India’s frontline health workers and surveillance infrastructure that helped eradicate polio will strengthen primary healthcare and scale up Ayushman Bharat, but the world needs far more preparedness against a fast-moving airborne pandemic, said Christopher Elias, president of the Global Development Division, Bill & Melinda Gates Foundation.
Do you think Ayushman Bharat will work?
India like every country has expressed the aspiration for universal health coverage (UHC). The foundation of UHC is primary healthcare. So how do you build a primary healthcare system? India actually has a pretty good start. India has one of the largest per capita number of frontline health-workers with the Ashas (accredited social health activists), anganwadi workers and ANMs (auxiliary nurse midwives). Between the ministry of health and the ministry of child development, India already has a very strong primary healthcare system. Like all primary healthcare systems, it needs to be strengthened.
UHC has two components. One is the protection from financial ruin if one has a life-threatening illness, the second is the widespread access to primary and where necessary, secondary and tertiary healthcare of good quality and affordability.
I’m excited about Ayushman Bharat. It is obviously a relatively new initiative but an exciting one in that it addresses both financial protection as well as strengthening the primary healthcare system. Building on what I think is a good start and good frontline-worker access of most of the communities in India. If you can then strengthen the primary healthcare system through Ayushman Bharat, at the same time that you are providing financial protection to families from significant illness that might require secondary/tertiary care.
It is early days and it has had a rapid expansion in the first 100 days to reach quite a few people but it has an ambition to reach a lot more. And as with most things, as it proceeds, it will learn where it needs to adapt and strengthen. We are supporting the Aushman Bharat initiative and we are very happy to be doing that and we are also very interested to see how we can be technically engaged to make it as big a success as possible.
Is India on course to achieve UHC?
Yes, you are headed in the right direction. You are not there yet, very few countries are. But you are addressing the key factors. Protection against financial run and strengthening a system of care that emphasises primary healthcare, that’s the right direction to head in. It’s a long road, it’s sometimes a bumpy road, but are you headed in the right direction? Yes.
How important is data in public health?
In big countries like India, there is tremendous diversity in disease burden across the different states and territories, as is true in most large countries. Action to improve public health is typically taken at a local or state level, so knowing the disease burden state by state is actually quite important.
We found that not just for the burden of disease but even for FP2020 (global partnership in rights-based family planning). The performance monitoring and accountability for the PMA2020 work started out with national periodic assessments every six months to 12 months. This was then increased to get sub-national data because that is where decisions are made to drive family planning programming as well as disease control efforts. You have to know what you are trying to deal with.
How can India keep up its universal immunisation (intensified Indradhanush) momentum, given that there is no endgame, like for polio?
There is no endgame but there is a clear goal, which is 90% plus universal immunisation coverage for basic childhood vaccines. If you can get high enough coverage, you can create a herd immunity that prevents transmission even in those few who are unimmunised. If you don’t have coverage, you get outbreaks of infectious disease.
So I think there are a couple of components. There is good evidence from intensified Indradhanush programme to both increase the coverage level as well as provide the platform for the introduction of new vaccines. The number of new vaccines that India has introduced in the last few years is unprecedented – the MR vaccine, pneumococcal vaccine, rotavirus vaccine, injectible polio vaccine, the switch from trivalent to bivalent polio vaccine… What mission Indradhanush has done is build a strong momentum in the immunisation field so it can both increase coverage and introduce new vaccines.
I remember at the beginning of my career when we would introduce a new vaccine, we would worry if we would actually have coverage go down because we distract people (with too many vaacines). But what Mission Indradhanush has done is build a strong momentum in the immunisation field so it can both increase coverage and introduce new vaccines. An effective vaccine delivery programme does a few key things.
One is keeping up that momentum. There are a couple of elements to it. The first one is strengthening the logistics and cold chain the adoption of the e-vin system for understanding when the cold chain may be failing and having logistics to support that cold chain reaching everywhere, and not just the easy places. The other is good vaccine-preventable disease surveillance. India’s significant achievement, as you know, is that it’s been eight years this month since the last case of polio in the country. To achieve that historic achievement the National Polio Surveillance Programme (NPSP) was built up. India has probably the largest and most effective polio surveillance programme in the world. Since polio’s gone, there’s been a repurposing and broadening of focus of the NPSP to look at broader vaccine-preventable disease surveillance.
The other is the challenge of a successful immunisation programme and that is people forgetting what the benefits are. Because it’s prevention, and people don’t see prevention. People forget that if we don’t have this immunisation coverage we would have measles outbreak, we have other outbreaks – we have this problem in the US, including in my home state. Having a good vaccine preventable outreach programme is a key part of strengthening the outreach.
