Are There Still Shortcuts on the Road to Health? The Role of Philanthropy, Technology, and Community Health Systems

Nearly forty years ago, Jon Rohde wrote a paper that argued that the “road to health has shortcuts,” advocating a strategy of expanded childhood immunization that helped inspire the UNICEF and World Health Organization campaign to improve child survival. In recent years, the field of global health has been moving away from donor-funded international initiatives on individual diseases, and toward mostly domestically-financed investments in universal healthcare, quality health systems, and achieving health for all. The role of philanthropy in this transition remains a work in progress. This meeting of CFR's Global Health, Economics, and Development Roundtable Series held a discussion of that role and whether technology-driven, community-focused initiatives might still offer shortcuts on the long road to better health.

The featured speaker for this discussion was Dr. Rajiv Shah, president of The Rockefeller Foundation.

BOLLYKY: Perfect. Good morning, everyone. Thank you. Thank you so much for coming. My name is Tom Bollyky. I’m a senior fellow here at the Council on Foreign Relations. And it’s my great pleasure to welcome you here for this roundtable entitled “Are There Still Shortcuts on the Road to Health? The Role of Philanthropy, Technology, and Community Health Systems.”

So to start this event today, I’m going to frame it with a—with a story. Jim Grant, shortly after assuming his position as executive director of UNICEF, received a package in the mail from Jon Rohde, a pediatrician by training that Grant had met during a trip to China. In the package was a report that argued that nearly half of all child deaths in lower-income countries were due to a handful of conditions that were preventable at relatively low cost. In short, the road to health, Rohde said, has shortcuts.

The science, the epidemiology, the interventions, the evidence base around those interventions, those were all there. But the delivery, the political will, the resources were not. And this is what Jim Grant and UNICEF and partners would bring, and it’s no small thing. And in that paper were the seeds of a strategy that grew up into the Child Survival Revolution, a campaign which among other things would immunize 70 percent of the world’s children in eight years and, together with the water and nutrition interventions that UNICEF pressed, saved 25 million lives.

Now, there are lots of connections between this story and our speaker and our event today. Grant was a(n) assistant administrator at USAID. His father was a medical officer in China at the Rockefeller Foundation. Jim Grant himself had been on the Rockefeller board. Rohde, in fact, was at Rockefeller when he wrote that paper. The Rockefeller Foundation was an important partner in the Child Survival Revolution.

But I bring this story up here today for two reasons. The first is this story is basically every think-tanker and academic’s dream: that you would write a paper, it would fall in the hands of somebody who has the ability to move it forward and change the world. So I have a natural affinity for it. (Laughter.) By the way, Raj, all my papers are on the CFR website. (Laughter.)

Second, the situation that Grant found himself—looking for that big idea, that handful of interventions that could move the dial on global health but also make the next quantum leap at the institution he was leading—is, I imagine, a situation that’ll be familiar to Raj in his new role.

So, with that, let me introduce our next speaker, who will talk—tell us today about whether there are still shortcuts on the road to health and the role of philanthropy and technology in finding them. He’s a perfect speaker for this job. He’s well-known to all of you, so I’ll only describe him briefly.

But Raj Shah is the 13^th president—13^th president of the Rockefeller Foundation. He previously served at the—as the USAID administrator. He was appointed by President Obama, unanimously confirmed by the Senate—which is amazing these days that still happens, but apparently it did—and served until 2015. Previously, he had served as chief scientist and undersecretary of agriculture for research, education, and economics. And more importantly to me, as I understand Raj is a fellow member of the three-kid club.

SHAH: Yeah. (Laughter.)

BOLLYKY: And nevertheless, he looks spry. He looks productive. (Laughter.) So that gives—that gives me confidence in the future. Raj had the good sense to have his three kids when he was a little bit younger.

So let me start with giving him the opportunity to say a few remarks for about 10 or 15 minutes. Then I will ask a few—a few questions to start the conversation going, and then I will turn it over to you. We will end promptly at 9 a.m., as we do with all Council events.

Before I start, just several warnings. This meeting is for attribution. Anything you say can and will be read back to you at your confirmation hearing. (Laughter.) Please turn off any electronic devices and refrain from leaving the meeting early.

And, with that, I turn it over to Raj.

SHAH: Thank you. Thank you, Tom. And thank you to so many of you who are friends and colleagues, and folks that I’ve admired and learned from for quite a long time.

I am a member of—(laughs)—the three-kid club. I only joke because—and some of you might have been subject to this—I used to—after my third kid we had when I was at USAID, and during a particularly challenging period of time—I think it was like the Pakistan floods and all kinds of stuff—and I started to, like, systematically counsel colleagues who were having their second kid to say: stop there. (Laughter.) And then the HR department was like, you’re not supposed to do that. (Laughter.)

But anyway, it is great to be with you. And, Tom, thank you for hosting. I enjoyed reading your bio and was a little intimidated by all the stuff you’re doing, but it’s exciting to pull this group together.

Since there’s so much knowledge around this table and experience around this table, I intended to be fairly brief and really use this as a chance to learn from you around sort of a few big questions that I’ll frame. But just to give you some context for that, let me—let me make a few remarks upfront.

