The following is a conversation between Dr. Madeleine Ballard, CEO of Community Health Impact Coalition, and Denver Frederick, the Host of The Business of Giving.

Denver: In a world where countless community health workers, mainly women, labor tirelessly without proper support or resources, the Community Health Impact Coalition (CHIC) is making a significant difference. Leading this transformative effort is Dr. Madeleine Ballard, CHIC’s executive director. Her vast experience, from shaping Liberia’s National Community Health Program, to academic contributions at the Icahn School of Medicine at Mount Sinai has positioned her as a key figure in global health.

A Rhodes scholar, Dr. Ballard’s leadership is pivotal in advocating for and affecting policy changes that uplift the role of community health workers globally. Welcome to The Business of Giving, Madeleine.

Dr. Madeleine Ballard, CEO of Community Health Impact Coalition

Madeleine: Thanks so much for having me, Denver. Really appreciate it.

Denver: It’s great to have you here. Tell listeners of the pivotal role that community health workers play in transforming healthcare systems, and especially in resource-limited settings.

Madeleine: Sure thing. So, community health workers are the unsung heroes of health systems around the world, and the case for CHWs is vast. We know from the research that community health workers reduce deaths and reduce sickness in communities at some of the fastest rates ever recorded in human history.

We know that community health workers are not just the champions of the health system when things are going well, but certainly as I think most folks around the world now know, having just come out of the worst of the COVID pandemic, CHWs are on the front lines when things aren’t going well and are key to pandemic resilience.

So, we know that where community health workers are well-supported to do their jobs, regular services continue, and we know that CHWs are key to getting folks the information and resources they need to kind of weather the worst of these pandemic storms.

Finally, we know that it’s good for the health system and the economy. There’s been a lot of research on how, if you’re investing in community health workers, every $1 that you spend actually comes back to the economy tenfold in terms of a healthier and more productive population and job creation, particularly in rural areas. CHWs serve in urban areas but they’re certainly more common in rural ones.

Denver: That is certainly an impressive ROI, no question about it. So, how does the current healthcare model fall short in supporting community health workers despite this crucial role that you just described?

Madeleine: Yeah, it’s really, I think, surprising for most folks to learn some of what you’ve shared when we opened the conversation. One, that despite these huge contributions, the fact is that millions of community health workers are not salaried, skilled, supervised, or supplied to do their job well.

So, we have this workforce, as you said, that are 70% women and a really critical dual side of the human rights issue on our hands, where CHWs are both exploited from a labor perspective. 86% of CHWs in the continent of Africa, for example, are not salaried. And they’re less effective for patients, you know; they’re out of stock one third of the time, and they’re often, again, not getting that coaching that they need, like anyone needs on any job, to continue to improve their skills, their ongoing training like other medical folks have access to.

And the end result is that we know from, again, heaps and heaps of rigorous research that we just talked about, that CHWs are key to saving lives during pandemics, key to saving lives of children, mothers in really difficult settings.

But that in most national programs, the results that we see in a hundred studies are not coming to bear day to day because the implementation, the execution is just not there. And yet tons of million people are going to go their entire lives without seeing a health worker, and it’s very much a solvable problem.

Denver: Yeah. Yeah. Well, you’ve laid a nice foundation for me to ask you: What is the mission of the Community Health Impact Coalition and the critical role you play in global health?

Madeleine: Yeah. So, Community Health Impact Coalition is a coalition of community health workers of aligned health organizations, who come together to change the status quo, to make professional community health workers salaried, skilled, supervised, supplied, the norm worldwide, by changing guidelines, funding, and policy. And our vision is really quality care for everyone, including those who provide it.

“But if you’re under the care of a community health worker, they’re equipped to actually, again, go seek out patients, find them, make sure they’re in care, make sure they’re doing well, make sure that whatever problem they’re facing– for instance, ‘Hey, I don’t have enough food to eat. So, when I take these HIV medications, I feel sick, so I’ve stopped taking them,’ can be resolved because, again, a lot of these health problems are actually infrastructure problems.”

Denver: You know, you mentioned remote and rural a moment ago. Beyond distance, what are the main challenges families and remote areas face when accessing healthcare?

