Integrate Health: Jennifer Schechter on Listening to the People Closest to the Problems

Carolyn Robinson: Could you please introduce yourself and tell us about your work?

Jennifer Schechter: My name is Jenny Schechter. I’m one of the co-founders and the CEO of Integrate Health. Integrate Health is a social impact nonprofit organization that’s working in partnership with communities and governments to scale high quality primary healthcare. We work primarily in West Africa with a focus on rural communities that have traditionally had very difficult access to healthcare services.

Carolyn Robinson: What is distinctive about your approach?

Jennifer Schechter: Within the broader global health field, there’s a subset of organizations that are focused on community health, who leverage the use of community health workers. That’s because community health workers are a very, very effective way to close the know/do gap, to get solutions that we know will work – namely medications, tests, diagnostics, treatment – to patients who don’t currently have access. What makes Integrate Health unique is we work in a seamless manner to ensure that healthcare delivery is integrated across the community, the clinic and at the facility level, making sure those two sides of the equation are equally invested. That creates a very effective mutually reinforcing feedback loop where patients receive great care at home from their community health workers whom they trust, and then listen when they’re referred to facilities for follow-up care, where they also receive great care, reinforcing the trust they have in their community health workers.

Carolyn Robinson: Why did you decide to approach your work that way, in particular with community health workers?

Jennifer Schechter: Our organization was originally founded out of a partnership between American Peace Corps volunteers and a community-based association of people living with HIV. Our original focus was on providing care to patients living with HIV at a time when access to treatment was not yet available in Togo, where we work in West Africa. In that context, community health workers started as peers, that is, as fellow individuals living with HIV who are often the only people accepted into the home of an individual living with HIV. They are one of the most effective means of delivering psychosocial support, nutrition assistance and ultimately medical care in the form of antiretroviral therapy.

Carolyn Robinson: Is there something unusual in that approach, or is it fairly common?

Jennifer Schechter: It is. I would say it’s an evidence-based intervention. There’s a large body of evidence in peer-reviewed literature to support community health workers. However, many countries still deploy or employ volunteers as community health workers. What we’re working on is demonstrating that they have a very important role in the health system, that they should be formally recognized, accredited and professionalized as a key cadre.

Carolyn Robinson: Who else are you partnering with?

Jennifer Schechter: We are a founding member of the Community Health Impact Coalition, which is working on this issue. We started that work alongside five other peer organizations. Now that coalition has over 20 members, maybe far more at this point. 

Carolyn Robinson: Could you share an example to illustrate the impact of your work?

Jennifer Schechter: We work with community health workers who are recruited from their own communities. I remember being with a community health worker in a village called Sara Kawa. She was a young woman, walking from home to home in the village, and as we passed by the chief’s house, he came running out to tell me how incredible the work of the community health workers was. This community is a very hierarchical community, a very stereotypical patriarchal community. To see a chief, a respected community elder, going on and on to praise a young woman for her work and her contributions to the community was really astonishing. 

The community health workers tell me stories upon stories of women who had their last child at home, but are now choosing to give birth in a facility because they’ve come to understand the importance of that, and who call them in the middle of the night to provide care when their children are sick. We also published a research study that showed a 30% reduction in the under-5 year old mortality rate in the communities where we first piloted this approach to primary care, so we have evidence and data to back up the stories as well. We expanded to Guinea about two years ago. We support about 200 community health workers in Togo right now, and 100 in Guinea at this point.

Carolyn Robinson: We want to hear more about what’s working and what isn’t as far as the funding you get and the support you’ve received. What’s surprised you and turned out to be an effective catalyst to grow and operate sustainably?

Jennifer Schechter: The most valuable type of funding we receive is unrestricted multi-year funding. We’re very fortunate to have a number of partners who give in that way, and who have been with us for a number of years now.

Carolyn Robinson: That approach allows you to do what you need to do without constantly reapplying, is that right?

Jennifer Schechter: Yes. Like any organization, we have a strategic plan which guides our work, how we’re organized, the systems we build, the people we hire. It’s the roadmap. We try to fundraise to that roadmap, because if that’s what we say we’re going to do, then that also dictates the resources that we need. When we find partners who say, “Great, we’re going to invest in that strategy,” that allows us to fund and work to the strategy as opposed to restricted funding where they say, “We will fund these things,” and then we have to figure out how to maneuver and contort within our strategy to make that funding fit into the overall roadmap of what we know we need to do. The unrestricted funding is actually a far better use of a funder’s resources, because we don’t have to spend time and money figuring out how to fit into their frameworks.

Carolyn Robinson: Besides the Rippleworks grant, have you received other funding recently?

Jennifer Schechter: Rippleworks funded us with a one-time grant a couple of years ago. We have a roughly $10 million budget that we have to raise every year, and more as we grow. We have about 40 different funding partners right now.