The first is I’m so glad you described a little bit of that history. I started at the Bill and Melinda Gates Foundation back when we were in a converted call center next to Lake Union. And there were—actually, Patty Stonesifer ran it at the time, and Gordon Perkins (sic; Perkin) was running our health effort. We had just launched GAVI. And folks in the building were still kind of wondering, like, are UNICEF and WHO really a part of GAVI or not? Should they be? (Laughs.) Why shouldn’t they be? And I didn’t know the appropriate answers to that because I was brand new. But I managed to get an office right next to Bill Fahey at the time, and that—you know, for someone just starting, interested in global health, just felt like such a unique opportunity. So I would go sit in his office whenever he was there and distract him, and he would tell these amazing stories about—mostly about Jim Grant, but really about that history and that period of time.

And I came away with sort of two or three big lessons from just listening to him. The first was, you know, the sheer kind of political will, and enough will to achieve the goal that Jim and his colleagues at other institutions were willing to really put their egos and their institutional egos aside and develop the committee on child survival, and work together to achieve a stated goal—that was his number-one message, was that, you know, you have to build that kind of consensus, not just amongst leadership but in a context where people can put aside what they think they need to deliver institutionally to deliver a bigger goal together.

And when I look at the SDGs today—especially as they relate to health and child and maternal health, but across the board the health SDGs—it feels like we need to rebuild that mindset of we’re in it for the goal. We have all these tools and capabilities and knowledge. There are public actors and private actors, international actors and local actors. But we really do have to come together with an absolute determination to measure and achieve the outcomes we seek. In that context, the Rockefeller Foundation is fully committed for the next decade to the—to achieving the global health Sustainable Development Goals, first and foremost the child and maternal health goals in that sphere.

The second observation was just you had to find something that people could practically do that would move the numbers enough so that there’s a sense of accomplishment. Paul ran the U.S. response to the Haiti earthquake on the ground in Port-au-Prince many years ago. And, you know, it was a—it was a dire situation with all kinds of complications, but the thing he did that was brilliant was every day—or maybe every week, but certainly every couple of days—he was able to produce data and information that said, you know, there were 3 million—we need to reach 3 million people with food, we’re at 1.7 million, we’re going to be at 2.1 (million) next week. You know, like, just the constant sense of progress around achievable metrics that let people believe that, yes, by working together we could get there. And we haven’t necessarily identified any unique answers, but we do believe in this next decade that we can work aggressively in the area of community health around the world to help drive community health activities towards those types of measurable performance gains.

And we landed on community health in particular for a couple of reasons. First, we have this great recent history of working on universal health coverage and health-system strengthening. And it feels like in a world where noncommunicable disease burden will go up, and where pandemic threat surveillance is even more important, and where we’re still trying to achieve the last-mile coverage around achieving the SDGs, that instead of picking a disease area to work in, if we could identify a cross-cutting platform for extending the reach of basic health services grounded in measurement and data and informatics, we could help achieve the SDGs but also build a platform that can deal with the next wave of noncommunicable disease threat and the next wave of improved surveillance for pandemic threat protection, particularly in the most challenging parts of the world.

So that’s our hypothesis. That’s what we’re going to focus on. Some of that will be trying to organize the financing of community health workers. Some of that will be working hand-in-glove with governments on the ground to build integrated data and performance-measurement systems. Some of that will be, maybe with many of you, trying to advance the thinking on how do we measure community health outcomes in ways that are more sensitive and specific than under-5 mortality or maternal mortality. What are the both intermediate measures towards that endpoint, but also what are broader human-capital approaches that could help us understand the impacts we could have?

Just to give you one example, we’ve looked a lot at information about if you start to reach aging populations in communities with simple, low-cost eyeglasses and walking assist—and mobility-assistance devices are very cheap—you could potentially create more demand for home-based community health. And there is some information that shows the intergenerational power of that strategy can also have impacts on child and family health. So we don’t have answers here, but we’re looking at it more broadly than sort of a disease-specific lens and believe the future really does hold a lot of potential for a community health-based strategy.

And the third learning I took away from Bill in those early days was around just data and information. And, you know, it’s obvious, everyone says it, but if you can’t measure it you can’t really manage against it. And the measures we have come to rely on that ultimately lead to the SDG outcomes in child health in particular are super important. They are more measurable.

Chris and I were just talking about one area of real interest we have, which is to say could we help leaders in the field develop more predictive analytic tools so that the community health workforce and other strategies for reaching people at the last mile could be more targeted to where deaths occur or where severe morbidity occurs, and the limited state and public and NGO capacity that exists to reach people could more preferentially target the more vulnerable—not just populations or communities, but actually households and kids? And I’ll just say I—you all know what I did in my last—former work, but as part of that we were out, you know, knocking on doors in Columbus, Ohio, in a—in a lower-income minority community before the 2012 election. And I was just struck by—you know, you knock on a door, the data you’d have in your hand was everything. Like, you’d knock on the door, there might be six people in the home, and five are not paying any attention to voting, haven’t registered. But you would ask for the one person who was registered and simply say, you know, do you need a taxi? How do we get you to the polls? And that precision analytics helped us politically, you know—(laughs)—and then you all know what happened next. But, you know, if we can do that here, and if we can now use Facebook or Google or whatever to be so effective at hyper-targeting people based on health-related information, but also just general behavioral/observational data that might not ultimately seem health-related, we ought to be able to—in a world where people will be online before they’re healthy and wealthy, we ought to be able to target and identify vulnerable families, and take the capacity we have that’s very limited and go and reach those families.

