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 The following book excerpts have been reproduced with the
permission of Oxford University Press as a courtesy.
Ashoka: Innovators for the Public has not paid for the right to
distribute this material and has had no editorial involvement in the
publication of How to Change the World:
Social Entrepreneurs and the Power of New Ideas.

© 2004 David Bornstein

David Bornstein is a journalist who specializes in writing

about social innovation. His first book, The Price of a
Dream: The Story of the Grameen Bank was selected as a
finalist for the New York Public Library Book Award for
Excellence in Journalism. His articles have appeared in,
among others, the Atlantic Monthly and the New York Times; and he co-
wrote the PBS documentary "To Our Credit." He lives in New York City.
 Oxford University Press
198 Madison Ave.
New York, NY 10016-4314
(212) 726-6000 telephone
www.oup.com

Dear Reader:

In early 2004, Oxford will release one of the most exciting

books I have ever had the privilege of editing: David Bornstein's How
to Change the World: Social Entrepreneurs and the Power of New
Ideas. I'm very pleased to be able to share this advance excerpt with
you. Given your interest in social entrepreneurship, I am sure you will
enjoy the book.

As you know, the field of social entrepreneurship is exploding

around the globe – a remarkable story that, as Bornstein points out,
goes largely under-reported by the media. Until now, there has been
no definitive book that explains what social entrepreneurs do and why
they are so vitally important in today's world. Oxford University Press
is proud to be publishing this volume, which we believe will quickly
establish itself as a must-read for those interested in accomplishing
social change through innovation and entrepreneurship.

How to Change the World is an ambitious title for an ambitious

work. It represents the culmination of five years of research by David
Bornstein, including interviews with hundreds of people in eight
countries working in education, health, disability, environmental
protection and other fields. It's an impressive combination of anecdote
and analysis, full of inspiring stories and useful lessons. I hope you
will share my enthusiasm for this remarkable book, and help us to
spread its message.

Yours sincerely,

Peter Ginna
Editorial Director
 The Global Emergence of Social Entrepreneurship

Social entrepreneurs have existed throughout history. St.

Francis of Assisi, for example, the founder of the Franciscan
Order, would qualify as a social entrepreneur – having built
multiple organizations that advanced pattern changes in his
"field." Similarly, Florence Nightingale created the first
professional school for nurses and established standards for
hygiene and hospital care that have shaped norms worldwide.
What is different today is that social entrepreneurship is
establishing itself as a mainstream vocation not only in the
United States, Canada, and Europe, but increasingly in Asia,
Africa, and Latin America. In fact, the rise of social
entrepreneurship represents the leading edge of a remarkable
development that has occurred across the world over the past
three decades: the emergence of millions of new citizen
organizations.
Consider that twenty years ago Indonesia had only one
independent environmental organization. Today it has more than
2,000. In Bangladesh, most of the country's development work is
handled by 20,000 NGOs; almost all them were established in the
past twenty-five years. India has well over a million citizen
organizations. Between 1988 and 1995, 100,000 citizen groups
opened shop in the former communist countries of Central
Europe. In Canada, the number of registered citizen groups has
grown by more than 50 percent since 1987, reaching close to
200,000. In Brazil, in the 1990s, the number of registered citizen
organizations jumped from 250,000 to 400,000, a 60 percent
increase. In the United States, between 1989 and 1998, the
number of public service groups registered with the Internal
Revenue Service jumped from 464,000 to 734,000, also a 60
percent increase. Given the long history of citizen activity in the
1
 United States, it comes as a surprise that 70 percent of registered
groups are less than thirty years old. And during the 1990s, the
number of registered transnational citizen organizations
increased from 6,000 to 26,000.
Historically, these organizations have been defined in the
negative – as nonprofit or nongovernmental organizations. Today
they are understood to comprise a new "sector," variously dubbed
the "independent sector," "nonprofit sector," "third sector," or, the
term favored in this book, the "citizen sector." Hundreds of
universities in the United States, including Harvard, Stanford,
Yale, Duke, and Johns Hopkins, have established college courses
and centers to study this sector. In New York City, during the
1990s, while overall employment grew by only 4 percent,
employment in the citizen sector grew by 25 percent. Similarly, a
Johns Hopkins study of eight developed countries found that,
between 1990 and 1995, employment in this sector grew two and
a half times faster than for the overall economy. Peter Drucker,
the management expert, has called this sector America's leading
growth industry.
Although public service organizations are far from new,
this worldwide mobilization of citizens is new in several
respects:

(1) It is occurring on a scale never before seen;

(2) The organizations are more globally dispersed and diverse
than in the past;
(3) Increasingly, we find organizations moving beyond stop-gap
solutions to more systemic approaches to problems – offering
better recipes, not just more cooking;
(4) Social entrepreneurs are less encumbered by church and state
and, in fact, exert considerable pressure on governments (as
witnessed in the International Campaign to Ban Landmines
and the creation of the International Criminal Court);
(5) They are forging partnerships with businesses, academic
institutions, and governments – and, in many cases, refining
the government's representational function; and;
(6) Because of the natural jostling for position that occurs when
a formerly restricted sector suddenly enjoys "open entry" and
2
 new players crowd onto the field, the citizen sector is
experiencing the beneficial effects of entrepreneurialism,
increased competition and collaboration, and a heightened
attention to performance.

