Opening Gates magazine | 1st Edition, 2017

OPENING GATES 1st edition |2017

WHY

WE GIVE Bill and Melinda Gates speak about their approach to philanthropy

THE IMPORTANCE

OF A GOOD IDEA The foundation's take on innovation

WHAT WOMEN

REALLY WANT Why we need the data to make decisions

Zebiba Yusuf holds her healthy six-month-old child, Moaz Behari, as her other children stand beside her. Silte, Guraghe Zone, Ethiopia.

2

OPENING LETTER

Inside Gates

We put this publication together because we heard from some of you, our Africa-based partners, that we don’t communicate clearly enough about the foundation’s work – and this sometimes makes it harder for you to do your work. We are serious about being transparent about what we do and why we do it in ways that make sense to you.

Welcome to Opening Gates.

Bill and Melinda started the foundation to advance the cause of equity. No matter where children are born, Bill and Melinda believe they deserve the chance to lead a healthy and productive life. They believe the key to getting this work done is innovation, which you’ll read more about in this magazine.

But promoting equity through innovation doesn’t tell you precisely what the foundation does day to day. To understand that, we need to give you more insight into what the foundation calls program strategy teams, the groups of experts that make grants to tackle specific problems with specific strategies. The magazine provides summaries of the program strategies that are working in Africa right now.

As the Africa director, my job is to help make sure that all the strategy teams in Seattle have access to the ideas, knowledge and people to be successful in Africa. It would be naïve to think they can sit in an office in the United States, invent solutions, develop strategies for delivering them and expect that everything will work flawlessly.

That’s why the foundation invested in having a presence on the ground on the continent. We work with you – with African institutions and leaders – to translate local knowledge about what needs to change, what can change and how change can happen back to Seattle so that the organization as a whole makes better decisions.

Through this magazine, we’re trying to help our Africa-based partners peek behind the curtain of the organization back in Seattle, so that we can all get better results for Africa and Africans.

I hope you find it useful, and my team and I look forward to working with you over the coming year.

Dr Ayo Ajayi Africa Director @DrAAjayi 3

Contents “ TO GO INTO THAT HOSPITAL IS A DEATH SENTENCE!” THE MOMENT THAT TURNED BILL GATES TO PHILANTHROPY

10

SAVING WOMEN TIME

AND HOW MELINDA THINKS WE CAN USE DATA TO DO IT

14

WELCOME 3| PEEKING BEHIND THE CURTAIN

How Mark Suzman went from journalist to global policy player

Here’s why you need to read this magazine

65| MEET THE FOUNDATION

70| “I WAS A LITTLE NERVOUS”

The faces of our top leaders

PERSPECTIVES FROM THE TOP 8| “I'M INSPIRED BY THE YOUNG AFRICAN ENTREPRENEURS” Bill Gates delivers the 2016 Nelson Mandela Annual Lecture

12| “REAL, LASTING CHANGE REQUIRES COLLABORATION” Think innovation is the work of a solitary genius?

Think again, says Bill

16| “WE’RE SEEKING TO LEARN FROM OUR AFRICAN COLLEAGUES” Gates Foundation CEO, Sue Desmond-Hellmann, talks about her goals

AT A GLANCE 6| MAKING PROGRESS

The latest breakthroughs that are changing lives

20| WHAT IF WE COULD SPEED UP PHOTOSYNTHESIS? OR MAKE POO SMELL BETTER? Investigating development game-changers is fascinating work

68| THESE ARE WORTH A THOUSAND HAPPY WORDS If you really want to know our team, you need to see some of them at work

WIDE AWAKE IN SEATTLE EVER BEEN TO OUR SEATTLE HQ? HERE’S WHAT’S IN STORE

66

A CLOSER LOOK AT OUR WORK

30 | BREAKING DOWN THE WORLD’S BIGGEST PROBLEMS

18| ADVANCES DON’T HAPPEN BY ACCIDENT

Read about our 16 programs that are helping to change the world

Why R&D can sometimes be the most impactful investment of all

22| “YOU CAN’T FIX WHAT YOU CAN’T DEFINE” Precision public health could revolutionize healthcare in Africa

24| WHEN TIME AND MONEY COUNT The foundation’s emergency-response program is all about quick thinking

26| STORIES THAT ARE SHAPING THE WORLD

Read about our groundbreaking work with the media

28| PHILANTHROPY CAN BE A DOUBLEEDGED SWORD A top South African health official explains how it can be wielded effectively

This magazine was produced by the Bill & Melinda Gates Foundation's Africa team Writer: Jeremy Derfner Design, layout & copy-editing: Flow Communications Project coordinator: Buhle Makamanzi Project manager: Moky Makura This magazine was printed and produced in South Africa.

Gates Foundation offices in Africa: Bill & Melinda Gates Foundation South Africa office 4th Floor, The Firs Cnr Cradock & Biermann avenues Rosebank, Johannesburg Bill & Melinda Gates Foundation Ethiopia office c/o International Livestock Research Institute Bole Sub City Kebele 12/13 Addis Ababa, Ethiopia Bill & Melinda Gates Foundation Nigeria office 43 Agadez Crescent Wuse 2 Abuja, Nigeria Email address: info@gatesfoundation.org Follow us on Twitter: @GatesAfrica

update

PROGRESS

We call ourselves impatient optimists because we believe that the world is improving and that the lives and the health of the very poor are better than they were 20 years ago.

14

3.

Seven countries eliminated trachoma, including three in Africa: Gambia, Ghana and Morocco.

Things that prove we are going in the right direction.

Trachoma is the leading infectious cause of blindness worldwide. Fewer than two MILLION people today are visually impaired because of the disease.

2.

1.

From 2008 through 2015, Rwanda cut its newborn mortality rate by 30 percent.

The country achieved this in three key ways: promoting breastfeeding in the first hour and exclusively for the first six months; cutting the umbilical cord in a hygienic way and kangaroo care: skin-to-skin contact between mother and baby to raise the baby’s body temperature.

6

A reanalysis of the 2013 Global Enteric Multicenter Study pinpointed the microorganisms that cause childhood diarrhea, helping to establish priorities for future programming and research.

The reanalysis, which identified the cause of 90% of childhood diarrhea cases, found that only six specific pathogens cause 78% of moderate to severe diarrhea, led by rotavirus (vaccine available) and shigella (vaccine in development).

