Pablo Bravo Vial, Vice President of Community Health, is responsible for the overall leadership and management of Dignity Health’s community health department, which includes prevention programs, community benefit reporting, community health needs assessments, community and social innovation partnership grants, investments, international community health, in support of Dignity Health’s mission, values and strategic goals. The Vice President of Community Health is also responsible for developing policy and providing strategic alignment and facilitation of Dignity Health’s community health. Prior to his time at Dignity Health, Pablo was the Fiscal Director for the city and county of San Francisco Department of Mental Health Children Services and Managed Care. Pablo has a degree in Economics and an M.P.A. from University of San Francisco. Pablo currently serves on the San Francisco Accelerator Fund board, Religious Community Investment Fund, and on the Dominican San Rafael Socially Responsible Investment Committee.
Conversation with Gary Gunderson.
Gunderson: I’m talking with Pablo Bravo in the offices of Dignity Health in downtown San Francisco. Pablo’s been a key influence in the emergence of the development of Stakeholder Health across several years. We have close mutual friends in Kevin Barnett and work of the Governance Institute, but when you look, Pablo’s been involved in many of the collaborative learning initiatives that are really the heart of where the movement is coming from and where it’s going, so I didn’t want to miss the chance while I was here seeing my grandchildren to come downtown and talk to you. Tell us a little bit about what framing your work is and we’ll talk a little bit more about how you became you.
Bravo: Sure. Well, it’s nice to see you just the same, even though you came here for your grandkids and not to specifically see me, but that’s okay. I won’t take it person. What’s the framework? The framework I base everything on is the fact that we are an organization that is rooted in the communities and it is our responsibility as those rooted anchors in these communities to address issues in the community that are impacting the health of individuals. Most of my work is framed around assisting the individuals, families that are poor, disenfranchised, and that are at the edge of everything.
The mission of the organization is what really sets the framework of the work I do. It’s been great working in an organization with Dignity Health that was created by women religious is the that the women religious started by working in the streets with individuals whether it’s providing food or providing wound care of education. And now you have these incredibly large systems that are providing care but also have the sights of what is it within the community that needs to be helped.
Gunderson: Let me connect that work with your earlier work in your career, the finance for the city and how you got from that to this and how they informed each other is just fascinating to me.
Bravo: Actually, when I first got out of college with a finance degree, I went to work for a nonprofit, and it was called La Familia Center of Marin and the nonprofit was basically set up to help new immigrants in the time of the civil unrest in Central America. I was the associate director and also in charge of finance. Unfortunately, California passed proposition 87 which said no more help for anybody who’s illegal. There was no funding, so the organization had to close because there was just no funding available.
From there, I went into reinsurance and I was lost. I found myself in this great big fog and one day I realized that that’s not what I wanted to do, I wanted to go back to working in health care and that’s when I came back and I was lucky enough to find a position with the city in county of San Francisco. The original job that I was offered was to be the finance officer to develop the first capitated mental health project for at-risk youth. From there, I became finance director for the Department of Mental Health Children Services. So I never really lost; I’ve always wanted to be doing finance with a significant or impactful meaning.
Gunderson: It’s always money making something possible?
Bravo: Right. I really enjoyed doing the capitated model and this was during the period when Hillary Clinton came into the White House and wanted to change healthcare and then started talking about capitation, so the senator of California said, “Can San Francisco test out a capitated model for addressing issues for high risk youth?” So that was my responsibility is to basically develop the capitation model with the help from other folks. It wasn’t just me about me. You always have a partner or partners who make it possible.
We basically took on the highest risk youth in the city and wrapped them around with services, because with capitation you could do that. But then there was some risk. You wrap the service around the individual to make sure that the individual didn’t land in the hospital because the hospital would just lower your capitation. Moving forward, at one point after working with the city for several years, I realized that working for government wasn’t really what I wanted to do for the reason being that I was tired of the regulations and the controls and all that goes along with government, and so I am here.
I was going to take a sabbatical, I was in a board of community development financial institution and one of the sisters was on the board and she found that I was going to take a sabbatical and says, “What are you going to do?” and I said, “I don’t know. I’ll just have to grow up.”
Gunderson: You never say that around a sister.
