Offline: How to fail well in global health

I am an expert in how to destroy global health initiatives. It is a strange fact that I witnessed firsthand the demise of three promising organizations that sought to advance health in low-income settings: the Global Forum for Health Research, the Health Metrics Network and the Independent Expert Review Group on Information. and Accountability for Women’s and Children’s Health (iERG). All three died of multiple causes. With such a dismal record, it was no surprise that the new head of a world health organization made it clear, not entirely joking, that he would never consider me on his board. Yet failure is useful currency that must be spent wisely. What lessons can be learned from sifting through the ashes of these valiantly unsuccessful global health programs?

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The Global Forum for Health Research was established in 1998, largely with funding from the World Bank, and has campaigned to reverse the “10/90 gap” – only 10% of research funding in health have been invested in settings where 90% of preventable deaths have occurred. It produced valuable reports on the progress of investments in health research and held an annual meeting which served as a platform for the promotion of health research. The Forum was an important voice in global health. But it existed in a competitive landscape. The Council on Health Research for Development (COHRED) had overlapping interests. And the creation of the Forum prompted the WHO to strengthen its own role in promoting health research, which led to the influential 2004 Mexico Declaration on Health Research, accompanied by a landmark report, Knowledge for better health. The Forum merged with COHRED in 2010 and its work crumbled. The Health Metrics Network was a partnership primarily funded by the Bill & Melinda Gates Foundation and established in 2005. The network’s goal was to strengthen countries’ health information systems. A secretariat is based within the WHO in Geneva and an Executive Board guides the strategy. The initiative got off to a good start, launching a framework and standards for health information. A WHO resolution followed. But again, there was perceived competition between an independently funded entity and the WHO. Rivalries flourished and eventually became shockingly personal. Donors withdrew their support. Personnel changes failed to resolve the crisis. The Network was finally buried in 2013. The iERG emerged from the 2011 Commission on Information and Accountability for Women’s and Children’s Health, chaired by President Jakaya Kikwete (Tanzania) and Prime Minister Stephen Harper (Canada). Its aim was to track commitments to women’s and children’s health and to hold those in power accountable for their promises. We have produced four annual reports (2012-2015) and presented them annually at WHO/UNICEF sponsored side events at the UN General Assembly. The iERG evolved into a different organization after 2015 and I think it’s fair to say that the influence it had gradually diminished to extinction. Participation in these initiatives has exposed the unpleasant realities of how global health is practiced today. How those who support global health initiatives manipulate programs, individuals and governance structures by threatening to withdraw funding for crucial work. How multilateral organizations have such thin skin and such precarious characters that they can’t stand anyone else interfering in what they consider their exclusive territory. And how the titans of global health profit from generous spending and reimbursement policies for personal gain.

Photo taken on March 30, 2021 shows an exterior view of the WHO headquarters in Geneva, Switzerland.  (Photo by Chen Junxia/Xinhua via Getty Images)

I draw several conclusions for those who are doing their best to guide initiatives in this perilous global health landscape. Be ruthlessly clear about your purpose (avoid company vision and mission statements). Understand your comparative advantage. Be original. Challenge the consensus. Ask tough questions. Surprise your audience. Pivot quickly to seize opportunities. Take risks. Hire people smarter than you. And remember five uncomfortable facts to stay alert. First, your board is still only one meeting away from firing you. Second, never trust your backers – you are just a means to an end. Third, don’t make your host hostile. Fourth, your team is your therapy – take good care of them. Finally, maintain momentum (mass x speed) – a steady stream of products delivered at pace and with direction. One last lesson. Forge your own vision of the world. To be indispensable, do not be a prisoner of the ideas of others. And there lies the ultimate and terrifying reality. No one is really essential.

Headstones are seen at Arlington National Cemetery on October 20, 2022 in Arlington, Virginia, USA.  (Photo by Beata Zawrzel/NurPhoto via Getty Images)

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