Presenter Name 1 Presenter Name 2 Presenter Name 3 · “Across the world, 20-40% of health care...

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WHAT WE DO

© Bill & Melinda Gates Foundation | 6

Ensure more children and young people survive and thrive

Empower the poorest,especially women and girls, to transform their lives

Combat infectious diseases that particularly affect the poorest

Inspire people to take action to change the world

The foundation has four missions that help us achieve our vision of a world where every person has the opportunity to live a healthy, productive life:

In 2017, the foundation invested US $4.7 billion in these areas


FOUNDATION FUNDING SUMMARY

Numbers include grants and direct charitable expenses (DCE), but do not include Program Related Investments (PRIs)

Global DevelopmentMaternal & child healthNutritionFamily planningPolioEmergency responses

Global HealthHIV/TBMalariaEnteric & diarrheal diseasesPneumoniaNeglected tropical diseases

Global Growth & OpportunityAgricultural developmentWater, sanitation & hygieneFinancial services for the poorGender equality

“This is the number-one question I get from our partners” - Trevor Mundel, President Global Health, BMGF


HOW DO YOU DECIDE WHAT TO INVEST IN?

https://medium.com/@trevormundel/the-four-toughest-questions-i-get-c790ab8c6e48Mundel T. Honing the Priorities and Making the Investment Case for Global Health. PLoS Biol. 2016 Mar 2;14(3):e1002376.

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LEARNING FROM PHARMA

• Healthcare value reflects $ per DALY• High “Game Changer”• Med “Solid Advance”• Low “Me Too”

• Bubble size represents health impact (given product success)

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Shape the market

Shape the org. and ecosystem

Shape the product

Marketing and consumer insightsShape product R&D

Supply chain

Market access and pricing

Sales and channel partners

Government and regulatory affairs

Patient support and consumer engagement

Medical affairs

Mindsets

Launch project management

Organization and partnerships

1

2

3

4

5

6

7

8

9

10

11

Define problem and set ambition0

Localize to markets12

▪ This framework describes key launch elements

▪ It is only one framing to look at launch activities(different organizations may group activities in different ways)

Key elements

LAUNCH FRAMEWORK

One key task is demonstrating value and affordability … in the unique contexts of specific country health systems


WASHINGTON POST INTERVIEW WITH BILL GATES,

MAY 17 2013

Ezra Klein: How do you make […] decisions about what is and isn’t worth paying for?

Bill Gates: The way that this is talked about is, what’s a year of life worth? They call it a disability‐adjusted life year (DALY). When you’re running a poor country health‐care system, you can’t treat a year of life as being worth more than, say, $200, $300 or else you’ll bankrupt your health system immediately.

EK: We’re very uncomfortable putting a value on human life. The way I see our [US] health system is we’ve chosen to pay a huge premium in order to avoid these questions.

BG: Yes, someone in the society has to deal with the reality that there are finite resources and we’re making trade‐offs, and be explicit about that.

https://www.washingtonpost.com/news/wonk/wp/2013/05/17/bill-gates-death-is-something-we-really-understand-extremely-well/?noredirect=on&utm_term=.f2853cb7eee5


1 2 15 4 5 6 5

12181818

2529354249524749

81

67

76

0102030405060708090

# of Articles

Publication Year

5,319Ratios

649Cost-per-

DALY analyses

1100211104203315155182540395368618783114145177226228

300360400384369

495

597580

772707

905

0100200300400500600700800900

1000

1976

1979

1982

1985

1988

1991

1994

1997

2000

2003

2006

2009

2012

2015

# of

Art

icle

sPublication Year

7,292Cost-utility

analyses(1976-2017)

27,801Utility

Weights 18,424Ratios

NUMBER OF $/DALY & $/QALY ARTICLES (ALL COUNTRIES)


SOURCE OF FUNDING FOR LMIC HEALTH PRIORITY SETTING STUDIES (1995-2017)

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

% o

f art

icle

s in

a g

iven

yea

r

Publication Year (number of studies)

None/Not Stated

Other

Other government

Intergovernmental

Gates0

20

40

60

80

100

120

Gates

WHO

GAV

IEu

rope

anUnion

UNICEF

UNDP

/WB/WHO WB

UNITAID

PAHO

EDCT

PGA for T

BDD

UNPF

UNAM

A

Num

ber o

f studies

Organization

BMGF and intergovernmental sources

15

INCONSISTENT METHODS & REPORTING STANDARDS

0% 20% 40% 60% 80% 100%

DALY standards

Equity

Affordability

Comparator

Societal perspective

Time horizon

Uncertainty

Source: review of 20 published CEAs funded by BMGF since 2000 in four program areas: malaria, TB, HIV/AIDS, and vaccines

© Bill & Melinda Gates Foundation |

REFERENCE CASE PRINCIPLES

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NORMS & STANDARDS

Better Decisions. Better Health.