Madeleine: There are a number of challenges. So, CHWs, again, do serve in remote areas because of this distance. You often see that folks are potentially many, many kilometers from the nearest health center, or they aren’t that far as the bird flies, but there’s a number of rivers or poor roads or other infrastructure barriers in their way.

That being said, as you said, other barriers include things in an urban area you can imagine– language. If you’re a recent immigrant, maybe you don’t speak the language in which services are provided. Time… you know, folks sometimes, again, they’re close, but the public transportation is off. They’re working two jobs. They can’t get to the health services provided when they’re open. Folks coming to you really solves that problem.

Third, even just certain types of care, preventative care, promotive care. If you’re an HIV patient, you don’t turn up for your appointment, no one’s going to come find out how you’re doing, you know, that you’re too depressed on your couch to come in and why that’s the case, and support you.

But if you’re under the care of a community health worker, they’re equipped to actually, again, go seek out patients, find them, make sure they’re in care, make sure they’re doing well, make sure that whatever problem they’re facing– for instance, “Hey, I don’t have enough food to eat. So, when I take these HIV medications, I feel sick, so I’ve stopped taking them,” can be resolved because, again, a lot of these health problems are actually infrastructure problems.

And so, we see with community health workers, in HIV specifically, for example, the alive and in care rate for HIV patients is better in some parts of rural Haiti than it is in New York City with all its exceptional hospitals.

So, it’s a linchpin for this type of care. It’s relevant, whether you have HIV or you just want to lose weight. Some types of care are better provided in the community. It’s not a second-best option, it’s a first-best option, even if you’re in a city.

And, unfortunately, we just don’t see that robust community-based care infrastructure very well supported, in a number of countries. But that’s changing.

“And, I think, we need to zoom out and look at the context in which many of these folks are working. And that’s a context where poverty and limited access to decent work opportunities, especially for women, means that unsalaried volunteer work is not really a free choice.”

“And I think what’s devastating about the situation is that it’s often actually rhetoric around women’s empowerment that’s used to provide cover for these government, NGO, major overseas, donor-funded programs that actually use, and I use that term deliberately, female workers as volunteer and treat their labor like it’s cheap.”

Denver: Yeah, yeah, no, I’ve always been a big advocate of reverse innovation. And, in this country, in the US, we could use some community health workers instead of having everybody have to go to the clinic or the hospital.

Let me ask you, Madeleine, who are these community health workers? And I know we talked about 70% of them being women, but you also mentioned in Africa, the majority of them are unpaid. So, that sort of haunts me to want to take a moment and say: Who are these people? You know, what makes them tick inside?

Madeleine: Yeah, it’s interesting, because when we share that stat, folks are stunned; they’ve maybe gotten care from a community health worker themselves.They’ve seen maybe a clip online or, read a profile in the newspaper and they’re like, “These community health workers, folks who are just being good neighbors in their communities, who are attending to sick children in the night, who are making the rounds house to house during the day, what do you mean they’re out of stock, or they’re not paid, or the last time they had access to training was 10 years ago? That’s crazy! How can that possibly be?”

And, I think, we need to zoom out and look at the context in which many of these folks are working. And that’s a context where poverty and limited access to decent work opportunities, especially for women, means that unsalaried volunteer work is not really a free choice.

These unsalaried rules are often taken up by individuals who have maybe an implicit or even explicit desire for paid employment. They’re just hustling. They’re hoping that by volunteering, by contributing to their community, that’ll help them transition to a paid role. Kenya has recently made this transition from a volunteer to a paid workforce. And I know some CHWs in Nairobi, they’ve been working for 17 years, and they don’t have a paycheck.

And I think what’s devastating about the situation is that it’s often actually rhetoric around women’s empowerment that’s used to provide cover for these government, NGO, major overseas, donor-funded programs that actually use, and I use that term deliberately, female workers as volunteer and treat their labor like it’s cheap.

Denver: Yeah. Yeah. Well, as you said, it’s a double human rights issue, and they probably have the promise that there’s work right around the corner. You know, just keep at it for a couple more years, and it will, it will materialize.

Madeleine: It’s a “boiling the frog” situation for sure. And I think, when you say that, that’s when it clicks for folks and they say, “Wow. How do we let it go for this long?” And the longer that we let it go, the more it comes back to bite us. And, again, we saw this in the pandemic.

