Achieving global health equity: what will it really take?
Late one Friday evening last July, I attended a memorable dinner in Kinshasa, the capital of the Democratic Republic of the Congo (DRC). It wasn’t the food that makes the meal stand out so clearly in my mind, although the grilled goat, chicken simmered in peanut sauce, and baked fish from the nearby Congo River were delicious. Rather, it was the conversation among the dozen or so Congolese health leaders gathered around the table — the secretary general of the Ministry of Health, heads of the national immunization and AIDS programs, some of the country’s top young doctors and medical researchers — all of whom are working to rebuild a health care system in a country that has been decimated by war and corruption and that ranks 176th out of 186 countries on the United Nation’s Human Development Index.
I was there because PATH, the international global health NGO that I lead, is involved in a number of programs that focus on HIV, tuberculosis, malaria, and maternal and childhood health in the DRC.
In a lively discussion that went into the late hours, they described the immense challenges they face in delivering adequate health care to nearly 80 million people across an area the size of Western Europe, where roads, electricity, clinics, medicine, and doctors are all in critically short supply, and three out of four people live on less than US$2 a day.
But my companions also expressed a great deal of hope about new approaches that are making a difference in the lives of people in distant rural villages across the DRC and in the desperately poor slums of Kinshasa. With the country moving toward stability after years of unrest, they see a turning point in the struggle to lift the DRC out of poverty.
I share their hope.
During the past 25 years, the percentage of the world’s people who live in extreme poverty has been cut in half. Average life expectancy has increased by more than six years. Childhood mortality has been reduced by 50 percent. Polio has nearly been eradicated. These advances are unprecedented in human history.
There may be no better place on earth than the DRC to grasp how different the lives of people in the world’s poorest communities will be if we achieve the Sustainable Development Goals.
If we build on this progress, we can create something once unimaginable — a world where most people have access to health care, many deadly diseases have been brought under control, and few children die from preventable illnesses like pneumonia, diarrhea, and malaria.
This is the world envisioned by the Sustainable Development Goals (SDGs), which were unanimously approved by the 193 UN member countries just a few months after our dinner in Kinshasa. The SDGs call for further dramatic reductions in childhood and maternal mortality, the end of hunger, and the elimination of preventable deaths by 2030.
The ambitious agenda extends far beyond health to include education, gender equity, environmental protection, and much more. The goals are so wide-ranging and ambitious that critics say the world has neither the money nor the political will to achieve them all by the target date of 2030.
In global health, however, I believe the goals are within reach. Recent history shows that the right combination of cooperation, commitment, money, and innovation can lead to remarkable progress.
There may be no better place on earth than the DRC to grasp how different the lives of people in the world’s poorest communities will be if we achieve the SDGs. As the dinner conversation ranged from a promising new approach for stopping the spread of tuberculosis to a program to reduce HIV, I started to imagine a reunion dinner 15 years in the future.
The right combination of cooperation, commitment, money, and innovation can lead to remarkable progress.
It’s 2030, and we’ve come together to celebrate the incredible changes that have taken place with the achievement of the SDGs and to share stories of the people we have met whose lives have been transformed.
As I picture that dinner — the guests, the stories, the toasts — I find myself thinking about what we will have to do differently to make that celebration possible. What changes must we make to the way we work to improve health to achieve such dramatic results?
Where will impact come from?
A t every international conference on global health, everyone asks some version of the same question: what is happening in the world today that will have the greatest impact — positive or negative — on the future of human health?
You’ll hear almost as many answers as there are attendees. Some say it’s the emergence of new business models or the increasing empowerment of women and young people. Others point to the danger of new pandemics or the frightening increase in noncommunicable diseases, such as diabetes and high blood pressure.
While they’re not wrong, I have a different answer. I believe the greatest impact will come from social innovation.
Social innovation is a term that gets tossed around a lot at international meetings, in business schools, and around conference tables where people are trying to figure out how to improve health in desperately poor communities where traditional government and market-based approaches are inadequate.
The greatest impact on human health will come from social innovation.
But the term is used to describe so many different kinds of projects and business models — everything from traditional corporate philanthropy to corporate social responsibility, social entrepreneurship, shared value, and impact investing — that it’s hard to know what it really means.
I define social innovation as a disruptive approach that has a significant and sustained positive impact on the lives of large numbers of people through partnerships that span governments, businesses, and the social sector (which includes multilateral organizations, foundations, and nongovernmental organizations).
I’ve spent most of the past decade thinking about how to apply social innovation to global health issues, first as the head of social innovation at the global consulting firm McKinsey & Company, and now as both CEO of PATH and a lecturer on social innovation at Stanford’s Graduate School of Business.
