I’ve written quite a bit in these pages over the last couple of years about big bets (gifts of $10 million or more) focused on social change. Mostly, I have talked about donors—why they give, how they give, and how they could give smarter.
But the recipient—typically a nonprofit, or a group of them—is obviously key to whether a big gift is made, and whether it can be used effectively. Not surprisingly, nonprofits receiving multiple big bets on social change are often large organizations with familiar names, like The Salvation Army, Planned Parenthood, Teach for America, or World Wildlife Fund. But size and recognition alone do not make a nonprofit “big bettable.” Some of the most interesting big bets made recently are to organizations you’ve probably never heard of.
Upstream USA, an organization founded only a few years ago, is working to ensure that one day, every child born in America is a planned-for and wanted child. Last month, Blue Meridian Partners—a group of philanthropists seeking to radically improve the odds for our nation’s most disadvantaged children—invested $60 million in Upstream. (The Bridgespan Group, where I lead the consulting practice, has worked with both Blue Meridian Partners and Upstream).
How did a fairly new, and until very recently, quite small, nonprofit like Upstream make itself big bettable?
First, it addresses a compelling problem. In the United States, about half of all pregnancies are unplanned, and this rate is even higher for low-income and poor women. Additionally, a significant percentage of these pregnancies occur to women who are using contraception; the methods they are using are failing them. Most of the places where poor and low-income women get their healthcare don’t offer them IUDs and implants, the most effective methods of contraception. The result: in the US, there are 1.5 million unplanned births each year, and two-thirds of these children are born into poverty. But its focus is Upstream’s least unique feature. Thousands of nonprofits across the United States, of Upstream’s size or larger, are also working on burning issues.
Second, and far more important, the organization has identified a plausible pathway that is big enough to matter, and small enough to believe. Upstream has identified an opportunity: when women are offered the full range of contraceptive methods, including IUDs and implants, which are extremely effective at preventing unplanned pregnancy, they tend to choose the more effective methods, resulting in dramatic reductions in unplanned pregnancy. It has also identified a challenge: systemic and workflow barriers at health centers, particularly those serving poor and low-income women, prevent women from obtaining the birth control method of their choice. And it has developed a solution to the challenge: training providers and delivering training and technical assistance to health centers to help them improve billing and coding systems, change clinical workflows and improve counseling. This means that women can receive any method of birth control in a single office visit. When that happens, women tend to choose more effective methods, dramatically reducing unplanned pregnancy. Once the system has changed, existing financing mechanisms, rather than additional philanthropic gifts, can sustain the change.
Third, the organization has developed strong evidence that the approach works and can deliver the intervention effectively. Following an Upstream intervention, patients report more satisfaction with their care, and health centers are able to continue offering all methods of birth control long afterward. Upstream has also demonstrated the leadership and capacity to deliver the intervention. Without these elements, a donor may be willing to invest in research and pilots, but is less likely to make the kind of big bet that Blue Meridian Partners made in Upstream.
Finally, Upstream developed a detailed and plausible plan to scale its approach to reach health centers that serve 1.6 million women in five states during the first phase of scaling. Plans can change, sometimes a lot, as implementation proceeds and new circumstances arise—but without a clear roadmap to the intended goal, an organization is not an ideal candidate for a big bet.
The painstaking work of Upstream to develop its innovative and scalable approach to the tremendous challenge of unplanned pregnancy—and the very large investment that Blue Meridian Partners has made in Upstream — underscores what John W. Gardener, the Founder of Independent Sector once said: “We are all faced with a series of great opportunities—brilliantly disguised as insoluble problems.
