urban climate change resilience in ten Asian cities. This community of practice brings together evaluators, program managers, grantees, and policy makers concerned with learning what works in interventions aimed at adapting and building resilience to the effects of climate change and extreme weather events in Southeast Asia. Resources and lessons are shared through online learning, onsite convening of SEA Change participants, and coaching, mentoring, and training provided by members of the community of practice throughout the countries of Southeast Asia.

Addressing Asymmetries | The Rockefeller Foundation is supporting the formation and strengthening of regional developing-country networks and the first-ever regional institutions to train, coach, and mentor evaluators, and to partner with evaluators from other regions. Through these platforms and networks, the foundation aims to help rebalance the asymmetries of choice and opportunity for developing-country evaluators to control the evaluation process in their own localities and to improve the quality of evaluation by partnering with evaluation leaders globally.

One example of this is the African Evaluation Association (AfrEA), a pan-Africa umbrella organization comprising more than 25 national M&E associations in Africa, and a resource for individuals in countries where national evaluation bodies do not exist. AfrEA, which has more than 1,000 evaluators from all regions of Africa, receives Rockefeller Foundation funding to enable the formalization of its organizational, operational, and management structure, and to build communities of practice among its membership to tackle the most pressing evaluation challenges on the continent.

The Centers for Learning on Evaluation and Results, located in Africa and Asia, are another example of an effort aimed at addressing asymmetries in evaluation in developing countries. Together with a consortium of funders committed to building developing country capacity for taking charge of the evaluation agenda in their regions, the foundation is supporting regional centers³ in East and West Africa and South Asia to strengthen their skills, networks, and experience in monitoring and evaluation and results-based management capacity of public, private, and civil society development in the global south.

New Methods and Approaches | Traditional evaluation methods and approaches to learning, accountability, and feedback have not kept pace with the advances in technology and social media. The majority of evaluation practice is still largely paper-based despite great strides in technology, interactive web-based platforms, and multimedia tools that make real-time feedback from grantees and beneficiaries possible and accessible. The Rockefeller Foundation and its partners learned a great deal from Ushahidi, an open-source crowdsourcing project that allows users to send crisis information via mobile devices to map reports of violence or suffering. Inspired by the potential of these kinds of tools to democratize evaluation information, increase transparency, and lower the barriers for individuals to share information and stories, the foundation is supporting a number of innovative approaches to evaluation.

One example is GlobalGiving’s Story Telling project, an innovative way to gather local feedback from people in developing countries and to share it with communities, implementing organizations, and donors to create real-time feedback. With support from the Rockefeller Foundation, GlobalGiving successfully deployed a network of people in Kenya, Uganda, and Tanzania that has generated more than 20,000 tagged narratives from thousands of people. Some of GlobalGiving’s partners are deriving actionable intelligence from these stories, and GlobalGiving is discovering patterns in the stories that inform its own operational and strategic decision-making processes.

Another example is BetterEvaluation, an online interactive community of evaluation practice developed by the Royal Melbourne Institute of Technology in partnership with the Institutional Learning and Change Initiative and the Overseas Development Institute, with support from the Rockefeller Foundation and Pact. BetterEvaluation provides advice, online support, and good practice examples to evaluators in developing and developed countries.

Reshaping Development Evaluation

Philanthropists and development practitioners have a golden opportunity to join together with grantees and partners in developing countries to reshape evaluation to better respond to global change and to serve our missions and goals more effectively. To do this, we must be prepared to rethink and reshape our evaluation practice in at least four ways. We must:

1. Embrace a broader set of voices in framing our approaches to evaluation.

2. View collaboration and partnerships between developed and developing areas as mutually beneficial toward a common goal of expanding and sharing evaluation knowledge as a public good aimed at achieving better development outcomes.

3. Recognize the need to address issues of accountability, transparency, ethics, culture, and independence.

4. Address asymmetries in individual and institutional capacities for undertaking, driving, and owning evaluation in developing regions by promoting opportunities for professional excellence, networks, and sustained global partnerships in the discipline of development evaluation.