To get full immunisation coverage, you have to reach the most remote places. The remote places are the hardest places to maintain – there is the culture challenge, having modern cold chain equipment, modern monitoring techniques like the e-vin system is a challenge — so that you can know if there is a refrigerator that is not functioning, and that the vaccine supply is at risk etc etc. Those are some of the key components of sustaining that momentum.
Does India’s universal immunisation programme include all the essential vaccines?
You have to potentially looking forward to new vaccines. There are new vaccines in development, there are some that have been recently registered for diseases like cholera and typhoid, both of those vaccines are made by Indian manufacturers, The first pre-qualified vaccines for cholera and typhoid are Indian-made vaccines that are now available to the world. Generally they have been used in places where there is significant disease burden, so that’s where again the vaccine-preventable disease surveillance lets you know where you need these more targeted vaccines.
What can be done to strengthen routine immunisation?
There are some vaccines that may be more broad-based and the Gates Foundation is supporting some research and development on vaccines for maternal immunisation. For instance, one of the most common causes of serious neonatal infection is from respiratory syncytial virus, it happens in very young children, before the children can be immunised.
We are looking at whether it will be possible to develop a vaccine to immunise pregnant women to protect their newborns from this common respiratory infection. That vaccine is not available yet, but if the research pays off, like we hope it will, it may be in a few years that we have a vaccine that you would introduce into the maternal immunisation. India has very high ante-natal coverage, so you can potentially do that with an influenza vaccine as well.
So thinking about how the primary health system platforms can be used to bring new vaccines as they come out of the research and development pipeline is another way of thinking about the benefits of the system to not just prevent currently vaccine-preventable diseases but to prepare for new vaccines as they come.
Does India need to add more vaccines to its routine immunisation programme?
The biggest impact will come by expanding the recently introduced rotavirus and pneumococcal conjugate vaccine at the national level. We have seen that these are the biggest life-savers. Two of the most common causes of childhood mortality are diarrhoeal disease and pneumonia. In other countries where we have seen nationwide introduction, we have seen dramatic drops in mortality and morbidity. In the short term, expanding those two recent vaccines and introduction to full national coverage is probably the most likely short-term benefit from expanding vaccine coverage.
Zika and Nipah outbreaks were reported in India last year. How would you rate India’s preparedness for H1N1- and Ebola-like outbreaks?
Post the Ebola outbreak in west Africa in 2014-15, there was an emphasis on increasing preparedness for outbreaks. And one of the mechanism was through an approach was that a joint external evaluation where countries worked jointly with external evaluators to assess their surveillance.
One of the key elements for dealing with outbreaks, particularly of these viral diseases, is having the surveillance to find it quickly, having a system by which people report occurances of diseases as they emerge and having the capability, like you have in the national serology, to quickly analyse and study those viruses and their nature.
The Gates Foundation is part of an important initiative called the Coalition of Epidemic Preparedness Innovation (CEPI), which is investing in new vaccines and other counter measures for important epidemic diseases, like Nipah, like Lassa fever, like Middle-east Respiratory Syndrome. CEPI has made a couple of important investments already in research and development for new vaccines, for Nipah – currently we don’t have a vaccine for Nipah. But in the future, if we have a vaccine for Nipah, if we combine that tool with good surveillance, when you do have an outbreak you will be able to go in and immunise communities quickly and contain it. That’s what we are trying to do with Ebola outbreaks now in DRC and it looks like we now have an effective vaccine we didn’t have back in 2014.
India’s PHC system doesn’t make the cut in Primary Health Care Performance Initiative’s assessment on overall systemic factors, inputs, service delivery, outputs, and outcomes. Why is there so little data available for India?
It’s a major initiative we are supporting with WHO and the World Bank. The idea is to have a tool that allows the managers of the primary healthcare system to have information so they can take the right steps to improve the quality and coverage of their primary healthcare systems.
The unfortunate thing is that most countries – India is not unique – in fact, India is like most countries that don’t have all of that data. What’s interesting is most countries have a good understanding of their inputs. They understand their health human resources, they understand how much money is going in, what vaccines and drugs are going into the system and because of things like the burden of disease, we actually have a good idea of the outcomes. We know the mortality rates, we know what the immunisation coverage rates are etc.
We, as a global community, and this is most countries and development partners, have not actually been collecting data of what actually happens in the system. We know what goes in the system, what comes out of the system in terms of result but we haven’t actually invested in most countries in understanding what is in the system – what are the components of quality of care, what are the components of service delivery and that what’s the Primary Health Care Performance Initiative is meant to do.
We worked with the World Health Organization and the World Bank to create a framework and we launched it just a couple of months ago in Kazakhstan. We have 12 countries who had enough data to have at least three of the four dimensions of the scorecard completed. Very few countries have that.