It is possible to prevent the disease by administering the antibiotic azithromycin, which has been donated in huge quantities by Pfizer.

5.

The High Court of Kenya rejected British American Tobacco’s effort to block the Ministry of Health from implementing the country’s 2014 Tobacco Control Regulations.

This victory is an important example to other countries that there are solid legal grounds to fight wealthy tobacco companies and protect the public’s health.

4.

Three more African countries – Eritrea, Lesotho and Mauritius – introduced the pneumococcal vaccine, bringing the total number of nations that offer it to 38.

8.

Case counts of Human African trypanosomiasis, or African sleeping sickness, which occurs in 36 African countries, were the LOWEST in 70 years.

6.

A groundbreaking study showed that women can feasibly self-inject a new three-month injectable contraceptive, Sayana Press, which could make it much less burdensome for them to meet their family planning needs.

Each dose comes in a small bubble-shaped pack with a tiny needle. The pilot study in Uganda showed 90% of women were able to reinject themselves competently, and 99% said they would recommend the product to others.

7.

Sudan has announced that it would add the Meningitis A vaccine to its routine immunization schedule, becoming the first Meningitis Belt country to do so.

For decades, cases numbered in the tens of thousands.

In 2008, there were fewer than 10 000 cases for the first time in 50 YEARS.

12.

Donors pledged $12.9-billion at the Global Fund’s Fifth Replenishment 10.

New research provided the best evidence yet of the impact financial inclusion can have on emerging economies Among the key findings was an estimate that digital financial services can help add 1.6-billion people to formal economy and an additional 6% or $3.7-trillion to the annual GDP.

The amount raised in 2016 will save 8-million lives and avert 300-million infections.

13.

For the first time in history, more than 300-million women in developing countries are using modern methods of contraception.

9.

The Lancet’s breastfeeding series provided the most indepth analysis done so far into the health and economic benefits of breastfeeding.

The series found that the deaths of 823 000 children and 20 000 mothers each year could be averted through universal breastfeeding.

11.

14.

The African Union adopted a new law that will help countries register new health products faster.

Coverage for the basic package of childhood vaccines is now the highest it’s ever been, at 86%.

First piloted in 2012, the African Medicines Regulatory Harmonization initiative aims to cut registration time in half.

For every dollar spent on childhood immunizations, you get $44 in economic benefits.

7

who missed it …

FOR THOSE OF YOU

Bill Gates delivered the keynote speech at the 14th Nelson Mandela Annual Lecture in Pretoria, South Africa, on 17 July 2016. This essay is adapted from his remarks.

The first time I spoke with Nelson Mandela was in 1994, when he called to ask me to help fund South Africa’s first multiracial election.

It’s not every day that Nelson Mandela calls, so I remember it well. I was running Microsoft at the time and thinking about software most of my waking hours. But I admired Nelson Mandela, I knew the election was historic, and I did what I could to help.

I had been to Africa for the first time just the year before, when my wife, Melinda, and I travelled in East Africa on vacation.

Obviously, we knew parts of Africa were very poor, but being on the continent turned what had been an abstraction into an injustice we could not ignore.

Faced with such glaring inequity, we started thinking about how we could use our resources to make a difference. Within a few years, we established our foundation. It was when I started coming to Africa regularly for the foundation that I came to know Nelson Mandela personally. He was both an advisor and an inspiration.

One topic that Nelson Mandela came back to over and over again in his lifetime was the power of youth. I agree with Mandela about young people, and that is one reason I’m optimistic about the

future of Africa. Demographically, Africa is the world’s youngest continent, and its youth can be the source of a special dynamism.

Economists talk about the demographic dividend and the potential for Africa’s burgeoning youth population to accelerate economic growth. But for me, the most important thing about young people is the way their minds work. Young people are better than old people at driving innovation, because they are not locked in by the limits of the past. I was 19 when I founded Microsoft. Steve Jobs was 21 when he started Apple. Mark Zuckerberg was 19 when he created Facebook.

So I’m inspired by the young African entrepreneurs driving startup booms in the Silicon Savannahs from Johannesburg and Cape Town to Lagos and Nairobi.

The real returns, though, will come if we can multiply this talent for innovation by the whole of Africa’s growing youth population.

To make that a reality, all of Africa’s young people must have the opportunity to thrive.

If we invest in the right things – if we make sure the basic needs of Africa’s young people are taken care of – then they can change the

. Bill Gates was in Mamelodi in South Africa in July 2016 to deliver the prestigious Nelson Mandela Annual Lecture, in honor of the late, great statesman.

8

Image by Phill Magakoe, Pretoria News, 18 July 2016. future and life on this continent will improve faster than it ever has.

In my view, there are four things that will determine Africa’s future: health and nutrition, education, economic opportunity, and good governance.

When people aren’t healthy, they can’t turn their attention to things like education, working and raising a family. Conversely, when health improves, life improves by every measure.

I’m especially concerned about HIV. Africa’s youngest generation are entering the age when they are most at risk of HIV. We need to get more out of the HIV prevention methods we have now – while developing better solutions like an effective vaccine and easier-touse medicines that people are more likely to use consistently.

Nutrition is another critical area of focus for Africa. Malnutrition and micronutrient deficiencies rob millions of the continent’s children of their physical and cognitive potential. Fortunately, there are cost-effective solutions like making sure mothers breastfeed their infants, enriching cooking oil, sugar and flour with important vitamins and minerals, and breeding staple crops to maximize their nutritional content. We need to make sure the people most at risk know about and have access to these solutions.

Second, we need new thinking and new tools to make sure a high-quality education is available to every child. Educational technology using mobile phones has the potential to help students build foundational skills while giving teachers better feedback and support at the touch of a button. Governments also need to invest in high-quality public universities for the largest number of qualified

students to launch the next generation of scientists, entrepreneurs, educators and government leaders.

Third, we need to create economic opportunities to channel the energy and ideas of Africa’s youth. Through the Comprehensive Africa Agriculture Development Program, countries have a framework for transforming agriculture from a struggle for survival into a thriving business opportunity. But the investment needs to follow, so that young Africans have the means to create the thriving agriculture they envision.

Africa also needs more electrical power to increase productivity.

In East Africa especially, governments should invest in hydro and geothermal sources of energy, which are both reliable and renewable, as soon as possible. The immediate priority is for governments to get tougher about managing their electrical grids so they’re producing as much power as possible.

Fourth, countries can benefit from enhancing fiscal governance.

