Scaling Pathways
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Scaling Pathways

HCWH: Pearls of Scaling Wisdom

As part of this Scaling Snapshot, see also Health Care Without Harm’s Organizational Overview, Getting Ready for Scale, and Key Scaling Strategies. You can find the full snapshot PDF here.

Photo by Skye Studios on Unsplash

1. Prioritize Self-Care As You Navigate The Grueling Journey To Impact At Scale.

Adapted from HCWH Founder Gary Cohen’s July 2019 blog, It’s Time for a New Myth of the Social Entrepreneur.
Ambitious organizations have dreams to bring their innovations to more places, impact more people, raise more money, and save the planet. The expectation is to raise your ambition by at least a magnitude of ten. But that pressure to scale our organizations takes a serious toll on our personal lives, reflected in disconnects from our partners and children and in our own health. It is easy to put our needs last and to deeply internalize the enormity of the suffering we are striving to address. But over the past 35 years, I have learned a couple of lessons to help manage this reality:

  • Value the perspective of time. We are part of a greater movement, and, while we are contributing to an important chapter, there will be more chapters to write by future generations (and, in fact, many chapters upon which we stand). So, try to hold on to the outcomes of your actions lightly, knowing that you exist within the maelstrom of a long-term struggle.
  • Show up for yourself. If I don’t care for myself, then I am not much use to anyone else; I’m only more likely to be impatient, resentful, and burdened by the ten thousand things that need to get done. It serves no one to deny my basic needs so I can devote more time to my organization and the movement. I’ve learned that meditation, yoga, and exercise are essential to my wellbeing. Eating and sleeping well are also critical, as is pursuing activities that replenish me, like walking in the woods. Self-care — as we try to repair the world — isn’t selfish.

2. Embrace Different Cultures To Create Widespread Change; You Have To Make It Work!

Widespread, systems change requires many different players on the field, each performing their distinct role but also working in sync to achieve a greater goal. Through our coalition-building work, we have engaged — whether through close partnerships or as part of our team — environmental advocates, research scientists, clinicians and other health system staff and executives, health care product manufacturers and suppliers, purchasing experts, government and multilateral institutions, and more. It has been a constant learning process for us, and we have continued to find the right types of engagement for all of the different players — making pivots along the way to bolster alignment and decrease conflicts of interest. Within our own organization, we have a number of different cultures as well: an advocacy arm, a membership arm, and a procurement arm. While we previously put firewalls between these groups, bringing them together under one umbrella has ensured that we are leveraging each other and aligning toward our common goal but requires constant attention to maintaining a collaborative internal culture.

3. Think Early About How To Capture The Value You Are Creating.

We have never believed that creating a monolithic organization was part of our goal; our mission is our goal, and the existence of the organization has always just been a channel to that goal. But as long as we, as an organization, play an important role in enabling impact at scale, we do need to sustain ourselves and capture some of the value we are creating. We have realized that just because we are often in the background, promoting the work through others, we cannot totally forget about self-promotion (to gain credibility with potential funders) or monetizing our work.

4. Align Earned Revenue With Mission.

While it’s important to capture the value you are creating, you must do so in a way that is aligned with your mission. When we originally grew the Practice Greenhealth membership organization, we invited both supply chain and health care systems as equal members and grew our earned revenue from their membership fees. We soon realized, though, that the supply chain member’s Interests in PGH were often in competition with the interests of our hospital and health system members. Moreover, we often found ourselves on opposite sides of the policy debate through HCWH’s advocacy work. We thus eliminated supply chain partner memberships and, several years later, created an “industry partner” category better aligned with our mission. Industry partners fall short of full PGH membership but have access to our tools and resources as well as other limited engagement opportunities for a modest fee.

5. Acknowledge — And Address — The Funding Challenge Of Working Across Sectors.

Health Care Without Harm’s work often fell between the cracks when it came to interest from donors. Donors who funded environmental initiatives didn’t understand the health aspects of HCWH’s work, and donors who funded health didn’t understand why the climate crisis was a medical emergency. We had to face the reality of this empty space between the two sectors and embark upon a long-term effort to build literacy in both sectors and the funding community to fill in this space and create an urgency in addressing it.

6. Make Change Happen Across Borders.

The issues HCWH addresses — climate change, chemical contamination, medical waste, and more — have profoundly local environmental health impacts. At the same time, none of these issues can be solved without a global approach. Almost from its inception, HCWH began working internationally. Its collaborations led to the emergence of a powerful worldwide health care network that helped win the Minamata Convention on Mercury and is now tackling the climate crisis on nearly every continent. Similarly, collaboration with international bodies, such as the World Health Organization, the UN Development Programme, and the World Bank, have been essential to the organization’s success around the world.

Published September 2020. Find the full Scaling Snapshot PDF at
Authored by Erin Worsham, Kimberly Langsam, and Ellen Martin.



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CASE at Duke

The Center for the Advancement of Social Entrepreneurship (CASE) at Duke University leads the authorship for the Scaling Pathways series.