Speeding up the Sustainable Development Goals: Innovation
Part 3
The lagging SDGs present a “burning platform” to the world. In health, WHO is working to speed up the health-related SDGs through its 5P strategy — promote, provide, protect, power, and perform for health.
Of these 5Ps, “powering health” addresses directly the question of how we speed up the SDGs beyond ‘business as usual.’ It is about disrupting and then improving systems of data and delivery, innovation, and partnerships. It’s about doing experiments in these areas and then taking them to scale.
My entire career I used innovation to tackle challenges. In the University of Toronto Joint Centre for Bioethics, we developed social innovations in advance care planning to improve end of life care. In Grand Challenges Canada, we have supported 1400 innovations in global health in 100 countries. In WHO, we conducted intra-preneurial experiments on how to power progress though scaling innovation, which are the focus of this blog.
Some lessons learned: First, people closest to the problem are best situated to solve it. This is why two-thirds of the innovations supported by Grand Challenges Canada are developed by innovators in low middle income countries. Innovation can breed self-reliance; it is a powerful tool in the decolonizing toolkit.
Second, innovation can be scientific/technological, social/service delivery, or financial/business (which i call innovative finance below). At the heart of Grand Challenges Canada is the concept of integrated innovation, the “coordinated application of scientific/technological, social and business innovation to develop solutions to complex challenges.” While technological innovation can give you a home run, social innovation can give you doubles and triples — and if you bat enough doubles and triples you can save many lives.
Third, to speed up the SDGs, innovation needs to be at scale, sustainable, and equitable. It needs to be more than a buzzword. It needs to save and improve lives.
Innovation is the path, SDG impact is the destination.
My top career advice for young (and not so young) people is to find a problem and solve it. That’s what innovators do! It’s also what we need to to do here: the lagging SDGs are the problem and innovation is one of the solutions. But the trick is in implementation.
This blog post will describe some promising experiments in innovation that if taken to scale, sustainably and equitably, could speed up SDGs. I have grouped these using the three types of innovations described above.
Scientific / technological innovation
You need look no further than COVID-19 vaccines to understand the life saving potential of scientific / technological innovation. It is estimated that COVID-19 vaccines saved more than 20 million lives.
But COVID-19 vaccine development was a triumph of science and failure of humanity. Vaccine inequity has cost more than an estimated 1 million lives. Helen Clarke has called this is a “toxic legacy.”
To me, the key lesson of vaccine inequity is that people will never be able to fully rely on global supply chains in an emergency. If you want a vaccine or other health product, the best way to make sure you get it is to make it.
This is why I think some of the most important initiatives to come out of the pandemic support local production. Promising experiments are the mRNA vaccine technology transfer hub in South Africa, its network of technology recipients, and the global manufacturing training hub in the Republic of Korea.
Local production can be incentivized by demand, as exemplified by the call by African Heads of State/Government for GAVI to procure African-made vaccines.
Hopefully, equity of health products will be improved by the pandemic agreement currently being negotiated. The agreement could certainly create an enabling environment for innovation, especially with respect to sharing knowledge: intellectual property, technology, and know-how.
But you can’t negotiate the spirit of creativity and perseverance of innovators and entrepreneurs, or establish a thriving domestic innovation system, through an inter-governmental agreement alone.
The opportunity: Imagine if many countries all around the world had thriving innovation systems to tackle their own problems and generate prosperity, jobs, and self-reliance.
My dear friend Abdallah Daar and I, with a group of talented colleagues, spent a decade trying to understand the experiences and lessons of low and middle income countries in building innovation systems to address health challenges. That work seems even more relevant today.
In 2004, summarizing studies of health biotechnology innovation systems in India, China, Brazil, South Africa, Cuba, Egypt and South Korea, we wrote:
The bottom line: seize the opportunity … developing countries can successfully build capacity in health biotechnology to both increase the availability of health products for their populations and provide opportunities for their economic development. …. Developing countries can actively harness the potential of health biotechnology to improve the health of their peoples and thereby reduce global health inequities.”
Similarly, in 2010, summarizing case studies of health innovation in Ghana, Nigeria, Rwanda, Tanzania, Uganda, Kenya, Madagascar, and South Africa, we wrote:
For African nations, health innovation represents an opportunity to increase domestic capacity to solve health challenges; for international funders, it is an opportunity to move beyond foreign aid and dependency. The shared goal is creating self-sustaining innovation that has both health and development impacts.