I was mentioning some of the research that’s been done there, and we actually just published something in Lancet Global Health, looking at the labor conditions of CHWs. But earlier than that, we published a paper in the British Medical Journal Global Health that looked at actual services provided by community health workers during pandemics.

And the thing about pandemics is that more people die from interruptions to regular services than catching whatever the novel disease pathogen is itself. And so, you saw folks dying in childbirth, children getting way off their vaccination schedules, and excess mortality from a whole bunch of causes like that.

But we actually looked at data from a number of countries where professional CHWs were salaried, skilled, supervised, and supplied. And we saw that they were actually in those areas able to maintain these services– the coverage, and the quality and the speed; the access to these services, in comparison again to what we actually saw, was huge worldwide disruptions.

So, I think again, it’s just one of those things where we were tolerating it  because it’s not happening to us. And then all of a sudden, it is happening to the entire world. And it’s because we haven’t built these resilient systems in all the places that we need to because unfortunately, pathogens, they don’t know any borders.

Denver: They don’t.

Madeleine: And, if someone has all of a sudden gotten tuberculosis, or we’re seeing smallpox come back where it was eradicated, that affects everyone. These are types of things that CHWs, we know from the research, help prevent if they’re treated like professionals, if they’re well-equipped to do their job.

Denver: And I can only imagine the CHWs are going to become more important because I think they’re predicting a 10-million health worker shortfall by 2030. And as I think about that, who else but these community health workers could help bridge that gap?

Madeleine: No, that’s true. And that number continues to get re-estimated every couple of years, and it’s never good news. But we know, again, that community health workers, as much as like any medical provider, they need ongoing training year to year, and are hopefully always learning new skills.

And we also know that you can get a community health worker up and running in a matter of weeks’ initial training on key care provision, like integrated management of childhood illness. These major killers of children– diarrhea, pneumonia, malaria– folks can be trained on those algorithms in weeks, you know?

And, I don’t want to undersell obviously the difficulty of making this transition, it takes time to establish trust. It takes time to select folks. It takes time to set up payment structures and supervision structures, et cetera. But it’s also the case of: this is the conversation that we’re having with ministers of health all the time, that this is a one-term change.

This can be any ministry of health’s legacy project. This is not, “Hey, we’re going to the moon in 15 years.” We actually have, on our website, this CHW policy dashboard that looks at 92 countries across the world, and it’s a map and you can see where are the professional CHWs, CHWs that are salaried and accredited, and where they’re not.

And, it shows that there are about 36 countries that have done this. And that means that two thirds still haven’t done it, so we have our work cut out for us. But it also means that, at this point, there is a critical mass of countries that have made this transition, and they’re reaping the benefits of this transition.

And so, regardless of what region you might find yourself in, what socioeconomic situation, there is probably a neighbor that you can learn from and lean on. And, actually, we were at the CHW symposium in Liberia, and Dr. David Walton, who is the head of the US President’s Malaria Initiative, who co-financed that program, was able to announce that child malaria prevalence in Liberia had declined from 45% to 18% in six years, which is among the fastest in history.

And, I could see my colleagues next door from Côte d’Ivoire beginning to Google, you know, what’s our prevalence? And it was around 45%, and Liberia had made big, big strides in that period, and Côte d’Ivoire was pretty much stuck with this exact same prevalence as they had six years prior.

Denver: So, what are the hurdles? I mean, if one third of the countries have done it and are getting, you know, outsized results, and I know data doesn’t convince people to change their minds, but what’s up with the other two thirds? I mean, what do you need to do to push them to be able to say, you know, join the party here. We’re getting some great health results.

Madeleine: It’s a number of things. And this is kind of what we’re working to change here at Community Health Impact Coalition. So, first off, it’s guidance. 2018 was the first time that the World Health Organization put out a guideline about how to run community health programs.

And community health workers, should be noted, have been around for a hundred years. In that time, you know, they’ve just been mercilessly ignored. And so, for the first time ever, WHO in 2018, you know, they did 15 systematic reviews. They did their whole, very elaborate, process to make sure they’re bringing together the best evidence to make the best recommendation that we possibly can give and what we know.

