Driving change: It’s not just about size
On January 12 of this year, a magnitude 7.0 earthquake struck Haiti, causing destruction and suffering on a scale so massive as to defy description. Days passed before death toll estimates were released, and even now, months later, those figures remain educated guesses, as do the number of Haitians whose lives have been forever changed, how long it will take to rebuild Port-au-Prince, and whether Haiti will emerge from this catastrophe stronger or more fragile. What is certain, however, is that one organization, Partners in Health (PIH), has been absolutely critical throughout the crisis. Founded by social entrepreneur Paul Farmer and four of his friends in Haiti more than two decades ago, Partners in Health is now the country’s largest health-care provider. Had its 100 doctors, 600 nurses, and 4,000 employees working out of 12 facilities not been on the ground, fully operational and functioning as the spine of Haiti’s healthcare system when the quake hit, there is no doubt that the number of casualties and sheer extent of human suffering would have been far greater and the country’s chances of eventual recovery far less. When asked by journalists and donors just how many lives Partners in Health has saved in Haiti, to say nothing of the additional 12 countries where the organization also works, Paul Farmer defaults to medical shorthand: TNTC, too numerous to count.
To the question, then, of whether social entrepreneurs can create “large-scale change,” my answer is an unqualified yes. Frankly, I’m really pleased to have the chance to address the question framed in this way, rather than having to swat away that pesky, more common version, whether social entrepreneurs can “get to scale.” Still, I can’t resist a bit of a rant on that point, given that the phrase “going to scale” has become something of a shibboleth in social innovation circles—leading even smart people to compare the Googles of the world with ventures like those in the Skoll Foundation’s portfolio. The question of scale, I have argued, should not focus on an organization’s size or budget, but the scale of its impact: its ability to transform systems, right injustices, and demonstrate that it can solve even the most intractable problems. This isn’t to say that social entrepreneurs shouldn’t grow their organizations, but only to restate my thesis; that how big you are is in no way a measure of how good you are at driving change. On that basis, Grameen and Google can be legitimately compared!
Inevitably, though, any and all questions of scale force us to consider numbers—what we count and what that information tells us. At the risk of voicing yet another earnest caution about the role of metrics, I readily admit that numbers only get us so far on the proof-of-impact imperative. Think, for example, of one of the most famous acts of philanthropy ever: Andrew Carnegie’s initiative to build public libraries, carried out between 1886 and 1919 through a “matching” grant program. More than 2,500 libraries were built as a result of this effort, the first in Scotland, most in the United States, but also across England, Canada, New Zealand, and even Fiji. Now, library buildings are easy to count, as are the books that fill them; circulation data—how many people are checking out how many books—tells us a bit more, giving us information about how many people are using libraries and what they’re reading. What’s much harder to measure is the arguably more important impact of those libraries on communities—whether their citizens are better educated and more informed due to the libraries. Common sense tells us they are. Common sense also tells us that Carnegie’s philanthropic intent was not simply to dot the landscape with libraries, but to ensure the people he believed to be a society’s “most industrious and ambitious” and “most capable of helping themselves” were afforded the means to improve their lives and their communities. Today, empowering those with the greatest stake in benefiting themselves and their communities continues to be core to the work of social entrepreneurs achieving order-of-magnitude impact. Within the Skoll Foundation’s portfolio, Amitabha Sadangi provides a case in point. International Development Enterprises (India) (IDEI) helps turn subsistence farmers into income-generating producers via easy and cheap irrigation tools. Over the organization’s 20 year history, its treadle pumps and customizable KB drip irrigation units have generated more than $1 billion in wealth, leading in turn to significant increases in health, education, and dignity for rural farm families. Beyond these direct impacts, Amitabha’s work has also helped counter two interrelated and increasingly threatening trends—groundwater depletion and climate change. IDEI’s products are 50 to 70 percent more efficient in their use of water than their competitors’ offerings, while simultaneously boosting crop yields by an impressive 50 percent. In addition, because IDEI’s hand-powered pumps have displaced gas-driven pumps, they reduce carbon emissions. Typical of a social entrepreneur, Amitabha has seized on this measurable benefit to obtain carbon credits under the European Union cap-and-trade system, bringing in additional revenues to support his work. IDEI is doing for poor rural producers what Grameen did for poor borrowers, literally design-building the field of micro-irrigation. The Gates Foundation’s recent decision to invest $27 million in IDEI to bring its model to Africa is just one more sign of the organization’s growing impact.
Back to Partners in Health, this time with an example of what I think of as the David effect: how social entrepreneurs tackle giants. Relatively early in its history, PIH came face to face with an epidemic of multidrug-resistant tuberculosis (MDR-TB) in the shanty towns of northern Lima in Peru. Treating the disease and arresting the epidemic required both providing drugs and administering them to an exacting protocol. To the World Health Organization (WHO), Goliath to PIH’s David, dispensing this kind of treatment in impoverished communities was “impractical and unaffordable,” even though MDR-TB is known to kill more than 2 million people a year, with most deaths in the developing world. Refusing to give in, PIH raised the funds and got the medicine on its own, and then, using the community-based treatment model it had developed in Haiti, succeeded in stopping the epidemic. Moreover, it achieved an 83 percent cure rate for MDR-TB, one of the highest ever reported, conquering not only the twin scourges of disease and poverty, but the giant WHO and its skepticism. Based on this proof of impact, the WHO and others involved in the fight against TB, including the U.S. Centers for Disease Control and Prevention, have now adopted the PIH model. Armed with evidence of what can and does work, the organization also raised its ambition: its new approach was accompanied by a plan “to increase the number ofMDR-TB patients receiving treatment worldwide from 16,000 in 2006 to 800,000 in 2016,” dramatic evidence of large-scale change, with the potential to cut MDR-TB mortality rates in half.
I could provide many, many more examples, drawing proudly from our Skoll Foundation portfolio. Mitch Besser and Gene Falk have led mothers2mothers, which works to halt pediatric AIDS transmission, on a growth of impact trajectory that has the organization now reaching one in five pregnant women with HIV worldwide. A 20 percent global market share of a target audience is a phenomenal achievement for any company, the more impressive in this case for being a market of mothers who are now able to protect their babies from AIDS. Soraya Salti of INJAZ al-Arab now reaches hundreds of thousands of students across the Middle East with life-skills and entrepreneurship training because she’s been able to get entire public school systems to embrace her program. Ann Cotton’s Camfed, the Campaign for Female Education in Africa, has developed a community-based model so powerful that the hugely influential Linklaters international law firm is documenting its principles and strategies in order to transform how aid is deployed in the developing world.
For medical professionals, TNTC, too numerous to count, is usually used in connection with measuring microbes. White blood cells that are TNTC, for example, spells trouble, indicating major infection; colonies of bacteria on the agar plate that are TNTC make it hard to distinguish one pathogen from another. But when Paul Farmer falls back onTNTC to answer the question of PIH’s impact, he’s talking not about microbes but about human beings. His use of the phrase is paradoxical, suggesting not only the vast number of lives he and his PIH colleagues have most certainly saved, and lives he has transformed, but that the impact he’s after really can’t be reduced to a number—no matter how big. For Soraya Salti as for Paul Farmer, for Ann Cotton as for Amitabha Sadanghi, and for those of us lucky enough to support them, large-scale change will always mean bringing about that more just, peaceful, and sustainable world we know is within reach. In the meantime, we will continue to rely on markers and evidence that tell us whether we’re on course…and on the inspiration of social entrepreneurs who prove what’s possible.