By Cheryl Dahle
Sometimes the best solution for a problem is the simplest: Each year more than 57 million women give birth without assistance of a health care worker, usually at home. About 1,600 women die each day from childbirth and pregnancy related complications, a substantial proportion of which are due to infection. To help women give birth more safely, PATH, a Seattle-based nonprofit that promotes health in the developing world, created clean birthing kits. The kit, small enough to fit into a box the size of a deck of cards, includes a plastic sheet for a delivery surface, a sterile razor blade to cut the umbilical cord, and hand soap. In use since the mid-90s, the kits have proven to substantially reduce post partum infection and have sold in Nepal alone at the rate of more than 1 million kits per year.
PATH's solutions can also range to the high-tech end of the spectrum. One of its current projects is a "lab on a card" invention that puts all of the diagnostic power of a multimillion-dollar medical lab on a piece of plastic the size of a credit card. Once in use, the technology will allow clinics in far-flung rural areas to diagnose the cause of fever or diarrhea within hours, rather than days-ensuring prompt, appropriate treatment.
Dr. Chris Elias, president of PATH, has spent most of his career in the sphere of inventing, adapting and implementing health strategies in the developing world Knowing which types of solutions are culturally appropriate, as well as logistically and medically feasible, is a major part of the challenge that PATH faces. When is a simple solution the best and when does a problem require sophisticated technology?
Under Dr. Elias' leadership, PATH's annual budget has more than tripled to reach $132 million, and the number of staff has increased by nearly 50 percent to about 450 worldwide based in 23 offices in 14 countries. Since he joined PATH in 2000, Dr. Elias has honed a sense of what works-and what doesn't-with regard to health in the developing world. Below he shares some of his insights about how donors and investors can create real impact in this vitally important field.
CM: One perception around health in the developing world is that there is a lot of money given that isn't always well spent. What is your sense of how this field has evolved and how efficiently it uses resources?
Elias: It's a question of the level of analysis. I don't think it's appropriate to ask the question of whether or not it's efficient at the global level. It's really about a project-by-project determination. PATH recently held a seminar on how to address corruption in developing countries. There's corruption in developing countries and there's corruption here in the U.S. A lot of the ways we address corruption are the same. It's about having clear plans and deliverables.
I recently met the head of a foundation who asked me how you make sure the resources you've deployed are used correctly. Our experience is that in even the most corrupt countries, you have to find the honest technocrats. These technical people work in low-paying jobs to try to better the health of the people in their country. They are even more upset about the corruption than external people. We would ask them, how do we manage this? They'd say, "We need to have a detailed plan and detailed budget. Then I can go to my boss and say they budgeted every $3 so we have to follow the budget or else they will pull out."
Of course, this approach only works if you collaborate to define realistic project plans and budgets in the first place. In response to my sharing this strategy, the foundation head told me about an episode of The Sopranos television show, where two of the mafia's guys go into a coffee house and ask for protection money. The clerk says, "Seattle will know if I misplace a single dollar." They threaten to break his legs. He says, "You can break my legs, you can kill me, but tomorrow there's gonna be a new guy in here with the same system." Then the mafia guys walk out saying, "Damn technology!"
It's the same theory at work in both scenarios, one real, one fictional: how do you build systems of transparency at a project level? That's the right level to ask questions about efficiency. So if you're going to invest in a project, how do you ensure efficiency? I would encourage funders to ask these questions about the specific projects they support. Asking the question on a macro level is just like asking, "Can we make a difference?" Of course we can.
Whether we'll be able to change things overnight is a different question.
CM: Two common lenses for choosing how to invest around this issue seem to be A)What approach gives you the biggest bang for your buck? and B)What's the most pressing problem? What's your take on those two lenses and their usefulness for a philanthropist?
Elias: Well there are two issues. One is, is the size of the problem important? Obviously yes. But only funding things that address big problems is insufficient. If you take disease burden and look at what kills people- AIDS, malaria, tuberculosis, diarrhea, etc.-you can quickly come up with 8 things that represent 80% of what kills people in the world. River blindness will not make it on that list because it affects a small part of a not populous part of the world. But our ability to eliminate this disease in communities that suffer from it is tremendous.
