Public Sector Solutions, Health
In 1733, Benjamin Franklin traveled from his home in Philadelphia back to his birthplace in Boston. Franklin was 27 years old. It was almost two decades before he attached a key to a kite, and more than three before he became America’s first postmaster general. Even in these early days, Franklin had an eye for innovation and that is what he encountered in Boston: The Boston Fire Society, one of the first colonial mutual aid organizations, which was set up to prevent the small house fires that typically led to destructive urban blazes.
On his return to Philadelphia, Franklin wrote a letter to The Pennsylvania Gazette using a pseudonym. In the letter, which he began by stating, “An ounce of prevention is worth a pound of cure,” Franklin suggested that locals follow in the footsteps of Bostonians. The next year, Franklin helped found the city’s Union Fire Company.
The adage has endured. Talk to government officials, and you’ll find that it’s a belief widely shared. In the fall of 2018, Social Finance, along with partners from the Public Health Institute and the Center for Health Care Strategies, did exactly that. With funding from Blue Shield of California Foundation, we set out to ask and answer a question that is at once simple and breathtakingly huge:
What will it take to generate sustainable investments in strategies that promote health and well-being and end violence?
To wrap our arms around that question, we decided we needed a better understanding of the problem itself. If an ounce of prevention really is “worth a pound of cure,” why don’t we invest more in prevention? We decided to ask current policymakers what they thought.
What we heard was honestly disheartening. People were frustrated; baffled by complexity, hamstrung by inertia. Challenges bled into and reinforced one another. In spite of all of it, we also saw kernels of hope. In every interview we conducted, public leaders suggested policy ideas that could help them navigate the challenges they described.
We hadn’t intended to write about either our pursuit of a clearer problem definition, or about policy solutions. But in the wake of these interviews, we’ve done both, broken into two pieces. The first, below, delves into the challenges to prevention that public officials described. The second, linked at the end of this piece, describes what governments and their philanthropic partners can do about it.
The forces that thwart prevention
At times it can seem as though the cards are stacked against prevention. If we haven’t been able to overcome the challenges that stymie prevention funding in the few hundred years since 1735, there must be good reasons.
We see four overarching issues most responsible for under-investment in prevention: uncertainty; a lack of accountability; reactivity; and, underneath these factors, wrong-pockets problems that, in the absence of greater collaboration, frustrate efforts to solve systemic, often dispersed problems.
Uncertainty: There is genuine ambiguity about which programs will achieve policy goals
A central reason we don’t invest in prevention hides in plain sight: Many of the leaders we spoke with aren’t convinced that investments in prevention pay off.
The social sector is flooded with claims of dramatic cost effectiveness, of “proven” programs, of unambiguous success. It’s common practice for nonprofits to claim a social return of $10 or $20 for every $1 spent; anything less seems, by comparison, prosaic. But there is a large and growing body of research that suggests an unwelcome truth: Social interventions typically don’t achieve the results they set out to.
Social problems can be like a Rubik’s cube...They’re complex, interdependent, and hard to solve.
Sociologist Peter Rossi famously summarized this challenge in his Iron Law: The expected value of any net impact assessment of any large-scale social program is zero. Skepticism, then, is usually warranted. Policymakers are right to second guess preventive interventions, even those described as “proven.” The reality is that programs face significant and pervasive performance variability.
We’re missing a more nuanced dialogue about complexity — about more than just what works or what doesn’t, but instead around how something works, for whom, and for how much.Senior California agency leader
Humility in discussing program expectations is too rare, and exaggeration only accelerates the cycle of inflated impact expectations that result in degraded credibility. Of course, there are great interventions out there, making real and measurable impact, and there is enormous value in scaling those interventions. But in the absence of more measured assessments of program impact, those “best bets” can be overlooked or undervalued.
The fact that it’s hard to make a measurable impact on the complex lives of vulnerable people shouldn’t surprise anyone. If most interventions aren’t successful, we should be all the more zealous about finding those with truly credible evidence of impact. But it’s also incumbent on all of us in the social sector to be realistic about the uncertainties that run through our work, and acknowledge that they can be valid barriers to action.
Accountability: Most programs are not measured carefully against preset standards
The public sector is trending toward greater outcomes orientation. But progress is slow going.
In the healthcare arena we are moving toward paying more for outcomes,” a senior public health official explained. “But for now, we are mostly focused on paying for services.
Though every public agency has planning and budgeting processes, few have a clear goal-setting, evaluation, and reconciliation built into their annual cycles. In the absence of specific, measurable, multiyear outcomes goals, accountability — really getting a sense of what works and what doesn’t — is impossible.