And many of you have worked on child survival over time, but take rotavirus vaccine coverage in India as just one example. We’ve been working on that for 20 years, talking about it aggressively. Chris, you might know the answers, but you know, there used to be 380 or so thousand rotavirus-related deaths annually in India. And despite achieving maybe 40 or 50 percent coverage population-wise, I’m not sure that has gone down in a commensurate way because the deaths occur outside of the area of reach for the health system. And, you know, we have to somehow break the mindset. And if we can use tools like predictive analytics tied to systems where either community health workers or public administrators or NGO implementers have practical, useful predictive data in their hands, we can potentially do something really unique at delivering on the last-mile goal.

And we need to do that fast because, you know, 2030 seemed farther away even a few years ago. We’re walking backwards, not forwards, in terms of public-sector leadership on these issues, despite the fact that we do have some extraordinary leaders trying very hard. And we have a lot of philanthropic capital going into this space, but it’s not as well-organized as it could be at the point of last-mile deliver because most philanthropies appropriately say that’s not where we can excel. We don’t know whether that’s where we can excel or not, but we’re going to give it a shot because we feel that’s an area where we can help bring people together and be determined about delivering the outcome.

The final point I’ll make is Wendy Taylor is working with us as a fellow. I’m very excited about that. For those of you who don’t know, she ably led the innovation platform in USAID’s global health division for a long time, launching a number of grant challenges including on Ebola and other efforts. And her effort is focused on pandemic threat prevention and response, which is another area where, frankly, I had hoped the world would have been much more active after Ebola. And I feel like all that great energy and all those task forces that—I was on one—that all came and said basically the same thing with slightly different Roman-numeral categorization, but the roadmap forward was pretty clear and pretty consistent. And yet, action has been lagging. So she’s thinking about how technology and our capacity to build political will can help advance that objective as part of this larger effort.

So thank you for taking the time. I’m eager to both answer questions but really learn from you. And the vision of success I’d leave you with is, you know, if we can—if we can organize data and informatics in a manner where you could get a few hundred thousand or even over time a few million community health workers—whether they’re actually community health workers, or they’re employed by Mercy Corps, or they’re the public-sector employees of the government of Senegal, or they’re, you know, wearing a UNICEF T-shirt; whoever they are, the people going out to do the work of community health—if they had real predictive technology that allowed them to use their capacity to be most effective at reducing mortality, morbidity, surveilling pandemic threats, and exploring the frontier correlations between those activities and efforts to prevent—even novel efforts to prevent the rise of noncommunicable disease, I think we could do something very special in this next decade on global health. And that’s what we’re going to try to be a part of.

So thank you.

BOLLYKY: Great. Thank you. That was a great—a terrific overview.

So I’m so glad you laid out the background behind the strategy because it does seem to be zigging where everyone else in global health is zagging, and I—and I think that’s a good place for an institution to be. And so much of the focus in global health right now is on specific—targeting specific diseases or building systems, and what you’ve described is a strategy for how to do any of those goals. It’s an integrative strategy, and in some ways it dovetails nicely with the focus on innovation and technology that you had at USAID from that perspective. So that makes a lot of sense.

But the strategy you’ve outlined depends on there being initiatives to partner with, big public-sector initiatives to partner with. And I wonder whether I could draw you out a little bit more about where you see those opportunities for partnership being.

SHAH: Yeah.

BOLLYKY: Is it working with countries that already have a large community health workforce? Where do you see as you might be moving next?

SHAH: Yeah. Well, I think there—immediately, there are sort of three things we’re doing. One is trying to build a global partnership across major institutions, local and international, to prioritize community health to drive a little bit more of the $35-37 billion of development assistance for health towards community health in particular. Our rough estimate was a $2-3 billion shift inside that allocation in a targeted and specific way would pay for, for example, a global community health workforce that others have estimated—you remember the Gordon Brown project, and that others have estimated—would play a big role here. So task one is sort of build that global partnership, work on financing solutions. We can put in a little bit of resources to help with some of that, but that’s largely a public-institutions, public-sector challenge.

The second is we are working with major institutions that do community health, like UNICEF and others, to build out—we haven’t named it yet—but a data architecture that can establish a set of standards so that whether your project is using—and this is getting in the weeds a little bit—but Medic Mobile or Dimagi or whatever the different—UNICEF has a proprietary one. A lot of different institutions have their own systems.

Whatever that point of interface is in terms of the data informatics platform, building on a project that’s happening in the East African community but trying to make it global. We can have sort of a set of standards that allow those systems to communicate, which will—over time—it’s really in the weeds, it’s somewhat challenging—but over time would give us much more access to both the data we need to do the kind of predictive analytics we described and, perhaps more importantly, the consistency and outreach to health workers, or whomever else is on the front line of service delivery in that context. So those are two major elements.

And then the third is really around we’re going to establish partnerships with countries and do this work at the country level. And so we’ll probably start by partnering with five to seven countries that have been a part of the child survival movement, that have shown out of state commitment, that have resources to commit and other partners, including philanthropic partners like Ajay Piramal in India for example, that can help us take these approaches to greater scale.

BOLLYKY: Great. So I moderated a panel this week at the—at the World Banks spring meetings, as perhaps many people here did in some fashion. And the one I did was about the private sector’s involvement in addressing financial protection for universal health care. And most of these are entities starting health insurance products and services using mobile technology. So you’re not the only one playing in this space around using mobile technology through either health promotion or, again, from the financial protection side. How do you see the private sector’s role potentially in what you’re—the strategy you’re talking about here?

