Heath Affairs Summit

November 1, 2007
Remarks by Cheryl Scott, chief operating officer

Thank you, Jamie.

It's great to see so many old friends here today. As you heard, I spent most of my career doing what you do—puzzling over the health care system in this country. When I retired, I promised myself an easy life. No more Medicare. No more Medicaid. No more 467 diagnosis-related group fees.

So to wind down, I joined the Gates Foundation and the global health field. But it turns out that the worldwide AIDS epidemic and resurgent malaria are no piece of cake either. Who knew?

It really is a pleasure to talk to this group. You have been solving health care problems in the United States for a long time. And, like me, you are turning your attention to global health issues more and more.

Our policymakers are fighting the diseases of the developing world in ways nobody imagined even a decade ago. The President's Emergency Plan for AIDS Relief. The President's Malaria Initiative. These are massive new commitments to helping sick people in corners of the world we didn’t even see when I was starting my career.

In fact, just two weeks ago, President Bush signed the Elimination of Neglected Diseases amendment, which gives companies more incentive to develop drugs for neglected diseases. Senator Sam Brownback got the idea for the amendment after he read an article by three economists in Health Affairs.

Or, take the NIH. It has the world "National" right in its name, but it knows that investing its awesome resources in getting results for the international community is a priority for everybody. The Gates Foundation is working with the FNIH on a huge initiative called Grand Challenges in Global Health, which is devoted to achieving research breakthroughs on the diseases that strike poor people in poor places.

Private companies are delivering products to countries that aren't on anybody's list of top emerging markets. Merck is working with us and the government of Botswana to scale up HIV prevention and treatment in that country. It was not that long ago that a lot of smart people said you simply couldn’t treat people who were sick with AIDS in developing countries. Now, Botswana is doing it every day.

These trends come just in time. Global health issues are hard. Very hard. And it is going to take the combined expertise of all the folks in this room to help solve them. That is what I would like to talk about today—how we can work together, as partners in this push on global health, to get the best results for people who are sick and dying of diseases we should be able to prevent or treat.

One of the main reasons global health is finally getting the attention it deserves is that we can see problems like we never could before. Technology is bringing us all closer together. On the Web, we can see pictures of what's happening in Darfur just minutes after they're taken. We can email with villagers in Bangladesh on old boats that have been converted into floating libraries. We can fly pretty much anywhere in a few hours.

The fact that we can see what is happening to our fellow human beings means that we are learning how to extend our caring beyond traditional boundaries. Our compassion has always been there; we just didn’t know where and how to plug in.

Bill and Melinda started the foundation because they believe that all lives have equal value. That is the premise from which all our work starts. But Bill and Melinda didn't realize exactly what that principle would mean for their philanthropy until just over 10 years ago. That was when they read an article about the millions of children dying from diseases that are all but forgotten in this country.

They often tell the story of how they felt when they read that a disease called rotavirus killed half a million kids every year. They had never even heard of rotavirus. How, they wondered, could they not know about a disease that was killing the equivalent of the entire population of Seattle every year?

But it's a giant leap from deciding it's time to tackle global health issues to figuring out how to do it effectively. That is a separate but deeply profound learning process.

After 10 years, our foundation is convinced that one of the most important "how" tools available is public-private partnerships. They make the impossible possible. Let me highlight two reasons why.

First, partnerships leverage expertise in a way that doesn't just increase impact but multiplies it many times over. Partnerships are not merely the sum of their parts. The effect is exponential. It is the only way we have found to leverage everybody’s expertise and capacity. 

We think about it this way. Our foundation has a lot of expertise and a lot of resources, but if we tried to develop a malaria vaccine in our offices, it would never happen.

Or if we tried to deliver the new rotavirus vaccine to children in Vietnam, they would never get it. On the other hand, the governments and NGOs that excel at delivery can't afford vaccines without outside funding. It is only when all the pieces fit together that we can have maximum impact.

The second reason partnerships are absolutely essential is that when we work together with people who come at these immense problems from different angles, it forces each of us to be much better at our piece of the job. What seems like a great idea to the Gates Foundation doesn’t always win support from the government of Mali. Nor should it. And so we both learn, correct our course, and move forward.

The conundrum of partnerships is that while they make the impossible possible, they can also be messy, cumbersome, and unpredictable. No matter how hard we try, they hardly ever go exactly according to plan.

So I am here to tell you something that you already know: that partnerships have as much art as they do science.

And even though the perserverance, humility, and plain speaking that go into that art may never be explicit in any strategy document, they are central to the work of achieving our goals.

