This paper responds to questions that people have asked about a Health Promotion Foundation in BC. The concept of a Foundation evolved over the past four years, following extensive consultation between the BC Coalition for Health Promotion (BCCHP) and individuals, organizations and frontline workers across the province. Through our research and community development, it became evident that communities need sustainable funding to address the determinants of health. The Frequently Asked Questions (FAQs) that follow are based on the values and principles of the Ottawa Charter for Health Promotion (WHO, 1986) and describe what a Health Promotion Foundation in British Columbia might look like. (See also our Implementation Plan – DOC.)
1. What is community-inspired health promotion?
Community-inspired health promotion refers to planned actions, generated by the grassroots, in which people are empowered to have greater control over the advancement of their own physical, mental, spiritual and social wellbeing. This approach acknowledges that citizens know best the strengths and challenges of their own communities. Community-inspired health promotion is most empowering when solutions are effectively supported through funding, information, learning opportunities, and technical assistance.
The following vignettes demonstrate community-inspired health promotion in action:
- Parents, advocates and frontline professionals come together to address issues associated with Fetal Alcohol Spectrum Disorder (FASD). They sponsor a community-wide conference, form a nonprofit society, publish a book of poems written by a parent, participate in a national CBC video and hire young people with FASD to be spokespersons for individuals and families living with the consequences of fetal exposure to alcohol.
- When young aboriginal mothers get together once a week to cook healthy meals for their children, they learn the benefits of fresh fruits and vegetables, how to use recipes, to budget, to shop for food and prepare healthy meals. They discover the advantages of bulk purchasing. As they spend time together, they not only discover the value of working together so their children can eat healthy foods, they learn from each other about their children's development, parenting, and about opportunities in their community.
- Thomas, who looks after his wife with Alzheimer's, is surrounded by a circle of friends facilitated by the Family Caregiver's Society. They support him with caring and compassion, in his own home and community by offering the gifts of friendship, respite, emotional support and time-out.
- When Dr. Peter realized he was dying from AIDS, he decided to share his experience and, in doing so, help the public, and in particular gay men, to understand more about HIV/AIDS. Each week on CBC television he told his story and outlined in detail what the disease was doing to his body. Through these broadcasts, Dr. Peter touched the lives of many people and offered practical advice on how to avoid becoming infected.
- The mother of a new-born creates a network of peers who meet weekly in each other's homes to exchange tips on parenthood; the young mothers are reassured by mutual support and by sharing information that helps them to effectively access community resources.
- Labelled mentally ill and drugged by the psychiatric system for almost 40 years, Daisy overcomes her addiction to prescription drugs. Aided by her psychologist, friends and faith community, she becomes an advocate, mentor and role model for others who are struggling in similar circumstances.
- Non-profit groups meet to create a Good Food Box Collective to address the nutritional needs of families in their area. The goal is to encourage young mothers and others unfamiliar with using fresh fruits and vegetables, to prepare healthy meals. Using group purchasing power, the Collective provides a recipe and a box of wholesome produce at a reduced cost of $10 to recipients. Under the direction of a coordinator who makes bulk purchases, volunteers divide the fruits and vegetables into boxes and deliver them to distribution depots for pick-up by the customer. The challenge is to find funding to pay the coordinator, since the $10 collected goes towards the purchase of produce.
These vignettes demonstrate the capacity of citizens to join together and use their talents and inner resources in ways that benefit themselves and others. They show how individuals, organizations and frontline workers can transform their ideas and creative energies into collective action by responding to the priorities identified by people within their own communities.
2. What are the Determinants of Health?
Our health is influenced by income, food security, equality, social inclusion, education, housing, childhood development, cultural diversity, the environment, genetic predisposition and health care. These factors are among the determinants of health. They are impacted powerfully by the actions of individuals and communities and are the focus for financing health promotion initiatives in British Columbia. The BCCHP funding framework and implementation plan highlight the vital role that communities play in linking funding organizations with the determinants of health.
3. Why is a Health Promotion Foundation needed in BC?
Health Promotion Foundations provide protected, sustainable funding for community-based initiatives that address the determinants of health. Some of these initiatives require technical and financial support, while others do not. Community aspirations often are accompanied by struggles to find even a modest amount of funding. Under current funding practices, the experience and self determination of communities can be undermined by top-down decision making and reliance upon expert knowledge, a situation that is compounded by the inequality of power and resources between funders and community agencies. To address emerging and ongoing issues, organizations must juggle the following options: align their mandates, goals and objectives with funder-directed guidelines and priorities; wait until the "right" opportunity surfaces and then apply for funds; submit applications for a single project to several different sources, all varying in format and criteria; go without funding and continue to depend solely on volunteers; or give up pursuit of the initiative altogether.