SHAH: Well, I’ll go back to what I just described as kind of the second area, building the standards. You know, if we can agree to standards that allow for more communication across those types of platforms, we can really unlock quite a lot of private sector innovation and technology development. So we won’t develop those technologies, but we recognize that there’s a huge range of firms already doing that. And dragging those applications into this mission will be our sort of focus. I’m in China next week.

One of—I think one of the most interesting platforms I’ve seen has been a project they’ve created to do initially rural health, but it’s quickly becoming an urban platform as well, in China, that is using AI and machine learning to help both do diagnostics and information delivery to community—to their version of frontline health workers. But over time, that will be a direct to consumer platform. And for a variety of reasons, mostly related to the lack of privacy protection so it’s not all positive, they will have more data to chew on and probably will get there faster than some U.S.-based venture-backed firms when it comes to doing predictive analytics and diagnostics in that virtual sort of way.

BOLLYKY: Great. Great. I have lots of questions, but I’m going to turn it over to the audience to make sure I get some of yours. I see somebody has been to one of our meetings before and already has their placard up. (Laughter.)

Q: You have to do it quickly.

BOLLYKY: Please put your placards up. I will call you in the order I see you. If you’ll just turn the names towards me because I can’t see you all. It’s a little bit of an awkward setup. When you ask a question, make it sound like a question. (Laughter.) And please state your name and affiliation. And, Lyric.

Q: Hi. I’m Lyric Hughes Hale with EconVue in Chicago. And I’m here for the World Bank meetings too.

And yesterday Jim Yong Kim talked about a program that I heard about first at the G-7 meetings in Japan for insurance. In other words, not just philanthropy but getting financial markets interested in this. And what I heard was quite exciting. And there’s a $450 million bond that was over-subscribed by two. And the bonds pay 8 percent interest. And this was for pandemics. So they have $450 million sitting, waiting, not—once something has happened they have that money ready to deploy. And now they’re going to be doing the same, a famine bond. So what do you think about those? It seems to me they are very creative initiatives and can galvanize—you know, put the profit motive in some of this too, yeah.

SHAH: Yeah. So I know enough to be dangerous on both of those, but not enough to be accurate. In general, I think they’re both excellent. I think the pandemic vehicle is, as you point out, creative and useful. For a variety of reasons, it’s not the whole solution. And that’s fine.

Q: Of course.

SHAH: You know, you can’t ask someone to solve the whole thing. That grew out of an experience in Ebola, where Jim in particular had—we all had trouble in the summer before the—you know, before September, sort of unlocking real capital for a big response. Capital wasn’t the only constraint there. The data was very poor. The signaling was very poor. The level three alert never happened, which activates a different kind of public sector multilateral response. So there were a number of things. But this will be a platform, as I understand it, that will give the World Bank president, together with the head of WHO, the capacity to move faster with their own resources.

The backend of it and how much of it is kind of public sector paying off debt versus a mechanism that has changed the nature of capital markets to play for this stuff, is probably debatable. And that’s fine. You know, everyone’s got to start somewhere. So I applaud—I applaud Jim for kind of making this happen over a few years.

Q: OK. Thank you.

BOLLYKY: Great. I had Alexandra next.

Q: Yeah. Thanks. So I’m perhaps the odd person out here. I work on peace and security not global health. (Laughter.) Nice to see you.

SHAH: Nice to see you.

Q: So I guess my question is—and maybe it’ll be out of left field, I don’t know. But with all the questions around security, personal data security, you talked a lot about, you know, let’s go around and let’s capture that through Facebook, you even mentioned specifically. I’m wondering—and in my field, when we talk about, you know, data and security, we’re worried about grantees’ safety, working on atrocities, et cetera. And so I’m wondering, in the global health field, how are you balancing the beauty of technology and the ability to gather all this personal data and harness it, come up with trends and solutions, all the while balancing what I think may be a growing global trend of saying: Well, I don’t want—you know, I’m not giving you my data. So.

SHAH: Yeah. So I think there is going to be a growing global trend towards being much more serious about data privacy. My instinct is that’ll be primarily driven in Western contexts, and upper-income contexts. People who have real expertise in this point out to me that no matter how much data privacy you build into the system—this is a famous Nandan Nilekani phrase out of India—it’s like, basically, people will give it all up for a free pizza. (Laughter.) And usually less. Usually a lot less.

And a little bit like—you know, if you recall way back on rotavirus vaccine there were a few cases of something called intussusception here in the U.S. Bottom line is for a very low—a low probability outcome, the vaccine was pulled off the market and reformulated, which was good for our environment here. But the risk/reward tradeoff in other places would have led you to a different calculus. My instinct is the same underlying math applies here, that the risk—I don’t think people think as much about data privacy. And that doesn’t mean we should take advantage of it, but we don’t want to miss out on using the science of our time, which is data science and predictive analytics, to apply it to attempts to solve this challenge.

But as you can tell, I don’t have a good answer. I don’t know that anybody really does. And folks in India and other emerging market settings would point out that—would say: You all think you have a lot more data privacy than you have, which is becoming, I think, more apparent just in the last couple of weeks. (Laughter.) So sorry for not a good answer to a good question.

BOLLYKY: Jonathan.

