Ai: Dr. Elias, you are the president of the Global Development division of the Bill & Melinda Gates Foundation. Can you provide us with an overview of the Foundation’s activities – and your division’s in particular– in the field of Global Health?

Christopher Elias: The Bill & Melinda Gates Foundation is guided by the belief that every person should have the opportunity to live a healthy, productive life. To reach this goal, we work in areas of greatest need, where we can make the bigger difference, taking risks others can’t or won’t and helping to make markets work better for the poor. Our Global Health division covers various areas from discovery and translational sciences to vaccine development and the fight against neglected tropical diseases. Its goal is to develop new health products that could transform the fight against the leading causes of death and disability in low- and middle-income countries. Our Global Development division works with partners around the world to scale up access to existing, high-impact health tools – such as vaccines, drugs, diagnostics, and contraceptive methods – for those who lack access to them. A major focus of this work is to help countries in Africa and Asia build effective primary health care systems. It also drives catalytic progress toward major global goals like polio eradication.

Ai: With this global perspective in mind, what are in your opinion the most urgent challenges in Global Health?

Christopher Elias: This year alone, five million children are expected to die before their fifth birthday. And hundreds of millions of others will suffer from diseases and malnutrition that sap them and their communities of their strength and potential. The world has already come up with pretty good solutions to many of these problems, so why do so many still die from preventable diseases? I spend a lot of time at the Gates Foundation working with researchers, civil society representatives, and governments to better understand why tools that work, such as vaccines or anti-malarial bednets, still aren’t getting to all the people who need them. Markets rarely work effectively for people living in the world’s poorest communities, and so we work to address market failures by investing in new tools to fight infectious disease and the leading causes of maternal and child mortality. We also work with global partners to strengthen health systems and finance the delivery of effective health interventions. These investments provide a huge return on investment by helping millions lead healthier and more productive lives. It is simply unacceptable that a child dies from malaria every two minutes; or that nearly 1,000 young girls and women, primarily in developing countries, are infected with HIV every day. Where you are born should not determine your chances at life. And health systems and economies that serve everyone ultimately benefit the whole world.

Ai: What does your provision of primary health care and your cooperation with state actors look like?

Christopher Elias: Despite tremendous improvements in Global Health, half of the world’s 7.3 bil- lion people still do not receive essential health services. Closing this gap requires building resilient health systems founded on strong primary health care. Primary health care is the cornerstone of the health system and can meet the vast majority of people’s health needs. It’s the trusted place in their communities where people can go for a range of essential health services – from vaccinations, to maternal and newborn care, to family planning.

The Foundation works directly with governments in select countries to help them improve their primary health care systems. For example, we’re working with the ­Ethiopian Ministry of Health to develop dashboards to better visualize data on primary health care systems and use this data to improve decision making.

In other cases, we support governments to leverage the unique strengths of the private sector to deliver care to more people in more places. For example, our investment in Africa Health Markets for Equity helps national purchasing authorities in Ghana and Kenya contract small-scale, private, primary health care clinics to deliver affordable, quality services to people living in poverty.

Ai: But you are not only active in stable states. How do political turmoil and precarious security situations affect the Foundation’s work on the ground?

Christopher Elias: Most of our work is dedicated to improving health, eradicating poverty, and helping to drive economic growth that creates opportunities for people living in poverty. This long-term development work simply is very difficult in the middle of conflict. In such situations, humanitarian organizations often have to focus on providing emergency relief rather than addressing the underlying problems that prevent ­people in poorer societies from achieving their full potential. To do the latter, you need a degree of stability that doesn’t exist in a war zone. Nevertheless, while the link between the security situation of a country or a region inevitably has consequences for what we do, we try to apply a long-term development lens to our work.

Ai: Could you give us an example?

Christopher Elias: The Gates Foundation spends a lot of time supporting the global commitment to eradicate polio, which is very close to becoming the second ever human disease – after smallpox – that the world will have successfully ended. Of the 125 countries where polio was endemic when the Global Polio Eradication Initiative began, 122 have eliminated the disease. Only three countries are still considered endemic for the disease, and we’re only seeing transmission in two – Afghanistan and Pakistan. It’s no coincidence that Afghanistan and Pakistan represent the final steps against polio. Both have large regions with hard-to-reach and vulnerable populations, including conflict areas and settings where it is difficult to access children for immunization. Very high population coverage is needed to eliminate polio transmission. Conflict areas are also some of the most likely places for disease outbreaks to erupt and spread, as we’ve seen with Ebola in the DRC, Guinea, Sierra Leone and Liberia, and with cholera in the Congo basin, Yemen, and the Horn of Africa. The challenge we face is that until a disease can be eliminated from its last stronghold, it can easily escape and make its way back into the world. That’s why we say polio anywhere is polio everywhere.

Ai: Regarding your global partners: The Foundation cooperates intensively with states, first and foremost the United States. Is Washington under the current administration retreating from its leading role in Global Health?

