Setting the bar high. (Photo by Lucas Foglia)
Two decades ago, I joined a group of Malians and Americans partnering with communities on the edge of Mali’s capital city. We aimed to bring care quickly to patients’ doorsteps, with no out-of-pocket fees. Volunteering our time, working out of a converted storage closet, we saw tremendous preventable suffering. When our neighbors struggled and failed to get care in time, we watched a toddler die from malaria. We mourned a young mother who died from an untreated cavity.
It is difficult to describe how excited we were when a leader in a large global health financing institution told us that her institution could finance our first healthcare system, fully, for the first few years. However, she had one condition: Her institution would fund us only if we kept out-of-pocket fees in place. No fees, no funding for any portion of our work: In her opinion, the cost per patient served, even though less than $1 per month, was not scale-able.
We turned her down.
At that time, I was traveling back and forth between our work in Mali and my training at Harvard Medical School in the United States, where we spend one thousand times more per person on average for healthcare, where we would not hesitate to spend more than $100,000 on a single patient’s hospital admission. The argument that $12 per person annually was not affordable at scale, for people facing extreme poverty, strained credulity.
More importantly, community recommendations and rigorous research showed us that user fee removal was necessary if we were to solve the problem of equitable, timely access to healthcare. We devoted months to trying to persuade this potential funder, bringing forward the research of Nobel Laureate economists and the expertise of community members. When she remained unconvinced, we made the difficult decision. In the years that followed, we struggled to raise necessary funds from month to month. But when the results came in from our first research study, done in partnership with the Malian government, we found that the communities we serve had increased patient visits tenfold, and had achieved, to our knowledge, the largest and fastest improvement in child survival on record.
The Trouble With Scaling Cheap
Social entrepreneurs have often faced pressure to lower standards, to scale what is cheap, and to work where it is easy. The pressure comes not only from contracting official development assistance agencies; it comes from philanthropy. But despite good intentions, these recommendations endanger the lives of those we serve, and the moral foundations of our field. They would set us on a path toward a world of greater inequity and injustice.
This argument is not new. In 1978, representatives from 134 nations converged in Kazakhstan, in the city of Alma Ata. Together these nations made a historic declaration—and committed to pursue healthcare for all. Soon after, however, global north-based institutions pressured global south governments to cut healthcare spending and to charge sick people fees for healthcare. Now 40 years later, an extensive body of research has shown us the consequences of these fees: delayed and reduced access; widening inequity; the deaths of millions of children; and one billion people pushed annually into or further into poverty by healthcare costs.
It has been argued that as official development assistance contracts, social entrepreneurs should determine what funding government has available to pay, and then design solutions that are cheap enough to match that price point at scale.
The recommendation to design solutions with and for the public sector, that the public sector can finance, is long overdue. The cost needs to align with what the government can and will pay for.
However, the cost of a solution is not set; the amount of money a government can pay for a solution is not fixed. Paul Farmer described the myth of insufficient resources as the socialization of scarcity, a dangerous belief that poor people deserve lower standards because we’ve accepted artificial scarcity as normal. We know that giving people a lower standard of healthcare because they are poor is wrong. But we convince ourselves that our abundant world lacks the resources to pay for what is needed, and that we must accordingly lower our standards.
Sometimes there are pots of money sitting untouched in government coffers, already allocated to solve the injustices of poverty, just waiting for social innovators to partner with government, to unlock and deploy them. Indus Action, one of this year’s Skoll Awardees, is a great example of this kind of social innovation: They create tools that make it easier for the poor to access government benefits in India, work that is urgently needed and worthy of support.
Far more frequently, however, the magic pot of funding does not (yet) exist. The inequities we seek to solve persist, in part, because of the lack of a financing pathway. Standard-setting work creates future ability to pay (rather than waiting on it to magically appear).
In short: Social innovation can change both the price point and ability to pay, as partners work together to create a financing pathway that did not exist before.
New Financing Pathways
Antiretroviral treatment for patients living with HIV shows us what this can look like.