“Across the world, 20-40% of health care spending is wasted… as much as half driven by inefficient mix of interventions within health benefits packages”

– WHO’s World Health Report 2010

Health technology assessment (HTA) and health benefit package design aims to inform health policy and decision-making processes concerning health technologies

HEALTH BENEFIT PACKAGE DESIGN

Country translation Afghanistan Ethiopia Pakistan Zimbabwe Cote d’Ivoire eSwatini (Swaziland) Negotiating Numerous countries in Africa Large interest from countries elsewhere Piloting with the World Bank

to accelerate large uptake

DEVELOPING AND SCALING GLOBAL PUBLIC GOODS

NEED TO MOVE BEYOND HEALTH: PRIORITY SETTING IN OTHER AREAS OF DEVELOPMENT


Ensure more children and young people survive and thrive

Empower the poorest,especially women and girls, to transform their lives

Combat infectious diseases that particularly affect the poorest

Inspire people to take action to change the world

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BMGF TAXONOMY OF HEALTH FINANCING

FUNCTION

Raise

What is the size of the pie and how can we increase it?

Allocate

How do we distribute what is available, including donor and domestic resources?

Spend

How do we get more value from each piece of the pie?

Within healthAcross sectors

Gov. &policy

Servicedelivery

Level

Provider

Area/disease

External

Domestic

Health enablers

Other

Health

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THE TAXONOMY LAYS OUT CHOICES AND ACTIONS

FUNCTION

CHOICES

ACTIONS

Raise Spend

Dev. Banks and DFIsBilateral donors Multilateral donorsFoundations and private Public/social (national and subnational)Private sectorOOP

AllocateWithin healthAcross sectors

Education, Water and Sanitation, etc.

MiningTelecommunicationsIndustryTransportationNon-health services

Community, primary, secondary, tertiary; national, subnational

Gov, private, NGO

Disease verticals, family planning, etc. Inputs: Salary, medicine,

vaccines, staff, equipment, infrastructure, etc. Outputs: Service purchasing or output-specific funding

Tech. & analytical

Fiscal space expansion strategies, pre-payment design

Advocacy Decision maker engmt, pub. mobil., influence comms, shaping fin. mechs

Tech. & analytical

BCA, budget development, rationalization

Advocacy Evidence/analysis, public mobilization, influencer comms

Tech. & analytical

Prioritization, CEA, HBP design, provider payment; pooling mechanisms

Advocacy Evidence/analysis, advocacy capacity building, decision maker engagement

Tech. & analytical

Resource tracking, provider payment, financial controls

Advocacy Evidence/analysis, decision maker engagement

Directsupport Direct

supportDirectsupport

TA, gov capacity building, macro fiscal policy execution

TA, gov capacity building



Admin, planning Policy, standards & regs (e.g. disease control) Infrastructure (ports etc)Population programs: gender, income etc.

Directsupport


NORMS & STANDARDS


EARLY USE OF THE GUIDANCE“Suppose that our foundation hadn’t invested $10 billion in Gavi, the Global Fund and GPEI over the last 18 years…”

• Invested into the S&P 500, then invested returns in LMICs

• Those countries would have received ~$12 billion• $17 billion if we factor in reinvested dividends

• Invested in energy projects• the return would have been $150 billion.

• What about infrastructure? • $170 billion.

• “By investing in global health institutions, the $10 billion that we gave to help provide vaccines, drugs, bed nets and other supplies in developing countries created an estimated $200 billion in social and economic benefits.”

Cut tuberculosis deaths 95%

$2011$2011Trade

Reduce world trade restrictions (full Doha)

Gender Universal access to contraception

Ensure women’s rights to own and inherit Increase women’s political representation Increase women’s economic opportunities