Summarizing the lessons these case studies in his preface, the late, great Calestous Juma wrote:
The papers draw from experiences in Ghana, Kenya, Madagascar, Nigeria, Rwanda, South Africa, Tanzania, and Uganda to provide a clear view of the elements of the emerging African health innovation system. First, they demonstrate that the emerging innovation systems are driven by local health concerns and not by external interests. Second, the case studies underscore the importance of investment in research and development (R&D) and the generation of solution-oriented knowledge. Third, the essays demonstrate the importance of creating incentives and building institutions that can help to facilitate the commercialization of research results. Finally, the case studies show that Africa’s health innovation systems are integrated into the global knowledge ecology and benefit from extensive international partnerships.
In 2010 we also identified in 25 ‘stagnant’ health technologies (technologies that have been developed or are being developed, but have failed to attain commercialization) in Africa and studied the reasons they stagnated:
The cultural mindset of scientists and domestic and international policy-makers whose focus is not commercialization. As in the rest of the world, academic researchers are typically judged by publications rather than economic impact or lives saved.
Lack of institutional mechanisms to sup- port further validation and subsequent commercialization exacerbates the problem. For example, there are few “innovation funds” to support proof of concept and prototype development
Other barriers identified by researchers included poor government and institutional policies to support commercialization, inadequate or poorly understood intellectual property regimes, regulatory bureaucracy, and user perception favoring foreign products.
In 2012, summarizing studies of health biotechnology companies in India, China, Brazil and South Africa, we wrote:
… recent developments in the emerging markets have the potential to change the global drug development model itself, with a promise to making it more productive and accessible. It offers the possibility for more cost-effective innovations and significant impacts on health systems everywhere.
The challenge is to make domestic innovation a reality around the world, at least at the regional level.
Social/ Service delivery innovation
This child is receiving oxygen through a solar-powered concentrator – an innovative solution that can save lives in places with frequent power shortages, such as this hospital in Somalia.
Pneumonia accounts for 800 000 deaths per year of which 20-40 % could be saved with oxygen, and COVID-19 has accelerated global demand for medical oxygen.
Between February and March 2021, solar-powered oxygen concentrators were installed in a regional children’s hospital in Galmudug state, Somalia. This innovation pilot has already saved hundreds of lives, and it is being scaled in Somalia.
It’s an example of what can happen when a mature innovation in the pipeline of an innovation funder is matched with demand from countries through the WHO country office.
In innovation, demand matters because you can’t push a string.
We tried to picture this system below in the WHO Innovation Scaling Framework.
The greatest challenge in innovation is scale and sustainability. I have looked though both ends of this telescope. What I saw at Grand Challenges Canada was a pipeline of more than 1000 innovations with about 10% ready to go to scale. What I saw at WHO was a platform of 150 country offices with trust between government and WHO that could connect these innovations to national health system priorities.
The opportunity: Imagine if the pipeline of innovation funders could be combined with the country platform of WHO to create scale, sustainability and equity.
The promising experiment is the WHO Innovation Hub, which has begun to apply the innovation scaling framework not only to solar powered oxygen but also to innovations in mental health and primary health care, for example in support of scaling the Friendship Bench in Zimbabwe which provides culturally adapted cognitive behavioural therapy delivered by grandmothers on a park bench.
Other examples include SEEK Group Psychotherapy in Uganda which has reached 20,000 people, or Blue Box Clinics, which set up primary health care along trucking lines to reach sex workers and others, reaching more than 100,000 clients in 2019.
To move the needle on the SDGs, innovations need to reach millions of people. But just imagine if this system was extended to 10 innovations, or 20, or 30. And WHO country offices helped them to scale. Then we start to accelerate progress on the SDGs.
To get things started, Dr Tedros proposed that WHO help to scale 5 innovations to 5 million people each in 5 years.
The challenge is the same as the opportunity: to link pipelines of mature innovations with country demand so these innovations can achieve impact at scale and move the needle on the SDGs.
While lessons learned across innovations are important, it’s not always easy for an Organization with a culture of promoting norms and standards to focus on specific innovations.
