Keynote address by Dr. Eric Goosby of UCSF, presented at CFAR HIV Research in International Settings (CHRIS) meeting in San Diego, October 1, 2014. Dr. Goosby discussed. "Global Health Delivery and Diplomacy: The Long Road to Sustainable Programs."

1. GLOBAL HEALTH DELIVERY
AND DIPLOMACY:
The Long Road to
Sustainable Programs
CFAR: HIV Research in International Settings, UCSD !
Oct 1, 2014
Eric P. Goosby, M.D.
UCSF Global Health Sciences

2. Ebola
Western
African
Outbreak
• Liberia
52%
(3280/2917),
Sierra
Leone
30%
(1940/597),
Guinea
16%
(1022/635),
Nigeria
(20/8),
Senegal
(1/0)
– Timeline:
December
1st
to
September
28th
• Total
Cases:
6263
(Sept
28,
2014;
Confirmed
Cases:3487)
• Total
Deaths:
2917
• DiagnosLc
Tests:
IgM
ELISA,
PCR,
Viral
Culture
– AnLgen
ELISA
test
• Experimental
Treatments:
– Z-­‐MAPP
(monocolonal
Ab)
– NIAID/GSK’:
Vaccine
phase
1
end
of
August
– Newlink/
DOD:
Vaccine
– Tekmira
(RNA
interferring
parLcles)
and
Biocryst
Pharma
(BCX4430):
AnLviral
drug
development

3. Applying proven systems practices and rigorous evaluation
methodologies to global health:
a partnership between academia, private sector, citizens
and governments

4. WE KNOW
WHAT WORKS!
BUT WE ARE NOT!
DELIVERING
There are diseases we know how to prevent, diagnose and treat effectively. The
fact that we are not doing so is impacting millions of lives and costing billions of
dollars around the world

5. DISCREPANT RESULTS
AROUND THE GLOBE ARE
UNACCEPTABLE
Example: Maternal Deaths
Although African countries reduced their overall maternal mortality ratio from 745 deaths per 100,000 live births
in 1990 to 429/100,000 in 2010, the risk of an African mother dying during pregnancy or childbirth remains 20
times greater than the risk to American women.
We have the tools to reduce maternal mortality, and have used them effectively in the west, but they need to be
delivered and used in smarter ways in the developing world.
Too many lives will be lost if we wait another 20 years.

6. CHANGE THE PACE OF
PROGRESS AGAINST
DISEASE
We need to change the pace of progress against diseases
causing the highest burden of disease in the developing world.
Although there have been notable successes in reducing new infections and treating those with HIV and TB,
they remain the leading two killers of adults between 15 and 50 in Africa. In addition, over 180,000 infants are
newly infected with HIV every year during pregnancy and breastfeeding in the developing world, whereas in the
US and Europe infant infections are now exceedingly rare because of successful preventive treatment
programs.
How can we encourage and promote development when TB and HIV are still ravaging the young and
productive core of many African societies?

7. OTHER ILLNESSES HAVE !
SIMILAR STORIES
Childhood diarrhea, hypertension, diabetes,
cervical cancer and other illnesses have a similar
stories…
We can’t just focus on individual diseases and conditions…we need to build upon successful disease-specific
responses and develop greater effectiveness across health systems.

8. IT’S NOT JUST
ABOUT
MONEY
Science has given us the tools, but most development efforts take an inordinate
amount of time to implement. This is not about throwing money at the challenge.
We have failed to meet most of the MDG targets – despite all of our best efforts…

9. IT’S NOT
ABOUT
TIME
Years of global health efforts have not seen the development !
of enough sustainable programs that have lasting impacts.

10. WE ARE IN A
CONSTANT STATE OF
EMERGENCY
PROGRAM FAILURE
We see repeated start-up efforts for the same disease that never mature into an evolved
response. Programs have not developed the rigorous real-time evaluation capabilities to
allow for adjustments over time as needs change.
We can no longer afford to have a sequence of unsustainable emergency programs that
fail to address local communities’ health priorities.

11. WE ARE NOT
LEARNING FROM
OUR FAILURES
(OR OUR SUCCESSES)
PROGRAM FAILURE OR SUCCESS
Programs finish, and whether they fail or succeed they are discontinued…there is scant attention paid
to carefully embedding successful programs into sustainable national programs.
and no one is outraged

12. WE NEED TO CHANGE
THE WAY WE
THINK ABOUT
HEALTH SYSTEMS
DELIVERY

13. TO CREATE
LOCALLY OWNED
AND SUSTAINABLE
SOLUTIONS

14. WHAT’S THE BIG IDEA?
Health Diplomacy
& Advocacy
+
Delivery Science
Academia
(Rigor)
Private Sector
(Efficiency)
Community
(Ownership)
National & Local
Government
(Management)
Health systems need all four legs of the ‘delivery stool’
Combining health diplomacy, advocacy and delivery science through academic, civil society, private
sector, & government partnerships.