Carolyn Robinson: Without getting into specifics, how many give you that multi-year unrestricted model versus something else?

Jennifer Schechter: We’re quite lucky. I would say about 85% of our funding is unrestricted.

Carolyn Robinson: Any bold shifts in funding needed to strengthen the voices of people closest to the problems you’re working on?

Jennifer Schechter: Funders need to be flexible to meet organizations where they are, to try to understand the context better so they do not cause organizations to contort and put in extra work just to communicate within frameworks that funders understand.

Funders need to be flexible to meet organizations where they are.

– Jennifer Schechter

Carolyn Robinson: Is there anything about working in French-speaking countries that funders need to change the way they fund?

Jennifer Schechter: A lot of funders impose geographic restrictions, the result of which is that there are big pockets of the African continent that get far less funding. West Africa is one of them because of the language barriers and other reasons. Not coincidentally, child mortality rates are significantly higher in West and Central Africa. I think the less restrictions there are, the more open and flexible that funding can be, the better chance we have of driving it towards where the need is the greatest. Because we work in two Francophone countries, language is always the first barrier that comes into my mind. I joke that my role is really chief translator because I explain to funders in English what our teammates are doing. 

Carolyn Robinson: Sounds like you need translators, perhaps on a community level or on your staff. Do you feel that’s funded appropriately?

Jennifer Schechter: Translation, yes, but also just understanding that our work is global in nature. We have four constituencies. We have our patients, we have our government partners, we have our funding partners, and we have our staff. We need to build an organization that’s capable of meeting the needs of all of those constituencies. Which means we need people who speak the local language, people who speak French, which is the government language, people who speak English, which is often the funder language. We very much believe in the idea of proximate leadership and that the voices of those who are closest to the problems should be heard. To do that, we do a lot of things like supporting community health workers to participate in advocacy and communications training, and then support them to speak at international conferences. We also recognize that we need a global team and people with a lot of different skills.

The voices of those who are closest to the problems should be heard.

– Jennifer Schechter

Carolyn Robinson: How do you think about growth with the funding you receive?

Jennifer Schechter: We think about scale with our government partners. Helping them see the evidence we’re generating, the innovations we’re testing, how can these be integrated into national government policy and funding plans? We first need private philanthropic resources, and then we can move into accessing bigger bilateral or multilateral funding and government funding.

Carolyn Robinson: You’ve received both capital and project support from Rippleworks. What aspects of that support were most helpful, and what specifically has made the most difference in your work?

Jennifer Schechter: The unrestricted funding is key to help us do the work. The second piece that Rippleworks offered that was extremely helpful was a talent grant. That really allowed us to think about our human resources and how we can be intentional about capacity building with our team. Both of those were invaluable.

Carolyn Robinson: Is there anything that would have made that kind of support better? Would it have made any difference if it had been done in a different sequence?

Jennifer Schechter: We received the capital investment before the HR talent grant. That made the most sense, because if we had gotten the talent grant first, we would have been worried that if we didn’t get the project funding, it would have been harder to invest that in human resources.

Carolyn Robinson: What would you say are the main things that you need to unlock your ability to sustain and expand your work?

Jennifer Schechter: We need talent. I say that because we’re at a fundamental disadvantage as a nonprofit organization. Our compensation structures are not competitive with the private sector, or in the case of global work, the UN agencies or the Gates Foundation, for example. We can’t compete purely from a compensation standpoint. Talent is a really, really big challenge. Funding is a huge challenge. It takes so much work and energy to consistently raise your budget every year. 

We can’t compete purely from a compensation standpoint. Talent is a really, really big challenge.

– Jennifer Schechter

Carolyn Robinson: Can you talk a little bit more about your struggles with talent? How do you attract local talent when they could easily work for the UN or somewhere else for a lot more money? What makes them want to work with you? What’s your strategy?

Jennifer Schechter: One piece of our strategy is investing in emerging talent. If we can find individuals with high potential, high capacity and the right values alignment, we can help them build their skills. It does mean we’re always stretched a little thin and we’re always reaching. We always have a team that’s pushing themselves to the limits of their own experience and expertise.

Carolyn Robinson: Because of that investment in local talent, do they feel a sense of belonging and loyalty to your team?

Jennifer Schechter: Many do. We also work closely with the government. If we have staff who have been with us and have learned from us, and then they go to work for the government because they see it as a more stable, long-term prospect, that’s a net positive for reinforcing the healthcare system overall. We’ve started to think more holistically about investing in regional capacity. We work in certain countries, but there’s a lot of talent within the West Africa region, within other Francophone countries. A lot of family groups and communities and cultures cross borders anyway. Taking that approach to a talent perspective makes a lot of sense.