There are, of course, many inefficient, wasteful, and

corrupt organizations in the citizen sector. However, because of
the new surge of activity, citizen organizations increasingly are
being pressed to demonstrate their efficacy. Faced with a wave of
energetic social entrepreneurs who are building organizations
that are strategic and fast moving, people managing sluggish,
outdated institutions no longer find "business as usual" to be a
safe stance. In fact, it is getting riskier by the day to remain static
or to coast on reputation. The arrival of entrepreneurialism and
competition represents an early, but fundamental, change in the
dynamics of the citizen sector, one that history has shown is
highly conducive to innovation.
Despite their magnitude, these changes have gone largely
unreported. Almost everyone knows about the explosion of the
dot-coms – a much smaller phenomenon – but millions have still
not heard the big story: the worldwide explosion of dot-orgs. It is
a story with far-reaching implications: By sharpening the role of
government, shifting practices and attitudes in business, and
opening up waves of opportunity for people to apply their talents
in new, positive ways, the emerging citizen sector is reorganizing
the way the work of society gets done.

3
 Vera Cordeiro, Brazil: Reforming Healthcare

If Florence Nightingale were alive today, she might be

doing something along the same lines as Vera Cordeiro, a
physician in Rio de Janeiro who is working to redefine healthcare
in Brazil. Cordeiro is the founder of Associação Saúde Criança
Renascer (Rebirth: Association for Children's Health), the
flagship in a network of organizations that extend care to poor
children after they are discharged from public hospitals.
Tens of millions of Brazilians live in urban slums that lack
decent housing, clean water, and proper sanitation. Millions of
children are stunted from chronic malnutrition. Cordeiro founded
Renascer in 1991, while she was working in the pediatric ward of
Hospital da Lagoa, a public hospital in Rio, because she could not
bear to see so many children discharged only to return weeks
later, sick again.
From the perspective of a doctor, it makes no sense for a
hospital to discharge a poor child back to the slums without
following up. But that is the norm today, and Cordeiro intends to
change it. To her, health and social conditions are two sides of the
same coin. "Hospital treatment as it is conducted today – ignoring
poverty and the conditions of the family – is a false treatment,"
she explains.
To date, Cordeiro has extended her work to fourteen public
hospitals in Rio de Janeiro, São Paulo, and Recife, bringing direct
benefits to 20,000 children and influencing a growing circle of
medical practitioners. Her goal is to carry Renascer to every
public hospital in Brazil.
There may be no city in which the juxtapositions of wealth
and poverty are more stark than Rio de Janeiro, where poor
people in hillside favelas (urban slums) look out on the rich in
beachside enclaves such as Copacabana and Ipanema. Each day
4
Vera Cordeiro made the commute from her leafy suburb, Barra da
Tijuca, where she lived with her husband, Paulo, an IBM
executive, and their two daughters, Marina and Laura, to Hospital
da Lagoa, which served some of Rio's poorest areas, including
the Baixada Fluminense, the lowland slums, and Rocinha, the
largest favela in Latin America.
Rocinha is a massive hillside expanse of cinder block,
wood, tin, and cardboard. From afar it is a beautiful sight. At
night, lights sparkle and sounds of percussion drift down to
neighborhoods below. But although they are not exclusively
poor, Rocinha and the other favelas that are home to millions in
Brazil are unhealthy places. Gangs dominate the slums, and the
sound of gunfire is commonplace. Families are pressed together
in ramshackle houses, in which children often sleep on damp
concrete or dirt. The streets are full of vermin, and the stench of
sewage rises from narrow alleyways.
At Lagoa, Cordeiro encountered the by-products: children
with pneumonia, tuberculosis, rheumatic fever, anemia, birth
defects, and other ailments. The kids often had skin lesions.
Many suffered from leptospirosis, a disease caused by bathing in
or drinking water contaminated with rat urine, with symptoms of
fever, jaundice, vomiting, and diarrhea.
Cordeiro found that many of her patients' mothers were
single parents, without child support, living in dilapidated
shacks. They lacked basic knowledge about health, nutrition, and
sanitation and were totally unequipped to manage their children's
illnesses or prevent recurrences.
The children would be admitted to the hospital, treated, and
discharged – and then they would be readmitted, sometimes
within weeks. It was a grim cycle. "I could not stand to go one
more day seeing children locked in this cycle of hospitalization,
rehospitalization, and death," Cordeiro said.
"We were stuck," Odilon Arantes, the head of Lagoa's
pediatric ward, told me. "Here you have a government-run
hospital with the best equipment and the best doctors. After
making this huge investment in the children, we just let them go.
Of course, we had to discharge the children at some point, but
how could we discharge them into the same conditions that
5
 produced the disease?"