4. What will a Health Promotion Foundation fund?
A Health Promotion Foundation in BC will fund concrete and effective community action in setting priorities, making decisions, planning strategies, implementing activities and evaluating them to achieve better health (WHO, 1986). It will support initiatives with values and processes similar to those in the vignettes described in question #1.
5. Who will be on the Foundation's Board of Directors?
Consistent with international examples, the Foundation will need to be legislated by an Act of Parliament but remain at arm’s length from Government. The Board will have a minimum of 51% grassroots representation and, therefore, not consist solely of people in power. Members must be competent, willing to expend effort and represent the "real" community. Board participation will be voluntary with emphasis given to cultural diversity, rural representation, and individual and organizational representation chosen on the basis of job descriptions and interviews. People with experience and training will be recruited at all levels of the organization.
6. How will the Foundation's Board operate?
The Board must have a strategic plan that is implementable, reasonable and achievable. Its primary focus will be community building, promoting capacity, outreach and personal visits to communities. Decisions will be made locally by an independent body of local people, thus avoiding the resentment that can occur when outsiders make decisions about allocations. Financial administration should ensure that governance is funded separately from the activities of the Foundation. So they not be viewed as government employees, Board members will not be paid. Clear lines of accountability will be needed: staff will be accountable to the Board of Directors and the Board will be accountable to grant recipients and those who finance the Foundation, e.g., Governments, corporations and the general public.
7. What ethics will guide the work and relationships of the Foundation?
The Foundation will take a holistic approach to all activities and operate in an open and transparent manner. It will focus on solutions and share responsibility and power concerning its decisions. It will be accessible and flexible. Work of the Foundation will be supported by an underlying faith in the capacity of communities to do what they say they will do, given appropriate assistance and support. The values of respect, equity, social justice, inclusion and compassion will be integral to all operations.
8. How will the Foundation ensure that its values are put into action?
Strategies will include the use of well-defined criteria that are based on health promotion values and principles. Staff, Board and volunteers associated with the Foundation will make a commitment to being part of a learning organization, understanding the strengths and capacities of communities and placing an emphasis on networking and open communications. They will collaborate with communities to promote meaningful partnerships and good working relationships amongst different groups that share similar values.
9. What principles will guide the Foundation in its work with communities?
The Foundation must be visible, minimize hierarchy and function in a way that is empowering to communities. It will operate in a positive, supportive manner, assist with referrals and never say "no" without explanation. Criteria will be kept to a minimum with consideration given to the applicant's understanding of health promotion, the group's level of involvement in its own community, non-duplication, cooperation on ventures, and inclusion of diversity such as the environment, sports, and the arts. Guidelines will reflect the broadest understanding of community through use of plain language, outreach, community visits, and involvement of marginalized people at all levels. To understand how funds are allocated, the Foundation will need to know what currently exists and what innovative approaches can be employed. Once regional boundaries are defined, efforts will be made to tap into existing local application processes, e.g., with municipal governments and committee structures such as Social Planning Councils.
10. What kinds of assistance besides funding will the Foundation provide?
Characteristically, Health Promotion Foundations offer training opportunities and enhance learning and information exchange through website communications and sponsorship of conferences. They facilitate bridge-building, promote mentorship, provide forums for exchange of ideas and foster partnerships and collaborations across groups, e.g., matching relationships between corporations and business sponsors. Written materials, such as evaluation frameworks, lessons learned, and examples of what works well are also helpful.
11. How will the Foundation be linked structurally to communities?
Funds will be divided geographically with decisions made locally. It will be essential to respect the unique characteristics and relationships within each region. Using these guidelines as a starting point, community organizations might prefer direct contact with the Foundation or choose a process of regional representation with local committees that can provide feedback, make decisions and distribute funds. Geographic advisory committees are one option and would include representatives from the various communities submitting proposals. The Foundation's role will be to ensure that local or regional groups are representative of the proposals submitted and the communities served.
12. Where will the funds come from to finance the Foundation?
Funds will be accessed from a combination of sources, e.g., public and private, and be guided by ethical fundraising principles and consistency with health promotion values and principles. They must be removed from political influence. Government will contribute but not control operations of the Foundation. Building partnerships amongst funders will assist in pooling resources and improve coordination of funding priorities through a cost-shared grants process. To ensure sustainability of funding sources, it will be important to maintain a good relationship with donors via annual reports, newsletters, website dissemination, conferences, publishing health promotion journals, networking, word of mouth and special events. The Foundation will require core operational funds separate from those which are distributed.