I believe that social innovation is the key to creating the kind of world that the SDGs envision.
And when my colleagues from the DRC and I gather for dinner in Kinshasa in 2030 to celebrate the achievements of the previous 15 years, the initiatives that will have had the most significant impact will be those created through multisector partnerships that include governments, businesses, and the social sector.
A tale of two transformations
Why social innovation? More specifically, why is social innovation so critical to achieving the ambitious global health goals outlined in the SDGs?
It’s because two fundamental transformations from outside the world of global health are creating unprecedented opportunities to reinvent how we develop and deliver the global health interventions needed to make progress at the scale and speed required.
The first is the incredible global economic expansion of the past three decades, which has lifted hundreds of millions of people out of poverty and into the middle class. China is the most dramatic example. I lived there in the early 1980s as a student at Beijing University and have been back many times since.
The Beijing of today, with its dense traffic, spectacular architecture, and expensive restaurants, is nothing like the city of bicycles of 30 years ago, where I lived on a steady diet of cabbage and rice in an unheated dorm.
The changes haven’t all been positive — the environmental costs, for example, have been staggering. But more than 600 million people in China have been lifted out of dire poverty, and the country has seen improvements in health, educational attainment, and living standards that few people thought possible.
Something similar, though less dramatic in terms of pace and scale, is happening across the world in countries including South Africa, India, Vietnam, Thailand, Malaysia, Brazil, Kenya, Tunisia, Morocco, Egypt, Ghana, and Namibia.
This demographic revolution creates the conditions to reinvent how we tackle global health.
Instead of the old post–World War II model in which a handful of rich countries decided what poor nations needed to do to improve their citizens’ health, we’re becoming a world of middle-income countries that have the resources, institutions, and commitment to determine their own paths forward.
And instead of thinking of global health work as aid for desperately poor recipients, we can consider ways to reach people who are consumers of health products and services — sometimes at subsidized or low prices and almost always through partnerships between nonprofit and for-profit organizations.
In the future we will have to think more about how to help poor communities, not poor countries.
The second fundamental transformation is the advent of disruptive technologies such as mobile devices and apps, big data, cloud computing, and genomics that are creating exciting new opportunities to increase our understanding of the underlying causes of poor health and improve our ability to deliver breakthrough solutions.
In the future we will have to think more about how to help poor communities, not poor countries.
A great example is the fight to control malaria.
Over the past 15 years, the widespread use of bednets embedded with insecticide and drugs that kill the mosquito-borne parasite in people who are infected has led to a 60 percent reduction in malaria deaths. While this is a great achievement, malaria still kills more than 400,000 people every year, most of them African children under the age of 5.
One country that has been particularly successful in reducing malaria is Zambia. In the Kazungula District in southern Zambia, infection rates have fallen from 50 percent of the population to less than 0.5 of a percent in just ten years.
What’s remarkable is that this progress isn’t the result of new drugs for treating malaria or new ways to kill the mosquitoes that transmit it.
The difference is that rural health workers have started using mobile phones and new data models to send reports to regional health centers detailing the number and location of new malaria cases and providing up-to-date inventories of their supplies on hand.
This approach makes it possible to track every new case, find isolated pockets of the disease, and identify and treat those who carry the parasite but have no symptoms, a critical piece for controlling and eventually eliminating malaria.
It almost sounds too simple, but in a country lacking adequate roads and telephones, the ability to use digital information to track malaria outbreaks in real time and respond quickly is revolutionary. That data, coupled with advanced analytic and visualization software, ensures that the right supplies get to the people who need them.
Now, the prospect that Zambia will soon be malaria-free is tantalizingly real.
All pilots, no passengers
T o be clear, we won’t be able to address the world’s more pressing health challenges solely through technology solutions that target consumers in middle-income nations. To make progress at the speed required to achieve the SDGs, we’ll need to create solutions that are designed specifically to reach very large numbers of people in poor- and middle-income nations around the globe.
Our romance with new gadgets often distracts us from the real challenge: the SDG targets can only be achieved by delivering innovations that help huge numbers of people. Not thousands or tens of thousands, but millions — even hundreds of millions.
A trip to Kampala, Uganda — where PATH runs a program to address the staggering impact of cervical cancer among women who lack access to prevention and treatment options that most women in the developed world take for granted — helped drive that point home. A group of community health workers there told me about the desperate need for new screening tools and better systems for delivering the vaccine to prevent human papillomavirus — the main cause of cervical cancer.
What they don’t need is more mobile phones. One worker showed me four phones she’s been given, each from a different nonprofit with good intentions for its own well-designed mobile health project.
We laughed as she complained that she’ll soon resemble the multiarmed Hindu goddess Durga — but instead of a sword in every hand, she’ll have a phone for every finger, each running its own app for a different disease.
