The Equity-First Vaccination Initiative's Challenges and Successes

Throughout the pandemic, and particularly before vaccines became available, Black and Latinx people in the United States have been disproportionately impacted by COVID-19. The Rockefeller Foundation saw an opportunity to promote equity in the COVID-19 response through vaccination, and in April 2021, launched the Equity-First Vaccination Initiative (EVI). The primary goal of the EVI was to reduce racial disparities in vaccination rollout, with the secondary goal of supporting public health systems strengthening in the United States over the longer term.

Through the EVI, the Rockefeller Foundation invested $21 million in nearly 100 community-based organizations (CBOs) through 33 grants and contracts for the 12-month initiative. The initiative used a collective impact approach, identifying “anchor partners” in five cities: Baltimore, Maryland; Chicago, Illinois; Houston, Texas; Newark, New Jersey; and Oakland, California. The anchor partners then selected and subgranted to dozens of local CBOs that used hyper-local approaches to build vaccine confidence and decrease access barriers in their communities. The foundation also invested in communications, advocacy, and learning partners to support the five cities to scale up their promising practices to promote vaccination equity.

The EVI was rooted in three guiding principles. The first was a focus on community-led efforts that build agency, autonomy, and the capacity of those who know their communities best. A second guiding principle was that interventions must be delivered at a hyper-local level, meaning at the level of ZIP codes, neighborhoods, and blocks—not states, counties, or even cities. The EVI's third guiding principle was that efforts should be holistic. While the initiative was called the Equity-First Vaccination Initiative, it operated on the belief that vaccination equity is only achieved alongside equitable outcomes in health more broadly, in economic opportunity, and in all other sectors of our society.

The EVI CBOs implemented a number of different approaches to promote COVID-19 vaccination equity. Their efforts have centered around six broad strategies:

• sharing accurate, trustworthy, and accessible information;
• providing transportation assistance to help bring people to vaccination sites;
• maximizing convenience—in other words, bringing vaccines to where people already are—their homes, their churches, their food banks, their concert venues;
• ensuring vaccination registration and appointment processes are streamlined and inclusive;
• working with policymakers to design incentives that are meaningful to their communities and have real value; and
• addressing health-related social needs in their communities, before (or in addition to) broaching the topic of vaccination with their clients.

Evidence of the Initiative's Impact

One of the Rockefeller Foundation's learning partners, the RAND Corporation, collected, analyzed, and cointerpreted with other EVI partners both quantitative and qualitative data throughout the initiative. As detailed in RAND's final report on the EVI, there is clear evidence that the EVI reached its target population, with more than 90 percent of the nearly 65,000 vaccinations delivered through the EVI going to Black or Latinx individuals, or people identifying with two or more races. In contrast, while not a direct comparison, at a national level, Black and Latinx individuals make up only 31 percent of people who have received at least one dose of a COVID-19 vaccine. The initiative also played a role in improving vaccination equity in the five participating cities. While the EVI was in place, from April 2021 to April 2022, the number of first and second doses of COVID-19 vaccines given per month at the national level steadily declined; over the same period, vaccinations through the EVI continued to trend upward, suggesting that the EVI built momentum in some of the highest-risk communities in the United States.

Importantly, the RAND team also found that CBOs that did not previously work in the fields of public health and health care (as traditionally defined) proved that they could quickly and effectively pivot to address barriers to COVID-19 vaccination, thereby playing a critical role in pandemic response. They did this through offering vaccinations at every type of community event from barbeques to health fairs to tenant association meetings; holistically addressing the myriad health-related social needs of their community members such as housing and food insecurity; and serving as trusted messengers who conducted continuous outreach door to door, through phone banking and text messages, through billboard messages, and on social media. Collectively, the CBOs participating in the EVI:

• made almost 15 million connections with people to provide accurate, community-tailored vaccination information,
• provided assistance with vaccination almost 155,000 times through addressing health-related social needs,
• offered vaccinations at more than 4,500 community events, and
• administered nearly 65,000 vaccinations.

While these numbers are impressive, they don't tell the whole story. The CBOs have built health communication infrastructure and skills, such as how to recognize and counter mis- and disinformation in local vaccine-related messaging. They have established relationships with city governments and academic institutions and formed networks of like-minded organizations. And they have advocated for equitable policies in their communities. In other words, CBOs built lasting capacity to respond to the COVID-19 pandemic and to confront other pressing needs in their communities going forward, such as the ongoing mental health crisis.

Challenges Encountered

However, while these successes are to be celebrated, it's important to reflect on the challenges the EVI encountered, what was learned, and what was done to overcome them. In particular, the initiative encountered several challenges related to the need to move quickly to address this urgent public health crisis:

• First, rapidly developing this complex initiative made it difficult to formulate and effectively communicate partner roles and expectations at the outset. The funder and learning, communication, and advocacy partners decided to offer certain types of support to the CBOs and conduct a range of data collection activities without first fully understanding grantee capacity or their needs for support and data. Often, the data collection requirements (that is, participating in interviews or reporting their activities from the prior month) added a burden on the local partners that were already stretched thin.
• Second, with a time-bound initiative lasting only one year, it was crucial to hit the ground running, but it was challenging to move funding out to the many partners quickly enough to keep up with the constantly changing pandemic.
• Third, given the power differential between local CBOs and larger institutions and funders, it took time and care to navigate these relationships and establish trust and open communication among partners.
• Finally, the pace and complexity of the EVI made it difficult to link the moving pieces of the collective impact model so they leveraged each other's work, such as ensuring that what the CBOs were learning on the ground was informing the advocacy partners' work at the policy level, and vice versa.

