Opinion: Answers to the global development community's tough questions.

Last week, Bill and Melinda Gates released their 10th annual letter, focused on the 10 toughest questions they receive in their work. To mark the occasion, the heads of the Bill & Melinda Gates Foundation’s three global programmatic areas — Global Development, Global Growth & Opportunity, and Global Health — answer the toughest questions they are asked.

Here they are:

Trevor Mundel, president of Global Health: Why don’t you invest more in fighting noncommunicable diseases?

This is an increasingly important question.

When the Gates Foundation was established, we focused our attention on infectious diseases. That’s because there was — and still is — a huge disparity between the burden of infectious diseases in developing countries and wealthy countries. In 2001, United Nations Secretary-General Kofi Annan also called for a massive mobilization of funds to help the world respond to HIV, tuberculosis and malaria — three epidemics that were threatening to spin out of control without concerted action. The foundation answered this call by committing billions of dollars to the development of new tools to prevent, diagnose, and treat these diseases.

In the intervening years, the world has made huge progress against infectious diseases. This is evidenced by the 50 percent decline in maternal and child mortality since 1990 and by the nearly 30 million lives that have been saved through the work of the United States President's Emergency Plan for Aids Relief, President's Malaria Initiative and the Global Fund. But the truth is that we still have a long way to go in reducing the burden of death and disability caused by preventable pathogens.

So, the Gates Foundation will continue to invest heavily in the development and delivery of new tools and technologies to fight HIV, TB, malaria, pneumococcal diseases, enteric and diarrheal diseases, and neglected tropical diseases in countries where they remain major barriers to health equity and economic opportunity.

On the other hand, there is incredibly compelling evidence that there must be more global investment in noncommunicable diseases to sustain development progress in the countries where we work. The foundation is fully committed to using health data to identify and respond to the biggest disease burdens — regardless of their underlying causes — so that we can ensure that our resources are having the greatest possible impact.

The case for increased global investment in NCDs is overwhelming:

• NCDs accounted for 72 percent of all global deaths in 2016, and most of those deaths — 31 million — occurred in developing countries.

• According to the World Health Organization, NCDs now account for 53 percent of the total burden of deaths and disabilities in developing countries, and that burden is expected to rise to 64 percent by 2030.

• Often misperceived as diseases of the wealthy, NCDs such as cardiovascular disease, cancers, chronic respiratory diseases, and diabetes disproportionately affect the poor in high-income countries, and emerging data show that these trends are recurring in developing countries as these nations make gains in economic growth.

• The social and economic costs of NCDs are enormous, with one World Economic Forum report projecting that the impact of five major NCDs in developing countries could cause $21.3 trillion in economic losses between 2011 and 2030.

So, what does this mean for the Gates Foundation’s own approach to NCDs? Obviously, our strategies need to be responsive to major trends in population health. We also need to explore where existing funds from governments and other donors are insufficient and where our support and expertise could potentially have catalytic impact.

For example, there’s a strong link between poor nutrition in the first 1,000 days of life and lifelong susceptibility to overweight, obesity, and diabetes. We know that children who suffer chronic episodes of severe diarrhea are predisposed to develop metabolic disorders and physical and cognitive disabilities. Routine immunization against human papilloma virus (HPV) and hepatitis B play a major role in preventing hundreds of thousands of cases of cervical cancer, liver cancer, and cirrhosis every year. We also support a broad array of primary health care interventions that have been proven to help children grow up smart and strong.

Beyond these investments in maternal and child health, the foundation is also a major funder of tobacco control efforts in sub-Saharan Africa and Asia, and we have support Resolve to Save Lives, a new initiative by former Centers for Disease Control and Prevention Director Tom Frieden that aims to scale up life-saving strategies to reduce the global impact of cardiovascular disease.

Altogether, these investments represent a commitment of more than $330 million per year, and the foundation currently provides 28 percent of global funding for NCD health systems support and 23 percent of total global spending on tobacco control.

There’s no doubt that more global action is needed to prepare for a rapidly approaching future where NCDs will account for most of the burden of disease in developing countries. For example, we still have much to learn about how to prevent and treat hypertensive disorders of pregnancy that often lead to gestational diabetes, preterm birth, and severe long-term health consequences for both mothers and babies. On this and other areas of need, the foundation is committed to working with partners to identify new high-impact interventions that can create a healthier world for everyone.

Rodger Voorhies, Executive Director, Global Growth & Opportunity: Why does a foundation like yours engage with the private sector? Markets aren’t designed to serve the most marginalized.

The foundation’s new Global Growth and Opportunity division was established to get at some of the underlying structural changes that need to take place to help people exit extreme poverty. Part of how we attempt to do that is to leverage the power of markets and private sector actors.