The SDG targets can only be achieved by delivering innovations that help huge numbers of people.
Like some of the best jokes, this was funny because it touched on an uncomfortable truth.
Digital technology is critical to transforming health around the world, but rampant enthusiasm for small-scale projects using mobile apps is so widespread that in 2012, Uganda’s Director General of Health Services ordered a moratorium on pilot projects involving mobile phones. As one minister of health aptly put it, it’s “all pilots and no passengers.”
The class I teach at Stanford is called “Taking Social Innovation to Scale.” There we explore what it takes to create global health services, products, and systems that can help millions of people. A key focus of the class is what happens on the long journey from a great idea to an effective solution that can make a difference for an entire nation, or across a continent.
Some people call it a journey through the innovation “valley of death.” Navigating it successfully is part art and part science. It takes a smart business plan, strong partnerships, knowledge of regulatory processes, and a willingness to rethink an idea at every step.
The issues and challenges are complex, and no single approach guarantees success.
But the global health sector can learn a great deal from business about scaling innovation, including better processes for product development and testing, more systematic approaches to gaining regulatory approvals, smarter ways to use market dynamics to speed distribution, and more rigorous measurement of results.
The global health sector can learn a great deal from business about scaling innovation.
With our focus on delivering innovative solutions at scale, PATH has achieved some notable successes at scale with our partners in the private sector.
One example is the vaccine vial monitor, which solved one of the biggest barriers to safely delivering lifesaving vaccines to children in poor and remote communities: a lack of refrigeration in places where electricity is unreliable or nonexistent. Most vaccines are heat sensitive, so it’s essential to be able to confirm that they haven’t been compromised before they are administered.
In the 1980s, PATH teamed up with Temptime, a New Jersey company that had come up with an indicator for perishable food that changes color when exposed to heat. Working together, we used that technology to create a monitor for vaccines in the form of a small circle that is placed or printed on a vial. Today, every vaccine vial that is distributed where lack of refrigeration is a challenge has one of these heat indicators.
Developing it wasn’t easy — we had to reengineer the indicator, work with World Health Organization to win approval, and design a sustainable business model for the companies that manufacture and distribute it. But it’s hard to imagine a better example of social innovation than this.
To date, more than 6 billion vaccine vial monitors have been used, enabling health workers to identify and replace nearly a billion doses of heat-compromised vaccines, saving hundreds of thousands of lives. It also enabled Temptime to build a thriving global business around the vaccine monitor and a number of related products.
A role for “non-state actors”
This kind of prominent role for the private sector isn’t just desirable, it’s essential. There’s simply no way for governments and the social sector to develop and distribute all of the interventions needed to prevent and treat diseases and address the underlying causes of poor health at the scale required without incorporating the practices, expertise, resources, and market incentives of the business world.
The private sector is already making a significant difference in the lives of people in the developing world — and can do much more.
But it’s not a foregone conclusion that the private sector will be fully welcome to take on such a significant role. At around the same time that UN Secretary General Ban Ki-moon was announcing the SDGs with Unilever CEO Paul Polman at his side, the World Health Organization was promulgating policies to limit the role that “non-state actors” — code for for-profit businesses — can play in global health.
This ambivalence is understandable. After all, important questions about conflicts of interest, economic inequality, and market-driven priorities need to be considered. But as Temptime’s role in developing the vaccine vial monitor makes clear, the private sector is already making a significant difference in the lives of people in the developing world — and can do much more.
A recent example is Novartis Access, a multisector initiative launched in Kenya in October 2015 to provide low-cost access in poor communities to drugs for chronic noncommunicable diseases, such as diabetes, asthma, heart disease, and breast cancer.
As we make progress against infectious diseases that disproportionately affect poor communities, this problem will worsen dramatically. The World Health Organization predicts that by 2030, more people in developing countries will die from cardiovascular disease than from all infectious illnesses combined.
Tackling chronic illnesses — which depends on early detection and long-term treatment — is particularly challenging in low- and middle-income nations where access to health care is sometimes limited and the cost of drugs can be prohibitive.
Working in partnership with the Kenyan government and nonprofit partners, Novartis aims to make essential medicines for chronic noncommunicable diseases both affordable and widely available in Kenya, with costs to patients expected to be $1.50 per treatment per month or less.
In addition, an important focus of Novartis Access is to work with partners to improve the drug distribution system and train health care workers to diagnose and treat heart disease, respiratory illnesses, diabetes, and breast cancer. The company intends to introduce the program in Ethiopia and Vietnam next, and expand to as many as 30 countries in the future.