At the same time, evaluations — determining which programs work best — are rare. Evaluation is a mechanism without a constituency, seen as wasteful by conservatives and as reductionist by liberals. For elected officials, it’s often preferable to point to positive anecdotes and claim success rather than risk finding negative results.
Structural under-investment in evaluation creates fertile ground for uncertainty. When policymakers can’t rely on trustworthy information about program effectiveness, strong and weak interventions get confused, and the credibility of programmatic impact gets watered down. This makes it hard for policymakers to devote political capital or taxpayer funds to long-term prevention.
The shortage of strong evaluations is, in part, a data access problem. Government caches are carefully protected and rightly so. But the firewalls guarding access to the insights needed for program assessment and improvement have become nearly impenetrable. The promise and value of big data can’t be realized in the face of entrenched conservatism and legal pessimism.
In the past five years, we’ve seen examples of states and counties that have build integrated data systems, and used those frameworks to fund tailored programs — interventions with defined impact measurement criteria, careful evaluations, and outcomes-based funding mechanisms. Examples like these are rare, but they suggest pathways for others to follow.
There’s greater pressure to resolve urgent crises than to prevent them
Prevention involves mobilizing resources today to avoid negative outcomes tomorrow. This is a problem, because elections require officials to demonstrate near-term results and dis-incentivize longer investments.
It’s important to be able to show the results [of a program]...We need to know if things are working, and to demonstrate to the public that their money isn’t going to waste. So many things are the right thing to do but the payoff is long term...No one wants to do work now and get paid far in the future.
Near-term incentives can diverge from long-term interests. Emergencies can eat up resources and political capital.
When things are huge, short-term cost savers, it’s a no brainer [to invest in prevention]...But when it comes to the rest — the important stuff, even things like saving lives — it takes moral leadership.
Underlying it all: Wrong-pockets problems
Social issues don’t fit neatly into agency or jurisdictional silos. Multi-factorial challenges touch on the work of dozens of agencies spread across cities, counties, states, and the federal government.
Consider chronic homelessness. Funding for shelters and rental support flows from the U.S. Department of Housing and Urban Development to local Continuums of Care, which then often receive supplemental funds from state and local authorities. The chronically homeless tend to require frequent emergency department visits and hospitalizations; those health services are partially reimbursed through insurance plans, which are in turn funded via an intricate mix of federal and state dollars. They many need substantial behavioral health support and substance use treatment. They are more likely to be incarcerated (in county jails, or less frequently, state or federal prisons), more likely to require emergency transit (via ambulances often accompanied by city or county fire engines) and to generate (largely city) police calls.
This is all to say, complex social challenges span jurisdictions and agencies. The advantages of solving these issues are therefore diffuse. Yet, there are few mechanisms available that support benefit-sharing between agencies or levels of government. So, the activation energy needed to fund prevention remains prohibitive.
For some issues, greater cross-agency communication and priority alignment may be enough to spur change. For others, deeper partnerships — those with meaningful financial implications, with shared risks, with carefully defined (and sometimes even contractual) terms — will be necessary to make hard choices around program direction, divvy up value and cost, overcome legal and regulatory barriers, and to ultimately build sustainable structures worthy of the challenges they’re up against.
Looking ahead: A more sophisticated public sector
In the face of these challenges, innovators across the country are stepping up.
Forward-thinking public servants are using vast stores of administrative data to improve grant selection and actively monitor performance. Evidence-based policy experts are helping to establish more nuanced criteria for assessing intervention evidence and balancing that evidence against capacity and expected cost. Governments are developing more sophisticated approaches to spending, such as building value-based purchasing models and even using outcomes-based payment terms.
We’re also beginning to see more substantial conversations about social value. In choosing programs to fund, cost is easier to account for than benefit; and while there is a longstanding infrastructure set up to ensure accountability for public spending, there’s nothing like it to ensure accountability for impact. However, new, more effective tools, matched with risk-taking, boundary-pushing leadership, allow more officials to address both sides of the cost-benefit equation.
In the next post, we’ll review various policy proposals meant to counteract the roadblocks to prevention funding. These include strategies for strengthening inter-agency collaboration; enabling multiyear goal-setting; accelerating leadership development and training; simplifying data sharing and use; building communications tools for describing the value of prevention; and cultivating forums for analyzing and agreeing on which programs are the best bets for taxpayers.
Read about these and some of the other policy proposals the Social Finance team collected while speaking with California policymakers on the topic of prevention funding here.
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Written by Jake Segal, a vice president at Social Finance, with support from associate director Annie Dear. This piece was developed through a grant from the Blue Shield of California Foundation, in partnership with the Public Health Institute and the Center for Health Care Strategies.
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