One day a one-year-old boy arrived at Lagoa. His hand

required amputation. Cordeiro was often called in to counsel
patients in stressful cases, and she tried to prepare the boy's
mother, Pedrina, for the amputation. Pedrina told her that she had
just lost her job as a maid. She didn't know where she was going
to live or how she was going to buy food. She couldn't begin to
think about purchasing a prosthesis for her son.
That night, as Cordeiro sat in her living room with her
daughters, amid the stereo, sofas, and plush carpet, she could not
get Pedrina out of her mind. She remembered how shaken she
had been when her daughter, Marina, had contracted a serious
infection and had been unable to eat for days.
"And I have all this help," she recalled thinking. "I have my
mother, two maids, the best pediatricians.…" Her thoughts
drifted to other mothers she'd met over the years who had had to
make what she called "Sophie's Choices": buy medicine for one
child or food for them all.
The next morning she canvassed the hospital to solicit
contributions for Pedrina. It would help a little, but it was far
from a solution.
The following day, Cordeiro was asked to counsel another
mother whose seven-year-old son had kidney cancer. This
woman was thirty-five but looked sixty. She had ten children.
She'd come from another state and was staying with relatives in
Rio who were extremely poor.
"The mother asked me if I had something to cover her son,"
recalled Cordeiro. "She said, 'If I don't have something to cover
him, he might catch cold and then the doctor will stop the
chemotherapy. Do you have a blanket or a sweater to give me?'"
What good was chemotherapy when patients lacked
blankets?
Increasingly, Cordeiro found herself dwelling on these
contradictions. In 1991 she was forty-one years old. The previous
year she and her husband had reunited after a four-year separation.
With Marina thirteen years old and Laura ten, Cordeiro found that
she was needed less at home. The time was right to take a new step.
6
 One Sunday in April
1991, Cordeiro wrote a
proposal for a healthcare
project to stop the cycle of
readmissions among poor
children. She presented it to
Lagoa's directors and was
promptly told: "Vera, this is
the government's work."
Undeterred, she spent the
Vera Cordeiro. Credit: David Bornstein next six months persuading
staff in the pediatrics unit to
help her.
On Friday, October 25, 1991, at 7:00 P.M., she brought
together fifty colleagues in the playground of her apartment
building, announced her plan, and raffled off a set of sheets that
her mother, Cordelia, had embroidered. The $100 they raised was
used to cover the incorporation fees for Associação Saúde
Criança Renascer, a new organization that would begin where
hospital care ended.

7
 A Real Treatment

Today, Renascer's main office is located in a forested park

five minutes' walk from Hospital da Lagoa. (For six years, an old
horse stable had served as the office.) The building is crowded
with psychologists, social workers, nutritionists, volunteers, and
mothers of sick children. A storeroom remains stocked with food
and medicine. A bulletin board by the entrance lists supplies in
need. On various visits, I noticed that the list included fans,
shoes, mattresses, cradles, blenders, water filters, eyeglasses,
clothes, blankets, a wheelchair, a sewing machine, a nebulizer, a
safety fence, and a carriage for a child with hydrocephalus.
The most critical work in Renascer's office takes place in
the volunteer room, where volunteers interview mothers about
their children and help them develop "treatment plans." On one
of my visits, I met a woman named Maria whose seven-year-old
son, Daniel, had hydrocephalus, a life-threatening condition
characterized by extreme swelling of the head. Maria had grown
up in a village and come to Rio as a teenager to support her
parents. She had an alcoholic husband and two sons whom she
supported by selling sandwiches and juices to police officers at
the city morgue.
Daniel had undergone three operations. He needed to have
fluid drained regularly from his head. Because it was dangerous
for him to move around, he spent most of his time indoors. The
volunteers were trying to procure a special carriage so he could
spend more time outside.
At the next table sat Ivonete, a woman of twenty-five with
anxiety lines etched deep into her face. She had been referred to
Renascer by a social worker at Hospital da Lagoa after her son
Marcos had been hospitalized for dehydration due to diarrhea. At
the time, Ivonete had two other children and was pregnant with a
8
fourth; there were "serious troubles" at home that she didn't want
to get into. Renascer had been closely monitoring Marcos's
health for a year. Ivonete had learned how to improve the family's
hygiene and diet. Renascer also helped the family move out of its
damp basement dwelling into a healthier living space. Now
Ivonete wanted to start a small business selling sweets. Renascer
was helping her to get it started.
The most striking thing about the volunteer room was the
seriousness of the work. At every table, mothers and volunteers
were discussing problems, making decisions, and planning
actions. It wasn't all smiles. Some mothers became frustrated
when they ran into Renascer's limitations, and some volunteers
became frustrated when mothers didn't live up to their promises.
But no one seemed bored or resentful. No one was saying:
"That's not my department." or "Fill out this form and come back
in three weeks." The prevailing attitude seemed to be: "Let's roll
up our sleeves and see what we can do about this problem."
The bottom line was clear: Without Renascer, children like
Daniel and Marcos would be hospitalized more often. They
would suffer more; their families would suffer more; the doctors
would suffer more; and society would bear the expense.
In 1999, the director of Lagoa's pediatrics unit, Odilon
Arantes, reported that, between 1991 and 1997, Renascer's
follow up had brought a 60 percent drop in readmissions in the
unit. The impact, he said, was "stunning." Doctors and nurses

Renascer’s volunteer room. Courtesy of Renascer

9
 were now able to do what they had trained to do: heal. "It has
completely changed the motivation in the unit," Arantes told me.
"Before Renascer, we used to spend lots of effort and money in
the emergency room or ICU [intensive care unit] on treatment
knowing that there was a high probability that kids might die
afterward from lack of assistance and follow up at home.
"Now when we discharge a poor child, we can feel at peace.
And this makes our work more meaningful and rewarding."
What, then, in the context of poverty, constitutes a real
treatment? Cordeiro has found that, on average, it takes about
eight months of regular contact between mothers and an
organization that can address a range of social problems to do the
trick. Sometimes it takes twelve or fourteen months, sometimes
longer.
And sometimes even that isn't enough. Cordeiro frequently
has to remind herself that Renascer does not exist to solve all of
Brazil's woes. Its job is to ensure that vulnerable children treated
at Hospital da Lagoa actually benefit from the medical care they
receive and, as far as possible, stay healthy outside the hospital.
It's a limited mission, with measurable, time-bound goals.
The idea is to do it systematically, showing the way so that, in
due time, the Renascer treatment becomes the standard
treatment.