While the role of the private sector in improving health seems most promising in nations like Kenya and Vietnam, where a new middle class provides millions of potential new customers, even in poorer countries like the DRC we’re beginning to see interesting multisector partnerships that can have a huge impact on people’s lives.
In 2014, I traveled with Dr. Lievin Kapend, head of the DRC’s HIV/AIDS program and one of my dining companions in Kinshasa, to Katanga Province in the country’s southeastern corner, about 1,000 miles from the capitol. There we visited a massive open-pit copper mine in a remote part of the province that borders Zambia. The operation employs more than 7,000 people, nearly all of whom live in villages and small communities that have sprung up since the mine began producing ore in 2009.
The World Health Organization predicts that by 2030, more people in developing countries will die from cardiovascular disease than from all infectious illnesses combined.
I was there to explore how the Ministry of Health, PATH, and Tenke Fungurume Mining, the consortium of international resource extraction companies that operate the mine, might continue to work together to improve living conditions and health care for the miners and their families who live in the surrounding communities. Funded in part by the United States Agency for International Development (USAID), the program included a malaria prevention initiative, efforts to improve access to clean water, and the construction of new clinics.
Partnerships like this are relatively uncommon and still somewhat controversial. We’re still figuring out how to align the interests of all parties so the benefits truly reach those who need them.
And plenty of people think it is wrong to work with companies in industries like resource extraction that have an inconsistent record on issues such as environmental protection and workers’ rights.
But in poor countries like the DRC — and even in emerging middle-class nations like India, Nigeria, and Vietnam, which still have large numbers of people living in poverty — we’re increasingly seeing multinational enterprises engage in partnerships to improve local infrastructure, create jobs, and improve health.
These businesses are learning to measure value not just in terms of profit and loss and access to new markets, but also in meeting corporate social responsibility goals, improving reputation, and strengthening the communities in which they operate.
Innovation and the seeds of progress
A few years ago, PATH, the international mining company BHP Billiton, and the South African government joined together to test an approach to improving the health of newborns by working with health care providers in small local clinics.
In 2013, I met a midwife who runs a small clinic in a township near Johannesburg. She possessed a sharp sense of humor and even sharper opinions about how to bring down the staggeringly high child mortality rates in her district, less than 50 miles from Johannesburg.
She showed me the government-issued log book where she records information about every woman who gives birth in her clinic. She had added several handwritten columns to capture additional details that she believes can help her clinic achieve better results in the future. This is the seed of social innovation — observations that lead to insights that in turn suggest new solutions to old problems.
The next step will be to confirm that what she has observed correlates with better outcomes. If it does, I can imagine the South African government, an NGO like PATH, and a private-sector technology working together to incorporate it into a digital health tool that is distributed to midwives across Africa.
This is the seed of social innovation — observations that lead to insights that in turn suggest new solutions to old problems.
This is how we will eliminate malaria, control tuberculosis, reduce the incidence of cervical cancer, and ensure that people in remote communities have access to adequate health care — through a dramatic expansion of public-private partnerships that are designed specifically to transform promising insights into affordable interventions that improve the health of millions of people living in the world’s poorest communities.
Most importantly, this is how we will improve the odds that mothers live through childbirth and babies survive the first few years of their lives, when they are most vulnerable to pneumonia, malaria, diarrhea, and other diseases that still kill more than 4 million infants in poor communities every year.
Nothing tells the story of the transformation of health around the world more clearly than the child and maternal mortality rates, which have dropped by half over the past 25 years. The graph of that number shows a nice, even downward curve that illustrates a 50 percent reduction over the past 25 years.
And you can assume that the downward momentum will inevitably continue. After all, the trends toward economic growth, greater technological progress, and ongoing investments in global health mean that we can expect fewer people to die each year from preventable diseases and poor living conditions.
But we shouldn’t settle for this. To accept that it’s okay to continue on our present path when we have the opportunity to save millions of lives and improve hundreds of millions more would be a tremendous failure.
To get where we need to go — to achieve the SDGs and create an equitable world where poverty is rare, good health is to be expected, and lives filled with hope and opportunity are the norm around the globe — we need to make that downward curve much steeper.
If you graph the decline in child and maternal mortality based on current trends, the line falls in a smooth, gradual descent from now until 2030. But the SDGs call for something more ambitious — the end of preventable deaths of children under the age of five and a global maternal mortality ratio of less than 70 per 100,000 live births.
The graph of that line falls much more quickly. And every year until 2030, the gap between the gentle arc of today and the steep declines called for by the SDGs widens.
In the gap between those two lines are millions of women and children whose lives depend on whether we can usher in disruptive innovations that deliver significant positive improvements on an enormous scale.
Those are lives we will celebrate — or mourn — in 2030 when we meet again in Kinshasa.
I welcome your comments.