13. How will the Foundation's funds be distributed?
Funds will be distributed according to the strengths and priorities identified by communities, ensuring that there is compatibility of values between the Foundation and the applicant. Distribution guidelines must be flexible and fair with the intention of reducing barriers and minimizing rules and regulations for applicants. It will be important to align funding with desired outcomes, while at the same time, allowing for a change in direction as projects proceed. British Columbia communities have recommended the following guidelines:
- Do not attach distribution of funds to themes, groups, trends, best practices, or other current political priorities.
- Base funding on merit, rather than who knows who.
- Ensure inclusion of marginalized populations and those with unique needs, e.g., make provisions for funding transportation requirements in rural and northern areas.
- Avoid duplication, build on what has gone before and do not fund what can be funded elsewhere.
- Reduce fragmentation by encouraging applicants to demonstrate partnerships and community buy-in, to show that they are in concert with community.
- Be willing to experiment, take risks and tolerate ambiguity.
- Streamline grant application and approval procedures, have flexible timelines.
- Do not penalize a group for having existing funds.
- Allow for inequities in the ways that groups write proposals with awareness that those which read well do not always represent the greatest need.
- Advise unsuccessful applicants by letter; look for solutions by referring good projects that do not fit the Foundation's mandate.
14. How will the Foundation relate to provincial Health Authorities?
Health authorities are funders in their own right and will be viewed as potential partners in the funding process.
15. What kinds of projects will the Foundation fund?
When funding projects, the Foundation's primary commitment will be to address issues important to communities, thus promoting community investment and ownership. Both short-term and long-term projects with grants of 3-5 years will be funded and will be inclusive of funding for administration costs. Our research has identified the importance of acknowledging the long-term nature of health promotion and ensuring sustainability through contributions to core funding.
16. How will decisions be made when there isn't enough money to go around?
The Board will make high-level allocations only. Communities will identify the criteria, set priorities and collectively decide what projects are funded. When requests for funding exceed the amount available, the Foundation will engage in a community consensus process, a third-party facilitation model that increases transparency and supports the values of health promotion. This approach reduces bureaucracy and lessens competition by facilitating truer, more legitimate partnerships. When people come together they learn to think holistically. Distribution is more equitable because funds do not necessarily go to the best proposal writer and groups that participate gain understanding as to why their proposals are, or are not, accepted.
17. How will the Foundation be evaluated?
The Foundation will be a model for others, conducting regular self-examination to ensure consistency with its values, goals and objectives. Evaluation methods might include confidential surveys to past and present grant recipients and to those who had been declined funding in the previous year. Some Foundations carry out social audits every two years; others engage in a multilayered process that includes evaluation by the groups receiving funds and partner organizations, an external evaluation examining one focus area per year, and Board assessment of performance and review of the organization as a whole.
18. What guidelines will contribute to the evaluation process?
The Foundation will implement a community assessment of how well the funder and the funded groups are doing their jobs. It must comply with federal and provincial government regulations and be accountable to sources of funds, e.g., to donors (trustees) and Government (Ministry of Health). Within these guidelines it is suggested that the Foundation ensure its operations are responsive to community strengths, needs and priorities and that there is flexibility and consideration of the long-term nature of health promotion. In addition, it should place a limit on the amount of money spent on administration and overhead, share information through creative dissemination of results, successes and outcomes and engage in evaluation processes that are outcome-oriented rather than bound by rules.
19. What accountability measures will be used for organizations receiving funds?
The accountability framework will contain a built-in evaluation process for communities to follow, e.g., a series of guidelines or grid charts that can be used by every project. It is recommended that the Foundation be reasonable, make provisions for differing understandings of what constitutes "success", and attach accountability expectations to the amount of money allocated. There will be an emphasis on participatory evaluation methods that combine qualitative and quantitative data and inclusion of people's experiences and stories. External reviews are another option. The evaluation process will be outlined in the proposal and be inclusive of a final report and accurate financial statements.
20. What strategies will maximize the success of the Foundation?
Opportunities for community empowerment are greatly enhanced when people consult with each other and genuinely collaborate to advance the health promotion agenda. These opportunities fall to individuals, community organizations, professionals in the fields of research and community development, funders and various government sectors. Prioritizing health promotion in British Columbia requires a commitment to work together effectively, to build bridges of understanding that are characterized by equity, sharing of knowledge and collaborative long-term planning. To achieve sustainability, this kind of work must be supported at all levels by an enduring source of funding that provides for both short-term and long-term health promotion initiatives.