Moving from Partnership to Collective Accountability and Sustainable Change: Applying a Systems-Change Model to Foundations' Evolving Roles

Keywords: Sustainability, systems change, collective accountability, integrated careIntroductionIn a time of scarce resources and significant needs, funders may seek to maximize the impact of their grantmaking through collaboration. Foundations partner with other foundations to co-fund initiatives, or they partner with advocacy and trade associations to improve the policy environment. Many foundations move well from identifying a problem and needed changes to building broader awareness and forging key partnerships. Typically, though, they flounder in trying to move beyond partnership and collaboration to a sense of mutual responsibility or collective accountability for the greater good, which is a pre-condition for sustainable systems change.The systems-change1 process is complex and dynamic, and involves multiple interrelated players, strategies, and programs. Increasingly funders frame their work as focused on systems change, but too often their initiatives fail to reach their goals (Foster-Fishman & Behrens, 2007). Typically, demonstrations and interventions are implemented to address a problem, yet the result is rarely sufficient to cause a sustainable and permanent change. Institutionalizing and spreading a new approach requires changes in organizational cultures and behaviors, as well as policies, practices, and procedures within and across organizations. For systems-change investments to succeed, it is essential that programs move beyond the immediate goals of a specific intervention and transform into changes that are sustainable beyond the investment of grant funds and the funded initiative.This article provides examples of three complex initiatives that made sustainable changes in integrated behavioral health and primary care. Using a conceptual framework based on the Building Blocks of Systems Change model (Linkins, Brya, & Chandler, 2008), this article focuses on achieving collective accountability and sustainable systems change, highlights common challenges, and presents guidelines for funders. It details how various policy approaches and tools drove cultural transformation in the different funding regions. While the examples are health-related initiatives in Texas, California, and Maine, the conceptual framework and lessons learned apply to a broad range of environments and intended outcomes. These lessons can be used to move initiatives to collective accountability and systems change, so that the change becomes the new "normal," independent of external funding or expectations.Building Blocks of Systems ChangeThe Building Blocks of Systems Change model (Linkins et al., 2008) was developed as a practical conceptual tool (see Figure 1) to help align the activities and expectations of funders and grantees in designing and building strategies to achieve lasting systems and policy change. The model illustrates that the progression toward systems change is dynamic and ever evolving within programs and among the various participating stakeholders and systems. By design, it offers an accessible way to approach systems change by highlighting the key domains of implementation activities that occur during this complex process. Maintaining broad classifications enables the range of stakeholders (e.g., funders, grantees, other partners) participating in systems-change initiatives to identify or categorize where the majority of effort and resources are going and to make adjustments as necessary. There are several key questions associated with each domain of the Building Blocks of Systems Change model that facilitate the development of indicators to assess progress toward systems change within and across organizations and communities. (See Table 1.) These key questions help funders and grantees analyze their work and ground the array of implementation activities within the five domains related to systems change.While systems change is not a linear process, the Building Blocks framework positions the first three domains (understanding the problem, visibility and awareness, partnership and collaboration) of the progression as foundational. …