When highly active antiretroviral treatment (HAART) emerged at the turn of the century, this combination therapy proved capable of stopping the progression of HIV in its tracks. At the time, however, antiretrovirals cost $10,000 to treat a single person for one year. The broad consensus in global health at the time (among institutions based in the global north) was therefore that patients living in poverty in the global south would not and could not access treatment. Prevention and palliative care to ease the deaths of those infected were concluded to be the only viable, scale-able solutions.
However, a small group of social innovators decided to challenge this prevailing conclusion. A study in The Lancet by researchers at Partners in Health showed that it was possible to treat patients in Haiti with equitable outcomes, comparable to patients living in the United States; negotiations with pharmaceutical manufacturers and bulk procurement, driven by CHAI and others, brought the cost of treating a patient with AIDS down by 99 percent, from $10,000 to $90 in less than a decade; the Global Fund and PEPFAR were born, creating a financing pipeline, mobilizing resources from both global north and the global south governments to save 70 million lives.
The same pattern played out for the community health workforce itself. A decade ago, the idea of supporting Community Health Workers as professionals, not volunteers, was dismissed as the Cadillac of community health: too expensive, too difficult. A World Health Organization guideline, major financing, and 50 national policies later, it turns out it was just the car.
These social innovators did not lower their standards to meet the predefined price point and the status quo readiness to pay. Instead, they were able to:
- Prove that equitable outcomes were possible
- Lower the price point without lowering standards
- Build a financing pathway where none existed, raising the ability to pay.
This is the blueprint for social innovation we need now. Instead of assuming that the ability to pay is constant and dropping the standard of care to meet it, they kept the standard of care high, and made the price point and ability to pay converge.
And it is a playbook that can be used in many different places. In 2025, my colleagues at Muso supported our government partners in Cote d’Ivoire to use this same playbook for change. The Ivorian government sought universal access to healthcare and launched an ambitious universal health coverage program. Muso supported them to test solutions that would accelerate access to healthcare. Our team also tested ways to make the system more efficient without compromising quality. Over the course of two years, we found ways to reduce cost per person served by 20 percent per year without compromising standards or impact. Based on the results of joint research, the Ivorian prime minister directed nearly 3,000 rural public clinics to open care without fees for more than 13 million eligible people nationwide in 2025. World Bank financing covered the first few months, and then government funding took over. In a year when millions of people elsewhere in the world lost access to care amid official development assistance cuts, millions of Ivorians gained access to healthcare thanks to this initiative.
Here as elsewhere, cost-effectiveness and efficiency proved essential: Together we found ways to better steward resources to get more impact out of every dollar for patients, and to create a solution that government partners can pay for nationally. Lower costs without lower standards. Much more work remains to be done: to renew domestic financing, to ensure quality delivery.
Foreign assistance contracted dangerously, but it did not die in 2025. It derisked the first months of a historic national healthcare reform, that was then picked up by domestic financing.
The Trouble With Scaling Easy
Social innovators don’t only face pressure to go for cheap solutions; they also face simultaneous pressure to work in easier contexts.
Over the past months, I spoke with multiple other social entrepreneurs whose teams work in conflict zones and fragile states, who shared with me that they have faced pressure, not from global financing institutions but from private philanthropists, to abandon their partnerships in these contexts, and to focus on working where resources were more abundant and the winds of stability would be at their backs. Their logic is clear: For solutions to scale with government, the public sector needs to be ready and able to deliver that solution. Even in the best of conditions, achieving meaningful change in the lives of millions of people is a steep climb. It is therefore understandable why some recommend focusing on places where the path to scale is well-paved.
Does this mean, however, that attempts to scale equitable solutions in fragile and conflict states are misguided, or even delusional? Like the cheap enough argument, the easy enough argument breaks down because of three faulty assumptions: that need is universal, that potential to scale is fixed, and that governments in fragile contexts do not have that potential.