When Cordeiro first arrived at Hospital da Lagoa in 1976,

at age twenty-five, she had been assigned to the hospital intake
ward, where her job was to diagnose as many as twenty patients
each morning. Initially, the days were a blur. In time, however,
she learned to steal moments to talk with the patients, many of
whom were poor women. Cordeiro had long been interested in
the social and psychological roots of illness. After speaking with
the mothers, she began to make connections between their
physical ailments and the stress in their lives. That led her to
lobby the hospital administrators to establish a department of
psychosomatic medicine (psychosomatic medicine explores the
relationship between emotional stress and illness). In the unit –
the first unit of its kind in a public hospital in Brazil – Cordeiro
introduced an array of social and psychological treatments to
10
help patients cope with chronic diseases such as asthma, heart
disease, and hypertension.
In 1988, Cordeiro requested a transfer to the pediatric ward,
a decision that would set her life on a new course. "I worked with
adults for thirteen years and I never thought to start an
organization like Renascer," she told me. "But after I came to the
pediatric department, I realized that I had two choices: to give up
working with children or to continue working in a different way."

11
 The Most Important Person

Renascer's initial team was made up of ten people,

including Cordeiro, her mother, Cordelia, a few other
psychologists and nurses, and some friends. They operated out of
a small room in the hospital. They began by scouring their
Rolodexes, seeking contributions of milk, medicine, and food.
Each night they consulted with one another on the phone: Who
knows where we can get a vaporizer? Should we have a bingo
night? "We used to sit around a table and clap hands each time we
received a donation of milk or medicine," Cordeiro recalled. "I
would think, 'I'm a doctor, and here I am clapping for milk.' But
I knew that that was the way we would grow stronger."
Cordeiro's objective was to help the mothers of vulnerable
children learn how to prevent recurrences of illness and minimize
crises. So she enlisted doctors, nurses, and social workers at
Lagoa to identify poor children who were about to be discharged.
To entice the mothers to work with Renascer, she offered an
incentive: free nutritional supplements and medicine for six
months. In exchange, mothers had to agree to visit Renascer's
office at least twice a month.
On the first visit, Cordeiro or one of her colleagues would
interview the mother, inquiring about the family's income, diet,
and other social conditions. Does your house have running
water? Does it have a solid roof? Is there a toilet? Do the children
sleep in beds? Did they have adequate clothing?
Each family was given a baseline score for poverty,
education, employment, housing, and health awareness. Then,
over the next six months, Renascer's team would work with
mothers one-on-one. In conjunction with social workers and
nutritionists, they sketched out treatment plans and set specific,
time-bound goals, which might include such things as fixing a
12
roof, modifying a child's diet, getting into the habit of boiling
water, getting a bed for a child, or acquiring the documentation to
be eligible for government assistance.
"The key is that the mothers know exactly where they need
to go," explained Cordeiro. "Then, step by step, we help them get
there."
From the outset, mothers were informed that Renascer
would help them gain control of their family's health, but the
organization's support was temporary.
Each time mothers visited the office to pick up food and
medicine, they would discuss the progress of their treatment
plans with one of Renascer's volunteers. If necessary, mothers
might consult with a psychologist, nutritionist, or social worker.
With each visit, Renascer recorded changes in the children's
health. As problems emerged, the team did whatever it could to
try to solve them. That might mean anything from navigating the
health system, to procuring a water filter, to helping a mother
enroll in a hairdressing course.
In some cases, mothers failed to keep up their ends of the
bargain and Renascer "discharged" them. In some cases,
Renascer lacked the resources to bring about significant lasting
changes in the family. But most of the time, Renascer's work
made a real difference, and after a few months, a child was
beyond the danger zone or at significantly reduced risk of
recurrence, and the mothers had adopted healthier habits. These
successes occurred most frequently with acute cases, such as
malnutrition, pneumonia, tuberculosis, leptospirosis, and
infectious diseases. "This group are the happiest for us, because
the sicknesses come from poverty and we can bring a lot of
change to them," Cordeiro said.
With chronic illnesses, such as kidney disease, asthma,
sickle cell anemia, rheumatic fever, or neurological problems, the
goal was to show the mothers how best to manage the conditions
at home. And with terminal cases, such as AIDS or leukemia, the
goal was to keep the children comfortable until death.

