I initially began writing this book to recount the evolution of ECS, a regional nonprofit organization with programs delivering enhanced evidence-based home visiting models through multiple community-based agencies. We had built a sophisticated organization on the strength of what the model developers and other researchers had identified about how to support mothers and their young children. Our approach from the start was designed to take advantage of what science told us about brain development in young children and to give our children the best possible start in life. ECS was launched and guided by outstanding community leaders, broad-based community engagement, continuous learning and improvement, and an imperative to link science with strong program implementation.

For over 20 years, my accumulated files, articles, and correspondence documented our challenges and our successes. The story, I believed, was one worth telling because although we began with strong support and we delivered the program with vigor, we were highly successful in some areas but less so in others. What, I asked myself, could we have done better? Where did we miss opportunities? What were the barriers to success? What are the lessons for other nonprofit organizations trying to address large social changes or effectively replicate program models?

If you are a leader of a nonprofit organization, what I hope you will draw from this book is a new and perhaps different way of thinking about how one might initiate, manage, and fund a nonprofit. When you consider your nonprofit, how do you address problems? Are you getting outcomes that you didn’t expect? Are you getting sound information to document what is happening in the organization and how you are—or are not—succeeding? Is your funding incentivizing the right behaviors to lead to the outcomes you seek, remembering that budgets are policies? Have you considered the unanticipated consequences of funding and policy initiatives, policymaker changes, and competition? Are you brave when you are called upon to make unpopular decisions, looking squarely at the truth and responding appropriately? Are you taking small steps at first and breaking down the organization into what will attract funding based on need and merit and not what is currently philanthropically popular? Do you lean on accountability for guidance and transparency?

If you are a community leader—from private business, the faith community, a community action agency, other endeavors—what I hope you will take away are ideas about how to promote social good in your community. Are you volunteering your time and talents to help nonprofits succeed? What does your enterprise know that could be shared? Are you learning about the context of the community, the families that live there and the challenges they face? Are you part of the leadership that holds organizations accountable and will guide community change?

If you are a leader in philanthropy, what I hope you will reflect upon is how the narrow funding for demonstration projects does not add up to sustainable change and how to consider investments in longer-term growth and success of nonprofits aligned with your mission. So many foundations ask for a proposal that includes ideas about how efforts will be sustained, yet these are well beyond the control of most local nonprofit entities. And, when demonstration projects show successful results, what role can you play in taking things to the next level of scale and spread, rather than just chalking it up as a strong evaluation? Do you have responsibility to sustain what you have built for the benefit of the community?

If you are in government—in the legislative or executive branch—I hope you will see ways that programmatic and funding silos create limits on the potential for large-scale results in supporting families’ success and in creating optimal conditions for the next generation to grow. How can you use your role to increase opportunities for the service recipient? How can you remove barriers to community development and coordinated action? What I hope all readers will draw from this work is a new and perhaps expanded way of thinking about how our collective efforts can improve conditions for nonprofits and our communities.

Questions One Must Ask Upon Reflection

As I began to assess and reflect upon our work from my new vantage point as the retired program president, I could see the work and our evolution in a different way. I’ve been able to view the larger landscape and consider where we fit. I can be more realistic about expectations, more cognizant of the challenges facing all nonprofits, not just ours. This new perspective was illuminating. When days were filled morning to night with daily operations—budgets, staffing, reports, big and small emergencies—there was little time for reflection or more broad-based thinking. I realized that the ECS story was one worth telling, not to recount in detail how our days unfolded but rather the what, how, and why we were able to have some success but not always be able to achieve everything we set out to do. Rather, ECS was emblematic of a highly successful, well-supported nonprofit existing within a large community landscape where improved program coordination was needed and nonprofits continued to encounter barriers to success. As with many nonprofits, we were limited by various factors beyond ourselves, by structures and strategies embedded deeper in the funding, policy, and community mindsets.[pull quote]

ECS created a new respected institution in greater Cincinnati, identifying partners and stakeholders, creating linkages and systems for service delivery, gaining credibility and trust, and, not insignificantly, maintaining funding for over 20 years.