Q: Hi. Thanks for your talk, Raj. Good to see you again. And I’m with the Open Society Foundation.

And I then want to, first of all, say that there’s really thoughtful, purposeful problem solving in what you presented earlier. And my question—it’s a bigger-picture question here in relation to the various economic and political trends, especially geoeconomic and geopolitical, the ones that we’ll often discuss in this setting or in the pages of Foreign Affairs. How, in your mind, do some of these trends toward illiberal democracy, shrinking civil society space in some of the, you know, countries and communities where Rockefeller may be operating, rising inequality, some of these major trends. How are you thinking through them as they relate directly or indirectly to achieving the health SDGs?

SHAH: Yeah. I think in general our mission this next decade is shaped around bringing unconventional actors together to solve difficult problems. And our hope is we can choose problems that have real, human impacts and fundamentally lift up people, particularly, you know, who live and their experience is in the more vulnerable parts of the social system. But at the same time, we hope we can be a modest example of what success can look like, so people can have a counterpoint to the general trend that I think is underlying your question of deep populist retrenchment in our politics all around the world of, you know, a lack of belief anymore that this natural march towards liberal democracy is the—is the natural order of things, right?

And that—and that there’s a sense that faith in government in particular has gone down both more dramatically in the last few years and is at its lowest point. That government may not be able to solve problems on its own, but governance that sets goals, that brings in public and private actors, and that is practical, and pragmatic can actually do that. We can’t solve every problem. We may not even be able to solve this one, right? But it’s our sort of hope that extending Rockefeller’s long legacy of bringing people together to try, in a few areas where we have sort of outsized capacity, is what we’ll try to do going forward. So it’s not a full answer to your question.

And I would—you know, and I’m spending a lot of time because we have a—as you point out, Tom, we have an extraordinary history in China but, you know, if anything, China is sort of proving the point that the integration of technology and a certain form of authoritarian governance can sustain itself, even as incomes rise. And I do think, you know, we have to think about how are these examples of success going to get us to a place where we are back on track—or we on track—(laughs)—towards achieving some of the bigger goals you are laying out.

BOLLYKY: Great. I’m going to start taking questions in twos so that we can get through everyone. I have Carolyn (sp) next.

Q: Thanks. Actually, Tom, you started the conversation by mentioning one of the lessons of Jim Grant being about political will, and you also spoke about that, Raj. And so many of the intractable problems and the big problems that you and others, coming together, trying to solve, are really fundamentally—they’re less—yes, there are technologies that we need and data—whatever—but fundamentally they are political issues. They’re—often the barriers are less technological these days, but policy and political.

And there is a real important role for empowered and sustained advocacy from citizens to drive their governments to stay on course. Also, governments change so—a commitment from a head of state one day can be easily overturned the next, and that requires investment as well—investment in an empowered citizenry and so not just in open civil space, but actually a society that understands how to engage in the policymaking process all the way from national to community levels.

Your old agency, USAID, has been—we’ve been—PATH has been working with them in Uganda on something called Advocacy for Better Health which, as far as I can tell, is a really unique type of project where there’s actually stand-alone investment in a—in a—empowering advocates in communities to understand their health rights, engage in the health system, look and see whether—you know, go into the health centers to understand what—whether health services are being provided and bring that data back to local and national decision-makers to identify the bottlenecks and address change. And it’s showing a difference.

But it’s that missing piece of—when we talk about the health system—strengthening the—actually, there’s very little investment going into that.

So I just wonder if you could talk to that from the perspective of a funder of, like—there’s not—advocacy, and political advocacy, and citizen empowerment is—if we agree that that’s an important piece of it, how do we attract more resources to actually sustain and build that infrastructure in the same way that we are building data, and health systems, and the infrastructure in other ways?

BOLLYKY: Great. And, Toni (sp), you’re the other—

Q: So, Raj, thank you for your thoughtful presentation.

I, too, am going to swing out for a slightly more global perspective, and kind of connect the dots of my Middle East world, and also looking at opportunities, and as board chair here of Children’s Hospital.

So you—speaking to the issue of political will and partnership, I see opportunities of what you are discussing and what you did in your previous work with Gates, and as you know, Mohammed bin Zayed was a key partner on the polio initiative.

My view is that this is a very noble cause, but I think there are—I would urge you to kind of look at top down and bottom up, and look at trends of where partnerships—I steward one of the largest gifts here at Children’s Hospital, and we are the number one fetal medicine program. And what we see in pediatrics—the Gulf, now Saudi Arabia, as well, they’re looking at their problems with children.

This is a pathway for—and my view is you have to anchor them in the thought leadership of how they can actually be transformational. You know that the Emirates has been very involved in the SGDs (sic; SDGs), but lift it up and get them anchored in to do both, and how it touches them, and they will continue to be engaged.

I view this as a very interesting opportunity. I’d like you to sort of address that because we’re in—you know, Robert was just asking me, how do you see the Middle East. I don’t see it very calmly, but I do think this is a(n) extraordinary opportunity that you are tackling, but I urge you to kind of look at the broader opportunity here as it addresses the political will and leadership, that you might be able to really get them to leverage capital.

SHAH: Yeah. Maybe I’ll start with Toni’s (sp) point and then come to Carolyn’s (sp).