While some would counsel that “need is everywhere,” urging social entrepreneurs to go where the potential to scale would be easiest, need is not everywhere. Look at the global distribution of under-five child mortality. Our world faces more armed conflict than at any point since World War II, and half of all child deaths occur in fragile states and armed conflict zones (where child death rates are three-fold higher than in peaceful areas).
Going where the need is does not mean doing less. Our public sector partners in Mali, in the face of protracted armed conflict, have scaled up evidence-based interventions to more than six million Malians within the national health system: professional community health workers delivering high-quality care deep in conflict-affected areas, in line with WHO-recommended standards and decades of evidence.
I used to believe that the best that we could strive for in conflict settings is relief: cushioning the blow, palliating the atrocities of war.
Our community and public sector partners in fragile settings have since proven that “relief” is the wrong standard: Communities at our joint operational research sites in Mali have achieved child survival rates on par with the United States.
Any leader who has scaled a business or social innovation can tell you that potential to scale potential is not born. It is built. And fragile states are also building: Between 2003 and 2021, in the face of worsening armed conflict, Burkina Faso reduced child deaths by 74 percent, by scaling up multiple evidence-based interventions, removing fees for children under five, and pregnant women at public facilities nationwide.
If we choose only to fund and work in stable, well-resourced contexts, inequity gaps will widen, and millions of children will needlessly die. To build a more equitable world, we must be ready to work, to fund, to cultivate scale capacity, and to scale solutions in the most difficult circumstances, to give these contexts priority.
Certain partners have committed further in the face of conflict. In late 2025, for example, the Board of Gavi, the Vaccine Alliance, announced a 15 percent increase in financing for fragile and conflict settings, even as ODA cuts contracted their budget. We have also seen some of our partners in philanthropy change, to prioritize fragile states and conflict zones; settings where philanthropy is scarce and inequity is great. Our partners at the Patchwork Collective have prioritized grants in what they call philanthropic deserts. And the Dovetail Foundation launched a strategy to prioritize grants where inequities are greater and partners have been fewer, while supporting their partners to set the bar higher, to do work “worthy of those we serve.”
Scaling Right
Nelson Mandela once wrote, “It is always impossible until it is done.” Social innovation requires this kind of moral imagination, the capacity to articulate a future fundamentally different from the status quo, and to build a path to that future before it exists.
We do not need to choose between equity and scale. We do not need to choose between efficiency and equity.
We can scale right:
- Do and fund work that raises the bar, solves the problem, and pursues equity. As Kevin Starr has put it, if the solution is not good enough, it should not scale.
- Create solutions with the public sector, from the design phase, as innovation labs, and at every step on the path to scale.
- Build and fund credible plans to make the price point and ability to pay converge, mobilizing new financing pathways, pursuing efficiency and cost-effectiveness without sacrificing quality and equity.
- Work and fund in challenging places. Prioritize where inequities are greatest. Do not look for tailwinds. Charge into the headwinds. And create tailwinds together.
This approach does not guarantee success. In communities facing extreme poverty, the shocks of climate change, political fragility, and armed conflict, those we serve find systems rigged against them. They deserve better than wishful thinking: Progress will require the hard work of changing the rules of those systems. The Mulago Foundation shares a menu of tools that our team has found useful for what they call the big shift, to support the public sector to change those rules, to deliver and finance change at scale: collective action, policy change, and tech. With the right tools, partners, and policies, the price point and capacity to pay can converge on an equitable, just solution.
This path will require enduring commitment, not over months, but for decades to come.
A cocoa farmer once told me how she almost died in childbirth: “I was hemorrhaging, and the nurse said to me, ‘You don’t have enough money to pay for all the medicines we need to stop you from bleeding to death. Which one do you want to buy?’”
And these are the stakes. We can choose to reject the socialization of scarcity, to reject the premise that some people’s lives are worth less than others because of where they are born or how much money they have. We are here to do what has not been done before, to create the solution that did not exist, to build the financing pathway that did not exist, to scale right. That is how we deliver on the promise of Alma Ata, toward healthcare for all.
Read more stories by Ari Johnson.