The current model of addressing childhood diarrhea in India is broken, with gaps in both demand-driven and supply-side approaches. Mothers frequently seek a treatment that will immediately stop diarrhea; they too frequently turn to antibiotics or Loperamide. Pharmacists and doctors comply with mothers’ demands even though zinc and ORS are cheaper, more effective, and safer. At the same time, pharmaceutical companies lack an incentive to produce, promote, and widely distribute ORS and zinc due to perceived low returns on investment driven by the products’ thin profit margins. How can these daunting supply and demand challenges be overcome simultaneously to reduce child mortality?

The Indian Private-Public Partnership entitled “Sankalp: No Child Should Die from Diarrhea” is aiming to do just this – it is a collective effort targeting to prevent 200,000 child diarrhea deaths in India by 2015 by increasing ORS and zinc use. This effort represents what FSG calls collective impact (CI) – when organizations from different sectors agree to solve a specific social problem using a common agenda, aligning their efforts, communicating continuously, using common measures of success, and being supported by a coordinating backbone organization. CI initiatives consist of these unique components that, when combined, offer a fundamentally different way to solve complex social problems.

Sankalp involves more than 50 partners, including financial institutions; pharmaceutical, communications and energy companies; logistics consultancies; international NGOs; local public health foundations; academic/research institutions; communities of faith and the Indian government. Each organization (for a list of all partners, see Figure 1) contributes unique assets and expertise to the effort.

Figure 1. Sankalp Partners

The Sankalp effort goes beyond typical stakeholder collaboration as all partners agree on a common agenda – solving the childhood diarrhea problem by increasing zinc and ORS use. They’ve also agreed to focus in the northern states of India where 70% of diarrheal deaths occur (Gujarat, UP, Madhya Pradesh, Maharashtra, Rajasthan, and Bihar), with spillover effects reaching other critical areas. The efforts are further concentrated in underserved rural areas rather than urban centers and go beyond traditional mass-media mechanisms to effectively target this market, working in both the private and public health systems.

The partners are further organized by aligning their activities along two dimensions: geographically and based on key activities – demand creation, product innovation, and distribution.

Geographically, an initial district-level mapping exercise illustrated the location of current partners to reduce redundancy while ensuring coverage. In any collective impact effort, this is particularly challenging as various partners must reconcile the partnership needs with their own strategies. This was one of Sankalp’s earliest successes: mapping existing efforts to optimize geographic coverage.

For demand generation, several corporations and donors are contributing to large-scale advertising campaigns to educate families and health workers about the importance of using ORS and zinc. In terms of product innovation, new formulas such as premixed ORS and alternate presentations of zinc are being developed based on consumer research. Pharmaceutical companies are improving distribution by dedicating a portion of existing sales force time to promote ORS and zinc to pediatricians so that it is recommended as a first-line treatment for diarrhea. Innovative approaches to distribution are also being explored via joint ventures between pharmaceutical and consumer goods companies that have the capacity to distribute products widely; many of these JVs are modeled after or directly expand existing private sector medicine delivery models (e.g., Unilever’s Shakti network and Novartis’ Arogya Parivar program). Additionally, the Government of India will play a critical role in driving the effort forward. To date, the government has helped to advance supply-side scale up efforts through important policy changes, such as reclassifying zinc as over-the-counter (or Schedule K status) and providing guidance to state governments on zinc/ORS scale-up.

These aligned activities are complemented by continuous communication among the partners to learn from one another and monitor progress. As the group grew in numbers, smaller task forces were created to focus on the unique challenges associated with demand, supply, and distribution. In addition to quarterly calls and face-to-face workshops, the members also interact via an “Innovation Co-creation Platform” created by Infosys and launched by the UN Secretary-General at Davos in 2013 . This interactive website aims to facilitate unprecedented collaboration by allowing partners to upload and share videos of best practices, test new ideas, challenge existing ideas and co-design solutions.

Sankalp has three primary shared measures to monitor impact: coverage of ORS and zinc, tracked via household surveys; trends in ORS and zinc prices, based on market surveys; and ultimately, child mortality from diarrheal disease. Usage of ORS and zinc among children with diarrhea will be measured through national-level household surveys every three to five years – the next is scheduled for 2014 with a 2015 data release. Additionally, the Ministry of Health has created a “National Child Health Score Card” with key child health metrics, such as zinc and ORS coverage, that uses simple red/yellow/green indicators to highlight progress by state and district.

In any successful collective impact effort, the backbone organization is crucial to sustained success. For Sankalp, the backbone activities (facilitating communications, developing shared measures, organizing working groups, engaging stakeholders, etc.) during the launch phase were shared across the MDG Health Alliance, the Clinton Health Access Initiative, and the UN Foundation. As the effort transitions to a steady state, it will be critical that backbone responsibilities are clear and funded independently to ensure that the collective effort has the resources needed to maintain momentum. The effort will also benefit greatly from the active engagement of the government to ensure strong coordination across public and private sector activities and for translating the ambition of the partnership into practical action at the state level.

By using a collective impact approach, the Sankalp effort has gone beyond a typical awareness-building public health campaign with the goal of changing patients’ health seeking behavior and physician treatment norms to ultimately impact child mortality. As Leith Greenslade of the MDG Health Alliance commented, “If all of the organizations active in the critical areas of child health – pneumonia, diarrhea, malaria, newborn health and nutrition – worked in this way we could get a lot closer to achieving the MDG target of saving around 4 million children by 2015. Donors need to really pressure the organizations they fund to work collaboratively for collective impact, particularly in the countries where child deaths are concentrated. We have Sankalp in India, but we also need it in Nigeria, DRC, Pakistan and Ethiopia.” If Sankalp can continue to mobilize key partners and measure its successes, it can hopefully serve as a collective impact model for other organizations tackling MDGs.

FSG recently developed a report along with the Innovation Working Group in support of the global Every Woman, Every Child effort, looking at how companies can create shared value in women and children’s health. The report outlines opportunities for companies to contribute to the global efforts’ goal of saving 16 million women and children by 2015.  The report suggests that companies can do this by reconceiving products and markets, redefining productivity in value chains and by strengthening local clusters. 

The report outlined action items and additional resources for companies interested exploring shared value and CSR opportunities in women and children’s health. As follow up, these recent reports are great resources for background on the issues and opportunities for companies to become more familiar with the issues:

• State of World Population 2012: Released this month by the United Nations Population Fund (UNFPA), the report focuses on the need for more and better family planning worldwide. The report highlights that 222 million women want to use family planning methods but do not have access to the right resources.  Family planning can significantly reduce health risks to both women and children, and for those in the poorest countries, family planning could reduce infant death by upwards of 46 percent.
• UN Commission on Life Saving Commodities for Women and Children: The UN Commission released this report in September 2012 with recommendations for saving 16 million lives by 2015 by improving access to and use of essential medicines, medical devices and health supplies aimed at avoidable causes of death during pregnancy, childbirth and childhood.  Recommendations include improving markets for life changing commodities by shaping global markets and local delivery markets, investing in innovative financing methods, strengthening product quality, and improving regulatory efficiency.  Additionally the Commission recommends focusing on improving national delivery of life-saving commodities and improving integration of private sector and consumer needs through product innovation.
• Building a Future for Women and Children 2012 Report:  The Countdown to 2015 launched its report earlier this year outlining current progress towards reaching the Millennium Development Goals related to women’s and child’s health. The report includes detailed status updates and data by countries as well as opportunities to improve progress through policy, financial and system efforts.  

All of these reports provide helpful context on the current state of women’s and children’s health and the need for immediate investments and improvement in the poorest countries.  The challenge will be for companies to decide where and how to become engaged. For example, companies could look to identify opportunities within priority markets or those that align with core competencies and then see if these opportunities align with current CSR strategies, or if there is an opportunity to build a business case for the investment and create shared value.

Download FSG’s newest global health report to learn more about Merck’s experience designing and supporting MVN-A: Boosting the Immunization Workforce: Lessons from the Merck Vaccine Network – Africa.  Sponsored by The Merck Company Foundation, the report includes a summary of the impact achieved by MVN-A, while also describing seven forward-looking lessons that can increase the effectiveness and sustainability of programs to build the capacity of the vaccine workforce in developing countries.

By sharing these lessons, we aim to help others in their work to improve the delivery of immunizations around the world. Please help us by sharing the report with your contacts working in immunization, health worker training, and healthcare capacity-building more broadly.

Read the report: Boosting the Immunization Workforce: Lessons from the Merck Vaccine Network – Africa.

Question: Karl and Kathy both alluded to the challenges with their new models. Can they illustrate how they've addressed such issues as compliance e.g., FCPA (Foreign Corrupt Practices Act)?

KH: From PSI's perspective, the challenges around shared value partnerships are the conventional ones that any two business partners would face:  can each party meet its objectives better through partnership than alone?  In our space, price plays a major issue.  We are social marketers, and our product work often (not always) involves heavy subsidies.  When donors are available to underwrite such subsidies, our marketing activities can reach our target audience of low-income families.  Where there is no donor, and we are looking to a partnership with the private sector to try and meet health needs, pricing decisions on the part of our prospective partner are crucial to the success and scale of the endeavor.  Pricing decisions and especially concessionary pricing are tough calls for companies reporting to shareholders, and we have to recognize that.  

From our perspective, FCPA applies just as much to us as to our private sector partners, and we meet those obligations forthrightly, as we assume our partners do. 

Question: Are there any lessons learned to improve access to the last mile distribution to people who don't have access to traditional retail networks?

KH: Last mile distribution challenges are hugely significant.  The best distribution system in the world is meaningless unless this final piece is in place.  Like successful fast-moving consumer goods companies worldwide, we use lots of different strategies to close that gap, everything from bicycles, to hand-held baskets of community based distribution agents, to donkeys, to hovercraft (yes, we've used those in remote Madagascar).  The private sector knows how to meet this challenge better than just about any government anywhere, which is why we like partnering with and learning from them.

Question: What are the most valuable lessons learned in your experience working with different (profit vs. non-profit) partners about how to reach agreement on differentiated roles and objectives?

KH: Clarity about intentions and transparency all throughout the process.  These are crucial ingredients to successful partnerships.  And of course, even the best transparency can't always overcome fundamental differences -- sometimes, it just isn't possible to close the gap.  But clarity about intentions and transparency helps that reality become evident sooner rather than later.

Question: GSK's separate unit, the way it operates and its aspirations are quite impressive. Have all leaders in the company below the CEO truly embraced the commitment, or are there senior leaders who resist the significant change in mindset (e.g. lower margins, longer payback, volume vs. revenue)?