Bravo:Yeah, I know, and she says, “Well, how about checking out this position?” and I checked it out and I thought that it was an opportunity to do something different, bringing my financial skills but using the Dignity Health resources to make huge impact in the community. This is how I became the director for community grants and investments for Dignity Health.
Gunderson: The thread that I hear that’s common for many stakeholder folks is they have a technical body of expertise that normal people with that kind of expertise look away from the poor, look away from the highest risk people and essentially carve a really cool career out of that. The typical thread here is take that expertise and turn the other way. Look in the eye. I didn’t realize that you were crazy enough to hit San Francisco to look straight at the highest risk youth and adopt them as the capitation.
Bravo: It was an amazing project. When you hear people get into finance, people think the motivation is money. My motivation has never been the financial rewards. It’s been more of finding the meaning, not only the meaning, but the passion for the work, and doing debits and credits and balance sheets and income statements just didn’t… I liked understanding and learning what these tools are, but I couldn’t see myself working in an accounting firm just doing bookkeeping entries. In the days before they have all these nice systems that automatically do everything for you. But the motivation was basically can I use whatever skills I have, can I use that to have a little bit more meaning and really get my passion out of it?
Gunderson: I was talking to a group of public health folks, and public health folks usually have a really steady blood pressure which is pretty laid back and cool and sometimes you think you’re talking to the Department of Motor Vehicles, but I talked to some folks on the board of public health departments around the country and I said, “You know, you’ve got folks with all these amazing analytic skills but if you don’t love the public, if you don’t really love the people, it’s dangerous for you to do this kind of work” because those analytics are usually not used for life and death stuff. But your work is life and death, so connect that to how you bring that sort of eyes to an institution like this.
Dignity is one of the leaders and pathfinders in using not just discretionary margin, but actually seeing the full financial structure in radically different ways, so I want to talk a little bit about Dignity and I want to talk about this notion of the anchor institutions and your work with Democracy Collaborative.
Bravo: My role within Dignity Health is really community health or activities that happen outside of the hospital walls. With the tools that Dignity has provided us with community health, whether it’s the community investment program where we provide no-interest loans for different projects in the community, our sites, it’s really to address what everybody’s calling social determinants of health, and what I look at is the common things that you need to address to keep individuals safe, happy, and healthy: access to housing, access to food, access to education, health, the list goes on. Everything that we all have that we all should have access to live a healthy, happy life,. Dignity Health, being an anchor in communities, we feel that our mission is to address these issues that are impacting the health of individuals by using the resources they provide. That’s where I get my juice flowing because it’s an opportunity try to address these issues in the most creative way possible with the folks who are being impacted. You don’t come into town and say, “Oh, I’m going to resolve all your issues.” It’s more of how can we resolve the issues together? We’re here. We’re part of your community. Either good times or bad times, Dignity Health is always there.
Gunderson: Tell me the difference in how you think both as a finance person and mission person has the difference between margin and capital.
Bravo: You want to keep your eyes on both. There’s always the case where people will say, “no margin, no mission,” but on the other hand, if there’s no mission, there’s no margin. You want to keep an eye on both…
Gunderson: Don’t skip over that, because I often say that, but you actually know the details of why that’s not true.
Bravo: The way that at least I perceive it is that by being a good steward by taking a look at all the details are going to impact the financials, you’re able to have a bigger impact and longer impact than if you do it carelessly. So you want to be cautious from both sides. For example, I’m going to provide you with a loan, but I know you’re unemployed or don’t have any other resources, so the chances are I may not get paid back, so I’m going to lose and I’m going to put you in a position where you’re going to be just so stressed because you’re going to have to find ways to pay me back. And that’s the same with any resources that you have. You don’t want to provide the resources where you’re going to put the other individual or an organization in the position where it could fail, and you both end up losing. What you want to do is find that middle ground and say, “Okay, this is what I have. This is what you have. Can we do it? Can we find a way to work together? You use your resources, I use my resources, and where are we going?” In essence, look for that partnership and sustainability for each other and we’re going to watch each other and help each other.
Gunderson: I’ve never seen a hospital or hospital executive who doesn’t have another machine they could buy. How internally do you run the argument about, “Well, no we actually need to loan the money for this housing project” and you have women religious all over the world that are seeing communities with radicalized possibility.