And, it was only then that they said, “Oh yeah, hey, CHWs, they need to be remunerated financially, not with gum, boots or a backpack, financially, you know, according to the time they’re spending, the complexity of the tasks, and the nature of the job. And these CHWs, of course, they need ongoing training and, of course, they need supervision.

And all of these things, CHWs themselves are advocating for what they needed, but they didn’t have up to that point… and this is something that we were kind of instrumental in getting included in this guidance… They didn’t have this normative authority to which they could appeal.

And I think, for some folks, you think, WHO’s guideline, how much does that matter? But this is actually the playbook for a lot of countries when they go and make their policies. And so, for that to have been absent and for us to have been able to bring that online already, that was a big step.

And, again, that just happened within the last five years, and most community health policies, you know, they’re 5 or 10 years. They might not even have been written by the time this came online. So, that’s one piece of it.

And, of course, there are other pieces of relevant guidance dealing with the nitty-gritty aspects of everything from how you’re setting up payment systems to how you’re geolocating people in remote areas, and we’re working on those, too.

But, the second big piece is the financing piece. There’s actually a, $4-billion gap just in terms of what’s being spent, for example, on the continent of Africa, on community health, between now, versus what would be required to actually get all these systems up and running.

And, again, the ROI is very clear, but you need to make that choice to make that startup capital investment. And, I think, there’s two issues here. One, okay, there’s not enough money; we need to be bringing more money into the space. But two, a good portion of that money is not being optimally spent.

You know, it’s being spent on volunteer campaigns in an ad hoc way every now and then, and these campaigns might produce short-term results. Like it’s great to run a vaccination drive… that’s really critically important. But what happens two days later when a kid has, again, malaria or someone needs a painkiller?

And so, I think we have seen just such dramatic results over the last 10, 20 years from ministers of health and big disease-specific funding mechanisms like PMI for malaria, like the global fund for, it’s in the name, you know, AIDS, TB, malaria; and, PEPFAR, HIV.

And, I think, we’re at the point now where we’re realizing what got us here is not actually going to get us to universal health coverage because it’s not enough to just come around every couple of months or years and do the one shot or put the band-aid on. People can get sick any time.

Pandemics can strike any time, and we need one workforce that can provide any type of care that someone needs at any given time, and that requires sustained investment, and it also requires coordination. Can’t have, you know, one person in the village that’s treating this and one person that’s treating that.

I mean, there’s a reason people like superstores. You want to go in and get what you need and leave, and it’s more efficient, too, because then you’re training only one person. That person doesn’t have seven different forms to report to seven different, you know, non-profits or government programs.

And so, more efficiency there is also needed. And I think the last thing I’d focus on… and we work in this area as well, is just this issue of the CHW voice. So, CHWs, we said, you know, they’re women. By nature, most CHWs, they’re in remote areas by themselves. They may not even, again, be getting supervised.

And so, they’re not sort of standing shoulder to shoulder like the garment workers on the factory floor. They’re disconnected from their peers. And it’s really notable, I think, that we have an international council of nurses, an international council of midwives, but no international council of CHWs.

There’s not even a national association of CHWs in most countries. And we all know… what’s that old saying, you know, if you’re not at the table, you’re on the menu. And I think for about a hundred years, CHWs have just been on the menu. It’s like, Oh, well we couldn’t possibly interrupt their inherent caretaking desire and disrupt that with money.

Denver: They do this because they love to do this.

Madeleine: We can’t. We can’t drop that love. That would be terrible. And I think it’s a lot harder to say that. It’s a lot harder to say: What a wonderful volunteer you are, and I definitely wouldn’t want to pay you. Or I’ve heard worse, you know, I’ve heard in rooms folks say things like, You know, it’s so cheap, or: We were paying these people then replacing them with CHWs and now, it’s free. And I’ve seen the difference. All of a sudden, when there’s CHW in the room, oh, people don’t talk that way.

Denver: Yeah.

Madeleine: You know, because you go look someone in the eye and tell them: You’re cheap, your labor’s cheap, and we don’t value it.

And so, what we’ve been working to do is train CHWs as advocates, get them connected. And if you go to, you can take the course yourself and learn about the history of community health, the fact that there are actually CHWs from Kenya to India and beyond, who are demanding better conditions for themselves so they can take better care of their patients.