DL: You need to communicate consistently and very regularly so people in the organisation understand what the unit is about. The main challenge is around the fact that it dilutes margins but we are fast growing at the top line so that has been a big positive (and compensatory) factor. Our top line growth gives us the ‘currency,’ if you like, to invest more and for the longer term.

Question: You describe a new level of transparency in the pharma industry, with prices capped at 25% of UK prices and still creating economic value for GSK. How do you handle this issue with consumers in developed countries?

DL: We operate a tiered pricing policy across the whole company so high income countries pay more than low income countries for the same medicine. High income countries therefore support R&D for low income. Most politicians understand the reality of this.

Question: How is GSK addressing some of the country-level challenges around registration, pharmacovigilance and local manufacturing in order to achieve these increased volumes?

DL: For least-developed country markets, it’s about getting the basics right. So all of these areas are big challenges. Registration needs more resource and expertise from GSK in our countries and we need to better support ministry of health expertise. Pharmacovigilance is a big cultural/industry challenge. We are taking positive steps to educate here but it will take time. I am not a big supporter of local manufacturing because unless the population is very large, the volumes make this uneconomic locally. Of course there is a political dimension to this though that needs to be managed.

From extractive companies, to financial service firms, multinationals, to small social enterprises, Business Fights Poverty’s blogs capture the trend in how business and the social sector are redefining their relationships to tackle tough social problems. 

Curiously, multinational pharmaceutical and medical device companies are absent from much of the conversation. Yet, it is difficult to find such inherent creators of shared value, as these companies develop and market life-saving and life-enhancing products and services. There’s lots of history to explain why we don’t look at these companies at the vanguard of fighting poverty but times are changing, finally, and in a big way. In the past, many of these companies have not aimed innovations to create value for the poor. Fortunately, multinational companies are slowly but surely moving away from the past practices of addressing patients in low-and middle-income countries through donations and corporate social responsibility to treating the poor as customers. We’re seeing major innovations in how companies such as Novo Nordisk, GlaxoSmithKline, Novartis, and others are changing their business practices to serve these new customers.

FSG sought to capture this trend and better understand how companies are doing it. We recently released the findings in our report “Competing by Saving Lives: How Pharmaceutical and Medical Device Companies Create Shared Value in Global Health” that is based on over 70 interviews with corporate executives and leaders in global health. You can learn more about the report in the following blog post.

Here, we'd like to highlight the five key implementation principles to provide insight into how companies are moving away from the days of the past to embrace shared value for the future

1. Focused and determined leadership at the CEO and country level

Strong leadership was mentioned as a key success factor by almost every company. GlaxoSmithKline’s CEO, Sir Andrew Witty, set a corporate strategy to move beyond “white pills in Western markets” and was closely involved in the creation of their Developing Countries and Market Access Group – a business unit specifically tasked with serving developing countries. In addition, strong leadership within country affiliates and business units are essential since this is where shared value actually gets created.

2. A culture of innovation and learning reflected in structures and incentives

Without a culture that embraces entrepreneurial risk-taking, learning, and innovation, companies may miss opportunities to reach underserved populations. Companies are either creating cross-functional teams that coordinate across the company or separate innovation units that directly manage shared value initiatives. We’re seeing new business units such as GE healthymagination, Novartis’ Social Business Group, and Becton, Dickinson and Company’s Global Health group.

3. New approaches to measurement that track the link between business value and patient lives improved

Companies are beginning to capture the link between improved health outcomes for patients and economic benefits. Novo Nordisk calculates the net present value for their business, and for Chinese society for better disease management in diabetic patients. The company ties together the economic benefit of improved patient treatment with the direct business benefit of increased treatment sales.

4. New skills in identifying and acting on unmet health needs

Companies are changing whom they hire to meet the needs of the underserved in low- and middle-income markets. To implement shared value strategies, there is an emphasis on hybrid backgrounds and skills. Companies are hiring from non-traditional backgrounds and using leadership-development programs to get employees to think creatively about strategic problems associated with low- and middle-income countries.

5. New partnerships for shared value insights and implementation

A host of new partners that bring information and help to deliver products or build missing health care infrastructure are becoming more important for pharmaceutical and medical device companies. An interesting shift is happening where NGOs, once viewed as grantees, are becoming business partners in places where these companies lack consumer understanding, networks, and government relationships. 

In March, FSG hosted a launch event where company executives talked about the challenges in making these five implementation principles come to life. See here for key takeaways from the discussions. The companies recognize that there’s much to learn from each other to reach the underserved.

The conversation focused on reactions the recommendations in the report, and in particular, on how they could be implemented or further extended. Several key themes were raised by multiple stakeholders:

• The need for cross-sectoral partnerships to create the conditions for shared value creation, and to implement initiatives was cited by many. While participants recognized that these partnerships are not easy to structure or run, there was a strong recognition that companies rarely possess all the skills, expertise and credibility needed to succeed by working in isolation.
• Measurement was also widely noted as a key factor in a variety of contexts. Participants identified the need for careful market analysis, for metrics to enable organizational learning and improvement, and for evidence to build buy-in and support with key internal and external stakeholders.
• Participants pointed out that thoughtful and well planned communication – both internal and external – is essential as companies transition to a shared value approach.
• A key challenge was identified around aligning incentives and timelines. While it is not true to say that shared value necessarily requires long-term thinking, building new markets and strengthening health systems often takes time. It can be difficult for companies to align expectations on time horizons, both within companies and in the context of partnerships with others.
• Finally, there was discussion about the implications shared value on different aspects of corporate operations. Several participants raised questions about the implications of shared value for R&D – particularly with reference to product development partnerships. Others also reflected on the intersection of shared value with philanthropy (which undoubtedly has an important role to play, as we begin to set out in the paper).

For the full event overview, please visit the event page. All of these insights, along with others, represent fascinating questions for further analysis and discussion – and will in all likelihood be featured on this blog at some point in future. Watch this space!

In our work at FSG, understanding the impact of these tools in solving social problems is key to understanding how the organizations we work with can support these efforts to ultimately achieve social impact. The work of the Knight Foundation Community Information Challenge, for example, is inspiring communities around the US to think of how local information drives community health.

Crowdsourcing in Kenya
In environments where access to official information is patchy at best, tools that efficiently collect diffuse information and transform it into a complete picture can be invaluable. Ushahidii, an organization based in Kenya, uses messages sent from cellphones to track events such as violence and unrest and send updates to vulnerable populations that are spread over large areas with limited access to the internet. The Ushahidi platform also uses this crowdsourced information, sometimes in combination with data from other sources, to visualize trends over time and space and facilitate early response to provide near instant information to local communities. 

Ushahidi started as an early warning system after the unrest following Kenya’s election in 2008, with over 48,000 people using the website to understand threats of violence in their communities. Since then, the platform has been further developed and used to monitor elections in Lebanon and Afghanistan and to monitor medicine shortages in the Philippines.

The Ushahidi platform can used to aggregate and share data on violence, such as the incidents in Western Kenya, shown in the above map (Photo courtesy of Ushahidi)

This tool is a prime example of how communities can capitalize on the combination of crowdsourcing and open mapping to respond to threats of violence and lack of medical supplies. Do you know of other examples? If so, please tell us about them!

Community mapping in Haiti
After the 2010 earthquake in Haiti, OpenStreetMap became a key tool for collating spatial data and building an up-to-date map of Port-au-Prince. In this effort, the platform drew on data provided by 640 volunteers from around the world. This meant that a blank spot on the map became one of the most accurately mapped areas in the world, in record time and with only limited cost. OpenStreetMap has since expanded into a tool used by the UN and other large humanitarian actors.

A key strength of the maps created using OpenStreetMap is that they can respond to real time information needs of communities. After news broke of a cholera outbreak in Haiti following the earthquake, 200 schools in the Cite Soleil area were quickly identified and assessed for suitability as cholera treatment centers. This happened within a matter of hours. Similarly, over 100 IDP camps were mapped to provide information on the location and availability of wells and latrines along with pathways to these services.

To achieve greater social impact, the Humanitarian OpenStreetMap team (HOT) has been formed to build the capacity of local actors to take ownership of the mapping process. In contrast to GIS, which requires training and a software license, OpenStreetMap requires only a simple web browser and is easy to learn. This increases the ability of local actors to inform the maps produced and enhances the relevance of the products to those in need. This tool is a prime example of how communities are empowered by access to spatial data and open mapping, allowing them to maximize the use of already existing resources and target external assistance. Do you know of other examples? If so, please tell us about them!

Balloon/Kite mapping in Lima and Chile
Balloon/Kite mapping is a community engagement tool developed by the Public Laboratory for Open Technology and Science. Satellite-style images are captured by strapping a camera to a strong kite or set of balloons, and the entire kit typically costs less than $100. This low cost tool enables communities to:

1. Create  satellite-style, high resolution, hyper-local maps in areas where satellite maps are not of high quality or out of date

2. Map different aspects of communities over time to track changes in community conditions

Balloon mapping kit used in Chile (Photo courtesy of Ciudadano Inteligente)

This approach to mapping has been used to track health hazards resulting from water pollution, track oil spills in the Gulf of Mexico, and document peaceful protests in Peru. A recent project involved mapping access to, and quality of, public sanitation in Villa Maria, an informal settlement in Lima, Peru. With new maps of areas that were previously off the radar of government officials, the community is able to clearly illustrate their lack of basic services.





Image produced by members of the Villa Maria community in a kite mapping exercise (Photo courtesy of Anita Chan)

This tool is prime example of how communities benefit from cheap and simple tools that allow them to create powerful maps of threats to their communities. Do you know of other examples? If so, please tell us about them!

What can we learn?
The organizations described have a few key aspects in common in terms of how they have developed and scaled-up their impact. They have taken some or all of the following steps:
1. Identified a common problem faced by a vulnerable and underserved population
2. Innovated through experimentation
3. Trained community members
4. Used a coordination cell / backbone organization for synthesis, management and response
5. Integrated new tools into formal policy and strategies
6. Evaluated their results and continuously refined their approaches with community input

Individuals and organizations around the world are realizing the potential of these tools, especially as we continue to emphasize the power of local communities and informal actors in responding to urgent health and development challenges. When creating strategies for real, tangible change, the ability to visualize large volumes of information and draw on the people who are facing challenges on the ground is key. These grassroots mapping tools are allowing communities themselves to create strategies based on up to date, local information. These tools will also allow us, and the organizations we work with, to better map out how to fill the gap between what communities can solve on their own, and where the global community can step in.