The value of evaluation must ultimately be judged by its usefulness in helping to improve outcomes for target beneficiaries. The quest for impact is currently in the spotlight among foundations and development agencies as we seek collectively to maximize the positive benefits of our resources. We are privileged to work in an expanding field in which our evaluation findings can change lives for the better. Together with our peers, partners, and grantees, we can and should rethink, reshape, and reform the practice of evaluation to better meet that challenge.

See the complete evaluation supplement.

In this article we describe the Irvine Foundation’s approach to performance assessment and discuss some of the lessons we have learned over the past six years. We write from the dual vantage point of having been involved in creating and evolving the foundation’s approach to performance assessment as well as producing the annual report that describes our performance (report preparation is integrated into our assessment process). We define Foundation Performance Assessment as an effort to assess the organization’s performance by examining the various levers by which the institution can achieve its mission.

The Irvine Foundation was created in 1937 to benefit the people of California. In the 75 years since its inception, the foundation has awarded more than $1 billion in grants to thousands of organizations serving Californians. The majority of our grantmaking falls into three program areas: youth, arts, and California democracy. The youth program helps high school students build a strong foundation for success in both college and career. The arts program promotes engagement in the arts for all Californians. And our California democracy program advances effective public policy decision-making that is reflective of and responsive to all Californians. All three areas are guided by our mission of expanding opportunity for the people of California.

The Performance Assessment Framework

A major strategic planning process in 2003 led the Irvine Foundation to streamline its program focus and create a new performance assessment approach. As the result of a comprehensive review and planning process, we updated our mission statement and trimmed six diverse program areas to three.

Once we had identified where we would focus and what we sought to achieve, we turned our attention to how to measure and assess our progress toward achieving our goals. We assembled an ad hoc committee of board members and staff to help shape this work, and we spent several months studying the best practices of other foundations that were pioneering foundation performance assessment. Although a few foundations—most notably the Robert Wood Johnson Foundation—stood out, we concluded that few foundations were taking a comprehensive approach to performance assessment, and there was therefore an opportunity for the Irvine Foundation to contribute to the development of new ideas and approaches in this emerging area.

With the few existing models in mind and the knowledge that foundation performance assessment was still nascent, we created the Performance Assessment Framework. With the Irvine Foundation board of directors as the primary audience, the framework addresses six areas—the first three focusing on our programmatic work, and the remaining three providing a more institution-wide view.

We evaluate our performance in these six areas by asking the following six questions. The results of this inquiry provide the basis for our yearly report to the board.

1. What is the context in our program fields? This section of the performance assessment outlines information that helps our board understand how the Irvine Foundation’s work fits in a broader context. For example, we include external indicators and new research findings that are relevant to our program goals. We also report on grantmaking by peer foundations in similar areas. Board members have indicated that this context is valuable to their deeper understanding of the challenges and opportunities we face in each program area.

2. What progress are we making toward our program goals? This section reports on evaluation findings and program progress indicators that track the impact of our grantmaking. The progress indicators are developed by each program team and cover a range of information, both quantitative and qualitative. The indicators are organized by the goals and priorities in each of our programs. In many respects, this section covers much of what is traditionally considered to be “evaluation” of a foundation’s work.

3. How do lessons from our program work improve our approach? This section discusses how we have used our grant monitoring, evaluations, and other engagements in the field to inform and refine our strategies and implementation. Because the Irvine Foundation’s philosophy of evaluation is guided by continuous improvement and refinement, much of our work with the board during the year focuses on this set of questions. In this section of the annual performance report we summarize our activities and reinforce our commitment to ongoing improvement.

4. How is the foundation exercising leadership in the field? This section, which shifts the focus from specific programs to the broader organization, assesses the ways we can use our leadership platform and voice to extend our impact and advance the foundation’s mission. We do not presume that leadership is conferred upon us by virtue of our resources, but we are also mindful that foundations can play important leadership roles, especially when done with humility and through authentic partnership. Here we assess leadership activities undertaken by the foundation as well as ways we help to frame discussion, often via publications. We are beginning to integrate social media measures into this work.