Early on, Cordeiro discovered that she had a gift for

attracting helpers. "When Vera first started, she pulled in
13
 everyone," recalled Maria Aparacida Carvalho, who oversees
Renascer's job training programs. "She would say: 'Come work
with me! Come work with me!' 'We need you!' She has no idea
how much energy she projects."
Regina Milanez, who sits on Renascer's steering
committee, recalled how she got involved: "I saw Vera on the
cover of a magazine and called her up. You know that doctors
don't know how to deal with money. When Vera heard that I was
a retired financial analyst from IBM, she said: 'Please help us!' So
I started coming in twice a week. I looked at the accounts. And I
realized I really had a lot of knowledge about how to do this and
I was very excited to be doing it. And I developed a series of
costing structures to figure how many families we could serve."
Martha Scodro, who is the president of Renascer's steering
committee, saw an article in a newspaper. "I had small children
and I wasn't working. I went to the hospital to donate some toys
and I spoke with Vera. When I told her I was a psychologist, she
said, 'We need you! Please go into that room and help take care
of that child who is dying.'
"So that's how I started."
Cordeiro gets away with this behavior because her focus is
clearly not on herself, but on the work that needs to be done. She
seems to spend most of her life thinking about the needs of
others. She even seems to experience much of life through other
people's eyes. When talking about patients, for example, she
instinctively switches to the first person. Rather than say "This
woman was worried about her child. She didn't know what to
do," she will say "This woman said to me, 'Dr. Vera, please help
me. I am so worried about my child. I don't have anywhere to
turn."
Cordeiro also spends a great deal of time reminding people
of their importance to Renascer. The first day I visited her office,
she introduced four people as "the most important person in
Renascer." None appeared to doubt her sincerity. When Luís
Carlos Teixeira, a respected physician who is president of
Renascer's advisory council, dropped by one afternoon, Cordeiro
declared: "Luís Carlos is our King Solomon! The most important
person in the history of Renascer!"
14
 At the outset, Cordeiro saw that she would have to rely on
volunteers to reach a large number of children. There simply
were not enough professionals to meet demand. However, this
approach drew fire from social workers at Lagoa who informed
Cordeiro that it was "irresponsible" to have nonprofessionals
assisting poor women. Cordeiro countered that what was
irresponsible was discharging vulnerable children to the slums
and then forgetting about them.
Two questions that Ashoka interviewers commonly pose to
candidates during the selection process are: "Who are your
enemies?" and "Who are your allies?" "When you have an idea
that's going to change how things are done, that means you're
changing how people relate to one another," explains Bill
Drayton, Ashoka's founder. "You're changing their power
positions. You're threatening to obsolete their knowledge, the
'human capital' of their experience. This is not always welcomed
with open arms." And social entrepreneurs need to be prepared.
At Lagoa, it was the social workers who initially turned out
to be Renascer's "enemies." Why? "Renascer showed clearly
what should be done and what wasn't being done," explained
Odilon Arantes, the head of the pediatrics department. Tensions
mounted until a group of social workers lodged a complaint with
Lagoa's directors, seeking to shut down the program.
The hospital directors called a meeting. The social workers
aired their grievances. Then one of Lagoa's directors asked
Arantes to offer his opinion. He replied: "I had a problem in the
pediatrics department, a problem of children returning over and
over. Renascer solved my problem. If it goes, I will demand
something to replace it." The directors had nothing else to offer.
Afterward, the social workers quieted down, but the
directors asked Cordeiro to move Renascer's office outside the
hospital. Cordeiro knew she had to stay nearby, but she couldn't
afford to rent a space. Then she remembered Parque Lagé, where
she had played as a child. There was an abandoned horse stable
in the park. Its walls were crumbling, its roof leaked, and a drunk
slept on the steps. But it was only a short walk from Lagoa and
situated in as tranquil a setting as one could hope for in Rio.
15
 My Idea Would Not Die

In the summer of 1992, Candace Lessa received a call from

an Ashoka nominator suggesting that she pay Cordeiro a visit.
"The program was incipient then," Lessa recalled. "The
innovative aspect was introducing a new notion of what
providing medical care was."
That fall, Bill Drayton traveled to Brazil to conduct
"selection panel" interviews. As Cordeiro recalled, one of the first
questions Drayton asked her was: "What do you expect to have
in ten years' time?"
"It's a crazy question," Cordeiro recalls thinking. "I can't
even make plans for tomorrow! How can I think about ten years
from now?"
But reflecting on that interview almost ten years later, she
added: "I'm beginning to see that if you think this way your
dreams come true."
Cordeiro found herself moved by Drayton's interest in her
idea and her life. He seemed hungry to understand every detail of
Renascer's operations. How did they decide when to discharge a
child? How did they motivate the mothers? How did Cordeiro
plan to spread her idea? How did she plan to engage with the
government? No one had ever forced her to think so deeply about
the practical obstacles she would face as she attempted to expand
beyond one hospital.
Cordeiro outlined her vision: In a government system
otherwise characterized by corruption and indifference, the
public hospitals remained one of the few doors open to the poor.
And a child's illness was a powerful event that could trigger
change in a family. It was senseless to provide hospital care to
poor children without following up. But this was a new idea, and
the health system was not yet prepared to take it on. Citizens had
16
to develop the systems. Renascer had a solid base of volunteers –
no small achievement given Brazil's history of dictatorships. It
was helping to unleash the civic spirit of Brazilians. It was also
connecting people from upper and lower classes. "I don't know
who gains more in the exchange," Cordeiro said. "A person who
earns less than the minimum wage can transform the life of
someone from the elite. Because poverty is not only a lack of
money, it's a lack of a sense of meaning.
"This is the best antidepressant we have. It causes a
revolution in people. I am sure it will multiply not only in Brazil,
but internationally."
In October 1992, Cordeiro was elected an Ashoka fellow. A
year had elapsed since Renascer's launch in the playground of her
apartment building. She was working out of a stable with a leaky
roof. And now an organization with offices around the world was
telling her that her work would change healthcare in Brazil. The
distinction came with a Brazilian-level social sector salary –
about $9,000 a year for three years; no fortune by any means, but
the timing was critical. It doubled Renascer's budget.
More important than the money, however, was the
encouragement: the vote of confidence and the connection to a
network of like-minded people. "I remember very clearly the
clothes I was wearing" – blue pants with a flower print and a T-
shirt – "and how I cried the afternoon that I was told by Ashoka
that I was elected a fellow," Cordeiro said. "One of the fears we
had at the time was that what we were doing had no name, that it
would die even before it could be born. So, it meant so much to
me that other people understood the importance and essence of
Renascer.
"And I understood then that my idea would not die."

Meanwhile, at home, every family dinner was dominated

by discussion about Renascer. It would go on until Laura or
Marina would shout: "Mom, are you going crazy? Stop talking
about Renascer!" Paulo, Cordeiro's husband, recalled: "This
work was brought into the home each day of our lives from 7:00
A.M. until midnight."
"There was no food in the pantry," Cordeiro said. "There
17
 was day-to-day confusion in the household. I had no time and no
interest to do things at home."
It didn't take long for Laura, who was ten years old in 1991,
to come to despise Renascer. "It was like suddenly having a
younger brother, and it caused a lot of anger in my sister and me,"
she recalled.
Marina and Laura volunteered at Renascer, then quit, then
volunteered again. Despite their resentment, they found
themselves drawn into relationships with Renascer's families and
changed by their experiences. Today, Laura is studying law and
plans to devote herself to social causes. Marina, who is also
pursuing a law career, adds: "I plan to use my skills to help build
a more inclusive society."
"My contribution on a daily basis was to be a supporter,"
added Paulo. "To understand that more than anything Vera
needed time to devote to this."