Both the successes and challenges of the EVI reinforce four key takeaways from RAND's recent report that may be helpful for philanthropies, such as the Rockefeller Foundation, that are seeking to consistently put equity principles into authentic practice.

Key Takeaways for Philanthropies to Promote Equity

Minimize Burden

It is important to continuously consider the burden on CBO partners from added program activities, and make sure that funders' expectations for those partners are equity-focused. One way to support CBO partners is to develop tools and resources that are easy to use and minimize the extra work required. The EVI offered a great deal of flexibility in how the anchor partners reported progress indicators; partners reported that this made their jobs easier as they did not have to spend time putting things into a different format than they might typically use. Furthermore, every data collection effort should be in service of the partners and the value to them made clear. The Rockefeller Foundation and the learning partners did not do this effectively at the start but over time got better at clearly conveying the purpose of each meeting, interview, touchpoint, and data collection method, and how it would serve the CBOs. Finally, if a data collection activity is not effectively serving its purpose, funders and their learning partners must be open to modifying or discontinuing it.

Streamline Grantmaking

Second, through their experience with the EVI, the Rockefeller Foundation identified a need to re-examine internal grantmaking processes and requirements to be agile and move funding out quickly when needed. To improve equity, it is important to make it easier for all organizations, but particularly those that are very small or do not have experience with grant funding, to apply for and receive funding. For instance, funders could simplify the proposal requirements, setting shorter page limits and requesting fewer supporting documents. They could rely less heavily on written materials and incorporate more interviews and review of multimedia products (for example, organization's websites, social media presence, other digital content) into their assessment of potential funding recipients. In addition, funders could provide technical assistance to help with grant writing, by holding initial screening meetings and providing funded-supported grant writers to help draft proposal materials.

Empower Rather Than Direct

Establishing trust and open communication across all partners from the outset is critical. Even when there is a desire to move quickly, it is important to take the time up front to ask the CBO partners “what do you need?” and then bring in or build those resources and supports rather than telling them what can be offered. The CBOs are the experts on their needs and their community. They know how to best use their funding and who to partner with. They also know when they need to take time to rest, heal, and process their experience of the pandemic. Funders need to empower rather than direct them. How can this be accomplished? In a complex initiative such as the EVI with multiple types of partners (for example, implementation, learning, advocacy, and communication), relationship-building and in-depth planning, both one-on-one with the funder and across partners, needs to be the top priority at the start of the work. The objective of this planning is to collaboratively determine each partner's needs and capabilities, establish clear roles and responsibilities, and develop methods for shared accountability. Empowerment also comes down to trust. Funders need to trust the CBOs and provide flexible funding in support of a defined goal, but let the CBOs decide how best to use the resources rather than prescribing specific activities for them to implement (and report). While this approach comes with tradeoffs (for example, it makes evaluation across a large, multisite initiative more challenging), the benefits are immense.

Connect the Dots

Finally, to maximize the value of investments, funders need to do a better job of linking all of the moving pieces of an initiative together. Without these connections, opportunities for the partners to leverage each other's work and create synergies are missed. This can be done by facilitating peer-to-peer connections and identifying approaches to more effectively disseminate learnings across large initiatives. For example, when possible, it can be valuable to start new initiatives and partnerships with an in-person meeting to build professional and personal connections. Partners should be supported to leverage collaborative technology to make discussions (both formal and agenda-driven and informal, spur of the moment) and sharing information easier. Finally, purposefully crossing over siloes by designating a member of one team or organization to attend occasional meetings by another, can be helpful to ensure that the work is coordinated.

The EVI has demonstrated a path forward for the Rockefeller Foundation, and the philanthropy sector more broadly, to turn words more effectively into action as funders seek to center equity in their approach to grantmaking. The foundation is committed to applying these lessons learned to other initiatives and priorities.

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Laura Faherty is a physician policy researcher at the nonprofit, nonpartisan RAND Corporation and a practicing general pediatrician. Sarah Hanck is vice president of Strategic Learning & Impact at The Rockefeller Foundation. Nichelle Walton is a senior associate on the Strategic Learning & Impact team at The Rockefeller Foundation. George Timmins is an assistant policy researcher at RAND and a fellow at the Pardee RAND Graduate School. Gregory Johnson is the managing director of the U.S. Equity and Economic Opportunity Initiative at The Rockefeller Foundation. Jeanne Ringel is a senior economist at RAND and director of the Access and Delivery Program, a program of RAND Health Care.

This commentary was first published on November 3, 2022 on Health Affairs Blog. Copyright ©2022 Health Affairs by Project HOPE—The People-to-People Health Foundation, Inc.

Commentary gives RAND researchers a platform to convey insights based on their professional expertise and often on their peer-reviewed research and analysis.