We were able to exist as a strong program, but we were never able to significantly impact population health, serving only a fraction of those families eligible for our service. A fundamental question is this: Why, when we had most of the tools, community support, and a clear definition of need, couldn’t we serve more families? The answers are embedded in the reasons why most nonprofits can advance only so far—but no farther. The reasons likely include siloed programs, political decision making, policy and funding challenges, family perceptions and misunderstandings about the services, and perhaps deeper root causes that are just coming to light. These are barriers both subtle and overt. Creating a community forum to consider problems collaboratively, not just for ECS but for early childhood programming writ large, was not a priority. The explanations harken back to the early admonition from P&G’s John Pepper to business and community leadership when he asked for support for children ages birth to three, to give them the best possible start in life. “What is it about this that you don’t understand?” he pleaded.

Community-based nonprofits need individuals at the forefront focused on better coordination of services, reduced fragmentation, support for validated outcomes of success, more-accessible resources linked to an overarching emphasis on creating the continuum of service within the community. We need more authentic engagement in the co-design of services and systems, to overcome longstanding systemic barriers. We need a strong, well-respected community forum that includes home visiting as one part of that broader continuum. Collaboration is vital, and that was my second important lesson.[pull quote]

For those who think that a cooperative program delivery to enhance lives is impossible, look at what some other countries can do for their pregnant women and young children. Or, as Pepper once told us, “Our situation (in the US) is morally and ethically wrong. It is unfair for children’s futures to be so influenced by their family income, or by the ZIP code into which they are born.”

This continuum needs to be based not only on “what works best for whom” but also what works best for the community, rather than highlighting one program or another. It means devising a strategy that leads to making hard and brave choices regarding what stays and what goes. It also means that available resources are deployed most effectively so that a maximum impact can be achieved and receive help.

It seems obvious to me now—as a more objective observer—that a central place for making decisions for funding allocations, determining geographic service areas, clarifying program focus, and validating efficacy and equity is required if there is to be community-level change. And finally, what was illuminated was this: How do nonprofits ultimately operate most effectively when, as you have now read repeatedly, they are called upon to solve the most intractable problems with inadequate budgets, low overhead, and often limited information for decision-making? How can entrepreneurship by nonprofits be supported by funders on a more sustainable basis?

What was clear was that even as nonprofits like ECS approach their work with a business mindset and an entrepreneurial spirit, the ability to generate revenue and to help themselves become more independent is limited, because rarely are funds available to support even the most basic exploration of new ideas and new ways of delivering service.

Public monies and private monies are episodic and too-often based on political considerations. Time and again at ECS as we advanced innovative ideas to help families and grow our program, we encountered a wall, an impenetrable wall, and we could not go forward. Rather than having an environment where innovation and growth were valued, we found ourselves in a place where we had to move ahead slowly, if at all, not cause too much confusion and not be seen as too demanding. Most of our initiatives have been detailed in the previous chapters but basically, the wall, the largest impediment, is the inability to garner funds for the infrastructure and structural changes needed to take innovation to market and to scale effective strategies. Some changes are financial, others could address structural racism and poverty and improve opportunity for families.

Missed Opportunities

Nearly all nonprofits are charged with helping to solve big, important problems, frequently seemingly intractable problems. They are called upon to address these problems with inadequate budgets, low overhead, and too often limited information for decision-making. Opportunities to generate entrepreneurial income are stymied because even when they create a product or a strategy with income potential, they don’t have the funds for implementation.

Within these constraints, what could ECS, as a successful program, have done better? Where were the opportunities to create alliances, investigate program operational issues, educate the public, use our resources more effectively? Not knowing if the outcome could be different, with 20 years of knowledge and data, and what might we have done differently? With additional resources, determination, and partnerships we might have:

1. Mined the data file from home visits—nearly 700,000 records—with research to help us better understand the effectiveness of ECS, not only the what but the why. How many home visits does it take to achieve good outcomes? What works best for whom?
2. Developed a stronger and more sustainable funding approach, permitting us to serve more than 20% of the eligible population, to reach more families who would enroll and use our services.
3. Become a learning and innovation lab for the state or region, helping to affect the adoption of tested innovations.
4. Better understood how to deliver quality programming at scale and effect improved implementation—fidelity plus adaptation leads to improvement.
5. More thoroughly disseminated program innovation and enhancements—such as Moving Beyond Depression, Mom’s Groups and community engagement, family success criteria, early literacy, and Let’s Talk Baby—for the benefit of ECS families and the field of home visiting.
6. Secured resources to ensure that ECS’s community engagement efforts were as robust and effective as possible, continuing what we started in Avondale.
7. Built on our pilot project to adopt and sustain tiered teams with clarified roles for home visitors and community health workers, as well as better career ladders for those in both roles in the workforce.
8. Improved linkages with pediatric primary care and other programs sharing common interest and focus, building on our relationship with Cincinnati Children’s.
9. Fostered a stronger early childhood system with a continuum of care through better alliances with related maternal and early childhood programs—beginning prenatally.
10. Placed a stronger focus on a two-generational approach, giving more attention to maternal health, self-agency, and opportunities.