15. HOW TO DO IT: INTEGRATING
GLOBAL HEALTH DELIVERY
ACROSS KEY SECTORS
HEALTH
DIPLOMACY AND
ADVOCACY!
Constructive
engagement with
ministries of health
and other key
parties to identify
health priorities,
critical
implementation
issues and
barriers to
success.
THE PRIVATE
SECTOR!
!
Harness the
strengths and
networks of
business,
investors and
enterprise in both
the global North
and South to
address the
identified health
priorities in
partnership with
government
ACADEMIA!
Engage across
schools of
medicine, public
health and the
physical and social
sciences to lower
the barriers to
applying the best
science, data
solutions, policies,
technologies and
management
options for in-country
implementation
NATIONAL AND
LOCAL
GOVERNMENT
Draw upon and
be led by
government’s
natural abilities
to convene and
lead health
responses, and
seek to grow
government
ownership
CIVIL SOCIETY &
THE INDIVIDUAL!
Working with civil
society to
address local
health priorities
and needs that
will lead to
programs
focused around
patient
engagement
INTEGRATED HEALTH SYSTEMS DELIVERY

16. WHAT DIFFERENTIATES THE INSTITUTE:!
the four legs of the stool
• A comprehensive perspective of the Institute’s leaders and their networks, grounded on
the premise that the best results are those desired and sought by national and local
governments their stakeholders and citizens.
• The importance of cultural, political and diplomatic forces on healthcare delivery
systems, and have the expertise to address them with professional diplomacy and
analytic rigor.
• A balance of power among:
– Government contributes legitimacy and sustainability but lacks capacity.
– The Private Sector is timely, efficient and contributes hands-on know-how, but has
no desire to share its learnings and create global public goods.
– Academia does capacity-building, rigorous evaluation and shares lessons globally,
but has problems with timeliness, efficiency and hands-on know-how.
– Local Community and Civil Society as key players in the health systems which both
need to be aligned with government and private sector priorities and ultimately will
be involved in the sustainability of any health solutions developed.
• There are many institutions that have one leg of the delivery stool. A few have two legs.
all four legs are are needed to effect transformational change that doesn’t just help one
client but that serves as a model that enables change to propagate.

17. THREE!
RESULTS
FIELD ACCELERATION
RESOURCE ALIGNMENT
CHANGING SCIENCE & PRACTICE

18. KEY RESULT 1:
FIELD ACCELERATION
ACCELERATED IMPLEMENTATION
Reduce the time from engagement to self-correcting and sustaining systems
EVIDENCE-BASED METRICS
Define and implement a framework for evaluation to assess effectiveness as well as
efficiency harnessed by real-time accessible data
RESULTS TO POLICY
Stay in the game with local stakeholders until sustained scale-up

19. KEY RESULT 2:
RESOURCE ALIGNMENT
DONOR ALIGNMENT
Alignment of large funding motors with capacity development and program
sustainability at the local level (government and civil society), e.g. Global Fund ,
UNITAD, WHO, UN system, World Bank, PEPFAR and the Millennium
Challenge Corporation, BMGF, Bilaterals (DFID, Point-7)
INDUSTRY ALIGNMENT
Alignment of strategy with key industry players and the investment community

20. KEY RESULT 3:
CHANGING SCIENCE & PRACTICE
REPLICABILITY
Across individual ministries, rapidly move pilot to scale up across country
KNOWLEDGE TRANSFER
Changes in behavior and funding among other ministries and donors
SYSTEMS BEST PRACTICE
Collate and harvest country generated system tools that may be applied in other settings
LEADERSHIP ECOSYSTEM:
Create a cadre of expertise that may serve as technical assistance resources for the region

21. WE KNOW IT WORKS:
1. Evidence-based acceleration:
Optimizing PEPFAR programs "
by linking expenditures "
to outcomes
73%
Reduction
in costs
Successful task shifting:
More efficient use of human resources.
Significant savings in treatment:
Cost of annual antiretroviral therapy reduced from $1400 per person to $335.*
Massive expansion of treatment:
Over the last 3.5 years, from 1.7 million to 6.7 million people.*
*Ref: PEPFAR 2013 program data

22. WE KNOW IT WORKS:
CASE STUDY RWANDA :
2. Resource alignment
RWANDA HAS DEVELOPED A
SYSTEM THAT RECEIVES
DIVERGENT RESOURCES:
Multiple donors and the Government of
Rwanda apply funds to unmet needs with
one planning process, allowing the
divergent funds to be additive while still
maintaining transparency and auditability.
Sophisticated information systems create
feedback loops that inform decision-makers.
Civil society involvement in
planning and implementation is growing.
RWANDA HAS ACHIEVED:
90% ART coverage
89% PMTCT ART initiation
>85% drop in HIV incidence, 45%
drop in Death
Rwanda’s health budget is:
>90% from external donors
Rwanda’s health budget is:
100% managed by the
Government of Rwanda
They define and prioritize unmet need and make allocation
decisions.