We believe that when people are systematically excluded from participating in the economy — say, because they are poor, female, or considered to be “low caste” — economic growth and security is limited, and both public and private sector leaders must act. Governments need to ensure that infrastructure and policies are inclusive of the needs of the poor. (I define infrastructure broadly, by the way; it’s not only roads and bridges but also things like digital identification and open-source payment systems that enable cashless transactions.) Philanthropies like the Gates Foundation can bring seed funding to the table so great minds can research and develop promising solutions to difficult economic development puzzles. And the private sector can both contribute and benefit by making the most of all these incentives and opportunities rather than doubling down on markets and customers they already have.

Here’s a great example of how this has worked in India: The government adopted a policy that enabled payment banks to offer low-cost ways for people and businesses to digitally transfer money to each other. This new approach provides greater security and access to financial services for a huge untapped market of low-income customers, and demand is soaring. Since the policy change, four payment banks have officially launched. In about a year, they have acquired tens of millions of customers, and two more banks are launching soon. These numbers are powerful indicators of the potential for rapid uptake. Many countries are now looking to India as a model for this kind of innovative policy and infrastructure change and its positive impact on the economy.

As the India example shows, when businesses spot a big potential market and innovate and operate at scale, access and affordability for low-income customers is possible, and broader economic development gains can follow. It’s a virtuous circle. The expansion of a market fueled by private sector investment feeds further development, innovation and growth — all of which can help stabilize countries and regions, by the way.

Here’s another example of how we think about these issues: In our sanitation work, we are supporting efforts to develop and commercialize a “reinvented toilet” that requires little or no electricity or water, and that we believe will be safer than conventional septic tank and latrine systems found in many parts of the world. This pathogen-killing technology could be transformative for economies that are reliant on healthy, productive workers and which currently have only costly and sometimes fragile infrastructure options, like sewers. But governments can’t create an industry for this innovation on their own. Only the private sector has the tools, resources, manufacturing capacity, and market incentives to spur the commercialization of new toilets. And as we learn from early adopter communities that leapfrog over more traditional sanitation systems to reinvented toilets, a compelling business opportunity will develop for more companies that can continue to build a new, global sanitation market.  

Bottom line: Tremendous progress is possible when we bring together the unique strengths and capabilities of both the public and private sectors in the service of vital societal goals like reducing poverty and creating an economy that works for everyone. Foundations like ours can offer resources to help private and public players manage risks and ultimately serve low-income populations who’ve been shut out of markets for too long.

Chris Elias, President, Global Development: Do you have too much influence over the World Health Organization?

I get this question a lot, and it deserves a thorough answer.

The Gates Foundation is the second-largest financial contributor to the World Health Organization, trailing only the United States government. So, we understand why there are questions about our potential influence.

WHO is a specialized agency of the United Nations, and its mission is to help strengthen international public health. We agree that WHO should be solely governed by policies approved by its member states each year at the World Health Assembly. And that’s why the Gates Foundation only provides WHO with funding for initiatives that already have been authorized by a vote of the WHA.

The funding we provide to WHO is for programs that are closely aligned with the foundation’s own global health priorities. These include efforts to:

• Complete the global eradication of polio.
• Control, eliminate or eradicate 10 neglected tropical diseases.
• Accelerate the control and elimination of malaria.
• Eliminate preventable child deaths in low- and middle-income countries.
• Promote and improve maternal and child health. 
• Achieve the maternal and child nutrition targets that member states set at the 2012 World Health Assembly.

In addition, we provide WHO with flexible funding to help it accelerate organizational reforms that have been requested by its member states. To date, we have contributed $40 million to that effort at the headquarters, regional, and country levels.

The goal of our funding is to help WHO deliver on the many mandates that its member states have assigned to it, while also helping WHO strengthen its core functions.

Some have suggested that our funding distorts WHO’s mission, focusing it on a narrow group of infectious diseases rather than the broader interests of its member states. But the Global Polio Eradication Initiative — which currently represents about 66 percent of our total investment in WHO — and the global fight against AIDS, TB and malaria are priorities that were established by WHO’s member states long before the foundation was created and long before the foundation became a significant funder of global health efforts. So, we don’t see our investments in these priority areas as driving the WHO agenda. Rather, we see them as helping WHO close significant funding gaps and deliver on the ambitious goals that its member states created.

We also often hear that we don’t support WHO’s efforts to reduce the burden of noncommunicable diseases, but that isn’t entirely accurate. For example, we work closely with WHO on tobacco, which is the leading cause of preventable death worldwide. Tobacco use killed 100 million people in the 20th century, and it currently kills 6 million people each year. We’re excited to be a partner with WHO and the Bloomberg Philanthropies on the Bloomberg Initiative to Reduce Tobacco Use, which helps countries in Africa and Asia implement the Framework Convention on Tobacco Control. We have also supported programs for cervical cancer prevention.

We believe that the world needs a strong, effective, and fully funded WHO to ensure that it delivers on its mandate, and we’re concerned that the organization has been made accountable for many global health priorities without being given the resources it needs to deliver on them. The Gates Foundation has sought to address several of these resource needs in areas aligned with our own work, and we hope that WHO’s member states and other partners will increase their contributions to ensure that the organization isn’t saddled with high expectations for unfunded mandates.

Read more Devex coverage on global health.