5. How do key stakeholders perceive us, and how do their perceptions inform our work? This section reports feedback we have solicited about how important constituents view the foundation—typically collected by third-party surveys, confidential interviews, or other organized fora. We typically include results from Grantee Perception Reports administered by the Center for Effective Philanthropy, website user surveys, and other constituent feedback activities. We have found that the self-imposed requirement for external feedback to include in our annual report encourages us to identify more feedback opportunities than we might otherwise—a good development.

6. How are we performing on measures of financial health and organizational effectiveness? In this section we track a number of indicators related to the foundation’s investment performance, operating ratios and costs, board and staff diversity, and institutional developments. In contrast to other parts of the report, for this section we are able to draw on ready sources of financial benchmarks for comparable institutions in the field and for the foundation’s past performance.

It is important to note that when answering these six questions, we operate with the assumption that the measurement needs to fit the subject matter. As much as possible, we rely on quantitative data for maximum precision and clarity. For some topics in our framework, such as exercising leadership or gathering constituent feedback, a quantitative approach may not be as useful, so we try to balance the quantitative and qualitative.

Evolution, Refinement, and Improvement

Our Performance Assessment Framework has evolved using feedback from the board and our experience creating and using the annual performance reports. The most important evolution has been to change the sequence and emphasis of topics. The framework initially led with a review of new grantmaking during the reporting year, but we have reorganized the report to focus attention on the progress and results of our previously awarded grants. We include a grantmaking summary as an appendix to the annual performance report, but we rely on quarterly dashboards to keep the board members up to date on recent approvals.

An important goal in creating the Performance Assessment Framework was to create a view of the foundation’s work as a whole rather than as a series of parts. It was the quest for a holistic view that motivated us to organize the report by topics—the six questions—rather than by programs. That said, as a multipurpose foundation, we have three very distinct bodies of work in our three core programs, so although we take stock of the foundation as a whole, we do not attempt to aggregate measures into a single index for the foundation. Rather, we weigh progress and challenges to learn from each.

Audiences for Assessment

Over time we have broadened our thinking about the audiences for our performance assessment work. The main audience for our annual performance report is the foundation’s board of directors. The report is one of the primary deliverables for our annual retreat at which we conduct in-depth conversations with the board about our work. As part of the evolution of our framework and with our board’s feedback, we came to define three additional audiences for our performance assessment work.

Our staff, especially the program staff, are a second important audience that can derive benefit from both the assessment process and results. The annual performance report represents a regular checkin on our ongoing process of strategy development and refinement. Our work in evaluation and performance assessment helps focus program staff on the goals and outcomes for their grantmaking. We have found that challenges in performance assessment often help uncover areas where our strategy needs refinement and elaboration. The process of reviewing progress indicators and other material to develop the annual performance report helps us reflect on how the progress we’ve made should inform the work ahead.

In addition to the two internal audiences, we believe that the analysis in our annual performance report can provide grantees and other funders—our third target audience—with a better understanding of how we define success in our work. Over time, we believe this understanding can facilitate collaboration toward shared goals. We reconceived the foundation’s public annual report (which is different from the annual report we provide to the board) to integrate performance assessment content so that our grantee partners have easier access to the information.

The general public is a fourth, although lower priority, audience. By including more performance assessment in our public annual report and making it generally available, we seek to contribute to a broader understanding of philanthropy’s role in society beyond the grantmaking transaction.

Lessons Learned

Literature on measurement and evaluation reminds us that consciously building in opportunities for learning will help us use our results in actionable ways. At the Irvine Foundation, that wisdom has helped to guide our approach to performance assessment across the foundation. From the beginning, we knew we were experimenting; building on the work of pioneers in foundation-wide assessment, such as the Robert Wood Johnson Foundation. We also knew we did not have the answers, and now, after six years of creating and evolving our framework, we know that we still have more to learn. At the same time, we are equally persuaded that our commitment to foundation-wide performance assessment has made us a better foundation—one in which a culture of reflection, learning, and refinement has become even more pronounced, and in which we actively find ways to use what we learn from performance assessments to improve our strategic thinking and, by extension, to deepen our impact.