Other multilateral agencies can also play an important role or work together in scaling innovation, as this excellent report by a student group shows.
Innovations scale one at a time, depend on social entrepreneurs to scale them, and you don’t need many innovations to make a big difference.
Innovative Finance
Since the beginning of the SDG period the need for new approaches to finance has been clear, as recognized in the Addis Agenda on Financing for Development, led by Dr Tedros. The trick is to develop and test successful models of innovative finance to speed up SDGs.
However, my main lesson learned at Grand Challenges Canada is that innovative finance is hard: success is variable with potential risk and high transaction costs.
At Grand Challenges Canada, we made an anchor investment in the Global Health Investment Fund. This was successful, both financially and in terms of social returns.
For example, one of the portfolio companies successfully commercialized a cholera vaccine, which is helping with the cholera vaccine shortage. The company also had an IPO on the Korean stock exchange.
Other approaches had more mixed results. We made direct investments into innovative companies, attempted to engage individual investors in financing innovation, and developed a a social impact bond for Kangaroo Mother Care.
At WHO I had the pleasure of serving as the liaison to Ray Chambers, who is WHO Global Ambassador for Health Financing. Ray has had a very successful career in investing, and he applied his knowledge and skills to helping WHO think through its approach.
Ray had two important insights that strongly resonated with my own experience. First, that most initiatives in innovative finance were one-offs and therefore not at scale. Second, there was no systematic attempt to layer different forms of finance (domestic government spending, development assistance, charitable donations, concessional public finance, private social finance) into a coherent “capital stack” with each layer providing guarantees for the next.
The opportunity: Imagine if different sources of finance reinforced each other and supported national priorities.
When we reflected on these insights, we realized that in health WHO was in a strong position to be a systems catalyst, linking innovative finance to national priorities, and also different types of finance in the capital stack.
We embarked on a promising experiment by engaging with one Multilateral Development Bank (the European Investment Bank) and we launched pilots to test this collaboration in four countries / territories (Angola, Rwanda, Palestine and Ethiopia). WHO was identifying health gaps in countries and designing strategies for interventions and their corresponding investment plans. The European Investment Bank would invest in such projects, in accordance with their eligibility areas and rules.
After launching these pilots, the EIB decided to allocate 500 Million Euros in long term concessional loans to African countries for Primary Health Care, alongside funding for WHO country offices to help governments shape the funding.
WHO is now looking to develop a global platform to support Primary Health Care and to engage more multilateral development banks in the model.
The next stage would also bring in private investments for social impact.
This model addresses the issues Ray had described. It could be brought to scale across regional development banks and it could link public and private finance in the capital stack.
The challenge is mounting public debt. But debt is not inherently bad — it’s how it is used.
Recognizing this challenge, the UN Secretary General recently issued this call to action: “The high cost of debt and increasing risks of debt distress demand decisive action to make at least $500 billion dollars available annually to developing countries and convert short term lending into long term debt at lower interest rates.”
Investing in Primary Health Care is cost-effective for a country. What does not occur is monetizing the gains in productivity. This would be the most direct way to address debt: pay it back.
One thing is for sure: without new sources of finance beyond development assistance, and better synergy between tranches in the capital stack, the world will not reach the SDGs.
Meet WHO Colleagues
If innovation is a team sport, Louise Agersnap, who leads WHO’s Innovation Hub, is team captain. She networks with innovation funders, WHO collaborating centers, and across three levels of the Organization. Our wise WHO colleague Moredreck Chibi has long promoted innovation in the African region with a strong emphasis on sustainability. There has also been great support for innovation from WHO Country Representatives, such as in the case of Somalia, our talented WHO colleague Dr Mamunur Malik.
Kenza Zerrou leads WHO initiatives on innovative finance. I am not sure I have ever seen someone at mid-level in a large Organization make a bigger difference. She has been a remarkable leader.
Conclusion
Like Delivery for Impact, innovation is a strategy to speed up the SDGs. But only if it is at scale, sustainable, and equitable. The key is what we do now to implement: I believe the promising experiments described here can help show the way.
As a complex system, innovation requires partners — including funders/investors, countries, and multi-laterals — to work closely together, and WHO has an important role to play in catalyzing innovation in health. In the next post in this series, I will address another way to speed up SDGs: partnerships.