So, let me offer two examples of lessons we have learned along the way.

First, partnerships mean going against your institutional self-interest.

A few years ago, we worked with the Center for Global Development and its What Works Working Group on a project to document global health successes. The idea was to analyze 50 years of the history of the field and figure out what worked and why.

Well, it turned out that over all those years and after all those billions of dollars, health improved, but we didn't know why. We didn’t find 50 or 60 studies of the impact of large-scale programs, which is what we expected. Ultimately, we found just 17.

What we all realized was that relying on ourselves to do our own evaluations just wasn't working. We were all doing our own thing with different metrics, theories, etc. We needed a common platform—a way for all of us to pool the risks and rewards of grading our performance.

That is the only way for us as a community to know what policies and programs have the most impact. That is the only way for us to do our best on behalf of the people we are all trying to help.

So the foundation joined many other partners in setting up the International Initiative for Impact Evaluation, or the 3IE. By joining the 3IE, 14 partners are volunteering to surrender many of their institutional perquisites.

All these organizations are now committed to following strict evaluation standards that they didn't come up with. And when they do their own impact evaluations, an outside panel gets to check them over and make a public judgment about whether they were rigorous enough.

The 3IE is something new, and it's going to make us all a lot better at our jobs.

But it took a lot of convincing when the members of the What Works Working Group went back to their institutions and told them it was time to change their ways.

In the end, the key players in the field agreed that the 3IE is the right thing to do. And when the next working group comes together ten years from now, it will have good data to work with.

A second annoying aspect of partnerships is that your partners sometimes prove you wrong.

We are partners—along foreign governments, corporations, and other foundations—in a huge effort called the Medicines for Malaria Venture. The idea is to develop and deliver better drugs to fight a disease that kills a child every 30 seconds. There are now more than 20 products in MMV's pipeline, and we are very optimistic that some of them will be saving lives soon.

But the truth is we haven't always been this happy with the pipeline. A couple of years ago, during one of MMV's regular reviews, we raised a bit of a stink.

Our program officers felt like the pipeline included too many "me-too" products, which means MMV was using very similar formulations to develop multiple drugs.

We told MMV's scientific board what we thought—that me-too products weren't the best use of their resources. But they insisted. They told us it was important to hedge their bets because they anticipated that some of the products would fail.

There was some back and forth, but MMV's External Scientific Advisory Committee recommended staying the course, and in the end we accepted their advice.

We were skeptical, but then one of MMV's me-too products didn't work. Then, another one failed. Having similar drugs in the pipeline as backup turned out to be absolutely crucial. And we turned out to be absolutely wrong.

It's no fun eating crow. But it is rewarding to have a malaria drug pipeline that gives all of us the best chance to save lives.

And in the process, we learned an important lesson about how to manage a portfolio of products in other key strategic initiatives.

That is why we will continue to join with partners. Because none of us can do as good a job by ourselves. What makes partnerships so powerful is the diversity of talents and points of view they bring to bear on hard problems. It makes the impossible indeed possible.  And for all the art and improvisation that they sometimes demand, they are fundamental to who we are and what we do.

As I close, I think about partnerships in the context of my colleagues here in this room.  The issues of our world desperately need your set of talents, your point of view. The health care community in the United States is doing so much more globally than it ever has, but it has so much more to do.

Our progress thus far is just the tip of the iceberg. So I urge you to continue along the path you're on: funding U.S. government initiatives in global health, developing drugs for the developing world, researching the questions that matter to poor countries.

But I also urge you to dig deeper. There are so many challenges we have not yet faced. There are so many more we're not yet aware of.

Let me give you an example. Actually, this isn't new to you because you read all about health financing in the 25th anniversary issue of Health Affairs. Fifty percent of total health spending in sub-Saharan Africa is in the private sector. That's people paying out of pocket.  This is a problem, and it's an opportunity for you. I am hard pressed to find someone in this audience who is not thinking about health insurance solutions. Sub-Saharan Africans need the benefit of the creative thinking you’re already doing. And you should be excited about the intellectual challenge of thinking how to apply your expertise in new contexts.

There are folks in the audience with all sorts of comparative advantages: resources, technical knowledge, advocacy, policy wisdom. If you are willing to face the friction, the messiness, and the possibilities of new partnerships devoted to new problems, then together, you will create solutions.

And you will create big solutions, solutions that are finally big enough to meet the enormous moral, intellectual, and scientific challenges of global health.

Thank you.