While there is still a long way to go, we’re now beginning to see the results of these investments as more of these technologies launch in the market. The field is now beginning to devote greater attention to issues of access in order to ensure these products achieve their desired health impact.

Rosling’s talk was the first TED video I ever saw, and got me hooked on TED way back in college. With sharp wit and rapid-fire delivery, he shows how Westerners’ preconceived notions of global health and development can stunt the effectiveness of health interventions. An especially important insight comes around the fourteen-minute mark, when he notes the problem of using average data for countries when there is such variation within countries. When Rosling explodes Uganda’s GDP per capita into quintiles, and points out the importance of designing strategies for health access with a strong sense of context, you can’t help but nod your head in agreement.

2. Elizabeth Pisani, Sex, Drugs and HIV – Let’s Get Rational
“People do stupid things – that’s what spreads HIV.” Pisani starts the talk by saying that her own quote is only half-true – people get HIV from doing stupid things for perfectly rational reasons. Her ruthless take-down of our preconceived notions of what is rational for addicts and prostitutes completely reframes these destructive behaviors. Listen mid-way through for her discussion of the “compassion conundrum,” in which donors have trouble funding prevention for those engaging in risky behaviors, but easily open their wallets (for much more expensive interventions) once those individuals become AIDS victims. Pisani’s plea for political action at the end of the video should be a call-to-arms for the funding community to engage in advocacy and lobbying for policies that better serve those at risk for HIV.

3. Seth Berkley, HIV and Flu – The Vaccine Strategy
If Pisani shows us today’s behavioral approach to preventing HIV infection, Berkley shows us tomorrow’s vaccine approach to eliminating it altogether. He makes the case that vaccines for all kinds of ailments will be the key to preventing a massive global pandemic, and through the sheer force of his knowledge and persuasion makes it seem possible. This talk, though technical, carefully walks you through how vaccines are designed, produced, and distributed, and is a can’t-miss for new students of global health.

4. Bruce Aylward, How We’ll Stop Polio for Good
Aylward’s talk makes a moral, financial, and scientific case for ending polio forever. Watch at the end for a Q&A cameo by Bill Gates, who has also called for the eradication of the disease. In recalling terrible images of the polio epidemic, Aylward reminds us how we now take for granted the vaccine that changed the world. His earnest pleas to close the funding gap that will enable final treatment and eradication should be heeded by the global health funding community, and lessons learned from polio applied to the next horrific disease. In conjunction with the other talks on this list, he gets you dreaming about another TED talk, maybe thirty years from now, by some unknown scientist, about the final eradication of a disease that terrorizes us today.

5. Ernest Madu, Bringing World-Class Health Care to the Poorest
Much of FSG’s recent work in global health has focused on the disease burden of non-communicable diseases (NCDs) in developing countries: chronic illnesses such as cancer, cardiovascular disease, and diabetes. Madu makes a forceful and impassioned argument that NCDs can no longer be ignored in the developing world, and does one better by showing exactly how his Heart Institute of the Caribbean provides world-class health care at a lower cost than peers in the US. Smart design and superior technology are keys to his success. Madu exemplifies the increasingly bi-directional innovation trend in global health, of innovations arising in the developing world that are spread back to the developed world.

In just a decade the Global Fund has disbursed over $14 billion in grants to 150 countries, received contributions from more than 50 nations, private businesses, and philanthropies, and listed the likes of Bono, Bill Gates, and Carla Bruni-Sarkozy among its champions. It is credited with saving more than 6 million lives.

Lilly no longer manufactures TB drugs as of this year. So their work in MDR-TB means engaging with manufacturers and researchers and the field to answer big questions like how to improve the supply chain between when countries order drugs to treat patients with MDR-TB, to when those are delivered to the clinic. The exciting part of this effort was that it complements perfectly the theme of the Union conference this year which was focused on partnerships for scaling up and care. What happened in Lille was what we all hope will be the beginning of true partnership with global actors.

Funding for the global HIV/AIDS program has not been immune to these tightening U.S. budget restrictions. Thirty years after the first HIV diagnosis and almost a decade into the PEPFAR program, the monumental push for a response to the epidemic has down-shifted. The proposed 2012 U.S. global budget for HIV stands at $5.6 billion, virtually unchanged from 2011’s budget and only marginally greater than 2009 spending of $5.5 billion two years ago. These static numbers underscore what has been called the "flat-lining" of the U.S. commitment to HIV. It is mirrored by a shifting global agenda in the push for greater alignment of HIV with other initiatives, including non-communicable disease interventions (as discussed in detail in the recent post, NC-What?) and health-system strengthening strategies.

These new changes come on the heels of the treatment as prevention findings and stand as a major roadblock in the push for increased treatment coverage. According to UNAIDS’ "Aids at 30" report, with 1.4 million new patients starting treatment in 2010 and the global incidence rate dropping 25% over the same year, the results continue to support treatment as an effective strategy in transmission reduction. Yet without continued funding growth to match the rising demand for expansion of treatment, the progress against HIV is in jeopardy of stalling. 

*Source: UNAIDS "Aids at 30" report (June, 2011)

As HIV passes its 30th birthday, what does the flat-line in funding mean for future growth in treatment? The international community’s ambitious goal of reaching 15 million HIV+ people on antiretroviral therapy by 2015 means adding ~10 million patients to ART over the next few years. Considering that there are currently 6.6 million people on treatment today (according to the Aids at 30 Report), that means the number of patients on ART would have to grow ~32% each year for the next 3 years. By contrast, the whopping 1.4 million patients who were added to treatment in 2010—a substantial increase—amounts to 27% growth over the prior year. For this level of growth to continue (let alone increase further), it will require significant increases in funding for care and treatment programming over the long term.

The real challenge of supporting such growth lies in the snowballing cost of maintaining existing patients on treatment—the so called “treatment mortgage”. For each additional patient who goes on treatment, donors have taken on another lifetime commitment of paying for ART. Current estimates of the average cost of antiretroviral therapy (ART) can vary and nailing down a number is difficult. However, for the purposes of this blog, a quick read reveals that estimates generally range from $100 to $850 per patient per year. Splitting the difference and assuming an average cost of $500 for treatment worldwide, if we then apply that cost to the 6.6 million HIV+ individuals currently on treatment worldwide, the ongoing annual core cost of keeping those patients on ART is ~$3.3 billion, or roughly half of the current 2012 budget. Multiply that by the number of years each patient will be on treatment (say 20) and the total cost of treatment rises to about $66 billion—just to maintain current patient levels.

The prospect of adding roughly 3 million additional people on treatment a year for each of the next 3 years translates to $1.5 billion per year in added treatment costs. Therefore, in order to match the rise in costs of treatment (not including the indirect costs of diagnostic tools, commodities, health personnel, etc.), the budget would have to increase 27% next year alone.

A further factor of consideration for the “treatment mortgage” is the impact of increasing levels of resistance on treatment selection and the rising cost of new medicines. Treatment failure due to resistance is a major phenomenon in resource-poor places like Sub-Saharan Africa, the scale of which is only starting to be fully understood. As more resistance to first-line regimens is diagnosed, the demand for new and more expensive treatment regimens will likely rise with it and potentially cause further strain to the global treatment budget. MSF reports that the impact of changing a patient to newer second line therapy can increases costs per patient by as much as 6 times (MSF July, 2011 report). That multiple rises to almost 20 for third-line treatments ($2,766 per patient per year versus and average of $143 for first-line ART). If price reductions don’t occur in step with shifting demand for these expensive second and third-line drugs, these price increases could cause average treatment costs to balloon.

One potential relief to the treatment mortgage dilemma comes in the benefits of prevention. According to a recent article summarizing WHO impact projections, the expansion of the global HIV program could avert as many as 12.2 million in new infections and 7 million deaths between 2011 and 2020. These numbers are based on the WHO's new targeted recommendations for programming that assume only 13.1 million patients on treatment by 2015. From a funding perspective, that translates into $6.1 billion in savings on patient treatment per year (assuming our $500 average cost of ART per patient per year), or $122 billion if we again assume a lifetime treatment commitment of 20 years per patient. Therefore, by increasing cost outlays in the short term to improve the number of HIV+ patients on treatment, the international community could potentially improve the longer term sustainability of funding for the HIV mortgage by significantly reducing the growth of the mortgage. And while the true impact of these cost savings is difficult to project, the social impact of the lives saved through increased access to treatment is immeasurable.

In order to sustain the progress against HIV, the U.S., as a leader in the fight against HIV, will need to reexamine the long term implications of its flat-lining budget commitments. Taken together, the anticipated costs in treatment of sustaining the current progress against HIV undoubtedly present difficult tradeoffs for stakeholders and program administrators alike. But the potential human benefits of achieving scale in HIV treatment are beyond question. Policymakers must look at the future of HIV funding in light of all of these perspectives—not just the immediate.

Vaccines have never been entirely uncontroversial. Concerns date back to the anticompulsory vaccination league against mandated smallpox vaccination in the mid-19th century, and have never disappeared since. Most recently, the CIA’s tactic of using a fake vaccination campaign to try to confirm Osama Bin Laden’s presence in Abbottabad as well as Michelle Bachmann’s claims that the HPV vaccine may lead to mental disabilities, have brought the confidence issue back into the spotlight. As Dr. Larson pointed out during our discussion, the reasons for skepticism go beyond safety concerns and vary by region. In Kano, a northern, Muslim region of Nigeria for example, loss of confidence occurred after rumors spread that it was part of a plot by the US to make Islamic children infertile. In the US, a lot of the resistance stems from the right’s uneasiness with the idea of government telling them what to do. Mandatory vaccines are therefore contested for the same reason as mandatory health care.

So why not just let skeptics be skeptics? Well, for one thing, there is an ethical component. Because the science is often so overwhelming, it would be wrong to “give up” on those that choose not to believe in it, similarly as it would be wrong to let someone get in a car drunk, or practice unsafe sex. But there’s a second, broader reason to care. As Henry Miller and Gilbert Ross point out in their blog post, putting a single child at risk also puts the community at risk because the lower the rate of vaccination, the more likely it is for an epidemic to spread. It is thus critical for populations to achieve “herd immunity”, a level of collective vaccination that acts as a barrier to dissemination.

Given the above mentioned reasons, it is important to keep distrust in vaccines from spreading and to nip emerging erosions of trust in the bud. The fact that Michelle Bachmann is not backing down from her comments is worrying. In fact, it may well be that she will continue to stress the issue in the hopes of pushing her political opponent Rick Perry against the ropes. The platform of the primaries enables her to reach a national audience – and possibly instill doubts in the minds of parents currently not skeptical of vaccines.