23. Building from what we know works: from key
results to robust health delivery systems (7examples)
A government struggles to equitably improve health outcomes across regions with variable leadership
and diverse economic status. Effective Global Health must bring together diplomatic and delivery
elements:
• Proven health interventions with well understood delivery system requirements and economics.
• Strategies drawn from political science, anthropology, urban planning and business strategies
(through geo-mapping and surveys, combined with cost and health impact projections of targeted
intervention strategies) delivered in partnership between the MOH system and in-country
academic colleague and civil society.
• Proven and stable mobile enabled e-health technologies for diagnosis, monitoring and logistics,
backed by commercial infrastructure and funding.
• Application of market research expertise (real-world consumer analytics to understand supply and
demand failures, and to create and test strategies for improvement).
• Behavioral economics (rigorous academic evaluation of potential societal drivers of the market
failure and consideration of economic incentives, such as pay for performance).
• Quality improvement (promotion and support for quality improvement cycles and management
training).
• Large scale impact evaluation to demonstrate the effectiveness and efficiency of a new
intervention package to improve outcomes.

24. HOW DOES THE WORLD
CHANGE?
3. Changing science and practice:
The backbone of an effective Global Health model uses innovative programs based on
existing technologies and interventions that work with communities and a strengthened
healthcare referral system. !
Innovation Through Delivery

25. TEAM |
SOLVING
PROBLEMS
TOGETHER
AN INTEGRATED TEAM
An integrated vision needs more than public health expertise. We are assembling a world
class team of experts from across public health, industry, investment, communications,
appropriate technology, policy and diplomacy, collaboration and innovation and are linking
to local efforts.

26. GETTING IT DONE
Determinants of Performance

27. Objective:
Institute for Global Health
Delivery and Diplomacy
24 MONTH OBJECTIVE | DEMONSTRATION
Build a model demonstration laboratory

28. PLANNING TOGETHER
A DIFFERENT BUSINESS PLANNING APPROACH…
We are proposing a collaborative business planning process, working together
with foundations, multilateral partners, government ministries, communities,
corporations and NGOs to understand what a truly integrative process would
need to look like to succeed.

29. PLANNING
TIMELINE
4 Months
18 Months
Design
Feedback
Systems
KEEP
PLANNING
THROUGH
BETA
Take
the
integrated
delivery
model
into
two
test
countries
where
we
have
relaLonships
with
ministries
[Ethiopia,
Kenya,
Uganda,
Rwanda
and
Zambia].
Take
on
one
or
two
medical
condiLons
and
gather
iniLal
data
on
effecLveness
REPLAN
Use
the
year
one
beta
phase
as
data
to
re-­‐engineer
the
parameters
of
the
insLtute
Evaluate
for
Impact
Design on
Demonstrable
Success
SYSTEM DESIGN
Engage global
stakeholders from
across the system to
understand needs
and co plan the
institute
24 Months
A ROAD TEST TO REFINE OUR MODEL
24 Month Process

30. FINDING A MODEL
MODEL EXPLORATION:
The proposed collaborative business planning process has resulted in a flexible
model. Opportunities exist for traditional research institute funding as well as
hybridized business models downstream including consultative services to
national governments and donors. The plan will be refined with partners during
the first phase of planning.

31. COLLABORATORS…
INTEGRATION DEPENDS ON COLLABORATION
This work will require a variety of specialized partnership ecosystems – at the
local, national and international levels.
Partnerships will straddle industry, government, communications, public
relations and civil society, however we expect that specific partnership needs
will be emergent based on the business planning process. We have
developed a sophisticated partnership engagement process for both planning
and implementation.

32. PARTNERS
UNUSUAL PARTNERSHIP EXPLORATIONS:
We have already begun a series of partnership explorations including partners from
multiple schools (UCSF, UCB SPH, UCSD, UCLA, UCD) and academic disciplines
as well as institutional partners that include the WHO, UN, The World Bank, Clinton
Health Access Initiative, Bloomberg Foundation. ELMA Foundation the Governments
of Kenya, Uganda, Ethiopia and Rwanda.
We have made a commitment to DESIGN FIRST and understand partnership needs
based on a more evolved set of objectives and outcomes.

33. OUR INITIAL
CONSORTIA OF
INTERNATIONAL
PARTNERS
• Zambia
• Ethiopia
• Rwanda
• India
• South Africa
• Malawi
• Zimbabwe
• Uganda
• Kenya

34. Acknowledge
the
ContribuLons
• Nancy
Padian
• Stefano
Bertozzi
• Diane
Havlir
• Monica
Ghandi
• Charles
Holmes
• Elvin
Geng
• Jeff
Hamaoui
• Michael
Kleeman
• Todd
Khozein
• Eliah
Aronoff-­‐Spencer
• Deborah
Von
Zinkernagel
• Anthony
Fauci
• Amy
Lockwood
• Jaime
Sepulveda
• David
McKey
• Julia
MarLn
Improving health and reducing inequities worldwide

35. THANK
YOU
Eric
Goosby,
M.D.
Professor
of
Medicine
Global
Health
Sciences
PosiLve
Health
Program
SFGH/Wd
86
UCSF
School
of
Medicine
Eric.Goosby@UCSF.edu
+1
415
476-­‐5483
Improving health and reducing inequities worldwide