Stewardship, Strategy, Sustainable Financing A Key to Successful Health Transformation: Build Relationships September 22nd, 2017 Lindsey Alexander Senior Project Consultant Pedja Stojicic Project Director Rebecca Niles Senior Strategy Consultant Share Post Several years back, Atul Gawande, a surgeon, public health researcher, and staff writer for the New Yorker, wrote an article on how good ideas spread. In his piece, Gawande detailed the BetterBirth Project, which strives to spread safer childbirth practices in parts of rural India. Gawande wrote: To create new norms, you have to understand people’s existing norms and barriers to change. You have to understand what’s getting in their way. So what about just working with health-care workers, one by one, to do just that? With the BetterBirth Project, we wondered, in particular, what would happen if we hired a cadre of childbirth-improvement workers to visit birth attendants and hospital leaders, show them why and how to follow a checklist of essential practices, understand their difficulties and objections, and help them practice doing things differently. In essence, we’d give them mentors. Gawande’s article suggests that the heart of any real transformation is, quite simply, relationships. While in recent years we’ve become enamored with spreading ideas at the speed of light (think TED talks and the quest for the next viral video), the bottom line is this: effective relationships, which take time, are incredibly powerful. For those of us engaged in the art of regional health transformation, it’s imperative that we step back and reevaluate our relationships, considering both their quality and their quantity; pondering the extent to which they are productive and whether anyone important is missing from the table. Given the imperative of building relationships, we decided to take a look at just how multisector partnerships experience relationships in each of ReThink Health’s three practice areas of stewardship, strategy, and sustainable financing. What do effective relationships look like and what do these relationships enable partnerships to do? Stewardship: Building Relationships is More Than Networking Stewardship occurs when regional stakeholders–leaders, community members, organizations, and others across multiple sectors–align and act around shared priorities, strategies, and vision for fostering healthy people and thriving communities. Effective stewardship is often the key to addressing the core challenges facing multisector partnerships as they strive to transform regional health. In this process of alignment, relationships are critical. Let’s be clear about what we mean by “relationships.” We’ve found that some people confuse building relationships with networking. While networking is done to connect and get informed, building meaningful relationships requires commitment and some degree of openness and vulnerability. Unlike networking, relationships are open-ended, creating the opportunity for growth. It’s similar to the difference between checking how your friends are doing on Facebook and getting together in person for a coffee or dinner. The former will get you informed, but the latter helps you truly connect (and may even take you on an adventure!). Through ReThink Health’s work with regional transformation efforts, we’ve observed that multisector partnerships and integrator organizations with effective stewardship practices form relationships with at least three critical characteristics: Shared values – Shared values is about finding common ground; the areas where you agree. It does not necessarily mean everyone has to think or behave the same way. Instead, you can agree on a few foundational elements: that you want to improve health outcomes or increase economic vitality; or that achieving true systems change requires working together. The best way to create shared values is to explore and share stories that motivate us to act, such as deep personal stories that inspired us to do this work or collective stories that bind us as a community. Our Story of Self and Story of Now tools can help you do that effectively. Clear commitment – Clear commitment is the glue in any relationship. Taking action and following through demonstrate that you care and that you are committed to collaboration. These are indicators that a relationship exists. We often see stakeholders coming together around the partnership table and participating in meetings or networking without actually taking any action between meetings. Without commitment to each other to meet common goals, there is no relationship. A spirit of co-creation – Co-creation of new things is a sure sign of a meaningful relationship. Groups that have good relationships tend to be very productive. They might create a Value Proposition for Health System Transformation, implement successful campaigns to improve population health, or develop new guides or manuals for their partners. If you are not producing anything together, soon you will discover that you are not in an effective relationship. You are just playing it safe–because creating something new requires courage, collaborative energy, and creativity. Strategy: Understanding The Relationships Between Parts of the System Part of being in relationships with other stakeholders is understanding how each sees the multisector partnership and their own organization or sector as it relates to the partnership. It’s about understanding the perspectives of others. Most of us only know and understand one part of the system (our part), and it is only by coming together–and being in relationship with other key stakeholders in our region–that we can get a fuller understanding of the problems we are facing such that we can solve them. Consider the ancient Sufi parable in which five blind men come upon an elephant in the jungle. They each approach it from different angles, grab onto a distinct part, and begin to try to understand it. One grabs a leg and likens the elephant to a tree. Another grabs the tail and insists it is like a snake. A third finds the trunk and thinks the others must be crazy because, to him, an elephant is clearly like a hose. A fourth rubs its skin and believes it’s like a brush, and that the others must be trying to pull one over on him. In the parable, the blind men each have their own ideas about the elephant. They spend some time arguing their positions. And then they leave angry and hurt and distrusting of each other, hoping never to cross paths again. We see a parallel to this parable when we consider strategies for health transformation. People and organizations from various parts of the system are all trying to understand and influence the same thing: the well-being of their region. They bring to this effort their individual experience and expertise as well as their values and efforts. They may come together briefly to discuss new ways of doing things, but this usually occurs with varying levels of disagreement and ultimately ends with everyone going back home to doing things the way they always have. With no mutually agreed upon, overarching strategy for a region