Recognizing that our assessment framework remains a work in progress, we offer the following three lessons in the hope that they may inform others who are interested in foundation-wide performance assessment.

Lesson 1: The traditional structure of philanthropic activity can conflict with a commitment to performance assessment, so it is important to address related barriers and incentives.

Incentives within foundations are typically organized around the core activity of awarding grants. The IRS mandate to spend grant dollars annually helps to drive the requisite work of grantmaking—proposal review, site visits, docket preparation—all leading up to board decisions about grant awards at designated intervals throughout the year. When one cycle concludes, another begins—or more often, cycles overlap and docket deadlines are constantly looming for foundation staff. We have concluded that this structure tends to discourage careful reflection, thoughtful analysis, and distillation of lessons learned. Often, these activities are considered luxuries at their best and distractions at their worst.

For a foundation to embrace fully a commitment to institution-wide performance assessment, careful consideration must be given to addressing this structural barrier, which tends to focus us primarily on the next deadline at the expense of what we are learning and how we are using that learning. We have discovered a related temporal challenge. Because of regulations related to payout, grant budgets are often organized around an annual calendar. Our program goals and aspirations rarely follow annual timelines, nor should they, if they are sufficiently ambitious in scope. So how do we reconcile these different timelines?

At the Irvine Foundation, the discipline of producing an annual performance report to our board (and then sharing it publicly) has oriented us toward a sharper focus on reporting progress, not necessarily final results. To do so, we have had to orient ourselves toward identifying shorter- and medium-term indicators and measures of progress that we can track and report on in annual increments.

The need to clarify these indicators and measures of progress has been a valuable contribution to our strategy development and refinement as well, because it has forced us to articulate more clearly both the logic and sequence of outcomes we seek. We believe that any foundation committed to assessing its performance must determine how best to keep the grantmaking work moving forward while creating the space for consideration of broader progress assessment.

Lesson 2: Foundation performance assessment both requires and fosters a culture of reflection and learning that can lead to ongoing refinement and program improvement.

Much of today’s business literature speaks to the importance of building adaptive organizations that stay closely attuned to their external environments and retool strategies in ways that align with that ever-shifting context. Although foundations do not necessarily think in terms of “competitive advantage” or worry about going out of business, foundations do have an obligation to remain attentive to the context of their work.

Similarly, we need to find ways to create feedback loops that permit us to use what we learn to improve our strategies. A promising development over the past decade has been a more intentional focus on evaluation for learning and improvement rather than simply for auditing purposes or declaring success or failure. Although we certainly need to use evaluation to guide our understanding of whether we are succeeding or failing, we stand to benefit significantly if we can use what we learn to improve our strategies and their execution.

In this respect, performance assessment is inextricably linked to program strategy, and it has been our experience that a focus on assessment has improved the rigor and logic of our program strategy. As previously noted, a key contribution of this process has been defining progress indicators that allow us to determine whether we are making the kind of progress we seek in the short term, and if not, to understand what that might imply about our strategies. We have discovered that even the process of identifying these indicators can help us to surface possible instances of underdeveloped strategic thinking or unrealistic expected outcomes.

A commitment to foundation performance assessment can force us both to consider context and to build in opportunities for learning. From the beginning, our Performance Assessment Framework contained a section on what we call “program context.” It was designed to encourage us to collect data about the contextual issues related to our programs. We also annually collect data on other philanthropic investments in the particular areas we fund. Examining both of these contextual data sets helps us understand better how we view the foundation’s contribution and track other philanthropy and the broader trends in our focus areas. Interestingly, this contextual data has been one of the areas that our board has found the most interesting. It has helped them to position our work in a broader context and has encouraged us to find other ways to expose the board to the environment and context for the foundation’s efforts.

Understanding the context and reflecting upon our learning, however, can be useful only if it can then be translated into action. This is where we have tried to demonstrate our commitment to adaptability without falling prey to a tendency by foundations to embrace the issue of the day. For example, in our California democracy program we have remained focused on the goal of advancing more representative public policy decision making. As we have approached this priority from different angles, such as voter mobilization and civic engagement, the program team has analyzed the products of its grantmaking and adjusted its strategy as appropriate.