Enhance female education Vaccinate against cervical cancer

Reduce child marriages Illicit financial flows

Make beneficial ownership info public Exchange tax information automatically

Country-reporting for multinationals

Health

High blood pressure medication

Cut salt intake 30%

Increase tobacco prices 125% More health spending for 1bn poorest

Doubling HIV medication for sickest Reduce infant mortality

More health spending for 2.5bn poorest

Education Triple preschool in Sub-Saharan Africa

100% primary education in SSA Improve exams and teacher accountability

Increase secondary school completion

$5$5

Likely To Be Low

$7$7

$120$120

$3$3

Likely To Be HighLikely To Be High

$49$49Likely To Be HighLikely To Be High

Population & Demography Allow more migration

Discourage early retirement Promote urbanization

Increase birth rates in rich countries Give public pension for young old ages

Food Security and Nutrition Reduce child malnutrition

Research to increase yields Cut food loss with roads and electricity

Likely To Be HighLikely To Be High<$1<$1Low

$45+$45+

$45$45$34$34

$14$14

$43$43

$36$36

$22$22$13$13

$10$10$9$9

$3$3

$33$33$7$7

$4$4$4$4

Social, economic and environmental benefit per $ spent

$1299+$1299+Freer Regional Asia Pacific trade

Halve malaria infections More male circumcision against HIV

$39$39

$28$28

Stroke / Heart attack pill $7$7

More vocational training More training of older workers

UncertainUncertain

$47$47Expanded immunization $60$60

Aspirin heart attack therapy $63$63

Biodiversity Halve coral reefs loss

Halve forest loss Halve wetland loss

Reforest to store CO2 Increase protected areas

Infrastructure Mobile broadband developing countries

Universal fixed broadband Conflicts & Violence

Reduce assaults Improve policing

Eliminate violence against women and girls Eliminate violence in child discipline

More peacekeeping troops Energy

Phase out fossil fuel subsidies Modern cooking fuels to 780m people

Modern cooking fuels to everyone Electricity to everyone

Double energy efficiency Double renewable energy

Science & technology Increase skilled worker migration

More R&D spending in developing countriesClimate Change More energy research

2°C target Air Pollution

Better cook stoves to cut indoor air pollution Cut outdoor air pollution

Water & Sanitation

End extreme poverty by money transfers Social protection system coverage

Data for Development Data collection for all 169 targets

Better disaster resilience for poor Provide employment for all

Increase life satisfaction

$24$24$10$10$10$10

$7$7$0.85$0.85

$17$17$5$5

Likely To Be HighLikely To Be High

$17$17

$11$11$5$5

$15+$15+$15$15

$9$9$5$5

$3$3$0.8$0.8

$3$3$15$15

$11$11

$10$10$0.3$0.3

$5$5<$1<$1<$1<$1<$1<$1<$1<$1

<$1<$1

<$1<$1

Provide legal identity for all >$1>$1Governance & Institutions

Better institutions Reduce corruption and bribery

UncertainUncertain

Eliminate open defecation Better access to water for 2.3bn people Provide basic sanitation for 3bn people

$4$4$3$3

$6$6

Poverty

Climate change adaptation $2$2

Social, economic and environmental benefit per $ spent


OUTLIERS MATTER: THEY ARE OFTEN 1-3 ORDERS OF MAGNITUDE MORE EFFECTIVE THAN THE MEDIAN

0

50

100

150

200

BCR

Interventions ordered from lowest BCR to highest BCR

Distribution of BCRs from 79 interventions in Rajasthan


BENEFIT OF BCA: CONCEPT OF RETURN ON INVESTMENT IS EASY TO UNDERSTAND

• Message of BCA is intuitive

• Simplification of message is key – ‘one number rule’

• A visual representation of a ‘league table’ of BCRs is very compelling → dis ls hundreds of pages of analysis into one graph

“Mr Moïse said he found the value of wheat fortification the most surprising of the CCC’s findings, and promised to require it within half a year. That alone could justify the cost of the CCC’s research.”

‐ “A Possible Future for Haiti”, The Economist8 June 2017

WHAT DEVELOPMENT INTERVENTIONS WILL YIELD THE GREATEST RETURN ON INVESTMENT ACROSS AFRICA?

30

Benefits and costs of R&D investments for developmentBenefits and costs of available interventions

0 5 10 15 20 25 30 35 40 45

Off‐Grid Rural ElectrificationHigh Speed Train Network

Community‐Led Total SanitationGraduation from ultra‐povertyCHWs for hypertension control:

Solar energy for unreliable urban gridsSME training

Resilience to droughtUrban improved access to clean water

Improved child cancer treatmentCommunity Health Workers (CHWs) for…Expansion of Marine Protected AreasRural improved access to clean water

Soil fertility management from cell phoneVoluntary medical male circumcision for HIV

Delayed pregnancy among school‐girlsImproved cookstoves

Reduced child malnutritionBreastfeeding promotion

Expanded malaria interventionsTrade Facilitation in the ACFTA

Tobacco controlPreschool education

Vaccination against rotavirusR&D for agricultural yield increase

Women’s Empowerment Collectives Family Planning

…

Benefit-cost ratio> 155-151-5< 1

Better Decisions. Better Health & Development.

What should children receive specific to health, nutrition & education and when to maximize human capital potential?

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