Carolyn Robinson: Can you describe something that didn’t work, but you learned from it?

Jennifer Schechter: We work towards scale in partnership with government. We know that government has the mandate for delivering healthcare to the population. The way we can reach the greatest number of patients and communities is by having innovations delivered by government on a national scale. We are learning a ton about the best ways to do that. We have what we call handover sites, where we’re piloting district health teams to take over implementation and ownership of our sites. One thing we’re in the process of learning is that we could have done a lot more work on the front end to simplify things, to break down different approaches into their simplest forms and to think about what is going to be most effective when we hand it over. Now we’re getting ready to plan the second iteration of that work, which will allow us to test a new approach. We’re also learning that communication is so important. We communicate a lot with our government partners, but we’re finding that we need to bring them into the conversation sooner to get their insights and perspectives at every step of the process, so that we can maximize our chances for effectiveness.

Carolyn Robinson: What teachable lessons or insights would you have for anyone who wants to do similar work? 

Jennifer Schechter: For anyone who’s working specifically on scaling or working with government, we talk a lot about three things – communication, flexibility, and patience. Probably you could apply that to almost anything, but we’re trying to change national health systems and how healthcare is delivered for communities in some of the hardest-to-reach places on the planet. It doesn’t happen overnight. We always joke that if it were easy, someone else would be doing it. Lots of communication, lots of willingness to pivot and be flexible, and then a lot of patience and determination to just keep at it until we get it right and take the wins, then keep moving forward.

Carolyn Robinson: What role does trust play in your relationship with Rippleworks and with other funders? Are there certain interactions that are particularly helpful, or do you work best when the funder just leaves the details to you?

Jennifer Schechter: Trust is really important. One of the best ways to establish trust is setting a clear expectation up front. We’ve learned over the years to ask questions upfront to make sure we’re not assuming anything about what a funder wants or needs to see. The more a funder can be extremely clear with us in their communication and their expectations, the easier it makes our job. Honest equals kind, so just tell us what you need and we’ll plan for that. It’s easier to plan ahead.

Carolyn Robinson: The capacity-building support you received, such as the talent grant, the Leader Studio and others – did this help you to solve any specific problems?

Jennifer Schechter: Rippleworks has the talent grant, the Leader Studio, workshops that various members of our staff signed up for, expert office hours, and ongoing consultancy. What I like best about Rippleworks is that the array of offerings means I can always find what I need for any particular challenge. Sometimes it’s a one-off conversation, sometimes it’s a three to four-month project. I haven’t done the Leader Studios classes myself so I can’t speak to those, but I’ve heard positive things. We’re seeing some funders leverage other resources out there, in other words, making available other centers that offer classes or training programs for different topics as well. Partnering with other capacity-building service providers is extremely helpful.

Carolyn Robinson: Are there gaps between how Rippleworks aligns their approach to capacity building with the realities you face? 

Jennifer Schechter: Rippleworks does a great job with their project support, but it’s very much an expert advising our team, and then we have to do the work. Sometimes we need to hire a consultant with the expertise to come in and do the work. I wonder if there’s a way for Rippleworks to have that as another option.

Carolyn Robinson: What do you think funders don’t understand about capacity building? 

Jennifer Schechter: The main thing that is hard about capacity building is that it takes time. Often that’s the one thing we don’t have. We have to get very intentional with our team at all levels about how to carve out time and space to invest in yourself and your growth and development, while also doing the work that needs to get done on a daily basis. I’m not sure how funders can help us solve that, but that’s the reality.

Carolyn Robinson: What are your plans going forward and how can funders support that?  Any plans to work in other countries in the region?

Jennifer Schechter: We are continuing to support the government to scale our work in Togo while also starting to test new innovations that can address some of our remaining challenges, such as neonatal mortality, for example. We’re working to scale up our work right now in Guinea. We’re looking at expansion into a third country in the region over the coming years. With a lot of our partners, we’re looking at how to leverage effective delivery systems. Recently we partnered with Gavi, the vaccine alliance, to introduce greater focus on vaccine equity within primary care. Now we’re potentially looking at a malaria vaccine rollout integrated within primary care. How [can]we be more efficient, how do we learn to scale most effectively? 

This work is going to take a long time. These are goals we can’t achieve in a three-year funding cycle or a five-year funding cycle. We need, again, that multi-year unrestricted funding. We need to know that our partners are going to stay with us, we need more of them, and we need them to give more. We are at a point, particularly as an organization where we need mezzanine-level funding, and there’s not a huge bench of organizations providing that right now. Hopefully we’ll see more philanthropy open up, especially as there is a potential pullback on government funding for global health. This is an incredible time and opportunity for philanthropy to have a dramatic impact on moving the needle on systems change.

Carolyn Robinson: What about the potential third country you’re considering?