Lessons

The case of ECS is exemplary in many ways, as an example of positive gains and missed opportunities by a community-based, mission-driven nonprofit organization. The primary issue here is not whether the focus is early childhood or housing or nutrition, but rather how we can come together to effectively deploy available resources to really solve societal problems—not to turn our eyes, to present facile solutions, not to despair and be daunted by the scope of the need. How do we work cooperatively in our communities? How do we ensure accountability for effective service delivery, system change, and improved outcomes? How do we structure our partnerships, operations, and financing to ensure maximum success? In essence, how do we collectively adopt innovative ways of thinking about the challenges and effective ways to take them on that are both cooperative and competitive?

There is no foolproof strategy for creating and managing a successful nonprofit; I am unable to offer a panacea for community services fragmentation. Rather, I am presenting what I have found to be the key components of our successful venture, learnings from more than two decades leading ECS and outlining some of the societal factors that make this work so difficult and the challenges so daunting.

This case study documents learnings that have relevance far beyond one small program in Cincinnati, Ohio. And there is value in codifying those learnings for those who guide mission-driven nonprofits, work within them, fund them, and use their services.

1. Focus on investments to solve problems, not just fund programs. Nonprofits are called upon to solve the world’s most intractable problems with constrained budgets and pressures to succeed in short time frames. This is a huge challenge because if investments are not made that are commensurate with the size of the problem, only temporary or partial solutions are possible. The responsibility for funders is to hold organizations accountable and to make decisions based on evidence rather than social or political preferences. Changes in funding approaches that are focused on equity and structural changes to support family and community wellbeing are needed.
2. Understand that the system may not need more money but rather money spent more wisely. Systems and financing structures need to be improved to incentivize improved administration and deployment of services and dollars. At the same time, simply coordinating existing services better when there are big gaps in service systems cannot be the solution. Sometimes, more dollars and services are needed.
3. Remember that transparency, accountability, and outcome measurement are keys to success for mission-driven nonprofit organizations. We should all agree that the three measurement approaches can drive learning and improvements. These should be a priority and not be an afterthought or compromised.
4. Engage community. Strong, brave leadership along with community consensus and authentic partnerships are foundational to long-term success. A sustainable and scalable community-level response is based upon trust, effective cooperation, and collaboration among like-minded individuals and organizations that can together demonstrate value and results. Engaging the people who use services in the co-design and improvement of services and systems is essential.
5. Advance equity. Community-level, mission-driven nonprofit organizations have great potential for changing services and systems in ways that can reduce disparities (e.g., by race/ethnicity, income, geography, health status, gender, and other factors). Assessing the role of the organization in advancing equity in partnership with others is a place to start. Assuring that services are provided equitably, without discrimination or bias, is fundamental. It all begins with listening and learning together.
6. Use good business sense. Ensure nonprofits have: the latitude and resources to generate multiple sources of revenue—private, public, and entrepreneurial; sound business plans to be both sustainable and scalable; opportunities to follow science as well as community priorities, and leadership that is at least two steps ahead of current thinking.

A Closing Reflection on Perseverance

In 2011, John Pepper presented the keynote at the National Summit on Quality in Home Visiting that ECS hosted in Washington, DC with the Pew Charitable Trusts. Several years later, Pepper and I had breakfast with Shannon Jones, the former Ohio state representative and Ohio senator, who had initiated several important pieces of legislation and was widely recognized as a champion for issues that supported children and women. Pepper sent her a copy of his “Acting on What We Know to Be True” speech to illustrate the long-term nature of the journey we are on. Jones followed up with an email, and wrote:

In his speech, Pepper described the moral imperative and called upon all of us to continue our life-changing work. He told us:

Pepper ended his talk with a favorite text from Rabbi Tarfon (known as one of the first fathers of Judaism quoted in the Mishnah, Perkei Avot 2.16): “You are not obligated to complete the work, but neither are you free to desist from it.”