Lesson 3: Successful foundation performance assessment requires both buy-in and engagement from stakeholders at all levels.

The old adage that “leadership starts at the top” holds true for foundation performance assessment. Without demonstrated commitment and visible leadership from the board, the CEO, and other senior officers, foundation performance assessment simply cannot succeed. We put it this starkly because the effort required for foundation performance assessment mandates full institutional commitment and cannot be the province of just the evaluation director.

Obtaining the buy-in of the board from the very beginning was essential. We created a board task force to help us design our approach to foundation performance assessment, and from the outset we viewed the board as the lead initial stakeholder. We did so because we believed it would advance board members’ understanding of the foundation’s progress and impact—an important outcome by itself—but we also knew it would signal both internally and externally just how important this work was to the foundation.

For the process to take hold, it also requires broad-based buy-in from the staff. We were perhaps well-served by the fact that our foray into foundation performance assessment coincided with the adoption of a new strategic plan and the staff change that often accompanies a shift in new directions. The foundation’s staff embraced this approach from the outset, and it became part of the way we did business. Nonetheless, we recognize the need to ensure that staff view performance assessment not as an additional burden, but rather as a tool to inform better decisions.

Conclusion

This article explains how we have structured and evolved our foundation’s performance assessment. We are eager to share our approach, not just because we are persuaded that adopting an institutional view of performance assessment can improve a foundation’s work, but also because we want to create a broader community of foundations committed to learning from each other about this important dimension of our work. Fortunately, we have moved beyond the question of whether measurement and evaluation are useful, but there remains much to be explored about how the tools of measurement and evaluation can be applied across a foundation’s work. That’s where we have been experimenting for the past six years and where we know we still have a great deal to learn.

Among the questions that we have yet to explore is how an approach to foundation performance assessment can work in organizations of different sizes and scopes. Although the Irvine Foundation is a relatively large foundation, we are also regional in scope and focus on only a few program areas. How this approach can be applied in a foundation with a broader mandate and more diverse portfolio of grantmaking remains an open question.

We hope this contribution to the body of knowledge on performance assessment can support robust exploration of questions such as these. In the end, our institutions exist to provide a public benefit, and we must therefore embrace opportunities that might enable us to deliver on that promise more effectively. We believe that a commitment to foundation performance assessment offers one such opportunity, and we know there are more experimenting to be done, more learning to be accumulated, and many stories to be shared.

See the complete evaluation supplement.

In recent years, the philanthropic sector has neared consensus on the need to improve measurement and evaluation of its work. Although the philanthropies they lead use different methods, members of the Aspen Philanthropy Group (APG) have agreed that basic principles and practices can inform efforts to monitor performance, track progress, and assess the impact of foundation strategies, initiatives, and grants. They hope to build a culture of learning in the process.

Over the past two years these CEOs of private, corporate, and community foundations have supported a series of meetings on measurement and evaluation (M&E) with leaders of grantee organizations, issue experts, and evaluators. They have concluded that, when done right, assessment can achieve three goals. It can strengthen grantor and grantee decision-making, enable continuous learning and improvement, and contribute to field-wide learning. Below are broad observations from the workshop process, followed by articles from five APG authors describing the M&E philosophies of the institutions they lead. Their articles will be among those to appear in an edited e-volume, to be published by the Aspen Institute and continuously updated to capture evolving foundation practice and comments from voices in the field. This is what we learned.