You wouldn't want to miss the opportunity to eliminate a disease because of an over-emphasis on scale. So, yes, you need to look at the size of the problem, which should inform your decision. But the cost-effectiveness of the intervention also should inform your decision. If you have a highly cost-effective intervention for river blindness, you should be using it, almost regardless of the size of the problem.
Another issue is the trajectory of the problem. A good example is diabetes. Look at the projections around diabetes in China. PATH doesn't currently work on diabetes, but I have no doubt that we will be in 2025 because it will be one of the most common health problems in the developing world. So the question is, when do we start? There are problems coming, whether it's pandemic flu, diabetes, or injuries. As we solve some of the communicable diseases, other problems emerge.
How fast is a problem like diabetes developing? You don't want to wait until 2025 to start working on it, but rather when you detect the trend that this is going to become a big problem. You have to balance trajectory with cost of intervention and with size of problem. I resist the idea that there is just one measure of importance.
CM: Would you recommend that individual philanthropists, or someone with a small family foundation try to piggyback on some of the investments made by the larger foundations in this area?
Elias: My main piece of advice is that they should do what they are passionate about. If I was head of a family foundation and I read about malaria and was passionate about that, I would start by looking at the bigger organizations also interested in solving the malaria problem because I can't afford to do all the diligence myself. I wouldn't defer completely to it. I'd then want to look at the organization and do my own diligence, meeting the people, getting a sense of who they are to reassure myself. It would be an opportunity to harness the work that these organizations have done.
But often, the opportunity to leverage works in the opposite direction. We have had projects we've begun with small, modest support from family foundations and then used those proven pilots to bring in bigger donors. The best example is cervical cancer prevention in the mid '90s. It wasn't a priority for major funders, so we couldn't find support. We used small foundation and individual funds to do small, pilot projects to show that we could make a big difference in cervical cancer prevention. That work eventually led to a $50 million grant from the Gates Foundation. That would not have happened if we had not been able to do some preliminary research with support from small family foundations. Conversely, I wouldn't avoid an area because the major big donors are funding them. I would ask, "What are you going to do with my resources that is catalytic or that you can't do with the large foundation money?"
CM: It sounds as though the unique opportunity for small to mid-size donors is to fund really groundbreaking innovation.
Elias: Exactly. This is particularly true because of the way much development assistance funding works. Funding innovation is not a "safe" thing to do. Congress likes implementation of proven solutions, generally. Being able to show that something is working at a pilot phase is often a critical requirement for being able to attract larger funding from the government. At PATH, we talk about "innovation capital." The reason we're talking to individuals and family foundations is that they give us our innovation capital. It gives us flexibility to do new things without waiting for larger foundations or governments to fund them.
CM: What are the common pitfalls that you see investors in this space falling into?
Elias: People expect too much too soon. A lot of these problems are big and complex. The one thing I can say with confidence is that there are no magic bullets. We have hopes for simpler solutions, but the reality is that we are dealing with a complex global system influenced by geopolitics, trade, etc. Resist the temptation to think that you can go in and change it in six months. You have to match expectations to the complexity of the problem and solutions.
Another common pitfall is the unrealistic need for attribution-asking, what is my $200,000 doing, when that money is part of several different funding streams meant to change a complex system. That motivation drives people to do projects more isolated from the system just because they are measurable. They say, "I can't get my mind around health systems changing in Africa, so I'm going to put my money toward one child or one community." But how much of a difference does that strategy make? Is it sustainable? I think the solution is complex and if you need to know exactly what your contribution is achieving, you've set a difficult and ultimately limiting bar.
Also, there is a cultural arrogance that we can solve problems by finding obvious solutions that people in developing countries have just been overlooking. What I often see happen is that people, particularly those who have been successful in their own careers or businesses, assume that they can drop into another complex business and fix it.
What you have to understand is that our business is just as complicated as yours and the lives of the people we are trying to help are even more complicated than yours. You have to respect that. Going in and telling people what to do isn't going to help. That's how a lot of money gets wasted. Success necessitates having a respect for the people and the culture that you're trying to interact with. You have to understand that most things they can do, they've tried already. Part of the problem is the way we frame international aid as being about people waiting for our charity. That is not what's happening.
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