But how can trust be restored? Dr. Larson pointed out that there will always be a core of doubters – the task is to keep current vaccine users from stopping. My colleague David Zapol blogged about the challenge of changing perceptions of vaccines back in February, and rightly pointed out the difficulty in responding to individual’s fears and doubts about vaccines. Scientific evidence, such as the recent Lancet report which demonstrates that nationwide vaccination programmes for young women against HPV are likely to reduce the number of those infected, are immensely important. But they will not suffice. Religious beliefs, personal convictions, and ongoing rumors about persisting health dangers will continue to breed mistrust. Dr. Larson therefore calls for more research on the determinants of public trust, and on the mix of factors that are likely to sustain it. She’s currently working on a vaccine trust barometer, which will identify a growing confidence crisis at an early stage, and consider various factors to determine the best response. While an early warning system will be of immense value, it will take time to develop and its recommendations will still need to be implemented. According to Dr. Larson, opinions are very much (in)formed by peers, so listening to the fears and doubts of vaccine skeptics, and taking the time to communicate the benefits of vaccines is perhaps the most important way to take influence. So if you know someone who has doubts, take the time to listen to her or his reasons, but also make sure they understand what’s at stake. Thanks to vaccines, devastating diseases such as diphtheria, measles and polio have become rare and contained. Wouldn’t it be great if we could say the same thing for new diseases such as HPV?

If this kind of approach was easy – or this kind of team was easy to build – we’d all be doing it. Evaluation holds particular challenges. First, many funders and service providers are focused on measuring their specific impacts on social issues, since they need to justify their activities to stakeholders (such as funders). Second, it can be difficult to understand the relative impact of pieces of a collective or integrated approach to service delivery, particularly in the area of global health. The latter challenge is what this blog aims to address. Is it enough to be able to say that the combination of certain interventions achieves outcomes, or is more specific attribution of program components necessary? Would not greater understanding of the relative benefit and worth of specific interventions be more valuable? And if this is important, how can it be accomplished? Team-first teams do win championships, but this initial success can raise the price of the players to unaffordable heights due to salary caps or other financial limitations (a challenge not unknown in the global health sphere). It takes a skillful General Manager to correctly identify and invest in the most important and cost-efficient elements in order to replicate success.

The question of intervention-specific evaluation’s value has come to light through our recent work with a foundation addressing children affected by AIDS (for more on this subject, see this UNICEF publication). This is a target population for which integrated delivery of health, nutritional, educational, and economic support holds great promise, and for which knowledge of relative impact is important due to huge shortages in funding and the vast array of potential interventions. There is a strong need for development of best practices for integrated service delivery for children affected by AIDS.  I would argue that it is essential to develop best practices so that stakeholders can understand not just the best types of interventions to include in an integrated program, but the best mixes as well. Counterarguments to this idea are that it can be very difficult and expensive to measure the specific impacts of different inputs, which is true; educational outcomes and health outcomes are heavily affected by nutrition, for instance. However, using pilots that had different levels of funding and focus on various interventions such as nutrition, education, or health support could enable better understanding among funders and organizations on how to best target their resources.

The team-first mentality is essential for collectively tackling complex global health issues, but there are situations where understanding of the relative importance of interventions would be valuable. While a true sports G.M.-mentality of measuring individual impact may not be possible, there may be other ways to guide funders toward the types of interventions that should receive the greatest funding within a comprehensive model. How do you see this tension—between wanting coordinated approaches but also needing to evaluate the relative value of individual interventions—playing out?

Tuberculosis is a disease of poverty. Over 80% of cases occur in Africa and Asia, amidst poorly developed health systems and rampant poverty. China has slowly adopted methods for treating TB over the last 20 years, and the majority of the country is covered by the internationally recognized standard for treatment—DOTS (Directly Observed Treatment Short course).

The path that my mind takes me is: Okay so ‘non’ means that it’s not something. Wait…it’s not infectious? That’s great news! It must not be worst thing that can happen since whatever this disease is, I can’t give it to other people. That’s quite a relief when compared to rapidly spreading pandemics and the health scares like E. coli, SARS, avian flu, etc. that get media space. But it’s still a disease so that must mean that it isn’t good for you. Now that I have a general sense of what it is…what is it?

NCDs aren’t as foreign as you may think. The main ones are cardiovascular disease, cancer, chronic lung disease, and diabetes. I made this exercise easy for you by spelling out non-communicable disease. If the topic is ever to come up in conversation, it typically shows its face as NCDs – a three letter acronym that doesn’t mean anything to those not familiar with health. (As I’ve recently entered the world of global health, I’ve been warned by my colleagues on the abundance of three letter acronyms in the field)

In contrast, this 7 letter acronym: HIV/AIDS, is no stranger to anyone. Those 7 characters carry so much weight behind them and although I confess that it takes me a few seconds to tell you what HIV/AIDS stands for, within a split second I know what those letters are standing up for:

Life
Death
Health
Suffering
Hope
Courage
We can stop it!

HIV/AIDS is a movement and its power lies in those affected by it, their family and their friends. Without the massive mobilization generated by the HIV movement, tens of millions of more individuals would have acquired the virus and many who are alive today would not be.

The common theme that I ran across at the conference was the need for multi-sectoral, multi-national approaches and the need for health systems strengthening and integration of NCDs. In addition, The Global Health Council has a great brief that lays out recommendations for addressing NCDs and although you won’t explicitly find public, grassroots mobilization, it may be the critical mechanism needed to achieve rapid progress.

According to the World Health Organization (WHO), NCDs account for about 60% of deaths and nearly 80% of these deaths occur in low and middle-income countries. It’s kind of a big deal, so how can we raise public awareness on this important issue? Perhaps it’s too big of a disease bucket to effectively build a movement around, but as one conference panelist pointed out, the NCD movement needs to be rebranded. I hope to see the creative thinkers of our day tackle the rebranding of NCDs to help catalyze a grassroots movement in addressing one of the most pressing health and economic issue of our day. Until that happens, sign me up for the next “NCDs Walk”!

To learn more, see WHO’s NCD report

The TB rate in Russia more than doubled 1990-2000 and now multidrug resistance is rampant. From Moscow it appears the Russian public health system is a failure. There are public health books that scare people about global pandemics that originate in Russia. The litany of problems we heard about in this country are striking: almost half of Russian TB drugs are poor quality, diagnostics lack the reagents to actually be used, there is no budget for prevention. We visited patients, kids, held in hospitals for six months or longer (much could be outpatient for a fraction of the cost), often with outdated methods of aging, poorly paid and poorly respected TB doctors. Some believe as many as 100,000 people now have multi-drug resistant (MDR) -TB and most are fated to either suffer, remain on failing treatment for a long time, switch to painful treatments with horrible side effects, or die.

Historically, corporations and global health have not had the smoothest relationship. In the 1990s, most companies saw health and other social issues as far removed from their business: as an externality for governments to solve. Through the early part of this decade, they began to play limited roles through philanthropic contributions and price discounts – these efforts came about through a mix of charitable intent and stakeholder pressure. Over the past years many of these initiatives evolved further: expanding, becoming more strategic, and engaging a broader range of partnerships.

But it was clear at this conference that companies are thinking in new ways. First, the size of philanthropic commitments is no longer what wins accolades. Instead, the awards and recognition are going to efforts that incorporate innovative partnerships and catalyze sustainable change. These efforts include BD's collaboration with PEPFAR and the Government of Kenya on training and technology development for safer blood collection. By partnering in new ways and focusing on technology and skills transfer, rather than open-ended commitments, examples like these are dramatically increasing the impact of health initiatives.

Another evolution we heard about at the conference was around the fundamental roles that corporations can play in these spaces. Companies are beginning to realize the need to rethink their business models and see social issues as opportunities, not as costs of doing business. This idea of Creating Shared Value – which FSG co-founders Michael Porter and Mark Kramer wrote about in a Harvard Business Review article the other month  – was another theme of change underway. Mark spoke in the keynote at the conference about some of the specific examples and opportunities in the global health space, whether it’s GE’s Healthymagination initiative, a major strategy to develop affordable health technology products for use in emerging markets and globally, or Novartis’s investments in the health system in rural India that will facilitate the expansion of their generic pharmaceutical sales while dramatically improving the quality of care.

A team at FSG is actually launching a follow-up research project to the Creating Shared Value article. We’ll be completing a paper around opportunities, barriers, and examples of global health shared value among companies in the pharmaceutical, biotech, and medical technology industries – we've received initial support from Eli Lilly and Medtronic to complete the work . We’d be interested in how you view this evolution, and in examples you have of companies pursuing social impact through business strategies – please share comments here or contact me at matthew.rehrig@fsg.org.

Although Dr. Chan had already released her vision for reform earlier this month, she moved the agenda item from being the elephant in the room to being the center of attention last week by stating in her opening address that “WHO is now embarking on the most extensive administrative, managerial, and financial reforms, especially financial accountability, in its 63-year history”. Financial austerity among donor countries has certainly increased the pressure for reform. The newly adopted 2012-2013 budget ($ 3.6 billion) indicates a marked decline in funding compared to the current two-year budget ($ 4.5 billion), and the steady depreciation of the dollar has made matters worse, since WHO receives most of its funding in US dollars but pays its staff and its administrative costs in Swiss Francs. As a consequence, the WHO will be forced to lay off around 300 of its 2,400 Geneva-based employees.

Although funding cuts are a reality for WHO, Amanda Glassman states in her recent blog post that Official Development Assistance (ODA) for health has steadily increased in the past decade – from around $ 10 billion in 2001 to over $26 billion in 2010. So how to explain the cuts in WHO’s budget? In my opinion, there are three reasons why contributors are scaling back their funding.

Firstly, governments are increasingly under pressure to justify the money they are spending on development isn’t better spent at home. UK’s Coalition Government for example has commissioned a Multilateral Aid Review to assess value for money, and 16 major donors have created the Multilateral Organization Performance Assessment Network (MOPAN) to assess the organizational effectiveness of major multilateral organizations.

While these measures target all multilaterals, the second reason – the emergence of “vertical funds” such as the Global Fund or GAVI – is more specific to WHO’s budget woes. Vertical funds are issue-specific and characterized by clear results-chains, involvement of the private sector, as well as a strong commitment to transparency, evaluation and learning. In recent years they have steered significant amounts of funding away from WHO.