Definitions Matter | APG members found that differing terminology can undermine efforts by grantors and grantees to collaborate effectively in the design and implementation of an M&E system. Many grantors and grantees use the terms “evaluation,” “impact measurement,” and “measurement and evaluation” interchangeably. In fact, M&E encompasses distinct activities with distinct purposes, methods, and levels of difficulty. In his article, William and Flora Hewlett Foundation president Paul Brest separates M&E into three categories undertaken at three stages: theories of change described and logic models devised during the initial design of a project or foundation initiative; tracking progress against the strategy set during the life of the grant or initiative; and assessing impact after the fact. The first of these is essential background for M&E, and the three together provide a useful means of organizing the various activities and purposes of M&E. The second enables a grantor and grantee to gain the information needed to make mid-course corrections to the strategy and learn throughout the process. The third activity—assessing impact—is the most daunting. Brest notes that in some undertakings, such as policy advocacy or Track II diplomacy, exogenous influences make it hard if not impossible to attribute impact to any one actor or strategy. He argues for demonstrating “contribution” rather than claiming “attribution,” where contribution means increasing the likelihood of success, and notes that the true impact of such “risky” grants may not be possible to ascertain. Nonetheless, they are well worth pursuing.

Purpose Matters | At its best, M&E informs decision-making and provides for continuous learning. In his article, Matthew Bannick, managing director of Omidyar Network (ON), discusses why M&E is more likely to be used—and used to good effect—when it is designed collaboratively by grantor and grantee, and when data are gathered and organized around decisions that each needs to take. It is therefore critically important that they agree on their evaluation approach at the outset. Ford Foundation president Luis Ubiñas agrees, adding that “from the very beginning, grantees should have a clear sense of what benchmarks of success are expected of them at each stage of initiative development”—and why.

The Cost-Benefit Ratio Matters | Ubiñas points out the costs of M&E, arguing that in designing an evaluation system, careful consideration must be given to the burdens on each party. Failure to do so, he writes, can lead to “excessive data gathering” in which grantor and grantee gather as much data as possible in search of evidence of impact. The costs are fourfold. “First, it is a burden to grantees, creating surplus work for often tightly staffed and financially strapped nonprofits. Second, it undermines quality because grantees will provide the requested information to meet their grant obligations, but may not have time to supply the insight that is often more valuable than the data. Third, it inundates foundation staff with information but may leave them little time to use it effectively. Fourth, it may not provide the information that is actually needed to understand how effective our initiatives and grantmaking are.” According to Bannick, ON reduces the burden by using a limited number of easily collected metrics, and, as an alternative to the “time-consuming, costly, and complicated challenge of measuring impact,” ON often measures outputs as proxies. As for the price tag, Rockefeller Foundation president Judith Rodin notes the efficiencies gained by using technology to gather real time data. Brest notes (in Money Well Spent, coauthored with Hal Harvey) that “if you are a philanthropist with a long-term commitment to a field, it is well worth putting your funds—and lots of them—into evaluation.”

Culture, Context, and Capacity Matter | M&E requires a commitment to building capacity within foundations, grantee organizations, and the field of evaluation in general. The Rockefeller Foundation invests in M&E teams in both the developed and developing world to monitor foundation initiatives and to act as “critical friends” to its grantees, establishing monitoring and learning systems where none existed. The goal is to facilitate learning among grantees and within the foundation aimed at improving performance all round. But most important, it is to leave behind greater capacity among local M&E professionals. Rodin reports that the foundation has supported regional institutions that train and mentor local evaluators and partner with similar institutions elsewhere, with the goal of building lasting capacity. Bannick speaks to the importance of providing technical assistance to grantees. And, within a foundation, James Irvine Foundation president James Canales notes, it is important for there to be leadership by trustees and senior officers, as well as a readiness to devote time, dollars, and expertise to assessing the philanthropy’s strategy, initiatives, and grants. Doing so “mandates full institutional commitment and cannot be the province of just the evaluation director.” Beyond these important tangible contributions lies the requirement for building what Ubiñas calls an “impact culture” in which continuous learning and adaptation are enabled, required, and rewarded. “Goals, theories of change, and operating approaches are all necessarily imperfect; only by learning from our successes and our mistakes can we build an impact culture,” he writes.