Advances in digital technology are one way that governments can deliver services more efficiently.

It’s clear to everyone how big and complicated the challenges are.

But Africa has proven its resilience and ingenuity time and again, and there are millions of people, especially young people, who are eager to get to work. The future depends on the people of Africa working together to lay a foundation so that Africa’s young people have the opportunities they deserve. This is the future that Nelson Mandela dreamed of and it’s the future that the youth of Africa deserve.

9

give

WHY WE

By Julie Bort, as featured in Business Insider, 21 January 2015

Bill and Melinda Gates learn how to process sweet potato for research at the genetic engineering laboratory at the Mikocheni Agriculture Research Institute in Dar es Salaam, Tanzania.

Bill Gates talks about the heartbreaking moment that turned him to philanthropy.

About a year ago, Bill Gates ruffled some feathers when he dissed an effort to bring the internet to the developing world.

In an interview with Charlie Rose, Gates told the story:

It turns out, Gates didn't always think like that. In fact, his aha moment came when he, too, was trying to bring computers to impoverished areas of Africa.

“Well, the idea that a computer was relevant to the problems they were dealing with, where getting enough food, having decent health, getting any electricity, a reasonable place to live, it was pretty clear to me that, hey, I love this computer, and I thought it was neat and kids should have access, but they had to rig up a special generator so I could do this one demo. And they borrowed this generator. It wasn’t going to be there when I left. So the idea that there was a hierarchy of needs ... While still believing in digital empowerment, that was not at the top of the list. That was pretty eye-opening for me.�

Gates realized how ridiculous that idea was when he saw living conditions in Africa first-hand in 1997.

But the true moment that caused Gates to try to solve poverty was even more heartbreaking.

Now we know why he feels that way.

He said at the time, “Hmm, which is more important, connectivity or malaria vaccine? If you think connectivity is the key thing, that's great. I don’t.�

10

CATALYTIC PHILANTHROPY:

The gift that keeps on giving

“Bill and Melinda speak often about their approach to philanthropy — about why and how they give. Below is an excerpt from a speech Bill gave about what kind of philanthropy he thinks is truly effective – ‘catalytic philanthropy’.

“While the private sector does a phenomenal job meeting human needs among those who can pay, there are billions of people who have no way to express their needs in ways that matter to markets. And so they go without.

“In this gap government plays an important role. But government faces its own obstacles to funding innovation.

It generally does not take the long view, because election cycles are short. Unlike the private market, government is good not at seeding numerous innovators, but at backing only the ones that make progress.

“So when you come to the end of the innovations that business and government are willing to invest in, you still find a vast, unexplored space of innovation where the returns can be fantastic. This space is a fertile area for what I call catalytic philanthropy.

Melinda Gates, Bill's wife, told that story to Rose. Gates had visited a hospital treating people for tuberculosis during his visit to Africa.

He called Melinda, she recalls: “We often call each other when we are the road. Almost every day.

But it was a different call. Bill was really quite choked up on the phone ... Because he'd seen first-hand in a TB clinic hospital how awful it is to have that disease ... He literally said to me, ‛It’s a death sentence. To go into that hospital is a death sentence.’� So he decided not just to donate money to that one hospital, but to do things that could help “thousands and millions� get out of poverty altogether, Melinda said.

The Bill & Melinda Gates Foundation has been going strong now for 15 years [at time of publication].

“Catalytic philanthropy has the high-stakes feel of the private market, but the investor doesn’t need a share of the benefits – those go to poor people or sick people or society generally, all of whom stand to gain earth-shaking returns from the kind of innovations that business and government likely won’t pursue unless philanthropy goes first.

“Melinda and I have the honor and the responsibility to return to society, in the best way we know how, the resources we have received. But you do not need to be the chair of a large foundation to have an impact on the world.

“Risk takers need backers. Good ideas need evangelists.

Forgotten communities need advocates. And whether your chief resource is volunteer time or hard-earned dollars, for a relatively small investment, catalytic philanthropy can make a big impact.”

Copyrighted 2017. Business Insider, Inc. 127576:0317SH

11

good idea

THE IMPORTANCE OF A

Bill gives his take on innovation and how some of the best ideas the foundation has supported involved no technology at all. Find out more about why the foundation invests heavily in turning good ideas into great ideas.

Bill Gates takes part in a panel discussion with young innovators from across the continent on MTV Base Africa.

From left: Thato Kgathlanye (South Africa), founder of Repurpose Schoolbags that upcycles plastic bags into backpacks with tiny solar panels that turn into a lantern; George Mtemahanji (Tanzania), founder of SunSweet Solar that installs low-cost solar systems in rural areas; Chris Kwekowe (Nigeria), who founded an e-learning school offering virtual internships; MTV Base presenter Sizwe Dhlomo; Martha Chumo (Kenya), founder of Kenya’s first coding school for young people; Siya Xuza, founder of Galatic Energy Ventures that, among other things, developed microfuel cells to power small devices such as smartphones for longer; and Brian Matibabu (Uganda), who developed a portable device connected to a smartphone to diagnose malaria.

When Melinda and I got interested in global health in the late 1990s, we were coming from the world of technology. Every day at Microsoft, brilliant innovators made amazing discoveries that changed what people could do with computer software. We were used to innovation that moved incredibly fast.

But things were different in global health; innovation seemed to move slowly, when it moved at all, because the field was starved of resources. We learned that some problems – like diagnosing tuberculosis (TB) accurately – had been lingering for decades.

Meanwhile, in health sciences more broadly, new breakthroughs like the sequencing of the human genome were being announced all the time. We were convinced that investing more in innovations for global health would lead to a better TB diagnostic test, and 12

other solutions like new and better vaccines and drugs for deadly diseases.

So that was a big part of the founding ethos of the Gates Foundation – the idea that fresh thinking, new knowledge and creative interventions could transform the lives of billions of people.

We wanted to work with partners to drive more innovation, faster.

But innovation isn’t just one thing; it comes in many shapes and sizes. Most often people think of innovation as scientific discoveries that happen in a lab. And we support a lot of this kind of innovation all around the world.

For example, I met recently with investigators at the KwaZuluNatal Research Institute for TB-HIV in Durban, South Africa. While

Whatever form innovation takes, one thing is certain: it’s harder to do it in isolation. Real, lasting change requires collaboration.

Bill and Melinda Gates discuss different strains of sweet potato with Dr Joseph Ndunguru at the Mikocheni Agriculture Research Institute (MARI) in Dar es Salaam, Tanzania.