By 1994, Renascer had 508 dues-paying members whose

fees totaled $4,000 a month. Cordeiro had also received grants
from foundations and private sources. While she built up a
paying membership, she continued to deepen the work. She
persuaded transport agencies to provide discounted bus tickets,
which Renascer distributed to mothers.
She launched a program to connect middle-class families
with Renascer's families to provide nutritional and medical
supplements for six-month extensions as needed. She created a
work program to boost the incomes of mothers who had to stay
home full time with children.
When a TV producer who had received care at Lagoa got
wind of Renascer, Cordeiro was invited to appear on Fantastico,
a popular variety and talk show. Her appearance led to a spate of
newspaper and magazine stories and helped double Renascer's
paying membership.
Meanwhile, everywhere Cordeiro went, she invited people
to visit Renascer. Before long calls were coming in from out of
the blue: "We've heard you have a system that can help us. Can
we visit?"
"It was funny," she recalled. "We felt we had just started.
18
But already doctors were coming to us to learn how to multiply
the experience."
The first successor, Reviver (relive), was established in
1993. Next came Ressurgir (reappear), Reagir (react), and
Refazer (redo) in 1995. Cordeiro made sure replicators met four
criteria before she agreed to work with them: They had to have:
(1) a strong working relationship with their hospital, (2)
extensive experience treating poor patients, (3) a willingness to
sign an agreement promising to uphold Renascer's standards, and
(4) a "genuine need" to do the work.
In 1996 and 1997 Renascer's model began attracting
considerable attention and Cordeiro won a series of national
social service honors. By 1997, the model had spread to three
more hospitals. Since then, it has been adopted in nine more
hospitals.

19
 A Revolution

In 1998, Cordeiro received a phone call from Anamaria

Schindler, the director of Ashoka's Center for Social
Entrepreneurship in São Paulo. Schindler had established a
partnership with the São Paulo office of McKinsey & Company,
and she wanted to know if Cordeiro was interested in having
McKinsey consultants work with her pro bono. Cordeiro jumped
at the opportunity.
The world's richest corporations pay McKinsey &
Company millions of dollars a year for the firm's advice on
strategy and how to achieve "organizational excellence." Drayton
had initially established contact with McKinsey, where he had
worked for nine years, before Schindler turned the relationship
into a full-fledged partnership.
In contacting McKinsey, Drayton wasn't looking just to
drum up free consulting work for Ashoka's fellows. He saw it as
something much more important: an opportunity to build respect
and improve coordination between the business and citizen
sectors. What better way than by linking McKinsey, a leader in
its field, with leading social entrepreneurs at a point when the
entrepreneurs were gearing up for expansion? It would be a two-
way learning process: The consultants would learn from the
social entrepreneurs' strategic insights and their ability to achieve
results in difficult contexts, and the social entrepreneurs would
benefit from the consultants' management and organizational
expertise.
To convince McKinsey that it was a sound investment – not
merely an opportunity to "give back" to society – Drayton, in
meetings with McKinsey partners, stressed the institutional logic
from the firm's perspective. McKinsey's mission is to help
companies understand their environments and develop strategies
20
and management skills to seize new opportunities. In many
countries the growth of the citizen sector was outpacing growth
in the business sector by a large margin. At the same time,
boundaries between the business, government, and citizen sectors
were becoming blurred. These changes were well underway, but
the understanding had not yet caught up with the reality.
"Most of it is still unforeseen, but it is probably the most
important change in the world today and it promises a rapidly
growing opportunity over the next decades," comments Drayton.
"If McKinsey knows how to make this business-social bridge,
everyone will benefit. The firm will be positioned ahead of the
curve to understand new dimensions – economic, social, ethical,
professional – and its advice will be better and deeper. Its
consultants will better understand the whole future environment.
Social clients will benefit from business knowledge and business
clients will benefit from the social knowledge. And society will
benefit as a whole."

