A call for implementation science and systems innovation in global health

Nicole Grasset, who was the senior smallpox advisor for the South-East Asia Regional Office of the World Health Organization when it was struggling to eradicate the disease in the 1970s, took a tire, boxed it up, and sent it to the head of infectious diseases at the WHO, asking him to report back on how it tasted and to let her know if he needed some ketchup or mustard.

The head of communicable diseases, a notorious “skeptic in chief,” had vowed he would eat a Land Rover tire, should the team eradicate smallpox in India, Larry Brilliant recalled last week.

“You know there’s a lot of cynicism in the world today. We have a lot of reason to be on edge. There’s a lot of fear. And we may have forgotten what great and noble things we can do if we work together,” said Brilliant, who was on the team that led the successful WHO smallpox eradication program, of what he called one of his happiest moments.

Now, Brilliant is chairman of the Skoll Global Threats Fund, to which philanthropist Jeff Skoll just announced he would give $50 million for a program focused on pandemics. Spanning smallpox, Ebola, polio and threats that may be looming, his Ending Pandemics session at the Skoll World Forum made the case for strong health systems that provide not just for today but for the unknown and unusual threats we may face tomorrow.

Today is World Malaria Day, and the global health community will make a push for prevention, in an effort to get malaria to zero. The day falls during World Immunization Week, which aims to raise awareness and increase rates of immunization against vaccine preventable disease. Yesterday, the WHO announced that Ghana, Kenya and Malawi would be the first three African countries selected to implement the pilot of “RTS,S”, the first malaria vaccine.

But experts tell Devex that pilots cannot turn into progress without implementation science, which examines why some of those innovations that work in the lab fail in the field.

“We have an enormous challenge of going to scale and accelerating health improvements,” Peter Piot, director of the London School of Hygiene and Tropical Medicine, told Devex. “It won’t be possible without different modes of delivery. We have much better vaccines and drugs and interventions but they’re pretty useless if they stay on the shelf.”

He was building on his remarks from a recent talk at the University of Washington, where he made the case for considering innovation of delivery, not just delivery of innovation.

Last mile health care delivery is getting some well deserved attention — evident in the string of recent awards for the Liberia-based Last Mile Health — but there remains a big gap between developing new innovations and pressing them through, experts told Devex.

Take a birth center in Uttar Pradesh, India, for example, where following steps on a checklist saved a life.

Nurses washed their hands, put their gloves on, and asked the mother to push. The baby was out in just one push, but though her vital signs had looked good in the womb, she wasn’t breathing. She was blue and she was floppy and she looked like she would not make it, but the nurses took a series of actions, until something finally worked: A suction device that cleared the nasal passageways of the baby.

“I saw that baby start to breathe with just two minutes without a breath,” said Atul Gawande, a surgeon, Harvard School of Public Health professor, and executive director of Ariadne Labs, who worked with the WHO to develop a safe childbirth checklist that has transformed childbirth delivery in the places where it is used. “Five minutes later, you have a healthy, breathing baby, crying on her mother’s breast, warm skin to skin, the mother reaching out and grabbing the hand of the nurse who could breathe easily now. This is what we can accomplish.”

To develop his checklist, Gawande took inspiration from unlikely sources. He visited Boeing, where he learned about pilot checklists from a 777 flight simulator, and met with aviation experts. The global health community needs to think beyond breakthrough innovations, and support the follow through innovations, he said at the Skoll World Forum earlier this month. He explained that systems innovation is the next big opportunity to advance human well being, but it will require moving the sector out of a 20th century mentality.

Some global health organizations are taking this challenge on by bringing in new perspectives either internally or externally, or knowing their space, but playing beyond their lane, said Steve Davis, chief executive officer of the Seattle-based global health organization PATH.

As part of its goal to get innovation to scale, PATH has changed its approach in a number of ways, he said. For example, the organization is hiring economists. And it is shifting its model to acknowledge that while its beneficiary is the end user, its customers are in fact stakeholders at the national level, because they are the ones who can adopt a protocol, introduce a vaccine, or implement a program that would allow for scale.

Davis said innovation in what he calls the unsexy middle is what allowed PATH to succeed with the MenAfriVac, the first vaccine ever developed specifically for Africa, which the WHO and PATH partnered on to stop meningitis A.

Davis pointed to the Coalition for Epidemic Preparedness Innovations launched at the World Economic Forum annual meeting in Davos earlier this year as an example of the kind of cross sector collaboration taking place. But he acknowledged that one of the biggest challenges to collaboration is donors, who create a system of short-termism in the global health sector. He emphasized the importance of involving ministers of health, explaining that they will be the ones who ultimately have to manage and monitor whatever digital health architecture social entrepreneurs are trying to implement.        