I was there, I spoke with Dr Frederick Balagaddé and his team at the student-run Bioengineering Laboratory, who are developing a microchip that will allow a single health worker to perform hundreds or thousands of medical tests at the same time. This kind of boundary-pushing science is essential to advances in global health.

However, labs aren’t the only places where innovation happens.

Discoveries that solve problems in a lab also need to help people in the real world, which means they have to be tested in and adapted to local markets, climates and cultures.

Our partner, the Alliance for a Green Revolution in Africa, supports local crop scientists like Chrispus Oduori, the first person to receive a PhD in finger millet breeding. The average Kenyan millet farmer gets 500kg to 700kg of yield per hectare, but Oduori gets 2 500kg to 3 000kg in the fields where he conducts his research.

Oduori doesn’t just breed millet; he also runs demonstration plots and meets with farmers so that they can see the impact of new seeds and new agronomic practices with their own eyes.

There are also innovations that use new technology to improve old systems, often by widening access. Traditional financial services have tended to exclude people too poor to maintain bank accounts, but the advent of mobile technology means that these people can now use their phones and digital platforms like Kenya’s M-Pesa to participate in the formal economy for the first time.

Or take Rwanda, where the government launched a drone system to deliver blood to transfusion centers in the west, where roads and infrastructure make hospitals difficult to reach. Now all a doctor has to do is send a text message, and 15 minutes later a patient in desperate need of blood can be on the receiving end of a lifesaving transfusion.

Sometimes innovation doesn’t involve technology at all; it’s just about working with human nature. For example, exclusive

breastfeeding for the first six months of an infant’s life is one of the most powerful interventions we have to save and improve the lives of newborns. But not all new mothers do it.

Figuring out how to help mothers change their child-rearing practices doesn’t take new technology. But it does take a lot of insight and ingenuity, including understanding the feeding practices in a given culture and building communication and education programs around what new mothers actually need, and not what appeals to global health experts.

Elsewhere in this magazine you’ll read about the work of Alive & Thrive, whose work in Ethiopia raised the exclusive breastfeeding rate by 11% in just four years and helped improve the way the government teaches parents about nutrition.

Whatever form innovation takes, one thing is certain: it’s harder to do it in isolation. Real, lasting change requires collaboration. That’s why we always work in partnership with African governments, with NGOs and with the private sector.

One of my favorite authors, Steven Johnson, wrote a book called Where Good Ideas Come From that describes how important it is for people with different perspectives to build networks that new ideas can travel across, slowly building up into revolutionary insights. We all like to imagine that innovation comes when a solitary genius toiling away has a eureka moment, but that’s not actually how the world changes.

Most of the time, innovation is incremental, and often it is the result of people building on the best of others’ ideas. This is true whether the innovation is technological or behavioral, whether it works with systems already in place or creates new ones. When a lot of different kinds of innovation come together, as they do over and over again in our partners’ work, that’s what makes life better for hundreds of millions of Africans.

13

and Girls

WOMEN

By Melinda Gates

As far as I’m concerned, one of the best things about the Sustainable Development Goals is the way they face women’s and girls’ issues head on. It’s not just that Goal 5 is explicitly dedicated to gender equality; it’s that 11 of the 17 goals include gender-focused targets and indicators. That says to me the development community now understands that women and girls are central to the agenda.

Why does this matter?

Unfortunately, given the data the world currently collects – or, more accurately, doesn’t collect – it’s not actually possible to track many of those indicators or determine whether or not many of those targets are reached. We know we need to be thinking about gender when we think about development, but we don’t have the tools to do it well – yet.

First, it means we don’t have a fully textured understanding of the vital role that women play in society. We know they invest their time in caring for those around them, but we don’t know exactly how they subdivide that time, how else they would be likely to spend that time if they were assigned less care work, or how adjusting this balance might improve their family’s future.

That’s why last year I announced that our foundation would invest $80-million over the next three years to improve the way genderrelated data is collected and used. I believe that when we paint a clear picture of what gets in women's and girls’ ways, we’ll know how to help them overcome those obstacles.

Second, it means we don’t know how to save women’s time, because we can’t pinpoint precisely where it’s being invested now, or why it’s assigned the way it is. For example, some advocates talk about investing in small-scale solar energy to power electric stoves or washing machines, but we can’t be certain how much time it could save, so we can’t prove that it’s a worthwhile way to use our resources.

Some people are surprised to see that much money next to the word “data”. Shouldn’t we invest directly in the communities where women and girls live, they ask. Here’s my answer: If we don’t have the data first, we’re going to waste a lot more money on programs that don’t work in the first place.

Take the example of time poverty, an issue I’m particularly interested in. We know just from observing women’s lives that they spend a lot more time than men cooking, cleaning and caring for children. (This is true in every single country in the world, by the way.)

Let’s be clear: families and communities depend on this work – they literally couldn’t function without it. But it’s assigned to women because of their low social status, and the fact that care work is undervalued by society just reinforces women’s low social status.

But when I started digging into the numbers, to try to figure out how many hours women spend doing unpaid work compared with men, or how those hours are divided among various tasks, I discovered that the data is sparse, to put it mildly, especially for African countries.

14

And this is just one area where data can make a big difference.

Elsewhere in this magazine, you’ll read about the Ethiopian government’s new effort to register maternal deaths, so that we know who dies during pregnancy and childbirth – and why. Before Ethiopia had that information, it couldn’t develop a sound strategy to prevent maternal mortality. Now, it is implementing evidencebased policies in health facilities that will save women’s lives.

There are 520-million women and girls on the African continent.

In so many ways – because their health and education are neglected, because many can’t own land, because they are regularly subjected to violence ... the list goes on—they do not have the opportunity to fulfill their vast potential. If they did, they would transform the continent. We are all greater when everyone is equal.

Saying gender is important is a huge step, and people are starting to say it loud and clear. Putting in the resources so that we can act on the conviction that gender is important is just as huge. That’s the step we need to take, in the next decade, together.

MAIN FEATURE

There are 520-million women and girls on the African continent.

Some do not have the opportunity to fulfill their vast potential because of their circumstances. If they did, they would transform the continent.

Melinda Gates visits a baby in the Marie Stopes International outreach program at Wakhinane health post, Dakar, Senegal.