So as you have done so many times in your career, finding examples of effective partnership, however modest they may seem in the scheme of like big, global geopolitical issues, has often proven so important, right? And I would love to have—and we will put time, effort, and energy into trying to—across, you know, seven to 10 partnerships we might do over the next decade in areas like health, food, power, jobs, going forward which are our kind of main areas of focus—try to find opportunities to embrace key leaders and key institutions from the Middle East in that effort.

The one that I’m most enthusiastic about is actually—I mean, I’m very excited about this project, but over—next year sometime we’ll roll out an effort to rethink the way the world sort of produces and consumes protein, and in particular, with an environmental sustainability and nutrition lens that is more defining. I can’t think of a set of partners that would be better—right?—than those in the Middle East, both for their own economies, but also as a scientific partnership space where they can have outsized impact around the rest of the world and demonstrate some of that global leadership that they, as you point out, are so committed to sort of talking about. And we saw it in other settings: in Haiti, with the Qataris. I mean, there are examples, but we’d like to find a few of them that connect in here.

Q: This is really—

SHAH: I don’t—this could be one of those areas over time as we sort of do more—I guess they don’t call it telemedicine any more—but more technology backup for medical capability being distributed out to frontline workers, but we’re probably, honestly, a little ways away from being able to think that through.

On the—on the question of advocacy and political will, I completely agree—(laughs)—and so—look, we’re one modest partner. I actually—having run USAID and been at Gates, I think of us financially as less a big funder and more a convener, which limits to some extent the things we can do but is more expansive in many ways in how we might be able to do it.

And so, in this space, we will try to be a convener that helps enable others to be successful at a global level. It’s important to us that Henrietta Fore at UNICEF, and Tedros at WHO, and Jim at the Bank all feel like they are succeeding by delivering on a vision of community health outreach that tackles the last mile of delivering the SDGs, and frankly, they—it’s more important to us that they are kind of lifted up and visibly recognized for the leadership they offer on these things than necessarily us.

At a country level—and part of why we’re so country-focused—is your Uganda example is exactly what we’ll try to do—you know, build a partnership for community health outcomes that is locally owned, locally led. We have a new vehicle we call Co-Impact, which is a joint philanthropic fund we’ve raised with other—well, with Giving Pledge pledgers, I guess, and you know, there are—$360 billion have been pledged via the Giving Pledge. Very little of it has been actually operationalized so we created a little platform to say, if you find this work interesting, here’s a way to operationalize it.

The value of that is resources, but the bigger value of that is I can now get three or four prominent Indian philanthropists vested in the project, right? And they have access, and standing, and relationships that help to—help to add an extra dimension to what you just described—civil society, local governance, you know, leadership in government, as well as business and philanthropic leaders, all coming together to do something can be even more powerful than otherwise. So that’s one way we’re trying to address it, but I certainly hear you, and I—look, I’m—I think—I don’t know how it feels here these days, but I think we have—by walking off the stage on this stuff across the board, we’ve let a lot of other countries just step back and, you know, reduce their commitments to this work, reduce their leadership, their institutional vehicles that were the ones that lifted this stuff up. The G-8, the G-7, the G-20 feel less meaningful and aspirational, so this populist retrenchment and its consequences that Jonathan spoke about are—you know, are really going to undermine all of—achieving all of the SDGs over the next decade unless we do something more practical and more local to fight back politically.

BOLLYKY: Great.

This next round I have Chris and then Paul.

Q: So from the geopolitical to the more technical—(laughter)—I love the—

SHAH: Which then ends up being geopolitical.

Q: Exactly. (Laughter.)

I love the vision and—but the—even if you get everybody to use the same digital platform, let’s say, we all know now that the—well, we know about sort of the machine learning algorithms as they exist are actually very good where you have sufficient data to train. And it seems like the big challenge for you is to get the data on outcome and then the sort of risks at the household level that will allow you to get where these events are going to occur because the data collected by the health workers themselves won’t give you the outcome data.

So there’s this sort of looming gap there about how you get the data to train, and the volume of data required to train these algorithms is really quite large—

SHAH: Yeah.

Q: —is the one lesson I think that will last three or four years.

And there’s another part to that which is where are the households at risk and, you know, we are—as we know from, you know, vaccination coverage at the local level, which is horrendously bad, we actually don’t have—most countries don’t have great data on where households are and where people are, and I think there’s a technology fix for that, you know, with satellite imagery, and blending of local data, and satellite data, so there’s some space there to fix that problem, and I—it’s remarkable that in, you know, 2018, we actually have such poor information about just—

SHAH: Yeah.

Q: So, you know, any ideas about how you’re going to fill those gaps? Which might be your biggest impediment because the rest of it seems very tractable, to be honest.

SHAH: OK. Do you want me to address that?

BOLLYKY: I do, but Paul?

Q: So thanks, Raj. I’m Paul Weisenfeld from the Research Triangle Institute. Nice to see you again.

I surprisingly have almost the same question, so I think it works really well for you. At RTI we’ve done a lot of work on eliminating neglected tropical diseases. We were involved in the Ebola response, the Zika response. We’ve seen exactly what you’ve said: how data is enormously powerful and—excuse me—in targeting interventions to be effective, but particularly in low research settings to do it in a cost-effective way. And I think that’s something that we often miss. It’s not just about targeting but how do you deal with health systems that don’t have resources, and if you can reduce the cost of responding. I think data has that promise.