“We are breathtakingly close to a historic transformation in health if we can get these last pieces right,” said Ari Johnson, the CEO of Muso, which is on a mission to eliminate preventable deaths, starting in Mali then spreading elsewhere. The world is recognizing the urgency of this injustice, as he put it, and starting to mobilize. He mentioned, for example, the national commitments made at the Institutionalizing Community Health conference in Johannesburg, South Africa last month. “We've always had a collaboration orientation, but this will require different intensity and ambition in the way we collaborate — with implementers, with researchers, and with governments so we can accelerate this.”

There is a scene in Bending the Arc, a film on the story of the global health and social justice organization Partners in Health, which inspired the model of so many organizations including Muso, where Agnes Binagwaho, then minister of health for Rwanda, gets a phone call that causes her to stop an interview short. With the cameras still rolling, she listens carefully, but gives firm directions. She tells the person on the other end to isolate the person in question, then gives an order to isolate everyone that person has come into contact with, and after a brief pause when she hangs up the phone, she speaks to the interviewer: “First suspected case of Ebola.”

“Innovation is not necessarily invention,” she told Devex at the Skoll World Forum. “Innovation is a new way of doing business.”

Binagwaho is now vice chancellor of the University of Global Health Equity, where students from all over the world graduate with masters of global health delivery, in addition to their chosen field of study. Based in Rwanda, the university seeks to shift the center of gravity for health care education from hubs like London and San Francisco to East Africa. Health care delivery cannot succeed without a strong understanding of the systems, said Binagwaho, explaining that implementation science is an innovation of process within that unsexy middle.

“Don’t do for me without me,” she said, repeating a line she says often.

She recounted her own experience being unable to afford medical journals that would have been helpful to her work on health in Rwanda. And she said she is committed to making sure that this university is building not a community of intellectuals but a community of practice. She expects the first graduating class will walk away next month with their diplomas as well as with the know how to take on complex delivery challenges.

“We have to make sure that the people where we are delivering the innovation, where we are doing the implementation, are part of two processes,” said Yap Boum, regional representative for Epicenter Africa, the research arm of Médecins Sans Frontières. At the Skoll World Forum, he challenged the audience, asking how many social entrepreneurs have African people living in Africa as part of their board. Those are the people who will ensure that the work is relevant to the environment, and that will give the project a sense of ownership that is so often lacking from projects brought in by outsiders.

One of the moments that got a round of applause from Davis of PATH, Johnson of Muso, and other global health leaders in the audience for the Ending Pandemics panel at the Skoll World Forum was when Mark Smolinski, chief medical officer at the Skoll Global Threats Fund, said we need to maintain health systems, even when vertically funded programs such as malaria or polio reach their targets.

“We need to turn these warriors who are in these communities into all disease warriors,” he said.

The panelists talked about how Nigeria responded to Ebola by activating its polio infrastructure in order to identify Ebola cases. Ministers of health in the countries where polio has been eliminated have said they cannot believe they are losing thousands of people who knew their health systems inside and out, because the funding was no longer there to keep their jobs in place. They say they need consistently strong health systems to confront whatever threats may lie ahead, such as in Sri Lanka, where malaria was eliminated, but some of that same infrastructure is being activated to address a dengue epidemic that is now spreading across the island.

"The inability to deliver is the reason the world still has malaria," Kamini Mendis, an independent consultant who is an expert on malaria, told Devex in Colombo, Sri Lanka, on World Malaria Day. "It's so frustrating, because we have the drugs, but the problem is we are not getting them to these people."

The country is still tackling imported cases from sources including India, its malaria endemic neighbor to the north, and Chinese contractors who are moving from projects in Africa to projects in Sri Lanka, and bringing malaria with them.

"It's a small country but it's also a well-connected country," she said of the lessons Sri Lanka can offer other countries working to end malaria or other diseases.

This World Malaria Day and World Immunization Week fall during a time where much of the world seems to be turning inward, even as the global health community increasingly realizes the need to collaborate across borders and sectors to achieve progress, experts told Devex.

“I’m more optimistic than I was before about the world’s ability scientifically to come together,” Jeremy Farrar, director of the Wellcome Trust, said on the Ending Pandemics panel. “The biggest risk at the moment in various countries around the world, including tragically this one, is that we’re moving away from that sense of collective public good and going back to an isolationist, more nationalistic agenda, which we tried before. We tried it in the 20th century. And it didn’t turn out well.”

For more Devex coverage on global health, visit Focus On: Global Health