And that, as an individual CHW, no matter where you are in the world, you’re part of this larger story, and you can get connected to these people in your area, and we do that, but also in neighboring countries or even neighboring continents. You know, we had folks from the US National Association mentoring some folks from Uganda the other day as they’re trying to set up their own national association.

And I think within that story, there’s power, and I think there’s a change coming, and it’s a change that we’ve seen in the HIV movement, in The Disabled People’s Movement. Nothing about us without us. It really makes all the difference.

Denver: Yeah. Yeah. Well, we definitely have to make the last mile the first mile. And it is interesting how it just seems this sector is so focused on individual diseases, and you can get a lot of support maybe because people have been touched by them.

And I wouldn’t call CHWs a backbone organization in some ways, but the fact that they do everything, they just don’t seem to get the attention that HIV or something like that would get where people put money into it.

We mentioned a couple times that the preponderance of community health workers are women, and I want to stop there for a moment and ask you a little bit as to how the current system perpetuates gender inequality and how this is reflected in the broader systemic inequities in global health.

Madeleine: Oh, absolutely. Denver, gender equity is definitely a connected struggle here. We know that, again, from the research, 6 million women globally work unpaid or grossly underpaid in community health roles to prop up health systems. And actually, The Lancet recently did a commission on women in health and estimated that women globally contribute $3 trillion to global health annually.

And half of that is actually in the form of unpaid work, and that’s primarily women of color. So, this is, as with most struggles, a place where gender, labor, racism, health, like all of these things are intersecting. And I think particularly in the health field, yeah, there are just gender norms and power relations… that the disadvantaged women…. that lead to us assuming that care work is women’s work, and that that work should just be unwaged and not necessarily recognized or valued collectively or socially.

And that’s really difficult, and it relates back to what we were talking about earlier, you know, boiling the frog. The bottom line is a lot of women are doing this work because they’re being backed into a gendered corner.

They’re constrained simply by being women. If you’re a man, you might have greater mobility, education, more options, and that’s a shame. And I think, again, women enjoy this work, but they also want to be effective in that work. And they know what they need to be effective. They’re asking for it.

And I think state actors, charities, bilaterals, philanthropies, you know, who are supposed to be supporting women, who all have some paragraph on their website somewhere about how they’re going to do that are often, unfortunately, perpetuating one, inequality, unpaid women, you know, in their efforts to try to solve another… unequal access to healthcare.

Denver: Well, what they do is so vital, and it’s really unsustainable in many cases if they’re not going to be compensated, you know; you can only go on so long that way.

Policy reform, we’ve talked about, obviously, wages and things of that sort. Is there one policy reform that’s sort of the bee in your bonnet right now that you’re really obsessed with, would love to see enacted?

Madeleine: We just use the shorthand of professional CHWs. We want to make professional CHWs the norm. We want countries to make a transition towards professional CHWs.

And what does that mean? That means a basket of policies or a basket of measures in one, community health worker policy. And, again, we use the four S’s to summarize those. So, you get salary, skills, supervision, supplies– basically that value chain that any worker needs to perform well at their job.

And, again, we just know that, of course, other health workers, sometimes their paychecks are late, sometimes they’re facing stockouts, but CHWs are unpaid at vastly higher rates than other health workers. They’re out of stock more than twice as much as the facilities to which they’re attached.

If we’re wanting to improve primary healthcare as a whole, this is the place where we want to start because there’s a specific and intense underinvestment and underperformance here that can be easily rectified. And, I think, again, it’s really intuitive for folks.

If you have a factory and you didn’t pay the workers, you didn’t supervise the workers, didn’t train the workers, you know, at a certain point there’s no product. And that’s what we’re seeing, in a lot of areas around the world.

People should have access or they have access to care on paper, but they don’t in reality because these are really basic, again, it’s not rocket science. Workforce management things are not being set up, and these CHWs are not being set up to thrive. And, again, we can change that.

Denver: Community Health Impact Coalition, let’s focus on coalition. What’s it like to lead a network like this?  And how do you get people with different agendas from different parts of the world to collaborate?

Madeleine: I love that question, Denver. We actually just recently put up a page on our website called “How to Run a Coalition.” Because over the past couple years, we have  kind of an uncompensated side hustle where we’ve been approached, again and again and again by folks who want to know, you know: How do you kick off collaboration? How do you make it stick? How do you organize collective action to drive major impact? And they’re kind of seeking our advice.