Jennifer Schechter: We made the decision to start working in Guinea in response to an invitation from their Ministry of Health who had seen the evidence from our work in Togo. They asked us to come and support the implementation of their community health policy. We would look for similar conditions to expand into a third country, in other words a government that’s looking for a partner to help them in a specific area that aligns with our strengths. What has been great about our expansion into Guinea is that it has been entirely driven by the team based in Togo, leveraging their expertise. 

They’ve also used it as an opportunity to think about what we would have done differently, and how that can inform scaling up in an additional country. We’re also bringing a lot of lessons from Guinea to inform the ongoing work in Togo. It’s given us a second set of proof points that are extremely beneficial for those teams. It’s the same team that’s working across both countries, and they’re very integrated. It’s been really positive. Introducing a third country at the right time would bring additional value as well.

Carolyn Robinson: Does it make sense to go to other French-speaking places? Could the concept transfer to other languages, including perhaps local languages?

Jennifer Schechter: Absolutely. Integrate Health is a fully bilingual English and French organization at this point. It doesn’t have to be a French-speaking country, but we do know that that’s where the need tends to be highest and where fewer organizations are working. We established a number of criteria in the initial scoping. We’re really focusing on where we can have an impact, where there is a high need. Our funders joked with us that we don’t pick the easiest countries.

Carolyn Robinson: Do you consider a country’s geopolitical situation and stability?

Jennifer Schechter: Yes. We obviously want to make sure that our staff can operate safely, so there’s a number of factors.

Carolyn Robinson: Do you see expanding to other parts of the world, perhaps Asia, or is that beyond your scope of vision?

Jennifer Schechter: Some organizations have done that. We find that our value as part of the broader health coalition is our focus on Francophone West Africa. There are still multiple countries, districts and regions within countries that have tremendous needs. I don’t see us going outside of Francophone West Africa.

Carolyn Robinson: Anything else you’d like to add that would be useful for others who might want to support you?

Jennifer Schechter: I believe that investing in community health is one of the most high-impact investments you can make. We have plenty of capacity to continue to absorb investments, and look forward to working with anyone who is interested.

Carolyn Robinson: Would you want to broaden your work laterally to incorporate other kinds of healthcare beyond vaccinations and maternal child care?

Jennifer Schechter: It’s a great question. In the countries where we work, the governments have established a core package of services that they would like to be delivered by community health workers, which are primarily child health and a few maternal health services. That correlates perfectly to the burden of disease. The highest burden of disease, sadly, is still children under five and pregnant women. I’m open in theory to the idea of adding other services onto the community health worker portfolio, up to a point – because there is data showing that once you start to ask a community health worker to do too many things, they don’t have enough time to cover their catchment area sufficiently and do it all. There’s a risk in saying, “Oh, community health workers can do it,” because this approach might then become counterproductive. What I would love to see is that we eliminate childhood malaria, we reduce incidences of diarrheal diseases, and then community health workers can move on to the next biggest problem, and we can augment their capacity in that way.

Carolyn Robinson: Are there different health issues between Togo, Guinea and the third country you’re considering?

Jennifer Schechter: No, not significantly. The burden of disease is somewhat consistent across the region. There are certainly differences. Guinea is a much bigger country. Geographic distances are much more significant in Guinea. Some of our furthest villages are 35 kilometers from the nearest health center in Togo, in Guinea they’re 135 kilometers. I would say the differences are more in terms of geography, logistics and other barriers, but the burden of disease itself is not too dissimilar.

Carolyn Robinson: Anything else that you’d like to pass along to Rippleworks or others to address the struggles your organization is currently dealing with or foresee? For example, you mentioned the question mark around federal funding in the United States. 

Jennifer Schechter: This is a moment for philanthropy to look inward and ask, “Is there more that we could be doing?” There are federally mandated guidelines around the percentage of investment size that needs to be donated, but that’s a minimum threshold. Should we look at creating different guidelines? Can we unlock greater capacity? Should those taps be opened periodically in response to certain contextual factors, like the ones we’re seeing right now? There’s been such an interesting trend in philanthropy in the last few years with Mackenzie Scott and these big bet donations, and then a pushback against that. Sometimes we can get into semantics and lose sight of the fact that there are millions of children dying around the world from diseases that we can diagnose and treat for $2, so let’s just put our heads down and solve some of those problems while we can. Whatever resources we can open up to do that, we should be moving those resources from where they are to where they need to be as quickly and efficiently as possible.

Carolyn Robinson: Thank you very much for your time. 

Carolyn Robinson led Solutions Journalism Network’s broadcast initiatives for many years. She is an experienced television producer/reporter for global news media such as CNN, BBC and Al Jazeera. As an international media development consultant, she has trained local journalists and directed media programs in two dozen countries around the world.

**This conversation has been edited and condensed.

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