15

y dream is that other talented people who have skills M that they’ve developed in other sectors or other settings will come to the foundation, use all the things they’ve learned in their whole life, and apply them to such an incredibly exciting set of missions.

Sue Desmond-Hellmann, CEO of Bill and Melinda Gates Foundation, interacts with a family that’s part of EthioChicken, a foundation grantee that’s working to improve poultry farming in Ethiopia.

16

A CONVERSATION WITH

Sue Desmond-Hellmann

Meet the woman who runs the world’s largest philanthropic organization.

Q When you were first recruited to the Gates Foundation, what made it an exciting opportunity?

Two things. First, just the scope of the ambition to eradicate

poverty. And the seriousness with which Bill and Melinda were approaching the scale of ambition. I just thought that was really amazing that they could have the audacity to do something that important, that hard and that big.

Second was the idea that maybe my experience and skills could make a unique difference for the organization. The thing is, I didn’t need to leave my old job at the University of California at San Francisco (UCSF); we were doing great work in public health. I thought it was God’s work, so I didn’t need to go anywhere else to do God’s work.

But Bill and Melinda convinced me that if I went to the Gates Foundation, other really talented people would carry on with the work at UCSF. And they said they might not be able to find somebody with the combination of skills I had. And so that’s really exciting, when you think that you can matter to a cause that really resonates with you.

Q What is your dream for the organization?

My dream is that other talented people who have skills that they’ve developed in other sectors or other settings will come to the foundation, use all the things they’ve learned in their whole life, and apply them to such an incredibly exciting set of missions.

Q You’ve traveled to Africa a number of times to see the work of partners there.

What makes you most optimistic about the future of the continent?

Whenever I’m around young people. I was in Ethiopia and it was such a great trip. We visited two women smallholder farmers,

and we met their families, and I put the group photograph we took on my Facebook page as a banner.

I did that because seeing the look on the young girls’ faces reminded me about the power of human potential. They’re so inquisitive, and now they’re well-fed and vaccinated, and I think when these basics are taken care of, you’re left with so much hope. That’s the reason to be most optimistic: the things we can solve together that make human potential possible.

QW hat are the biggest challenges you see that will determine the difference between success and failure?

Helping governments see that their job one – job one, two and three – is investing in that human potential. Helping them recognize that it should be a much higher priority than anything else, because human potential is their most important asset, versus oil or mineral wealth or anything else. The thing is, it’s very hard to have the stamina and persistence to keep on investing in that long-term vision of the future. But doing it is the difference between success and failure.

Q In this magazine, you have a chance to speak to a lot of African grantees and partners. What’s one thing you want them to know about you and about the foundation?

I want them to know about the people who work at the Gates

Foundation. It’s such an impressive and thoughtful group of individuals who each come to this work with their own story.

Sometimes, the organization as a whole can seem faceless, but the people who make it work definitely aren’t.

And, collectively, I think we are seeking to learn from our African colleagues so that we can all do better work together.

Sometimes, there has been a significant learning curve, but I know the people I work with appreciate and respect the wisdom our grantees and partners bring.

17

THE DRIVING FORCE

behind innovation

One of the Gates Foundation’s core beliefs is that by focusing on research and development, the world can make huge strides in global health equity.

Barely more than a decade ago, AIDS was a death sentence; now, with the right care, it is a treatable disease. Diagnosing African sleeping sickness once required a painful spinal tap; now it’s a matter of a quick blood test.

These advances don’t happen by accident, and they don’t happen overnight. They are the result of an aggressive, long-term research and development (R&D) agenda in health and medicine. But when people who are sick can’t afford to pay for new products, companies don’t have much incentive to develop them – which means that innovation happens more slowly, or not at all, when it comes to global health.

That’s why we invest in leading researchers on the African continent and around the world to develop the tools we need to diagnose, treat and prevent the deadliest infectious diseases. And we’ve seen some great successes, including the development of MenAfriVac, the meningitis vaccine that is the first-ever vaccine specifically for the African continent. MenAfriVac is now saving lives across Africa’s Meningitis Belt.

Unfortunately, there’s a lot we still don’t know about what causes people to get sick and die.

That’s why we are pushing to develop better methods, like needle biopsies of various organs that generate accurate data about causes of death. Once we can be surer about what is killing people, then we can be more strategic in driving the global health R&D agenda for the next generation.

We are also trying to help African countries build up more regulatory capacity so that once new tools are developed, they can be introduced as quickly as possible to save lives. In developing countries, regulatory systems are often overburdened and underresourced. Our goal is to help countries dealing with similar issues to harmonize approaches, so that they can rely on each other to develop specific areas of expertise and share key data.

Innovation makes life better, and R&D leads to innovation. We hope to support a new R&D revolution that innovates for everyone and improves billions of lives.

18

“

Ninety percent of the global infectious disease burden is borne by those who live in developing countries, yet little attention is paid to health solutions to address these problems. The global research and development community has enormous untapped potential to help develop new and better drugs, vaccines, diagnostics and delivery systems for global health breakthroughs. The more the world taps into that potential, the more lives are saved and improved. –

”

– Trevor Mundel President of Global Health

Blood being processed in South Africa’s TB Vaccine Initiative in Worcester, South Africa.

$

HERE ARE SOME OF THE INVESTMENTS WE’VE MADE TO SPEED UP SCIENCE:

$460-million to the newly established Coalition for Epidemic Preparedness Innovations to shorten the time it takes to create and deliver vaccines.

$18-million in process to the University of Maryland, Baltimore, for studies in Mali, Kenya and Gambia on the impact of rotavirus vaccines on child health.

More than $150-million to the PATH Malaria Vaccine Initiative to advance development of next-generation malaria vaccines.

$3-million to Wits RHI to strengthen the evidence base for providing influenza vaccines to pregnant women in South Africa to protect their infants from the disease.

19

ide s 1 20 3 5 4 6 8 9 GOOD

Here are some of the big ideas we’re helping scientists and researchers explore.

An automated early warning system for

malaria transmission.

IDEAS

WE'RE EXPLORING

We’re working with a researcher in Colorado, US, to develop an early warning system for malaria. The system uses health surveys and satellite data to predict areas where malaria transmission will rise.

A multi-dose pill

that you take once, which will deliver medicine over an extended period of time!

What if we could speed up

photosynthesis

The foundation financed a four-year project in Boston, US, to develop a multi-dose pill. A patient would take a single pill that would release doses of a drug at timed intervals.

in plants so that they produce more food, more quickly?