Bravo: I’ve been very fortunate because Dignity Health really is very supportive of community health and the things that we do, and the fact that they have initiated this. One of the tools, which is a community investment program which provides access to capital in low-income communities, and they’ve stuck through it, and every year, it gets bigger and bigger and bigger the more investments we make. The support across the system is huge from the sisters, from our CEO, from our treasurer, from our CFO. They’re very supportive of this program and they’re always talking about it. We currently have an allocation that we can lend out to $140 million, and we’re a little bit past 100, but since inception of the program, we’ve lent close to $200 million.
Gunderson: Do you see a day where this could be sort of normal for at least faith-based and not-for-profit hospitals to do this? Do you think the practice is validating itself, your work’s credible enough that it all could just become normal? You are not normal.
Bravo: I’m abnormal. That’s what the anchor initiative is all about is trying to get other organizations to focus in this work. It’s one of the tools. If you have two or three tools that you can use to improve the health of the communities you serve, then you should be doing that. I guess I’m fortunate enough because I think it was common sense, common sense that you want to use as much as you can of your resources to improve the health of the individuals in your community. Ultimately, it’s going to come back in return for your own provision of care—the decrease in the inappropriate use of the emergency department that’s costing a fortune for this country. If there’s a way to invest in things that are going to avoid those admissions… it’s an investment.
Gunderson: Tell me a little bit about your partnership with Democracy Collaborative.
Bravo: There are currently 30 organizations coming together semi-annually to talk about three areas of focus: local hiring, local purchasing, and community investing. It’s been a great success because the momentum, and it’s only been two years, has been huge. The fact that individuals from organizations are coming to the meetings and then going back to their organization and getting them started on one of the three or even the three, it’s amazing. I think this is an opportunity for providing support for one another to see what can be done that is being done and for imagination, for innovation, and things in that nature to evolve within the anchors.
Gunderson: When I read those materials, and I was at that founding meeting, there’s a culture of almost more common sense application, these are things that we can do, but it takes a lot of courage to do that. Where do you see organizations finding the courage to do the right thing at a time when society is just drenched in fear?
Bravo: It provides a sense of hope. Knowing that an organization like Dignity Health has provided capital to provide housing structure that’s not only about the housing but it’s created some kind of neighborhood and it has a place for kids to run, a nice environment. That, to me, is the face. I can see a kid’s face when he gets up in the morning or he can bring a friend and not be ashamed of bringing them over to the house.
Gunderson: It’s an actual simple humanity that you’re describing. It’s beautiful. One last question. You may have even been in the room when I started joking about See2See [road trip] and driving across the country…
Bravo: That’s right.
Gunderson: And looking the opposite of a national meeting, so you were helping us think through where from San Diego to Raleigh and Wilmington we ought to go. But let me ask a different question. What do you think we’ll learn along that way? You’re in a senior role in a massive organization with massive geographical coverage. When you think about driving across that geography, what do you think we’ll be surprised by?
Bravo: I think what you’re going to be surprised by is the fact that we’re all worried about the same things, and when we’re talking about the poor, we’re all worried about housing. We’re all worried about healthy foods, the air that we breathe, the education that we’re going to provide for the kids, the job they’re going to have. That brings it all together. We’re all worried about the basic things. It doesn’t matter what your political thoughts are or religious thoughts. At the end of the day, it’s the basic stuff that you’re going to see that it all comes together.
Gunderson: We’ll be driving a week or so after the election and I’m guessing mostly red states along that route. I’m sort of curious about whether the polarization we see at the national scale is the same or different at local scales. How much is the commonality of what you’re afraid of in a local community, what you hope for in a local community, actually, we find ways to work together.
Bravo: I think that in some places or some individuals, we get so fearful because our life is on the edge for some reason, whether it’s a job or what-have-you, that we begin to isolate ourselves to protect ourselves. Fear that somebody may come and take the little things that we may have left versus finding a way to open up, get to know your neighbors, partner with them, and see if there’s a way that we can help each other. Ultimately, I think you’re going to find that there’s pockets of that and it hopefully will grow.
Gunderson: Well, you’ll be helping us find them along the way. I’m going to let you go on to your other stuff. Maybe another $100 million maybe by lunch time.
Bravo: I wish. It’s always a pleasure to see you.
Gunderson: Thank you, Pablo.