It didn't take long for the marriage between Renascer and

McKinsey to take. As with corporate clients, the consultants
came in and spent weeks inside the organization, interviewing
everybody, inquiring about mission, values, opportunities,
problems. "These McKinsey consultants – they're so serious,"
Cordeiro said. "They wear suits and ties every day. But I love
them."
"People fell in love with Renascer," explained Frederico
Oliveira, a McKinsey partner who became Renascer's champion
in his office. "The organization is straightforward and humble,
definitely very ethical, and very action oriented. In fact, you have
to hold back because Vera jumps on ideas like crazy. That attitude
is very exciting for us."
Consultants analyzed how Renascer selected and tracked its
cases, how it managed its volunteers, how it decided when to
discharge a child, and how it measured impact. They looked at
the organizational structure: who was responsible for what, who
reported to whom. They broke down service offerings into "core"
and "noncore," defined key "competencies," and assessed where
Renascer was strong, where it was weak, and what would need to
21
 be strengthened if Renascer were to grow by 30 percent within
the next two years.
With help from the consultants, Cordeiro prepared a
$250,000 "strategic plan" and convinced the Brazilian national
development bank to fund it. She established a new position
analogous to a chief operating officer to free her from direct
management duties. The consultants helped clarify
responsibilities and reporting lines. "McKinsey taught me that
you need to have a matrix for the guilt," Cordeiro said.
Renascer had records on more than 1,500 families, but the
information was not in a form that could be analyzed readily. The
consultants helped Renascer develop a database to track cases
from admission until a year after discharge. Renascer instituted
new documentation systems and produced operations manuals
for replicators. The organization also instituted guidelines for
evaluating the health, housing, and employment conditions of
families, as well as standard re-evaluation cycles for cases.
The discharge criteria was standardized: After Renascer's
intervention, a family must have attained a minimum monthly
income (after rent) of R$180 (Brazilian reais; in mid 2003, one
real was equivalent to about 35 cents) or R$250 for families with
more than five members. The family must be receiving all
available public benefits for seriously ill or disabled children.
The house must be a brick structure with a cement floor and no
serious damage to the walls or roof, with two rooms, a bathroom,
sink, shower, and toilet – either a pit latrine or sewer system – and
a water filter. The children's health must be evaluated as
"satisfactory" or "good" by Renascer. All children over the age of
four must be in day care or receiving special care as needed. All
children between five and sixteen years old must be in school. All
children under ten must be vaccinated. All family members must
have proper government documentation. The mothers must have
completed a family planning course.
"What McKinsey did was like a revolution," Cordeiro said.
But the revolution was not without complications. What happens,
for example, when you apply a business management framework
to an organization involved in social change? How do you
balance financial and human considerations? How do you
22
professionalize without losing intimacy? How do you standardize
without losing flexibility? These were some of the questions that
came up.
For McKinsey, working with Renascer was also a valuable
experience. "Nonprofits have a different way of thinking than
we're used to," explained Frederico Oliveira, from McKinsey.
"They look much more like family-owned companies, with many
soft aspects being taken into account in the management. We
have to find a way to work in these situations, not just apply our
pragmatic, logical frameworks. I think McKinsey as a whole will
learn a lot."
In addition to the "sheer personal satisfaction" gained by
consultants, Oliveira noted that McKinsey benefited by having its
junior and foreign consultants exposed to real-world difficulties
rooted in local context. "Any barriers are magnified in nonprofits
– lack of resources, infrastructure, management ability," he
added. "But they are more savvy at finding constructive solutions
and alternatives. They have no information technology
department to come and solve their problems."

23
 We Would Still Be Living In The Past

In 2001, Cordeiro was selected as one of Brazil's ten

"women of the year" and one of the country's twenty top social
leaders. She was also honored as a leading innovator by the
Schwab Foundation for Social Entrepreneurship. And in early
2003, Renascer was awarded the $100,000 "Most Innovative
Development Project Award" from the World Bank's Global
Development Network.
By 2002, Renascer had assisted 6,000 children and 4,000
other family members in 1,740 families. The replications had
assisted another 10,000 people. A 2002 study of families
discharged from Renascer reported that the percentage of
children whose lives were "at risk" dropped from 42 to 10
percent, while their family's average monthly incomes had
increased 58 percent.
The organization had opened a new office. The gift
manufacturing program was fast evolving into a professional
operation turning out quality bed, bath, and kitchen items.
Renascer had also added formal job training. By 2003, more than
600 mothers had completed courses in manicuring, hairdressing,
embroidery, seamstress work, and computer operation. Cordeiro
had also established a U.S.-based Friends of Renascer to advance
international replication of the model.
In their first meeting, Drayton had asked Cordeiro, "What
do you expect to have in ten years' time?" On October 25, 2001,
Renascer celebrated its tenth anniversary. Cordeiro, fifty-one,
recalled the raffle in the playground, the conflict with the social
workers, the day she was elected an Ashoka fellow, the years in
the stable, the Fantastico TV show, the spread to other hospitals,
the awards, the McKinsey "revolution," hundreds of volunteers,
thousands of children. They had come a long way since the days
24
of clapping for milk.
And yet, to fulfill her vision of carrying Renascer to every
hospital in Brazil, the next ten years will require even a steeper
climb. It will take salesmanship, savvy, and stamina to effect
change within the health system. Cordeiro will have to spend
years working to persuade doctors, hospital administrators,
health officials, and funders to adopt the model.
Looking ahead, I can imagine two possibilities: (1)
Renascer continues to be influential, but its replications are
sporadic and they fail to match the strength of the original; or (2)
Renascer transforms itself into a reference and training center
that successfully spawns and supports cells across Brazil. Every
major decision Cordeiro has taken since 1998 foretells the second
result.
When I imagine what the next decade may hold, I am
reminded of a comment made by Odilon Arantes when I asked
him what the key factor had been in Renascer's success. "Here I
can say with absolute assurance that the main element for
Renascer's success was Vera," he replied. "Without her, we would
still be living in the past. She is so persistent; she insists and
insists until she wins."
When I mentioned Arantes's comment to Cordeiro, she
insisted that everyone in Renascer had been a "co-creator." She
acknowledged that she had been the one to bring people together,
but it was their collective energy that made it all happen.
"Nobody is more important than any other person," she said. "But
sometimes a person has success because that person continues
fighting. I think if I have some value it is that I continue fighting."