driving the actions of everyone relentlessly toward shared goals, change will be anemic at best. In the parable, the primary challenge was of relationship. The blind men themselves did not have a productive relationship, and therefore none understood there to be valid differences in understanding when touching the same elephant. To understand this system, the blind men first needed to master the relationship between themselves. The blind men might have succeeded in building their shared understanding of the system if they would have: Admitted that they could see only a part of the system, and that much could be gained from investing in an understanding of the perspectives of others; Invited others into the conversation by rethinking the invitation list and designing the meeting to ensure everyone had a voice, especially those whose perspectives are most often overlooked; Slowed down and established trust by collaborating on something simpler first before jumping into a hairy debate; and Balanced advocacy for their own viewpoint with authentic inquiry into how others see the system. Once the blind men cemented their personal relationships, they could begin to explore the relationships between their vantage points to build a better understanding of how they are connected. At ReThink Health, we use a palette of systems thinking tools, including the ReThink Health Dynamics Model and the Strategy Portfolio Exercise, to help stakeholders in a multisector partnership build their understanding of how the critical relationships within the health system impact their region’s health. Sustainable Financing: Understanding the Organizational Interests of Key Regional Actors ReThink Health has been preparing a soon-to-be-released financing workbook entitled, “Beyond the Grant.” The title is a clue to our thinking about how relationships play out in financing population health. To sustainably finance operations, multisector partnership relationships must go “beyond the grant,” or think beyond current relationships with funders. Oftentimes, partnership leaders think of relationships having to do with their financing rather narrowly, as in, “I have a relationship with the local foundation,” or “I introduced myself to a local/regional/national funder at the last conference.” This, as referenced in the stewardship section above, is networking, and is not enough for success. Relationships require commitment and action. In financing relationships, there must be a commitment to understanding the business models of key players in your region so that you can truly understand how to effectively bring each player into your work. There’s a lot in that statement so let’s break it down. By “business models” we mean understanding how these key players financially sustain their work. What issues and outcomes do they care about? How do they deliver their services? How do they make money, or generate a profit? How does your work show up in theirs? It is, as Gawande’s article mentioned, about understanding “norms and barriers to change.” What are their business norms? What aspects of their operations get in the way of impactful change? Relationships in population health financing are best analyzed at the intervention level. (Interventions are any of the primary activities that your partnership engages in to advance your mission, such as the Diabetes Prevention Program or quarterly convenings with regional partnerships.) As such, the ReThink Health sustainable financing team has developed a “Considering Costs and Benefits” tool that helps partnerships think through–at the intervention level–how their work impacts others’ business models. For example, imagine you’re planning to advocate for a sugary drink tax in your region and in the planning stage you see that local retailers might be negatively impacted by a decrease in their sales. Since you are in the planning phase, you have options. You can invite the local retailers to the table to explore how best to alleviate the negative impacts–perhaps the tax is phased in, or retailers market more bottled water? Analyzing the business models at the intervention level also helps you spot opportunities and potential partners because you can see where interests align, and where conflict lurks. In the sugary drink tax example, there will be tax revenue. How might that revenue be divvied up to address any negative impacts? Are there powerful players who might come to the table if they got a share of it? Take the Relationship Challenge Cultivating and navigating relationships involves some of the hardest things we can ask of human beings (and the organizations they run). Who among us claims to be adept at navigating egos, power, and business models? While there are no shortcuts in this kind of work, there are ways to jumpstart your partnership’s relationships. The tools linked to throughout this blog introduce ways to explore key relationships and strategies. If you’re unsure where your partnership stands with regards to its relationships, or where to start, ask the following questions of your partnership: Is there clear commitment (remember: commitment means follow through and action) from and between your partnership’s key regional stakeholders? If you’re not sure, on your next partnership meeting ask people to report on things they did with other members since your last meeting to advance the goals of the partnership. Are you missing relationships with any key stakeholders? Check out our full list of sectors that contribute to a region’s health. How well are you balancing advocacy for your organization’s own worldview and interests against inquiring into the concerns and knowledge of others? Consider this brief summary of inquiry protocols and start to apply them. What assumptions have you made about the key stakeholders in your region? (Think about some of the more “powerful” ones, that you have been hesitant to approach.) Schedule coffee or lunch with one of their executives and explore a couple of your assumptions. (Focus on understanding their perspective, not getting them to understand yours.) Have you or will you explore these questions with the stakeholders in your partnership? Have you or will you commit to building more effective relationships with them? Share what you’ve learned about relationships as a means to health transformation by commenting below. The personal views and opinions expressed in this blog (and in any comments) are those of the original authors only, and do not reflect the opinions of The Rippel Foundation or ReThink Health. Neither The Rippel Foundation nor ReThink Health is responsible for the accuracy or validity of any of the information contained in the blog or any comments. All information is provided on an “as-is” basis. Join the Conversation stacy becker Hi Kitty, Great question! I asked myself this same question when preparing the typology. The short answer is that there are “true” reinvestments, although their number is limited. The longer answer is that I will think on this some more, and try to differentiate re-appropriation from reinvestment for those cases where there appears to be overlap.