Finally, WHO is struggling to define its role in a world that has changed profoundly since its inception in 1948. Given the rise of vertical funds and the increased involvement of developing countries in the determination of aid flows, WHO’s original mandate to promote “attainment by all people of the highest possible level of health” appears too broad in today’s global health landscape. As Amanda Glassman points out, a discussion on what WHO should and should not be doing is dearly needed.

So the case for reform is clear – but how? By signing a general agreement merely stating the need for reform the WHA sidestepped the details altogether. Similarly, Dr. Chan’s reform document remains vague. It admits that the “WHO finds itself overcommitted, overextended, and in need of specific reform”, but does not provide much information on how it intends to change this.

Perhaps the clearest recommendation in Dr. Chan’s proposal for reform is to establish the “World Health Forum”, a multi-stakeholder platform including member states, civil society, private sector, academia and other international organizations, that would "have a role in identifying, from the different perspectives of its participants, future priorities in global health.” Although both the specific activities and powers of this body remain unclear as of now, it is safe to say that the idea is not uncontroversial. Several member states and NGO’s have already expressed their concern over increased private sector inclusion, as they fear that big pharma could influence WHO’s sanitary policies (as was suspected when the WHO declared the H1N1 pandemic in 2009 – a charge the WHO was cleared of last week).

Such conflicts of interest must be avoided via institutional checks and balances, and financial contributions by private sector actors should be transparent to ensure that scientific evidence – not special interests – determines WHO’s decisions. But if done correctly, private-sector inclusion could be beneficial to WHO. Private Public Partnerships (PPPs) and Product Development Partnerships (PDPs) are both models that have demonstrated the value of leveraging private sector resources and capabilities in addressing global health issues, so thinking about ways to use the private sector to achieve WHO goals is a good idea.

Dr. Chan, who has good chances of being re-elected for a second term as Director General in 2012, has made reform a priority. However, as is so often the case, the devil lies in the details – and this is where the WHO will have to get much more concrete in the coming months.

In non-communicable diseases, we’ve been hearing lots of updates and reflections from the ministerial conference on NCDs that happened in Moscow, Russia at the end of April. It seems like most are seeing the meeting as at least a tentative success, with positive indications from country governments that they’re willing to make real commitments in the major UN summit on NCDs in September. It was also exciting to hear that WHO Director General Margaret Chan make positive references to engaging the private sector, including NGOs, researchers, and companies, in the global response.

In the infectious disease world, we’ve been following with great interest some of the recent news on the HIV front. In particular, the announcement of trial results that showed a tremendous reduction in risk of passing on the virus when HIV-positive individuals start antiretroviral therapy early – see here. This protective effect has been presumed in the past to a certain extent, but this study is a major confirmation of that fact. The question now is, what does the global health community do with this knowledge? Does this lead to a rallying of the advocacy community around the goal of ramping up treatment faster, as Elizabeth Dickinson at Foreign Policy poses?

Finally, on the vaccine front, Bill Gates called for a “Decade of Vaccines” in a speech to the World Health Assembly. The Gates Foundation’s blog has been particularly active on the topic this week, including some fun graphics like this one comparing the costs of various vaccines everyday purchases. Amid all the crucial high-level advocacy on the topic, it’s heartening that the foundation and others are also addressing the public perceptions of the importance of vaccines. This seemed particularly pertinent to me as I just finished reading Seth Mnookin’s excellent book The Panic Virus, which gives a riveting account of the damage caused by all of the myths and pseudoscience out there regarding vaccination. 

What's been sparking discussion in global health for you this week?

Only five months ago the HIV field was ecstatic when the results of the first clinical trial of Pre-Exposure Prophylaxis (PrEP – an approach of taking a pill with the drug Truvada daily to prevent HIV infection) called iPrEX found that healthy gay men on the treatment were 44% less likely to get infected with HIV than those taking a placebo. My colleague, David Zapol, blogged about these exciting results last November. Experts in the field naturally extrapolated on these results and began to see a future where heterosexual women (the largest growing population of new infections in Africa) and others could be protected from this stigma-ridden and debilitating disease. We were waiting with baited breath for the clinical trial results from testing the same drug and daily dosage as iPrEX on heterosexual women (FEM-PrEP) to provide similar results.

We have to wait no longer. Last Monday, FHI decided to discontinue FEM-PrEP after its Independent Data Monitoring Committee (IDMC) determined that the trial would not be able to answer the question of whether the study drug decreased risk of HIV infection among HIV-negative women via sexual transmission. Mitchell Warren, Executive Director of AVAC (and close friend of FSG), said “Today’s announcement about the FEM-PrEP study is disappointing. However, it must be seen as what it is – the closure of a single trial in a field that has generated exciting results in the recent past. Even with this finding, there is still a strong rationale for continuing other trials, including those in women, in hopes of obtaining better results in the future.”

What happened? Was it adherence issues? Participants self-reported 95% adherence to the study product, but FHI has yet to verify these numbers. Or, as TIME's "Healthland" blog writes, was it due to a physiological difference in how men and women acquire HIV, such as the difference in tissues involved during sexual conduct? Or a different, unknown reason? And why did women taking Truvada have higher pregnancy rates than those randomly assigned to the placebo arm?

All hope it not lost – Two other ongoing trials in sub-Saharan Africa are evaluating PrEP among heterosexuals. The VOICE trial is focused on heterosexual women and Partners PrEP is testing the HIV-negative member of couples in which one partner is HIV-infected.

The results of FEM-PrEP, while disappointing, should be considered knowledge gained about HIV prevention that will help the field hone its efforts moving forward. Once FHI finalizes its findings and determines the primary cause of the lack of effect in HIV-negative heterosexual women, then future trials can incorporate this knowledge when developing protocols for new clinical trials.

It’s clear that a silver bullet for HIV prevention is not just right around the corner and research will require continued and consistently high levels of funding. The US government recently released funding figures for programs in its Global Health Initiative. While the president has requested greater funding for 2012, Congress has yet to approve it. More importantly, the amount is less than the field needs and hoped for.

At a time where global funding is extremely tight in all areas, including R&D for HIV, how will these results affect momentum and future funding commitments from countries and multilaterals?

My friend called attention to what I’ve heard from many others around global health funding: that the economic recession and ensuing budget battles mean a major funding challenge for the world’s most pressing diseases, particularly for U.S.-based funders, who are the leading donors for many initiatives. According to the Kaiser Family Foundation, U.S. global health aid grew an average of 13 percent per year from 2004 to 2008, but projections show that this growth is set to decrease to around 6 percent for 2009 and 2010. UNAIDS’ 2010 Global Report revealed that between 2008 and 2009, total international assistance for HIV / AIDS effort did not grow, the first time that this has happened. While these changes in available funding present a daunting challenge, and one that only will get tougher in the near future as the battle over the 2012 federal budget emerges, there may be at least one silver lining: increased pressure on funding may force global heath efforts by low-and-middle-income countries (and supported by multilateral organizations) to find more effective and cost-efficient models for care.

Three important trends in the changing landscape of global health funding are integrating disease siloes, promoting country ownership of health efforts, and weighing the cost-effectiveness of programs. Approaches to U.S. health aid have already been changing. President Obama initiated the Global Health Initiative (GHI), which continues major contributions to HIV / AIDS, malaria, and tuberculosis, but places a greater focus on giving recipient country governments more ownership around directing funds. The extra pressure caused by reduced growth rates in funds available makes the stakes for the success of the Initiative higher. However, it may also help encourage focus on integrated care models that have exciting potential for making care more effective and sustainable, particularly by building in health service delivery into existing structures created to target other disease states.

Examples of this are taking shape in different contexts. South Africa is working to integrate tuberculosis care into its HIV / AIDS treatment delivery structures. There is growing interest and research on the potential for using infectious disease structures that have been built out in many low-income countries in response to the AIDS epidemic to tackle the rising wave of non-communicable diseases. Examples of greater focus on the cost effectiveness of health interventions are everywhere, from the development of lower-cost community-based treatment for drug-resistant tuberculosis to the questioning of expensive institutional care systems for orphans and vulnerable children.

It would be foolish to think that the coming reductions in global health funding will not have serious costs. As the world faces potential epidemics of drug-resistant diseases, the continued burden of HIV / AIDS, and the rapid growth of non-communicable diseases, reductions in global health funding are ill-timed and dangerous. Efforts to combat diseases with much lower prevalence but close to elimination, such as polio, will face even more pressure and controversy for using funds that could go to fight diseases with higher prevalence (recent posts on this blog on malaria--http://fsg.org/KnowledgeExchange/Blogs/GlobalHealth/PostID/78.aspx --and polio-- http://fsg.org/KnowledgeExchange/Blogs/GlobalHealth/PostID/61.aspx --weighed questions of cost-effectiveness and elimination strategies). But, in the midst of this gloomy forecast, let’s not forget hope. These changing circumstances could lead to improvement of global health approaches. Reduced funding could force greater emphasis on innovative interventions that maximize effectiveness, reduce redundancy, and enhance coordination at the policy, civil society, and community levels. However, this will only happen if those funders, international organizations, policymakers, community-based organizations, and others working in global health understand the changing funding context and work together to support the most effective and efficient responses.

Readers, what do you see as the biggest challenges posed by cuts in global health spending? What are other examples of new intervention models and programs that could drastically impact current disease states?

The last decade has seen great progress in the fight against malaria, and there is indeed impact to celebrate. As stated in the WHO’s 2010 World Malaria Report, the number of malaria-related deaths has fallen from 985’000 in 2000 to 781’000 in 2009, and eleven African countries have seen the malaria burden drop by more than 50% over the same period of time. These successes are due to a variety of factors – intensified funding (funds committed to malaria control increased steadily between 2004 and 2009, but have stagnated at $1.8 billion in 2010), increased usage of insecticide-treated bednets (ITNs) and indoor residual spraying (IRS) in malaria endemic countries, as well as the introduction of new drugs to name a few.

Roll Back Malaria (RBM), the organization behind World Malaria Day, has been crucial in aligning the Malaria community around a common vision and strategy. Its Global Malaria Action Plan (GMAP) lays out the community’s strategy to achieve its ambitious goals of controlling, eliminating, and ultimately eradicating malaria. While reductions in malaria rates are obviously a laudable first step in achieving control, the GMAP explicitly mentions “sustaining control over time” as the second sub-goal before elimination.