We’re supporting research into this idea in the US.

Normal flush toilets waste millions of liters of clean water. We’re helping develop

2

The foundation supports research into breeding more nutritious sweet potatoes

to tackle Vitamin A deficiencies in Uganda.

a “low/pour flush” toilet system that saves water.

Can we make more effective vaccines that are easier to store in places where refrigeration is a luxury?

We’re funding research into THE

“next generation”of vaccines.

Research to develop a disease-resistant breed of cassava

will help smallholder farmers get better yields.

7

Mobile banking is useless without cellphone network coverage.

We’re working on a project to allow

transactions on your phone without a SIM card.

Golden Rice is

a biofortified strain of rice that contains beta carotene (which is a source of vitamin A).

Vitamin A deficiency, which can cause blindness affects millions of children in the developing world.

20

10

11

What if we gave mothers

a neonatal survival kit

filled with medication and supplies?

We think it would save many newborn lives.

Modern flush toilets waste millions of liters of fresh water per flush.

We’ve thrown down the gauntlet to bright minds around the world – to help us

reinvent the toilet.

14

13

17

A vaccine

That’s why we’re supporting the world᾽s largest HIV vaccine trial, which is under way in South Africa.

company into

an implant

that could protect a person from HIV.

12

to people in developing countries using public toilets: the smell.

The smell of public toilets in developing countries is a key reason that people don’t use them. We’ve teamed up with a Swiss perfume-maker to investigate what makes poo smell so bad, so we can find a solution to the problem.

15

The Water Efficient Maize for Africa

16

would be the beginning of the end for HIV.

18 20

What if, instead of waiting for a person to produce antibodies to fight off a disease, you could simply give a person a dose of antibodies?

We’re exploring this fascinating idea of

biological medications.

19

We’re funding research by a biomedical

to tackle a key barrier

to have maize crops that withstand drought and pests.

under the sea.

a cooler box

kits that allow people to test themselves instead of going to a doctor or clinic.

partnership was our response to growing need by African farmers

life-saving drugs

that will allow vaccines to be transported safely across vast areas with no electricity.

HIV self-diagnosis

Investigating what makes poo smell so bad,

We’re funding a bioprospecting company that searches for new

Researchers in Senegal are working to develop

We’re helping test the usability of

The South African

TB Vaccine Initiative

is doing groundbreaking research into a new, more effective TB vaccine.

21

precision

THE PARADOX OF

Can precision medicine improve population health? The foundation’s CEO firmly believes it has the potential to improve health outcomes in global health.

Premature babies are cared for in the neonatal unit at Yekatit Hospital in Addis Ababa, Ethiopia.

22

public health

Sue Desmond-Hellman is fond of saying, “You can’t fix what you can’t define.” But reaching a definition of what needs to be fixed is easier said than done. This is especially true in the area of public health, and particularly in Africa.

Neonatal mortality is a perfect example of this conundrum. We know that millions of babies around the world die before they are a month old, but in too many cases we don’t have a reliable understanding of why these deaths occur.

Recently, a new approach to defining and solving the epidemic of infant death and other public health challenges has emerged.

It’s called “precision public health”, or PPH. This model aims to address issues of public health using data analysis to pinpoint how certain diseases are affecting specific populations.

With this data, doctors and public health professionals can target specific diseases in the places where they do the most harm, rather than trying to solve the same problems everywhere.

Whereas some public health models paint the world with a broad brush, PPH wields a fine-tooth comb to understand each community.

We are especially excited about this new approach to disease control and eradication. So how do we deploy it?

The first battle, and perhaps the most daunting, is to collect a large amount of accurate data that can be used to spot trends and pinpoint problem areas. Then, through analyzing that data, we can answer questions like, “What medication do we need in this community right now?” or “What illnesses should we be vaccinating pregnant women against in this village?”

Our primary warrior in the fight to gather data about newborn mortality is the Child Health and Mortality Prevention Surveillance

network, or CHAMPS for short. Since mid-2015, CHAMPS has been working with labs throughout Africa to collect scientific data “about how, where and why children are getting sick and dying”.

Dr Robert Breiman, the co-principal investigator at CHAMPS, says that the only way we can rapidly bring down infant and childhood mortality rates is to go beyond simple methods of assessing why children die, and obtain robust clinical information.

“This type of data,” he says, “will allow public officials to design policies to target mortality accurately and rapidly. Once we get that data flowing it will become publicly available within a few months, to the extent possible while respecting confidentiality and sensitivity.

“The expectation is that the data will be used at a number of levels.

It will be fed back directly to the family, so that if a child dies of tuberculosis, everyone in the household can be tested for the disease and treated if necessary.

“It can be used at the community level to establish local health priorities, and at the national level to enact policies that will support the goal of lowering mortality rates.

“Ultimately it will be available around the world, so someone with a very different perspective can look at the data and possibly identify patterns that we can’t see.”

CHAMPS already has a pilot program in South Africa, and projects in several more countries will be ready to go soon. But CHAMPS isn’t just setting up to fill an immediate need; it’s in the fight for better public health for the long haul.

“This is a 20-year programme,” Dr Breiman explains. “We want to expand to enough sites that our data will allow us to extrapolate insights to similar communities, rather than just the ones we’re studying.”

PPH and projects like CHAMPS have the potential to shape the future of public health – a future that is more effective, efficient and rapid at targeting the most pressing issues facing people around the globe.

23

money count

WHEN TIME AND

A little-known part of the foundation’s work is its investments in global emergencies like Ebola. Quick thinking and quick grant-making are the tools of this team’s trade.

When Senegal experienced its first case of Ebola, the country’s health leaders focused on stopping the outbreak. They succeeded, but in retrospect they believe the single-minded focus on Ebola distracted them from the day-to-day functions of the health system.

As a result, Senegal’s health leaders decided to start a Public Health Emergency Operations Center, or PHEOC, to prepare for the next public health crisis.

surveillance to communications. In any emergency, this is the first team to coordinate with other stakeholders from the health and other sectors and to organize a regional response; it has the ability to grow quickly if necessary by borrowing personnel from other relevant parts of the health system.

We made a grant to help Senegal get the PHEOC off the ground and to support its initial basic functioning.

The PHEOC conducts routine risk assessments to determine which emergencies are most likely to strike Senegal, and it draws up specific plans for each of these emergencies and organizes simulation exercises to boost preparedness.