And so, anyways, just in response to that kind of growing demand for insight into the art and science of coalition-building, we kind of wrote down what we’ve learned so far and our best attempt to kind of distill the why and the how of coalitions, along with some of the most helpful resources.

And, I briefly say, one, you know, Why do we need coalitions? And then two, What are some of the best insights or resources that we’ve learned along the way that make this, as you say, a little different from running a typical organization– more fun and also more interesting, but maybe harder, too? And I can talk through both.

In terms of why coalitions, I think, one, like we just have to learn how to work together this way because we know that complex nature of global problems demands it. We need to be acting on a scale commensurate with the size of the biggest migration since World War II, with climate change, with huge health inequity, and there’s no way around it: collective actions needed here.

And so, the types of organizations that drive this collection of action are called coalitions. They’re called multi-stakeholder initiatives. They’re called field catalysts. But what coalitions do is basically align, coordinate, and bring together the folks in an ecosystem to drive system change.

So, we basically describe three main actions that we take. We influence the direct action of others rather than acting directly ourselves. So, we don’t employ, for example, a single community health worker, but we are a coalition of community health workers. We certainly don’t employ funders and norm setters at WHO or the US Agency for International Development.

But we are changing every day how they’re writing policies and how they’re acting, and creating a space for ministries of health to change. Two, we’re not in it to scale up a particular organization or particular brand.

We’re trying to work together to change policies across the globe, to really change a system, to move from one norm where CHWs are volunteer, uncompensated afterthought, to another where they’re just understood like doctors, like nurses, like midwives as an essential part of the health system.

And then, finally, I think these types of organizations, and I am taking a minute just to explain this because I think a lot of folks are really familiar with charities or nonprofits that provide direct services like food for the homeless, or maybe malaria drugs for folks who are sick. But these types of field catalyst coalition ecosystem organizations are built because we’re built to achieve an actual system change.

We’re looking at who’s providing care. In most places, it’s the Ministry of Health. So, we’re not going to go and replicate or compete with that system. We’re going to try to get that system to change. And once we do, then we’re done. So, a lot of these coalitions, I would say, are thoroughly, you know, built to win, not to last, and are working really in the background.

And so, if you think about, you know, in the states, there were a bunch of coalitions that were set up to change the law on gay marriage. And then, when that law changed, they ceased to exist because that was it.

And there are similar organizations working on teen pregnancy, working on in just a number of areas, but for each of them, I think, what’s critical is there’s a scoreboard. And for us, that scoreboard is that map of the world.

How many countries have pro-CHW policy? You know, when we’ve tipped the scales, that’s it for us. I think sustained collaboration or the essence of really how we fight together, when we are acting together across countries, across regions, across skill sets, you know, bringing researchers, CHWs, health economists all together, you know, our voices are stronger, our resources go further, and we could do more for patients.

So, yeah, I think it’s a really cool way to work, but it definitely comes with some drawbacks because it is true that as much as these types of organizations, these multi-stakeholder issues have been studied, and there’s like, you know, good to great, there’s things that differentiate, companies that succeed and companies that don’t.

There’s things that differentiate coalitions that succeed and those that don’t. We also know that those lessons are too often not being applied, and actually, most coalitions don’t achieve their intended aims.

And so, sometimes, they get bad rap, but folks are like: Oh, your coalition coming together to sip tea and chat about, you know, your shared interest. And that’s the first thing that we say. We say, “If I had to give one piece of advice to anyone running a coalition, it’s ‘Be a team, not a club.’”

Denver: Yeah.

Madeleine: We’re not a club where everyone has a shared interest in community health workers. We’re a team with a shared mission. M-Hmm. And the mission is to make professional CHWs the norm worldwide, and that changes everything.

Denver: Yeah.

Madeleine: It’s like, “Hey, we know the scoreboard. We trust each other. We’re collectively achieving together.” And, I think, the resonance of this is, if anyone thinks back to high school, it’s like maybe you were in a club, maybe you were on a team, but probably for most people, I’m willing to bet, you’re still friends with the folks you were on the team with, not the folks that you were in a club with. And it’s because of that shared mission accomplished and purpose.