I believe this step is becoming ever more important if the world is to avoid a resurgence of malaria as witnessed in the 1990s. Margaret Chan, the Director-General of the WHO, and Ray Chambers, the UN’s Secretary-General’s Special Envoy for Malaria, mentioned in their blog post back in December that “recent gains against malaria are fragile, and while we hold in our collective hands a real opportunity to end malaria deaths in Africa by 2015, it could still slip through our fingers”. I share their caution, and see three main challenges for the malaria community in the coming years:

1. Developing next generation drugs to counter the emergence of parasite resistance to ACTs
2. Improving access and affordability of malaria diagnosis and treatment in endemic countries, especially in rural communities
3. Strengthening national health care systems

Undoubtedly, all of these factors are critical if recent successes are to be sustained. The third one however – strengthening national health care systems – strikes me as particularly tricky since it is beyond reach of the malaria community alone and bleeds into other development priorities such as governance and economic development. As Bill Brieger remarks in his recent blog post “strong health systems cannot exist in weak states”. In other words, political instability and malaria reductions don’t mix. To prove his point, Bieger points to the Central African Republic (CAR), which has endured years of political violence and where Malaria remains the leading cause of morbidity, accounting for 13.8 percent of all deaths. The correlation becomes even more apparent when looking at Sri Lanka, where Malaria persisted in the areas where the Tamil Tiger insurgency was strongest, and Malaria cases have jumped by 25 percent from 2009 to 2010 in the wake of political violence. Côte d’Ivoire, which is currently on the brink of civil war, could well be the next example.

A 2010 study by Andrew Tatem, professor with the University of Florida's Emerging Pathogens Institute and Center for African Studies, identifies political stability as a key factor in determining the feasibility of malaria eradication. Countries like Angola, Somalia and the Democratic Republic of Congo (DRC) – all plagued by political instability – are found near the bottom of the list of countries most likely to eliminate the disease. The reasons for this are self-evident. Generally, people in conflict zones struggle to put food on the table, so health treatment becomes less of a priority. In addition, many donor agencies tend to steer funding away from crises riddled areas, further reducing the availability of treatment. Finally, conflict zones within countries often receive less funding from their central governments, so health systems and infrastructure deteriorate.

The link between political instability and the resurgence of malaria is a perfect example of the interdependence of the world’s most pressing issues. But interdependencies work both ways! As the examples of Botswana and Rwanda prove, stability and economic growth lead to stronger health systems, which in turn lead to reductions in malaria related deaths.

So, how do we ensure virtuous cycles prevail over vicious ones? Suggestions anyone?

Our time in India was filled with tremendous contrasts. One moment, we’d be looking up at the sleek glass and steel skyscrapers and five-star hotels in Gurgaon; the next, we’d realize the humble bases of small houses and buildings from which they rose up. In the heart of Old Delhi, a rickshaw ride reveals narrow but crowded pedestrian alleys crossed by hundreds of loosely bound electrical wires and winding haphazardly through tightly packed buildings. A web of roads connecting these and many other disparate parts of the booming metropolis that is Delhi are jammed with masses of semi-trucks, cars, rickshaws, tuk-tuks, tractors, and scooters at most every hour of the day. A twenty kilometer trip on some of the newest and widest roads in the city can take anywhere from an hour to much longer, depending on traffic. The air is filled with unending streams of horns used more as traffic signals than displays of frustration as vehicles swerve across the road without any concern for the traditional use of lanes. As my colleague put it, traveling by car in India is more of a constant contest for any open space than driving.

Riding as a passenger on these roads drove home for me one of the key insights we learned during our time in India. Within India, communities of wealth with access to first-rate care and (large) areas of extreme poverty with much poorer treatment capabilities, particularly for NCDs, are packed tightly together. You do not have to go far from the shiny towers of Gurgaon to find the dull aluminum roofs of slums. And despite the much higher availability of doctors and medical facilities in large Indian cities than in other areas, challenges of confronting health issues like NCDs in peri-urban slum areas connected to cities are in many ways greater than those related to health delivery in rural settings. Reasons for this include poor diet, lack of exercise, lack of community leadership or cohesiveness that can enable effective education and prevention efforts, work and life schedules which make seeking treatment difficult, and transportation difficulties that can isolate patients from treatment resources. It was these last two reasons that creeping along the crowded roads of Delhi helped reinforce for me in a direct way.

Efforts in India to increase access to any piece of patient care (diagnosis, treatment, counseling, etc.) must take into account these constraints which our team was fortunate to tangibly experience, and which will continue to inform our thinking as we strategize about potential interventions within the country. The erratic hours of occupations such as rickshaw peddler or side-of-the-road vendor, and the even more erratic condition of transportation in many parts of the city, are clearly hurdles for patients seeking regular or specialized treatment for NCDs.

Readers, what kinds of insights have you gained from on-the-ground experiences that you might have missed if you had only studied the situation from a distance?

The State of the Problem

While we were aware of the problem of diabetes in Mexico, it was alarming to learn about the need on the ground. A staggering 70% of Mexicans are overweight, the country is first in the world in childhood obesity, and the latest government health surveys peg adult diabetes rates at 14%. The culprits? We heard diverse explanations: from overconsumption of foods high in fats and sugar, to a lack of cultural promotion of exercise. As an example of the former, Mexico is the world’s largest markets for Coca Cola products: per-capita consumption is around one and a half two-liter bottles per person per week.

The outcomes for patients with diabetes are also incredibly poor: an estimated 50% of patients don’t know they have diabetes, and only 20% of patients have good control over the disease by international standards – compare to 31% in the rest of Latin America, and around 40% in the US and Europe. The impact of diabetes on Mexico’s economic productivity in the next few years could be crippling: 75,000 Mexicans die each year from diabetes, rates of complications from the disease are high, and diabetes treatment costs the Mexican health care system $5 billion annually.

• ABC Hospital is a high-end nonprofit health care facility located in Santa Fe, one of the most economically divided sections of Mexico City. ABC operates a suite of comprehensive health services to underserved patients in a five-kilometer radius around the hospital. By deploying a range of interventions – door-to-door testing, a mobile clinic, centralized education and treatment efforts in the hospital, and a health promoter model using local community leaders in each neighborhood – they are working to radically change the comprehensiveness of care for low-income patients with diabetes.
• La Universidad Panamericana (Panamerican University) partners with local foundations and NGOs to operate community clinics that target the rural poor. One such clinic is in the village of Toxi in Atlacomulco, 90 minutes outside of Mexico City. It is staffed by “pasantes” from the university’s medical school – young doctors and nurses who provide a year of community service as a graduation requirement of their medical programs. The clinic provides comprehensive services to individuals at risk for diabetes, from training in basic hygiene and blood testing to insulin provision and assistance with income generation. This model aims to identify a sustainable way of caring for patients in these challenging settings, so that the model can be replicated elsewhere.

A public health devotee, I immediately volunteered the fact that there is no link between childhood vaccines and autism. A new book I’m reading called The Panic Virus describes the source of this concern as a peer-reviewed article that was based on a small set of parental recollections. It was ultimately retracted by The Lancet, and the author lost his medical license for fabricating data. There really should not be a debate as scientific study after scientific study has provided counter evidence.

Of course, there is never a completely safe vaccine; there have been manufacturing mess-ups and real risks ever since the original Salk polio vaccine caused 10 deaths in the mid-1950s. The challenge that I faced in responding to Max’s question was the same one that multiple public health stakeholders, from the CDC to the Government of India, face when responding to concerns about the new HPV vaccine. How do you reassure a skeptical parent, when you can never disprove a link? The debate has long ago taken to the public. Jenny McCarthy feeds these fears when she speaks publicly about her belief that vaccines caused autism in her kids. I can get worked up when talking about this issue and my conversation with Max was probably not an exception.

Changing the perception of vaccines among the segment of the public that still fears them remains difficult. Our Global Health advisor Heidi Larson writes about how vaccines, the centerpiece of UNICEF programs, have been questioned by populations globally from California to India. Bill Gates writes about the important role of vaccines in his foundation’s mission in his latest annual letter. While these tools are important, I’m still not sure how to respond to Max’s concerns in a way that will acknowledge and assuage his fears.
Last month the baby was born. Max now has a healthy and sweet-smelling little boy. I couldn’t be happier for them, but for me there remains a nagging question. Will Max’s little boy be protected from whooping cough, which killed six unvaccinated kids in California last year?

How do you engage productively and professionally in a dialogue around these personally charged choices that are important public health issues?

Eradicating 99% of polio cases has saved millions of lives, and averted incalculable suffering from a painful and paralyzing disease. Yet the last 1% of polio is proving tough to crack. Poliovirus cases have floated between 1,000 and 2,000 annually over the last ten years. Polio is a hydra of a disease – it mutates and pops in countries where it had previously disappeared, and four countries – Nigeria, India, Pakistan, and Afghanistan – have never freed themselves of the disease. 

Few ERs in Africa could deal with such a case but Muhimbili National Hospital’s ER is different. Staff are well-trained and resuscitation rooms are equipped with life-saving equipment. A command center has rows of computers to monitor the activities. There’s a top-notch ER director and specialists from the US provide new ideas and coaching, all courtesy of the Abbott Fund, the philanthropic arm of Abbott Labs. But the real miracles here are the young ER resident and registrar doctors who provide the manpower, passion, and optimism to deal with 200 patients a day. On a larger scale, they are the clearest hope for Africa’s health care challenges.

I’ve just returned from an eye-opening week at Muhimbili National Hospital, the home of the country’s only Emergency Medical Department. Along with three other FSGers, we’ve just kicked off a project to help the Abbott Fund chart its next five years of support to the hospital. The ER and the young residents and registrars who staff it quickly grab our attention.

Unlike in the US, where large numbers of patients use ER for sore throats and stubbed toes, Muhimbili’ s ER patients suffer from ectopic pregnancies, car accident wounds, severe malaria, or domestic violence. Patients make their way to the hospital in taxis or join other patients in crowded ambulances that are more buses than emergency vehicles. Patients are often held at a regional hospital, waiting days, until they fill an ambulance.


Pictured: Muhimbili ER Wonder Team: Resident Doctors Faith Ringo and Upendo George; Head Nurse, Sister Sepeku; Resident Doctor Hendry Robert.

Amidst the scenes of multiple, daily trauma, I meet Drs. Hendry Robert, Upendo George, Faith Ringo, Juma Mfinanga, and Philip Michael. Their responsibilities are extraordinary - 12 hour shifts, often at night, where they make life-and-death decisions without senior doctor support. During the rest of the day, they study and squeeze in sleep. But these young ER docs are some of the most confident and happy health care workers I’ve seen on the continent. They’re assertive, questioning, and unwilling to accept the cynicism that pervades public hospitals. What drives them?