But there’s a lot of bad data out there—kind of to go to this question—and I think people tend to assume that data is the answer to all of our problems, but not in settings where you have bad data. We’ve seen a lot of emphasis on SMS surveys, for instance, and we’ve seen how they’re very, very inaccurate because they skew data to certain populations and not others. And I don’t see a lot of interest in innovation on the data collection side. There’s a lot of interest on predictive data analytics on the back end, but I think there’s—big scope satellite imagery is one, drones are another. I don’t see funders talking about or funding how do you kind of do innovation on the boring collection side of it because, if there’s bad data going in, then your results are bad.

And the two other weaknesses I see there is if you get all of that right, and you are looking at a health systems approach, there is still a big question as to whether the ministries of health at regional and national levels have the capabilities to understand how to work with the data, and I think other people have talked about that. And it’s great if you get organizations like mine who can come in and do it in the middle of a crisis, but if you’re—if you’re trying to set up the system to respond over time, the capacity-building is kind of a tough slog, I think.

And the last point I’d make—or weakness in that model—is in many countries around the world, including our own country, we see a lot of desire to make decisions based on what outcomes people want rather than evidence-based decision-making, and just because we have good data doesn’t mean people are going to necessarily do the right thing. There’s a big emphasis on how do you drive kind of a culture of evidence-based decision-making.

So I’d love to hear your thoughts on that.

BOLLYKY: Yeah, small questions.

SHAH: I know, and in a past life I would have said, OK, that’s your job. (Laughter.) Now I’ve got—now I have to answer these questions?

Q: Well, I used to work for you, but I don’t now, so—(laughter)—

SHAH: In all honesty, you’ve done a phenomenal job in so many settings of tackling these types of things. Paul, in addition to running the Haiti response, set up Feed the Future, ran our major bureaus for USAID, and his gift was when systems are not likely to take—to have a culture of being data driven and delivering results, you somehow managed to get there. And I don’t exactly know how you did it, so I might ask you to answer the question—(laughter)—but I think it’s instructive. I mean, I—that’s a little bit why we’re sort of saying we want to start in five to seven countries, be present on the ground, bring people together, set the goal, build the political will around achieving the goal, and do the data architecture work outside of the bigger vision of the predictive analytics that chews on a lot of data—but just the HMIS data systems work so that the basics are in place. And ideally there’s enough either political will combined with, you know, just coordination on the ground to build that, if not culture around results, at least more leaning into that direction.

And you have done it in some tough places, so you know it can be done, right? It takes great leadership, it takes—it takes what it takes on—at a country level. Some of it is careful selection of where you want to work but, I mean, we’ve all seen it work in some settings, including the crises settings in West Africa and in Nigeria, right, when that was—when that was important in 2014.

I’d say that the other piece is something I’m very sensitive to because the long-term vision of success does rely—Chris, as you point out—on having the training data that covers—that implies you know where people are, right, whether it’s census or geospatial mapping—whatever it’s called, and that’s shockingly weak.

And then data on people and their behavior that goes well beyond what we call health systems data so that machine learning algorithms can develop the associations that, you know, a health system public health manager would not be able to. And I don’t really—(laughs)—have the answer as to how we’re going to do that—when I find you and other brilliant people and try.

I think—I’m sure you were referencing the work that Gates and you all did in northern Nigeria using geospatial mapping to do the census there. I’m sure you’ve seen Planet Rx and their approach to this in terms of how they are doing it. I think Bill Gates and others are now trying to expand that Africa-wide to do a better mapping of where the people are. But the northern Nigeria stuff that I saw about a year ago was pretty powerful at sort of being very, very different than all the official data and being much more accurate about where people were—where people are and how many of them are there.

And my understanding—Wendy, correct me if I’m wrong—was that grew out of the Ebola effort or at least they learned a few things by using geospatial analysis to do some population mapping in the spirit of protection against pandemic threat in that setting, and then that expanded into this bigger project.

That’s not to say that’s the answer but, you know, there will be tools that will help us know where the people are on a more global basis that we could leverage.

And then on the—on the how do we get data on people, this is an area I hope we can leverage our standing and our history a little bit to help out. You know, we have—we’ve had—I think we could get access to quite a lot of data from mobile providers, from others, for those who want to start to build and use these training data sets to see what’s possible.

I don’t know what’s going to come of that, and it’s not that others couldn’t do that but, you know, I’m always looking for areas where our name and our history can be leveraged to some good effect, and this feels like one of them. So we would be quite open to innovation on the data collection side, both by getting access to other people’s data that might be relevant, including, you know, if it’s—I mean, it’s not—as you know, these are low bandwidth environments so it’s not yet Facebook, but over time, it will be them, or others, or the mobiles that can help in addition to the geospatial stuff. And then if there are other ways to innovate, Paul, on the data collection side, we should explore that. I mean, that—it would be—especially in the countries where we want to prioritize early work, I think that will be very important.

BOLLYKY: Great. I think we have about five minutes left and three questions, so I’m going to take them all together. Please keep them short so that Raj has a chance to respond to you.

Kilaparti?

Q: Thank you very much. Great to be here, first time in Washington office—

SHAH: Welcome.

Q: And I am huge fan of yours so—

SHAH: Thank you.

Q: —it’s wonderful.

I’m glad that you talked about the SDG goal and what the foundation is going to do and make, you know, come together, but the point I want to make is that each goal is designed in such a way that it succeeds when all other goals succeed—you know, the interlinkages are just phenomenal.