Denver: Yeah. Yeah. I think also my observation has been, I don’t know if you see it this way as well, you have to often redefine success for members of that coalition, and a lot of that gets back to their own board because we have been so ingrained in terms of doing more as a single organization.

And that when you’re beginning to look at the holistic problem and challenge, the contribution you make to that is a little bit different measure than, you know, How many people did we feed last month? And once they can begin to sort of get that reset in their brain, they can approach the coalition completely differently because you’re looking to solve the problem systemically as opposed to telling everybody: This is what we achieved.

Madeleine: Hundred percent. And I think that that’s why again, that team mindset is so critical because the first question is, Well, what’s your scoreboard?

Denver: Yeah.

Madeleine: And for individual organizations, the scoreboard might be number of malaria nets distributed, you know, number of kids that were treated. And that direct delivery is critical. It’s also critical that we don’t have to keep donating to NGOs to do this ad nauseam forever. It’s critical that the systems that they’re filling in the gaps for, the national health system, gets fixed. And that’s our scoreboard as a collective.

So, these direct service delivery organizations are doing critical, urgent, immediate work, filling gaps. And then together, we have this policy scoreboard, which is, “Hey, can we actually improve the performance of the overall system that you’re filling a gap for so you don’t have to fill those gaps anymore, or you can go fill gaps somewhere else?”

And we reduce over time the number of gaps that need to be filled. And I think folks love that because they love the work they’re doing. They love to be interacting with patients. They love to be of immediate service.

But, I think, folks also take a generational perspective. They’re like: I don’t want, you know, my grandkids doing the same work that I’m doing. I want us as a country or as a world to have different systems and be living together differently and better than we are now. And that’s the type of work that we’re doing together and tracking.

Denver: Let me close it with this, Madeleine, what do you hope your scoreboard reads five years from now?

Madeleine: 91 or 92. Yeah. I mean like 90%. And I think we can get there. We know from just so many social changes that it’s a drop, a waterfall.

And I think that, you know, I’ve been working with community health workers and alongside community health workers for the last 10, 15 years now, and there hasn’t been a moment like this one, where community health workers are in the room, where the way that people who are not community health workers are starting to change how they talk about community health workers.

The respect is there; the reference is there where we’re seeing countries, at an accelerating rate, make this transition. Just at the end of last year, we had Kenya make this transition. You know, Zanzibar announced they’re making this transition. We have new ways to track. I mean, again, this map is nothing like showing someone a map. They immediately look, well, you know: How are we scoring?

Denver: That’s right.

Madeleine: It’s catalyzing whole new conversations and visions and, I think, there’s movement on the funder side too. The guidance is there, and they’re kind of saying, “Wow, alignment, transparency, like we need to do a better job.”

We need to know what parts of a national health system are being funded, what parts are being unfunded, and how do we fill the gap as opposed to just going in with our own agenda, which, I think, has been the previous approach.

So, I’ll say, I think, across each of these pieces, there are vibrations. They’re getting louder. And, I think, that waterfall could just be around that next corner. So, we’re excited to reach it.

Denver: Yeah. Drop, drop, drop, waterfall reminds me of Ernest Hemingway and he says: You go broke very slowly and then, all at once.” It’s the way things go.

For listeners who want to learn more or financially support this work of the Community Health Impact Coalition, tell us about your website and what they’re going to find on it.

Madeleine: Absolutely. You can come find us by going to, or you just Google Community Health Impact Coalition, and you can join us. You’ll learn about what we do, where we’ve won so far, and what’s next.

And there are opportunities, again, to contribute financially or in-kind with whatever expertise that you happen to have up your sleeve. And we, like all movements, need to build a broad and focused tent to win. So, we’d love to hear from you.

Denver: Well, you’re doing an incredibly exciting and vital work, and I want to thank you so much, Madeleine, for being here today. It was a real pleasure to have you on the program.

Madeleine: Thank you so much, Denver. Really appreciate the opportunity again.

Denver Frederick, Host of The Business of Giving serves as a Trusted Advisor and Executive Coach to Nonprofit Leaders. His Book, The Business of Giving: New Best Practices for Nonprofit and Philanthropic Leaders in an Uncertain World, is available now on Amazon and Barnes & Noble.

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