25
 Why Was I Never Told About This?

After launching its work in India and Indonesia in the early

1980s, Ashoka had begun working in Brazil in 1986, just as the
country was emerging from the long enforced shadow of military
rule. Social entrepreneurs like Vera Cordeiro were suddenly
turning up everywhere – in the Afro-Brazilian community, in the
gay community, in the disability community, in the women's
movement. "It was perfect timing," recalled Candace Lessa, who
had joined Ashoka's Brazil program in 1988. "Brazil was just
opening up to democracy. The NGO [nongovernmental
organization] network was moving toward social change
organizations rather than just political movements. There were a
lot of lonely people with no money, and suddenly Ashoka came
in supporting people who were taking provocative stances vis-à-
vis the status quo."
"But people were also skeptical," Lessa added. "At first,
they thought Ashoka was like the CIA. Who was this strange
American coming in and interviewing everyone?"
That was the initial concern of Peter Lenny, a left-leaning,
Portuguese-English interpreter based in Rio de Janeiro who
received a call one day requesting an "emergency replacement"
for a finicky North American.
Lenny's first job with Bill Drayton was a five-hour
interview with a stonemason from a village in the south of Brazil.
"He'd developed this novel way to convert low-class housing into
a reasonable neighborhood," Lenny recalled. "In the end, he
wasn't selected; he wasn't really a social entrepreneur. He didn't
have the awareness of the potential of his own idea."
In time, Lenny got over his skepticism. As he continued
working with Drayton, he began to recognize patterns in the way
Drayton interviewed people. He saw that Drayton would press
26
forward with, say, a peasant farmer who knew how to work with
people, but he tended to shy away from academics. One of
Drayton's acid tests was to ask a how-to question in very specific
practical terms in order to see if the person would respond in
similarly practical terms (good) or go off on a tangent or give a
theoretical answer (not good).
The experience did more for Lenny than teach him how to
recognize social entrepreneurs. If not for Ashoka, Lenny says he
probably would have left Brazil and returned to live in England.
In the mid-1980s Lenny, like many Brazilians, had begun to
lose hope in Brazil's future. After the dictatorship fell, the media
turned its focus to corruption, inflation, and crime. It seemed
unlikely that free elections and a new constitution would produce
genuine social change. "Brazil is very big," Lenny says. "You
don't hear about anything that happens at the microlevel. The
whole idea that there was this ongoing social activity – these
people doing great things – was just totally invisible. No one
from the middle class sets foot in a favela. And if you hear
anything about any sort of social change organization, it's just
through the strangest chance, through your maid or a taxi driver."
Through Ashoka, Lenny discovered the work of social
entrepreneurs across Brazil, people like Mary Allegretti, who was
working to protect the Amazon rain forest from deforestation,
while ensuring a livelihood for local Indians and rubber tappers;
Silvia Carvalho, an early childhood educator in São Paulo, whose
organization, Crecheplan, was improving day care for poor
children; Marilena Lazzarini, who had launched a consumer
protection movement with her organization, Instituto Brasileiro
de Defesa do Consumidor (IDEC); João Jorge Rodrigues, who
was turning the percussion band Olodum, in Salvador, Bahia,
into a vehicle to activate the political consciousness of Afro-
Brazilians; Suely Carneiro, an Afro-Brazilian woman whose
organization, Geledés, was laying the foundation for a black
women's movement; Ana Vasconcelos, whose Casa de Passagem
was focusing national attention on the problem of female child
prostitution; Ismael Ferreira, whose cooperative, Associação dos
Pequenos Agricultores do Município de Valente, was connecting
poor sisal growers in rural Bahia to international markets;
27
 Normando Batista Santos, whose network of community-run
schools were reaching remote areas in northeast Brazil; Fábio
Rosa, who was delivering electricity to hundreds of thousands of
poor people in rural Brazil; Cordeiro, who had founded Renascer
to address a hidden gap in the healthcare system; and scores of
others.
"Suddenly," recalled Lenny, "I had this view of another
Brazil – nationwide – in all sorts of areas – through Ashoka's
selection process. And what I saw in a short while I wouldn't have
seen if I'd lived in Rio and read the newspapers for ten years.
"And I thought, 'Why was I never told about this?'"

28
 Excerpted from

How to Change the World:

Social Entrepreneurs and The Power of New Ideas

By David Bornstein

Available February 2004 - 320 pages - ISBN: 0-19-513805-8 - $28.00

How to Change the World will be available from booksellers

across North America beginning in February. Advance orders can
currently be placed with online booksellers. For information
about the book, or to find additional information about the
emerging field of social entrepreneurship, please visit
www.HowToChangeTheWorld.org.

For single copy orders, call 1-800-451-7556. Or order through

the Oxford University Press website; www.oup.com. Anyone
wishing to purchase 10 or more copies at discounted prices,
please contact Brad Andrews at 1-800-334-4249, ext. 6288.

For those interested in learning more about Renascer's work, visit

www.FriendsOfRenascer.org, or send an email to
info@FriendsOfRenascer.org. Friends of Renascer is a U.S.-
based tax exempt organization.

29
“ This is a
enlightening
wonderfully hopeful and
book. The stories of these
social entrepreneurs will inspire and
encourage many people who seek to build a
better world. ” NELSON MANDELA

“ The social entrepreneurs chronicled in this

book are part of the vital generation of
independent, creative leaders who are
sparking social changes in the United States
and in parts of world where people are most
in need. We will be hearing much more from
them in the years to come. ”
BILL BRADLEY

For more information regarding this book, please see:

www.HowToChangeTheWorld.org

OXFORD
UNIVERSITY PRESS
To order: Write Attn: MS, 198 Madison Avenue, New York, NY 10016
Or phone: 1-800-451-7556 fax: 1-919-677-1303
Or visit: www.oup.org

Date of Publication: February 2004

ISBN: 0-19-513805-8
Price: $28.00

If you plan to review this title please contact:

Barbara Fillon, Trade Publicity Manager
212-726-6113/726-6447 fax
fillonb@oup-usa.org