They answer the question: Autonomy for high-stakes decision-making, technology, international connections, and trust in their colleagues. It’s a great combination and, in the context of the nearly $80 million that Abbott Labs and the Abbott Fund have invested in Tanzanian health care system strengthening, the drive of these young ER docs is perhaps the best return.

I’ve spent the last 20 years focused on health prevention and treatment in Africa, particularly around the big diseases. Emergency care hasn’t been a priority for me or, frankly, the global health field. Perhaps that should change as the learnings are rich here:

1. Motivated, young health care workers are a critical part of the health care solution in Africa. ER departments offer a particularly fast-paced learning lab for the next generation of health care practitioners in terms of leadership, growth, and accountability.
2. Upgraded ER care acts as a catalyst for improvement in other parts of a hospital. ER departments are linked to radiology, labs, surgical services, etc. Higher expectations in the ER flows throughout the rest of the hospital care system.
3. ER care may be a source of revenue generation for hospitals as other, private facilities lack the vital mix of high patient volumes and specialists.

Muhimbili ER – I couldn’t find a better set of stars to watch!

That being said, the article presents an incomplete, misleading picture of the situation. 

To start, the auditor’s report found problems with specific grants, ones that represent a fraction of the Fund’s total distributions. The juxtaposing in the first paragraph of “a $21.7B development fund” and “…as much as two-thirds of some grants eaten up by corruption” makes the reader do quick math and think that $14B and change is being pilfered – not the case at all.

Second, the AP’s story is framed as an “expose” of sorts. The truth is, the auditor’s findings have been publicly available for quite some time, and the Global Fund and in-country law enforcement are already taking action on the specific issues. 

Finally, the AP article left me frustrated in its framing. The headline “Fraud Plagues Global Health Fund Backed by Celebrities” positions the fund as some sort of flash-in-the-pan effort that draws legitimacy only from the support of Bono and the like. Despite its flaws, at the end of the day the GFATM is likely the most transparent and recipient-country-owned funding mechanism the world’s ever seen.

There’s definitely more work to be done on improving internal audits and getting them to cover more grants, but I’d hate for these issues to make the Fund run away from its core principles of responding to country-determined needs and administering funds out of local coordinating mechanisms.

It’s been good to see in the last few days a number of sources pick up on these lines of criticism of the article: see this article, as well as this insightful blog post from Bill Savedoff at CGD.

The field needs to continue to push for efficient, effective, transparent, and accountable funding of global health programs – but the Fund is doing an admirable job on these fronts.

The Roundtable is planning to move its work forward along several planks, each led by a separate working group. At the launch event, we formed working groups to deal with the following issues: updates on UN processes, developing policy recommendations, stakeholder outreach, and communications.

Through our work with dozens of clients in formulating strategic plans, especially those involving multiple parties, FSG has developed considerable expertise in what we call collective impact strategies. I thought I would share my views on three action items that would be important for the Roundtable and the Working Groups to keep in mind as we move forward in this work:

1. Set A Range of Milestones: While there are overlaps between the working groups, each will need a clear plan for what it wants to achieve against a specific timeline. In addition to the most significant milestones, interim outputs are also important. For example, as the policy working group prepares to develop and launch a public report, it will be important to identify a series of intermediate steps (e.g., feedback from other members, launch plan developed in coordination with the communications working group, etc.) for the report to be successful.
2. Identify Tangible and Practical Asks: The Roundtable includes participants from the private sector, NGOs, consulting firms, government agencies, and industry associations. Each brings a comparative advantage in what it can contribute. The working groups need to identify realistic contributions from each member that can keep the work moving forward without overly burdening any single member. For example, industry members can contribute vignettes about their current NCD programs around the world, which can be compiled into a database to glean best practices on NCD diagnosis and treatment models.
3. Develop a Collective Impact Strategy: Finally, it will also be important to develop some broader goals for the roundtable so its work can fit in with the effort of others (e.g., the UN, developing country governments, etc.) in the field. Is the immediate goal to achieve a specific outcome at the UN Summit, to get country governments to commit to a certain amount of resources, to get increased funding from international donors, all of the above? Who else is working on these and how does the Roundtable’s work fit in with theirs? Identifying and prioritizing through this list will be important in developing a collective impact strategy to address NCDs through a truly global effort.

Since starting work on this water and sanitation project, it has been exciting to see the buzz around the issue and learn about innovative approaches to raising public awareness. For example, in December ABC focused an episode of 20/20 on the water crisis in Africa – featuring a project of charity: water, the most followed nonprofit on Twitter. Similarly, Matt Damon used his recent appearance on the Late Show with David Letterman to educate the public about water issues (Damon is the co-founder of water.org).

What can be done by biotech firms to overcome this continued inequity? Pharmaceutical, diagnostic and medical device companies provide some good examples for the industry:

1. Invest in R&D for neglected diseases: An investment in R&D for neglected diseases can take many forms. Drawing from work by FSG partners, Alnylam donated its RNAi patents to a patent pool to allow researchers in universities and non-profits to use their intellectual property. Medtronic is creating a business initiative to retool its business to create low-cost heart devices. Pfizer has invested in for-profit joint ventures and donated to not-for-profit R&D collaborations both to deliver product to the developing world.
2. Train a new generation of innovators: Develop capacity in the developing world to create new products to address local markets. Merck has supported Hilleman Laboratories in India, alongside Wellcome Trust, in order to both address neglected diseases like Chagas and build capacity for innovation globally. 
3. Create a new business: A few companies have identified product needs in the developing world and are going after these markets aggressively. For example Daktari Diagnostics, run by FSG Global Health Affiliate Bill Rodriguez, developed a portable CD4 counter which can be in the treatment and monitoring of HIV patients worldwide.

Ten years after the 90/10 report the landscape is also much more complex – there is a broader context for the innovation we need. For example in order to pull the field into investing there are new incentives- promises of revenues from Advance Purchase Commitments by donors, prizes for R&D challenges are being considered and the US Food and Drug Association has created regulatory incentives for companies to invest in neglected diseases. FSG Global Health Affiliate Paul Wilson has written beautifully about the broader landscape of vaccine access and R&D, and for more ideas about how this applies to biotech, BIO Ventures for Global Health and WHO/Tropical Disease Research and Universities Allied for Essential Medicines are great resources.

Despite these efforts, few biotech companies have engaged in R&D. What more can be done? If universities have been able to carve out provisions for developing country access, why shouldn’t they also be able to divert some of their royalties from US or EU sales into a fund for neglected diseases? As the epidemiology converges between developing and developed world, will we see more start-ups targeting globally needed technology as a part of core-business? As the US health system becomes increasingly cost-conscious, will the rest of the world benefit?

Question 1: What are we learning from the global response to infectious diseases? Assessing the response to the rising burden of NCDs against a few of the lessons from HIV, TB, and malaria shows mixed results:

• Focus global attention and make the crisis tangible: The 2001 UN General Assembly Special Session on AIDS marked a turning point in the HIV response, and this September’s high-level meeting on NCDs has similar potential. While the appetite for a major new global funding structure may not be there, we need to make sure we’ve got the leadership champions (see Kofi Annan’s important role in 2001) and strong advocacy organizations in place to inspire strong global action. 
• Don’t get locked into disease-specific silos: The constituencies around specific NCDs have done an admirable job in coming together and promoting a multi-disease, multi-risk factor focus. But there is more work to be done in linking NCDs to broader questions of health systems strengthening. We need new infrastructure in place (e.g., electronic medical records) if we want health systems to address the whole gamut of patient needs. 
• Balance attention to prevention, diagnosis, and treatment: To date (and perhaps rightly so), the main focus of most groups’ NCDs activities have centered around reducing the major risk factors like obesity, lack of physical activity, and tobacco use. But in reflecting on all of the swings in focus in HIV between prevention and treatment, we should ensure there is a more comprehensive response to these diseases – including diagnosis and treatment.

Question 2: How can we move from many disparate efforts within sectors, to a collective impact response? There are many efforts underway to align priorities on NCDs. The World Economic Forum is emerging as an information-sharing platform for companies making NCDs commitments; the NCD Alliance is a central hub for much of the civil society response; the WHO has coordinated the development of a global research agenda on NCDs. See Richard Smith’s insightful post over at the BMJ for an interesting assessment of each of these efforts.

But we need more examples of how these sectors can actually collaborate to achieve real impact on the issues. The WHO has developed strong research priorities, but how will they partner with governmental research agencies to support this work? Corporations are rolling out compelling workplace wellness programs, but how will they support implementing NGOs to scale their impact? Hopefully the preparations for the September meeting will unveil more of these cross-sector collaborations, including further thinking on the best coordinating structures for these efforts. See here for more of FSG’s thinking on collective impact approaches. 

Question 3: Where will innovation in the NCDs response come from? Many current efforts are focused on translating approaches and tools from the developed world into low-income countries (e.g., implementing tougher tobacco policies in emerging markets, pharmaceutical companies expanding access to current products).

But I’ve seen less momentum on innovation and new solutions in the space. What new strategies for scaling do we need based on locally-specific characteristics of NCDs? What drugs, diagnostics, and devices require the development of new formulations or entirely new technologies? What supporting services (e.g., packaging innovations, new human resources approaches) are needed? The organizations that answer these questions will be the real innovation leaders in the NCDs response. 

These are just a few of the questions that are percolating for me on the subject – I’d love to hear others’ thoughts!

Given their impact on morbidity and mortality in LMICs, NCDs are and will increasingly be a major cause of poverty and therefore call for immediate development action. Recognizing the urgency, the global health community will be gathering at the first ever UN Summit on NCDs in September 2011.

In LMICs, the NCD problem is compounded by poor access to medicines and healthcare services, which will likely be the biggest barrier to overcome. Pharmaceutical companies are more and more expected to play a central role in access given the relevance of their drug portfolios to NCDs. At the same time, it is becoming a business opportunity. Emerging markets like Brazil, Russia, India, China, Mexico or Turkey are exhibiting double-digit growth and outpacing sales progression in traditional pharma markets such as the US, the UK, France or Germany. Even less mature markets like South Africa represent latent opportunities that, despite their relatively small contribution today, might fuel pharma’s growth engine tomorrow. In mature markets, the ‘patent cliff’ is casting doubt on the ability of the classic blockbuster model to further sustain pharma returns in future. Timing, it appears, has maybe never been so opportune to engage the industry giants on the issue of access to healthcare and devise collaborative approaches between private and public stakeholders that build on each other’s strengths and deliver social impact whilst sustaining the business – an alignment of interest FSG commonly refers to as ‘shared value’.