The Unit of Analysis Matters | The good—and the bad—news is that almost any activity can be evaluated. It is important to sort out the different units of analysis, as is done in the Bill and Melinda Gates Foundation’s Guide to Actionable Measurement, which notes three distinct areas of focus. At the level of foundation strategy, the focus should be on measuring outcomes over impact (as Bannick describes), on assessing contribution rather than attribution (as Brest recommends for certain grants), and on the degree of harmony that can be achieved among grantees pursuing a given strategy. At the level of foundation initiative, the foundation should use grantee reporting data on outputs and outcomes to signal whether the initiative is making progress; track the program team’s activities other than grants (such as convening and public speaking); use independent evaluation; and capture both intended and unintended consequences of the initiative. And at the level of the individual grant, the foundation should align expected grant results with strategic intent; work with the grantee to track grantee inputs, activities, outputs and outcomes at critical points to manage and adjust each grant appropriately; and measure the foundation’s input of human, financial and technical resources.

Timing Matters | Just as the units of analysis differ, so too do the time horizons required to measure and evaluate the performance of a foundation’s strategy and grants. Many short and medium-term metrics are useful in assessing how well an organization is managing processes or reaching target populations. Longer-term longitudinal studies are critical to gauging the impact of a program and to establishing the causal relationship between intervention and desired outcome. Such rigorous, long-term studies can be particularly useful for those seeking to scale up innovations. Canales notes, however, that the annual grant-cycle poses a “structural barrier” to the longer-term undertaking of evaluating and learning, noting that “program goals and aspirations rarely follow annual timelines, nor should they...if they are sufficiently ambitious.” He points to the importance of “creating the space for consideration of broader progress assessment.”

Feedback from Grantees and Beneficiaries Matters | M&E must incorporate into the process the viewpoints and observations of the funder, grantee, and ultimate beneficiary through all stages of work—identifying problems, co-creating solutions, and implementing with a shared vision of outcomes. Under the leadership of APG member Carol Larson, the David and Lucile Packard Foundation solicits feedback from the on-the-ground staff of the grantee and has established written standards to help its program team to communicate with grantees. Grantees, in turn, can better assess community needs—and their performance in helping to meet those needs—when program beneficiaries provide them quantitative and qualitative feedback. At Ford, Ubiñas notes that the foundation selects grantees “managed by those living and working closest to where targeted populations are located.” Noting the Rockefeller Foundation’s commitment to evaluation practices that include stakeholders’ voices, Rodin cites the consensus of the Africa Evaluation Association: “only when the voices of those whose lives we seek to improve are heard, respected and internalized in our understanding of the problems we seek to solve” will philanthropy achieve its purpose.

Transparency Matters | Although the goals of M&E are to inform decision-making and enable continuous learning by those immediately involved, there is a larger community to serve and a larger purpose to pursue. By publicly sharing the data gathered and conclusions reached, grantors and grantees can contribute to field-wide learning. APG members agree that this is an opportunity to seize. The philanthropic sector has helped build communities of practice that generate knowledge. These evaluators form professional associations that set standards for the field. Independent organizations assess foundation and grantee performance and publish their findings. Donor organizations and networks transfer knowledge among philanthropies, and between grant-making institutions and individuals. And academic programs provide the intellectual underpinning for much of this work. Supported by philanthropy, these and other institutions provide some of the early hardware for wider impact. Moreover, the gradual evolution of principles that guide and practices that enable rigorous evaluation can contribute to its software.

But has a true system for philanthropic impact been designed and widely adopted? Perhaps not. And so, in publishing an e-volume and opening a conversation, Aspen’s Program on Philanthropy and Social Innovation will seek the wisdom of the crowd and ask the questions: What might the components of such a system be? Where will the breakthroughs occur? What sort of venture capital will be needed to finance the prototypes? And what markets will bring these innovations to scale? Or, building upon Ubiñas’s apt phrase, under what conditions might an “impact culture” spread? What would it take for its language to be adopted, its standards embraced, its methods refined, and its potential realized? And if that culture is to be global, dynamic, and enduring, how might it be informed and advanced by the new cadre of evaluators to which Rodin refers?

None of the architects or beneficiaries of modern-day philanthropy would claim that they alone can create such a world, but they may well agree that it is one worth imagining. Doing so together would make for a powerful beginning.

See the complete evaluation supplement.