The PHEOC is a small team of experts trained to deal with all aspects of public health emergencies, from logistics to disease

Of course, it’s not possible to plan for every catastrophe, and the PHEOC possesses the expertise to respond appropriately to any

Efforts to contain the 2014 Ebola outbreak in Guinea involved humanitarian and philanthropic groups from around the world. Image courtesy of European Commission DG ECHO.

24

health emergency and request support in or outside the country as needed. For example, when Senegalese pilgrims were injured and killed in the 2015 Hajj disaster, the PHEOC handled everything from transporting the injured back to Senegal to providing counseling and psychosocial support for the families of the dead and injured.

Senegal’s PHEOC is now seen as the gold standard for emergency preparedness on the continent, and many neighboring countries are investing in a similar capability.

Catastrophic emergencies like this happen nearly every day, affecting millions of people in thousands of communities around the world. Some come suddenly, like earthquakes and typhoons; others are protracted, like drought and famine in the Horn of Africa and ongoing violence in north-east Nigeria.

“

If we say that all lives have equal value, then it applies to people in emergency situations, too. We recognize the need to respond when people are in need, but we also look at it as an opportunity.

We try to use long-term innovative methods to improve day-to-day humanitarian response.

”

– Valerie Nkamgang Bemo Senior Program Officer, Global Development Special Initiatives

Our emergency response program quickly funds relief organizations that respond in the hours and days after a sudden emergency. These agencies provide the basics of life – food, water, sanitation, medical care and shelter – until the immediate crisis subsides, setting the stage for additional investments and a longer-term recovery.

For many communities, though, natural and manmade disasters are common. These communities must not only respond to immediate crises, but also build up the expertise to prepare for and respond to – and even prevent and mitigate – future emergencies.

Our emergency response program goes beyond relief to invest in a stronger global humanitarian system, so that local institutions, leaders and first responders have the capacity to respond to whatever may come. For example, we worked with Senegal’s Ministry of Health to create the PHEOC that has become a model for the region.

Many people affected by disasters will feel the impact for years, not days and months. Our emergency response program also looks for opportunities to provide long-term solutions for communities in crisis.

This is especially true for those displaced from their homes by food shortages or violence. The average length of stay in a refugee camp is more than a decade. Overcrowding in refugee camps leads over time to a lack of basic services like sanitation and primary healthcare.

We are working with many of the foundation’s program teams to adapt and introduce proven solutions, tools and approaches during emergency situations, including high-tech toilets that process human waste safely (and even convert it into valuable commodities such as energy), family planning, safe childbirth and newborn care.

Catastrophic emergencies happen nearly every day. Our goal is to help communities prepare, respond, build back better and thrive.

$

GRANTS MADE BY THE EMERGENCY RESPONSE TEAM INCLUDE:

• $50-million to support the scale-up of the Ebola response in 2014 • $400 000 over 12 months to help Oxfam-America help communities affected by flash floods in Sudan • $537 228 to provide residents of eastern Chad with vital medical and healthcare services that were catastrophically strained by vast influxes of refugees from neighboring Sudan • $1-million grant to help provide food aid for communities in Malawi and Southern Africa affected by the worst food shortages in nearly a decade

25

matter

WHEN STORIES

Not too many people know that the foundation invests in the media. We believe that the media have the ability to ignite public dialogue, amplify citizen voices, and channel audiences toward action by increasing knowledge and awareness. One of our media partnerships in South Africa tells how its stories have moved people to take action.

When Mia Malan started her career as a journalist, she began reporting on what was happening around her. Living in South Africa’s Eastern Cape, she saw local healthcare letting people down.

“The hospitals and clinics in the province were in a dismal state, and most still are, so reporting on health facilities was one of the first things I did as a journalist,” she explains. “It allowed me to 26

report on what I like most: how policy, or the lack thereof, impacts people. In a developing country, health is not just a medical issue; it’s a social issue.”

Good journalism shines a spotlight into the shadows and can empower people to take action. But good journalism is resourceintensive – and those resources can be difficult to find.

BBC World Service; The Conversation Africa; Africa Check; and others in our focus countries.

Now Malan is the editor of the highly regarded Bhekisisa Center for Health Journalism, which is part of South Africa’s Mail & Guardian.

Bhekisisa, whose name means “to scrutinize” in Zulu, focuses on providing balanced and accurate health reporting. Our grant will enable Bhekisisa to continue to expand its coverage and deepen its engagement with its audience.

Whether reporting on child mortality or HIV, Bhekisisa does not shy away from discussing controversial issues. For instance, it reported on a child rape in a South African township outside of Johannesburg, Diepsloot. The article had a huge impact: two months after publication, Dubravka Šimonović, a United Nations Special Rapporteur, visited Diepsloot to compile a report on the causes of violence against women and children in South Africa. Šimonović said that her visit was a direct result of reading the Bhekisisa article. The community also received a flood of donations to help sexual abuse victims, and there is now a greater openness about this crime.

But while Bhekisisa’s coverage in South Africa has been strong since it was founded in 2013, it has struggled to cover important stories in the rest of Africa. Our GMP grant aims to fix that. In February 2016, the outlet was able to double the size of its team – it now has six permanent members of staff and 10 freelance correspondents operating across Africa.

There is certainly an audience for the high-quality journalism that results from these investments: last year, Bhekisisa launched a stand-alone website and increased its online traffic by more than 30% over the previous year.

Children play with a video and still camera in Côte d'Ivoire.

Often, health reporting is simply bottom of the list when it comes to running a news outlet with commercial pressures and a limited budget. “I was always the only person in the newsroom reporting on health,” Malan says, “because media houses in my country can’t afford to allocate more than one person to the ‘health beat’.”

To address these gaps in information and public dialogue, the Global Media Partnerships program (GMP) funds established media organizations and those that support media to regularly and in greater depth report on and facilitate dialogue on public health and development issues.

In addition to the Mail & Guardian’s Bhekisisa in South Africa, we also fund health reporting projects for the Nation Media Group in Kenya; Premium Times in Nigeria; Code for Africa through the International Center for Journalists, based in Washington, DC; the

Malan explains that the collaboration with the foundation has been so successful because we “share many of the same objectives – to make crucial health information and research available to the public, to evaluate which health innovations and systems work the best, and to identify gaps in health systems that need to be addressed”.