What we’re hoping to do is create a framework that provides countries an opportunity to countries to see if they collect the data, they will have a dashboard that they can use. We were a little bit surprised when we put the dashboard together on how few countries actually had the data to complete it.
I think in the context of the priorties for primary care and Ayushman Bharat, it would be a great opportunity for India to look at the Primary Health Care Performance Initiative, look at what the data requirements are and to actually begin to collect some of that data.
Have you discussed this with anyone in India’s health ministry?
I didn’t, I’m on a very short visit, but it’s a good idea for a discussion.
Is India’s family planning programme on course?
India has one of the oldest family planning programmes in the world and it reaches a fairly high contraceptive prevalence rate. But what we do know that the best family planning programmes actually offer women and their families a wide range of choices. The recent step to introduce an additional range of contraceptives in India is actually quite important. It’s not as easy as it sounds. You have to get them and make them available etc, there are supply issues. But one of the most important things is to provide counselling, so women are aware of what the benefits, the shortcomings and the side effects of a new contraceptive method. Otherwise, you start a new contraceptive method and they start to quickly discontinuing it because they didn’t understand the side effects. So, (what is needed is) creating the counselling and the continuity of services for women for using a new method or switching to a new method if that method doesn’t work out for her.
The family planning we support globally through FP2020, we’ve been collecting a lot of data to understand where we are making progress and where we are not, and who is underserved and who’s well served. In most countries, including India, there is a need for a more concerted effort to reach young people. And this relates to some of the other priorities of the Indian government.
We know that if you want to further reduce child and maternal mortality and to reduce the levels of stunting, for instance, women ideally need to be able to space their pregnancies and in general — and this is not just in India but in many countries — reaching young populations with services they are comfortable accessing and are willing to go to and understand etc.
I think India has a strong family planning programme but like primary healthcare, it could be stronger. And the ways to strengthen it would be to focus on high quality introduction of new additional methods — like India has begun with the injectables and other methods — as well intensify efforts to reach young people who are interested in spacing and not just limiting the number of pregnancies they have.
In family planning, which countries are doing better than India, and which are doing worse? Like the US, may be?
Some of the fastest progress we have seen in terms of increases in contraceptive prevalence is in west Africa, where it was very low. We’ve seen significant increases in Kenya, in east Africa, where the political commitment to make family planning services affordable and accessible has resulted in meeting a lot of the demand that was previously unmet. Myanmar had fairly low contraceptive use but once they provided services, there was a lot of demand that led to significant increase and rapid progress. In India, where contraceptive prevalence is fairly high, you can make incremental progress.
What will be the next big public health challenge for the world?
Can I give you two? One is what I’d call the certain and slow challenge, which is the rising incidence of NCDs (non-communicable diseases). Partly because we are succeeding in reducing the burden of disease from communicable disease both proportionately and in absolute terms, the rates of non communicable diseases are rising and that’s true for hypertension, diabetes, asthma etc. As people live longer, chronic diseases and NCDs become more prevalent. This is reflected in the Global Burden of Disease data that there’s a increasing burden of NCDs.
The best way to deal with NCDs is primary healthcare. It’s not an easy onetime fix. You need preventive and promotive treatment which is best provided through the frontline workers, through the primary healthcare system. If you don’t address the NCDs in a strong primary healthcare system, you are going to pay very expensive costs to manage the outcomes, such as kidney failure, in the tertiary healthcare system. The steps India is taking to already strengthen its primary healthcare system are the critical steps to take in terms of addressing in what is a certain but slow onset and steady rise of NCD.
The second is a less certain and more acute risk of a significant airborne pandemic. Every since the Ebola outbreak 9in east Africa) four-five years ago, we have been focused on the preparedness for haemorrhagic fevers like Ebola or other viral diseases like MERS, Nipah or Lassa fever. Those are challenging, but they are not airborne.
But if we were to see today an outbreak like the world saw a 100 years ago with the Spanish Flu, we are not prepared. Not just India, United States … nobody is prepared for a fast-moving airborne high fatality epidemic. We as a global community need to think about. A 100 years ago, in 1918, the Spanish flu spread quickly around the world. That was before we had planes. Imagine how quickly it would spread today. The closest thing we saw was the H1N1 outbreak in 2010 and that was in eight countries before we knew we had a pandemic.
In the 20th century, we had three pandemics of influenza, so far in the 21st century we’ve had one. Fortunately that was a mild one. When we have a severe influenza pandemic, the world is not prepared in terms of the medical infrastructure, it is also not prepared in terms of the policy infrastructure vis a vis transportation and trade. We have a completely trade-dependent world right now. Do ships stop going? Do supply chains stop?