Just one point. In climate convention, when we talked about the impacts of climate, there was period of lull, but when the WHO came up with a report that—how the migration of the tropical diseases are going to temperate regions, it became really quite big.

The walking off the stage part that you mentioned have—about the world stage, and the impact of that on agenda-setting around the world, is just astounding. And the gap is really profound, and it needs to be filled. And whether you call it shortcut or otherwise, but the private sector and the foundations, you know, need to come together in terms of addressing these issues moving forward.

On the—you know, we had a $500 million challenge grant about questions, and it was oversubscribed by three times with lot of brevity. But then we can’t obviously deal with all of that. And, again, I hope that you and others like you would step in and do (the thing ?).

BOLLYKY: Great. Karabi and then Tony. Again, just a couple of minutes, so please keep it short.

Q: Sure. Hi, I’m Karabi Acharya with the Robert Wood Johnson Foundation.

So my question is a bit different. It’s really—if you think about globally sort of rising inequalities across countries—high- and low-income countries, I’m wondering if you are seeing opportunities for learning, particularly across high- and lower-income countries.

Our—my work is particularly about sort of learning from lower-income countries, bringing those solutions here, and we’re seeing lots of great opportunities for that.

BOLLYKY: Great. Tony?

Q: Raj, congratulations, and it’s great to hear you taking on a cross-cutting platform but still staying very focused on the SDGs, some of which—and child and maternal health are pretty precise. And so, given that, you know, there’s a tendency in the health sector to be very disease-specific—this is a bit of a contrarian strategy—I think part of that has to do with attribution, and as someone who is very focused on data and metrics, and on progress, I’m wondering how you are thinking about attributing what your contribution is through such a cross-cutting platform, so the specificity of some of those outcomes that you’re really looking for—because it could really be model for others to really look in a more integrative way.

BOLLYKY: Great question.

SHAH: Maybe I’ll take these backwards. (Laughter.)

So, Tony—for those of you who don’t know, Tony worked for Sam Power and led the U.S. negotiation around the SDGs, so I’m glad that you think it’s good that we’re working on the SDGs—(laughter)—because if you didn’t—if you didn’t, I’d be really concerned.

We’ve asked this to ourselves a lot. I’d go back to my Bill Fahey comment. I think we are an institution that’s maybe a little bit special and unique in that we really can, you know—I think our reputation has been earned over 105 years of delivering big wins, and that gives us the ability to maybe not need to do a press release every month to describe to the world what we’re attributing to our own leadership in terms of results.

I was at USAID with you, and we had the need to basically do that, right? I had to go to Congress—we all had to go to Congress every week and be like, last week we did this, and we did it, you know. You did it, you know, with your money.

And we all know—Chris knows perhaps better than anyone—none of that’s really true. It’s all a joint effort, and then we all count up all the lives we save, and as you and Bill Gates like to say, we—if we—if you add it all up—(laughs)—we’re saving a lot more lives than we’re actually saving.

So I don’t have—that’s a terrible answer and attribution—other than I don’t feel we need to walk around saying we achieved X, Y and Z. I think we could maybe hitch our stars more to the collective outcome and say if the—you know, but that’s—it’s a bit of a slippery slope because, at the end of the day, we do manage an institution, and you can’t get too carried away with that. But anyway, I just—one reason I love being at the Rockefeller Foundation is I don’t feel as bound to the reporting on what we uniquely did because I just don’t know how real it is anyway, and at least someone in this space should be able to step back and empower others and say, we’ll sit behind you.

You know, these guys in the political world, they need the credit because they need the support where maybe we can take a longer view.

You know, Bill Gates’ annual letter is a good example of that. I mean, they don’t in the letter say we did X. They’re sort of always raising up what partners are doing. But anyway—

Karabi, I think your point is excellent. I didn’t sort of talk about it here, but we—I believe—and Chris and I were talking earlier—I think the predictive analytics piece in particular has—and the community health piece has a lot of application to OECD country environments—a lot—and whether you are in Detroit, or Silicon Valley, or any other suburban setting, or a rural setting, those tools—the trend towards more community health in America, for example, is going to be a pretty powerful trend.

If you don’t believe me, look at the Aetna-CVS merger and the valuation that—who bought who? CVS bought Aetna. That, I think, tells you what you need to know because their vision is every drug store is going to be a community health center that is tied by technology but liberated from health system data systems, and tied more to consumer behavior data systems and analytic systems. And it’s a huge play, and I think it was, what, a 2(X), 3X valuation on where Aetna was. So that’s pretty extraordinary, and I think this trend has—will allow for learning in both directions.

And Kilaparti, thank you for being here. We need the Green Climate Fund to be successful—(laughter)—and so we need you guys to spend your money as fast as you can, and show, by making bold investments against the SDGs, whether it’s in health, or power, or any of the other areas that—at a time when—you are right—a lot of people are stepping off the global stage, there are some new institutions that are willing to step on to it.

Q: Yes.

SHAH: And the Green Climate Fund can be that kind of a new institution. I think some important Chinese institutions, like the AIIB, can be that type of institution. But we need a little bit of competitive energy, you know, fostered by speed, pace of action, scale of ambition, and we’re counting on you to be part of the solution.

Q: Thanks a lot. Thank you.

BOLLYKY: Great. With that, I want to thank Raj for being here, thank him for his government service, his public service, as well as wish him luck in his relatively new role, and I wish you would join me in that. (Applause.)

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