In the past, access contributions from pharma companies have been mostly limited to funding global and local third party-led initiatives and donating products. Although highly commendable efforts, these traditional CSR approaches typically lack scaling and sustainability potential. Going forward, successful access programs will need to be focused and goal-oriented – on specific diseases, geographies, and population groups – with robust programs that address several key bottlenecks simultaneously; of those, strengthening healthcare systems and infrastructure, increasing affordability of medicines, and driving adoption through education and awareness building will certainly be of paramount importance.

Recently, some pharma companies have pioneered innovative affordability models to increase access to medicines in a sustainable way: GSK, for example, is testing tiered pricing approaches in LMICs and set up an HIV/AIDS joint venture with Pfizer, opening up the entire drug line to generics manufacturers to produce and sell drugs at significantly reduced prices in developing countries. Those are encouraging signals that the pharma industry is rising more widely to meet the access challenge and turn it into an opportunity. In the past few months, FSG has been involved with several companies to rethink their access to healthcare strategies and sketch original programs addressing key access issues in a systemic and collaborative way.

We will be very excited to see those early efforts bear fruit in the coming years and to continue being involved with pharma stakeholders as they learn from those pilots and devise innovative, larger-scale approaches that can positively impact global health whilst preserving – or even growing – their bottom line.

And I’m definitely getting all of that! I’m rapidly adjusting to daily life in Kenya, from the catcalls of “Mzungu-Chinese” as I walk down the dusty road to town, to navigating the crowded “mboga” market where I get fresh vegetables straight from the farm. I’m also coming face-to-face with many of the difficult questions of global health work. Is it more paternalistic to bring “Western” expectations for performance or to accept local standards as “culturally determined”? How do I make sure that my work is sustainable and will last after I’m gone? And I’m seeing the operational difficulties that lie beneath the high level achievements – all the challenges of managing and operating a complex organization that don’t make it into the headlines.

Living here also brings the stark disparities in healthcare more into focus than when I was a two-week visitor. This is the macabre reality: If something happened to me or my wife, we would go to a private clinic for medical care rather than the government hospital where we work. We’re succeeding dramatically at making improvements, but we’re also desperately failing to provide the minimum level of care we might accept for ourselves and our loved ones. Being here has been a lesson in accepting that conflicting emotions can all be justified – to be okay with feeling angry, despondent, inspired, hopeful, and proud, all at the same time.

A final reflection is how immensely valuable my time at FSG was in preparing me for being here. Wrestling with all the challenges that leading organizations in global health struggle with taught me how to think rigorously about what works and what doesn’t. I have seen the importance of continuous evaluation, experimentation, and developing buy-in from stakeholders, and am able to bring those perspectives to this organization. Moreover, the management skills have been perfectly transferrable: Leading decision-making without formal authority, selling new ideas and practices to leadership, facilitating discussions, and juggling many tasks at the same time.

Now if only I had learned more about how to keep my shoes clean while walking on all these dirt roads…

I was listening to Park at the mHealth Summit in Washington, D.C. Organized by the Foundation for the National Institutes of Health (NIH), the event attracted over 2,400 attendees, and panelists included representatives from NGOs, governments, academia, and the private sector. It was fascinating to learn about the pace with which mHealth, short for mobile health, is taking advantage of new technology to create health impact. At the event, HMHB announced a bold new commitment by Text4baby to reach 1 million moms and moms-to-be by the end of 2012. While the impact of this program is yet to be seen, I was excited to hear about the coverage expansion.

Conference attendees learned about how cell phones, PDAs, the Internet, and even robots are becoming critical tools for improved health outcomes. While the Internet and other sophisticated gadgets – like a smart pill box that can call your phone to remind you to take your medicine – are changing how health care is delivered in the developed world, to me the real potential of mHealth lies in the use of cell phones in developing countries. In India, 50 cell phones are sold in a second, and in Bangladesh, there are now 60 million cell phone users. These markets can provide significant scale to any successful mHealth model.

Bill Gates also agrees. Speaking as a keynote, he noted the use of cell phones to collect birth data of newborns to ensure vaccine coverage in remote areas like Northern Nigeria as the most important use of mHealth.

Not everyone was equally excited about the use of mHealth, though. The lack of profitable models that can be scaled was a concern, as was the utilization of mHealth applications without really understanding the needs of end users. I think we absolutely need to take advantage of the technological advances, but we also need to identify some strategies and goals. We need a definition of what mHealth means, perhaps not a common definition for the whole field, since we all know how challenging that exercise can be, but for each organization attempting to use mHealth. Using cell phones to collect birth data, for example, requires very different resources and systems than deploying robots to carry around sick patients.

And while the use of cell phones by illiterate patients remains a challenge, I see a brighter side to this story as well. During my last visit home to Bangladesh, where cell phones are becoming ubiquitous, I saw rickshaw pullers and day laborers using cell phones. Typically, these are segments of the population that have little, if at all any, education. But with the popularity of cell phones, these users now have a novel incentive and method to learn to read and write in English, a pleasant unintended outcome of the use of cell phones. Hopefully the day isn’t far when these users will pick up their cells not only to call loved ones, but also to use applications that will improve their health outcomes.

Product Development Partnerships (PDPs) were developed a decade ago to help address these issues by combining the best of commercial pharmaceutical drug development and a commitment to accessible medicines to ensure that key drugs, vaccines and diagnostics are developed with the poor as their intended beneficiaries. There are several success stories from the emergence of this model – a new pediatric formulation of malarial medicine, the launch of an improved treatment for visceral leishmaniasis, and the recent promising outcomes from microbicide trials. But for many PDPs, the challenge of developing new products will take decades or more. In the mean time, they are committed to ensuring that their products are launched successfully, but for many, they struggle with the appropriate level of investment to make in “access strategies” due to the uncertain nature of drug development and the risks of prematurely raising expectations among beneficiaries.

Earlier this year the Concept Foundation supported a cross-PDP effort to examine a number of access-related challenges and commissioned a set of studies to identify some cross-cutting themes and lessons that might support PDPs in their access work. FSG was selected to author a paper on PDP Access Strategies, which examines the current status of access strategies, identifies diverse perspectives around the key challenges associated with developing these strategies, and proposes alternative approaches that PDPs can consider when they are ready to develop their own strategies. These are tricky issues that balance the tensions around unknown product development timelines, sensitive relationships with stakeholders in developing countries, and fulfilling the promise of a new model for developing drugs, vaccines and diagnostics explicitly for the poor.

These ideas were vigorously discussed by PDP access teams in Geneva this summer and we look forward to hearing your thoughts.

When FSG began our work with the Bill and Melinda Gates HIV team to set a five-year strategy 18 months ago, circumcision was the only new tool that had shown positive signs in clinical trials. The HIV vaccine field was languishing after years of negative results. Proponents of other biomedical interventions faced major challenges after many disappointing clinical trial results - so bad that some trials of microbicide gels reported harm to participants. Through our work on the cost effectiveness on the female condom with the Gates Foundation, we also are acutely aware that current technology is not sufficient to turn back the tide of the epidemic.

In the last year through a series of increasingly promising trial results the HIV field has turned around. Last fall the results from the RV144 HIV vaccine trial showed a glimmer of hope that a vaccine could have a protective effect. Then this summer at the AIDS 2010 conference in Vienna  the CAPRISA 004 microbicide trial showed that a gel could prevent vaginal transmission of the virus. I’ve been waiting all fall for the results of the first clinical trial of Pre-Exposure Prophyllaxis, or PrEP, a promising approach of taking an anti-retroviral pill before exposure. Today's news is a tremendous step forward, reporting 44% effectiveness in the trial population and an effectiveness of 90% in those who took pills regularly. One of the most remarkable aspects of the trial is that the pill (Truvada) is widely available for treatment now, and some physicians already prescribe it for prevention. It will have immediate impact.

For more details on the iPrEx study, start with the New York Times article, which includes a quote from FSG Global Health advisor Mitchell Warren Executive Director of AVAC. Mitchell is hosting a webinar with the clinical trial team tomorrow (Wednesday, November 20th at 9am).

While this is exciting for everyone in the field (and our client who contributed funding to the trial), there are some very tough discussions ahead. 

• In a time of decreasing resources, when we aren't even sure of how to fund our commitments to the 5 million people on treatment, and with millions still lacking treatment, how can we expand access to the uninfected? 
• Will insurers pay for it in the US? 
• How will we encourage greater adherence to push the effectiveness up closer to 90%? 
• Will longer-acting forms of the drug be developed and will they improve compliance?
• How will we avert resistance to the drug, an important tool in treatment, as it is used more widely? 

We're thrilled to have played a very small role in the field to date, and recognize the tremendous amount of work ahead. What are your thoughts on the path ahead? What questions does this bring to mind for you? 

But where is the attention for sustainable access to clean water to prevent waterborne diseases, reduce child mortality, and maintain children healthy so that they may attend school? What about adequate and safe sanitation to ensure nearby water resources are not contaminated? Who is chanting the rallying cry for the 1 billion people who currently lack access to clean water and the 2.5 billion people who lack access to safe sanitation?

Water, sanitation, and hygiene (WASH) have been neglected for far too long. Sanitation, in particular, had a millennium development goal named to its honor in 2002 – two years after all the others. The UN’s recent progress report on the MDGs found that reaching the goal for safe drinking water by 2015 appeared to be on track, albeit a bumpy track, however, progress towards the sanitation goal is way off.

The success of other MDGs, such as reducing child mortality and halting the spread of malaria and other diseases, depends on improved water and sanitation access. The world can no longer afford to turn a deaf ear to this sector. People have started taking notice and lending a voice to the cause. On October 15, Change.org organized a Blog Action Day, a novel concept begun in 2007 to unite the world's bloggers in posting about the same issue on the same day, thus raising awareness and triggering a global discussion around an important issue. This year’s Blog Action Day focused attention on the WASH sector.

The event drew the attention of many notable institutions including: the State Department, the White House, Google, TechCrunch, ONE, and many others. In total 5,711 bloggers from 143 countries participated in the event, reaching over 40 million readers. This was a great way to boost awareness and increase dialogue around the issue…for a day. But where do we go from here? How do we keep the dialogue going, increase the profile of the sector, and take the next steps towards greater action in reaching the MDG target?

Over the next few months, FSG will develop an advocacy strategy for WASH in the U.S. We hope to increase dialogue in the field and build on existing collaborative efforts to bring even greater attention to these long neglected issues. Additionally, we’d love to hear your thoughts or comments on how to raise awareness for WASH.