There were some worrisome signs that we saw (in previous outbreaks). Like in 2014, in west Africa, in the face of the Ebola outbreak, certain countries closed their borders, didn’t let farmers sell their produce. If that was the response in a non-respiratory outbreak, what’s the world’s response going to be to a large air-borne pandemic influenza outbreak?
We need to start modelling it, actually start practicing it, get senior officials in health and others to think through and do these table-top exercises and simulations to see if this happens, what do we do? Do we close the borders? Do we quarantine the ports? And we get the right medical counter measures developed. One of the things I mentioned is CEPI, which is investing specifically in Nipah, Mers and Lassa fever, they are also investing in they call their “just in case strategy” and they are investing in “just in time”.
Some of the most exciting work is platform technologies that take on a completely new virus, rapidly understand its genetic structure and develop counter measures very quickly. So you have research and development in new drugs and vaccines that aren’t specific to an individual pathogen, like Nipah or Lassa, but are actually built to be potentially applied to any virus that emerges because we know, based on the history of the 20th century, that we are likely to see a big influenza pandemic some time in this century.
There are all kinds of things we didn’t know about. We didn’t know about HIV till it emerged, we didn’t know about Ebloa too, we didn’t know about Nipah 20 years ago. We knew about Zika but we didn’t know it had potential for serious outbreaks till a couple of years ago so we have to be ready for the completely unknown, something called pathogen X.
There’s a perception that the Gates Foundation influences policy at the World Health Organization (WHO). Does it?
We are an important partner with the World Health Organisation and we provide significant support, both to specific projects as well as some flexible support to strengthen the institution. It’s important to recognise the governing structure, we are not part of the governing structure of the World Health Organisation, (which is) the World Health Assembly (WHA), which comprises the member states that set its programme of work. The last WHA endorsed the global programme of work 13.
The way we approach our collaboration with the World Health Organisation is we look at what the member states have said they want to achieve, what they want the World Health Organisation to do and we say, where’s that in line with our strategic focus and how can we help? So, we’re strong technical partners, we provide both financial assistance, technical assistance, we have seconded some of our staff to the World Health Organisation, as member states have as well.
In terms of the agenda, I’ve actually challenged some of the sceptics. I’ve given them the list of all our grants to the World Health Organisation and said, show me one grant that isn’t in the programme of work and I’ll cancel it. Just show it to me. And no one has showed it.
Sometimes I turn the criticism around. The member states, the governing body of the WHA gives the World Health Organisation a strong mandate and they fund about 25% of that mandate with the cess contributions.
The WHO depends on groups like the Gates Foundation and others for voluntary contributions for 75% of its budget. So as long as the WHO is dependent on raising 75% of its budget from other than the cess contribution of the member states, it’s gonna have to work with groups like us. And I think it should.
At the beginning of this week I was in Pakistan with the DG of the WHO, I’d just finished my two-year term as the head of the polio work, and I turned over the chairmanship to Dr Tedros (Adhanom Ghebreyesus), the DG (the director-general of World Health Organisation). As the first thing on both of our agendas, we went to Pakistan, which is final frontier of the polio eradication effort. We think 2019 may be the year we succeed in global polio eradication. India hasn’t had a case in eight years, we are now two and a half plus years since the last case in Nigeria. Last year, we had 29 cases, all of them in Afghanistan and Pakistan. Year before we had 22 cases, all of them in Afghanistan and Pakistan.
Pakistan had eight cases in 2018, it had eight cases in 2017, they have a strong emergency action plan. Dr Tedros and I spent two days in Islamabad meeting with the prime minister, the heads of all ministries, the emergency operation centres to reinforce that this the opportunity for achieving what would be the greatest accomplishment in public health. It will only be the second disease we eradicate in the world after smallpox. There’s an example of how we work together with World Health Organisation.
The resolution to clear polio eradication as a goal was made by the WHA in 1988, long before the Gates Foundation started. So we partner with them to achieve their goals.
We do have a technical collaboration etc but I think it’s not really fair to say we’re setting the agenda because the agenda is set through the WHA, we don’t have a seat there, we don’t vote on that programme of work. But we then look at that programme of work and say, were can we help? In polio eradication, maternal and child agenda, nutrition, endemic preparedness we are deeply engaged in supporting the WHO and its member states in achieving what are the ambitions for global health.
Have you ever said no to a programme?
Sure. We are a big foundation and we say no a lot. We say no to some of our closest partners, governments and the World Health Organisation because we can’t do everything. We have to focus our efforts. But where we have a strategic focus that overlaps with programme of work that member states have set for World Health Organisation, we are very happy to collaborate with them.