Christopher Elias: For decades the United States has been a leader in the fight against disease and poverty abroad. These efforts save lives; they generate important breakthroughs in science and technology; and American policymakers believe they make the United States more secure by identifying and containing health threats before they become pandemics. Historically, there has been strong bipartisan support in the United States for this work – for instance, PEPFAR (the President’s Emergency Plan for AIDS Relief), was created by President Bush in 2003, and was reauthorized by Congress twice since then, both times with significant majorities. As a strong international ally and partner of the United States, Germany worked with the United States to ensure strong funding for the major Global Health funds that have helped us make so much progress. These include the Global Fund; Gavi, the Vaccine Alliance; and GPEI. Presidential leadership is important, but congressional leadership remains critical as well. We’re hopeful that the President and Congress will continue to see the value in promoting Global Health security as something that is fundamentally in the interest of the United States.

Ai: So you are not too worried about the tendencies towards “America First” jeopardizing the progress of global initiatives for Global Health?

Christopher Elias: We are very concerned by some of the political decisions that have been taken under the banner of “America First.” However, there is a reservoir of strong support in the United States among different branches of the government, not to mention from the private sector, civil society and the general public, for Global Health initiatives. That support needs to translate into funding for the institutions that deliver basic health services as well as those advancing medical research, especially into poverty-related diseases. For the most part, it still is. But there is clearly a significant unmet global need.

Ai: Surely, one should not rely on any single nation to guarantee Global Health security. What role could and should Germany play in this field?

Christopher Elias: More than ever before, German leadership is crucial to the success of this work. Germany is the fourth-largest donor to the Global Fund historically, and its support has saved millions of lives. Germany’s continued leadership and commitment will also be critical for the Global Polio Eradication Initiative (GPEI), which is launching its 2019 to 2023 strategy this year. Thanks to the GPEI, partners and donors, we have seen a 99 per cent decrease in polio cases globally, and to eradicate this disease for good – and lay the groundwork for a future free of polio – we need the continued support of key donors like Germany.

I am therefore especially grateful for Germany’s incredible leadership on development and health. Through its successful G7 and G20 Presidencies in 2015 and 2017 respectively, Germany brought together the world’s most powerful economies to make new commitments that are ensuring more people have access to basic health interventions and services that keep everyone safer.

Getting results at scale and across borders means both investing in pro-poor research and supporting these strong multilateral organizations that are instrumental in bringing health to the poorest and most vulnerable among us. Germany’s leadership in both areas makes a big difference.

Ai: The Foundation not only cooperates with governments but also with non-governmental partners and international organizations like the WHO. What is the reasoning behind these partnerships?

Christopher Elias: While governments have the central role in improving primary health care for their people, donors can also play an important part in driving sustainable progress.

For one, we can help develop the global public goods needed to strengthen primary health care, like better data. Many countries have identified primary health care as an urgent priority, but don’t have the information they need to drive targeted improvements. That’s why the Foundation partnered with the World Bank and World Health Organization to launch the Primary Health Care Performance Initiative (PHCPI), an initiative that works to provide governments with the data, information and support they need to drive evidence-based improvements to primary health care systems. This fall, PHCPI partnered with twelve “trailblazer” governments to develop and launch the first set of “Vital Signs Profiles”, a new measurement tool that helps countries better understand, and ultimately improve, primary health care.

A critical moment for sustaining progress in Global Health will come later this year in October, when the Global Fund to Fight AIDS, tuberculosis and malaria will conclude its next fundraising round in Lyon, France. The Global Fund has helped distribute life-saving anti-retroviral therapy, insecticide-treated mosquito nets, diagnostics and other tools that have significantly reduced the burden these diseases place on many of the world’s poorest regions. Since the Global Fund was created, the number of people dying from AIDS, tuberculosis and malaria has been cut by a third. However, the new threats presented by growing drug resistance and insecticide resistance mean that we must step up our efforts now, or risk slipping back. This is of the utmost urgency.

Through these and other investments, our aim is to ensure governments have the tools, support and information to drive the changes that will help deliver better health care to their citizens. Ultimately, we envision a world where every person has access to a trusted source of health care in their community – and this begins by working together to strengthen primary health care.

Ai: Considering all the factors we have discussed, when will this world, where every person has access to a trusted source of health care, become a reality?

Christopher Elias: Well, I wish I had a crystal ball. Back in 2015, every country belonging to the United Nations signed up to deliver on that promise within 15 years. Specifically, they agreed to “ensure healthy lives and promote well-being for all” by 2030. It is an ambitious goal, but an achievable one. We are already well on our way to wiping polio off the face of the earth, a disease that just 30 years ago was affecting around 350,000 people a year. In the last 20 years, childhood deaths have decreased by half. Deaths from malaria and AIDS have also fallen by half since the early 2000s. If we sustain that rate of progress, a world with access to health care for everyone will become a reality sooner than we think.

The interview was conducted by Samuel Krug.

Choose PDF format for the full version of this article including references.