For our part, the foundation is delighted to be part of this success story, and to recognize the valuable role that the media play in ensuring health issues stay on national agendas. We believe that such partnerships amplify the simple but profound truth that all lives have equal value and that where you are born shouldn’t determine your opportunities.

27

and in health …

IN SICKNESS

We believe in strong and lasting partnerships, and rely heavily on our partners to help support and implement the work of our program teams. We invited Dr Yogan Pillay, the Deputy Director-General in the South African Department of Health, to give his perspective on working with the foundation.

Like most public health specialists, my decision to study medicine was motivated by a need to make a difference. To have an impact.

But, impacting public health can vary in the field of medicine.

Doctors make an enormous difference in the lives of individual patients. If you want to make a difference to entire populations, however, the answer lies in strong public healthcare systems. This is a complex, collaborative effort.

It means constantly shifting perspective from daily battles on the frontline to big-picture innovation that could lead to long-term solutions. As debates rage about the role of philanthropy in public health, I’d say that this latter area is where wealthy humanitarians can have the biggest impact: supporting the ongoing search for creative, sustainable, long-term health solutions.

I strongly believe that things that are routine must be funded by the government. But, things that are innovative, such as new models of delivery – that is where I think development partners and philanthropy can make their contribution. I’ve seen this borne out time and again in our work with Bill & Melinda Gates Foundation.

Solutions, I’ve noticed, are what the Gates Foundation is about. Unlike many organizations in this space, they come to the table with a very clear idea of what they believe will have the greatest impact.

Dr Yogan Pillay is responsible for his department’s HIV & AIDS, TB, and maternal child and women’s health programs.

28

Working with the Gates Foundation has been a unique experience.

My first interaction with Bill was back in 2007, when the foundation wanted to offer support to South Africa, at a time when the country was being devastated by HIV. Unfortunately, there was great concern globally, at the time, that South Africa had taken a denialist approach to the virus. This made collaboration with the government by the foundation difficult.

Fortunately, the South African government’s approach changed dramatically in the ensuing years, and so our relationship with the foundation has evolved and grown. South Africa now has one of the biggest antiretroviral therapy programs in the world. We’ve seen life expectancy climb by more than five years between 2009 and 2014.

And, through the support of partners like the Gates Foundation, South Africa leads the continent when it comes to research and innovation in global health.

Just last year, the country saw the launch of the historic HVTN702 HIV vaccine trial, a project supported by the Gates Foundation. The

Josephine Moso brings her daughter, Limpho Moso, for a TB check up at Empilisweni clinic in Worcester, South Africa. Empilisweni is a day clinic in the area that is run by the South African government. foundation has also been working with us to support the writing of the National Strategic Plan for HIV, TB and STIs. We’re in the process of designing a program with them that we think will be a game-changer for our TB program – it focuses on improving the quality of the program, and on advocacy initiatives to mobilise patients and communities.

It is this kind of long-term strategic thinking that can ultimately help South Africa leapfrog our healthcare hurdles. And this is where philanthropic organisations are valuable partners – to invest in the type of big-picture thinking that may not yield results tomorrow, but could make an enormous impact over time.

Solutions, I’ve noticed, are what the Gates Foundation is about.

Unlike many organizations in this space, they come to the table with a very clear idea of what they believe will have the greatest impact.

have access to some of the smartest people in the world in their fields. Then, be clear about what the foundation is offering, and then try to match your needs to what the foundation can offer.

Admittedly, the Gates Foundation is not a quick port of call for support. The time between agreeing to provide support, and

providing that support, is often a long, but worthwhile wait. This is the organization that you turn to when you want a fairly solid partner that will provide what’s needed in the long term.

Much has been written and said about the role that philanthropists play in public health. In truth, it can be a double-edged sword:

a balancing act between what philanthropists see as workable

solutions, and the kind of programs that partners believe will work

and want support for. But, from experience, I can say that a happy medium is possible.

This rigorous approach is apparent at every level of the foundation, not least of all with its founder. On the few occasions I have chatted to Bill, I’ve found him to be incisive. He asks tough, technical questions. He’s well read and well briefed, and he can put those two things together in a very powerful way.

On the side of recipients it works best if you know exactly what

So one piece of advice to new partners who are becoming part of the Gates-sphere is this: make the most of the fact that you will

Get all this right and I believe, and have seen, that strong, valuable

you want, you know how to use the money, and you can show

that the money will be well spent in a catalytic function. And, most

importantly, build your systems so that you’re never dependent on development aid.

partnerships can be forged for the greater good.

29

30

BREAKING DOWN THE

world’s biggest problems

A summary of the foundation᾽s program strategies in Africa.

Imagine if you applied the kind of problem-solving and rigor you’d find in a discipline like mathematics, science or even computer science to some of the world’s greatest challenges.

You would start with a big, complex problem that looks both daunting and unsolvable at first glance. But, once you start breaking that problem down into smaller solvable parts, you’ll find yourself left with many relatively small actions that, over time, can cause significant change.

We use a similar approach. We’ve broken up some of the world’s biggest global challenges into small, workable parts that we call programs. The individuals from around the world who work on each program form our program strategy teams, or PSTs. We have many PSTs, staffed by some of the world’s foremost experts, all focused on solving their piece of the global development puzzle.

Put together, our program strategies answer four of these broad challenges: Ensure more children and young people survive and thrive

Empower the poorest, especially women and girls, to transform their lives

Combat infectious diseases that particularly affect the poorest

Inspire people to take action and change the world

Contents 32| AGRICULTURAL DEVELOPMENT

48| MALARIA

34| ENTERIC AND DIARRHEAL DISEASES

50| MATERNAL, NEWBORN AND CHILD HEALTH

36| FAMILY PLANNING

52| PNEUMONIA

38| FINANCIAL SERVICES FOR THE POOR

54| POLIO

40| HIV

56| TUBERCULOSIS

42| INTEGRATED DELIVERY

58| TOBACCO

44| NEGLECTED TROPICAL DISEASES

60| VACCINE DELIVERY

46| NUTRITION

62| WATER, SANITATION AND HYGIENE

31

PROGRAM STRATEGY: AGRICULTURAL DEVELOPMENT

Africa’s future?

THE KEY TO

Bill and Melinda’s annual letter in 2015 predicted that Africa would be able to feed itself within the next 15 years. How is the foundation’s Agricultural Development team working towards that ambitious goal?

Africa’s future depends on the future of African agriculture. Poverty and malnutrition are two of the biggest challenges facing the continent, and a thriving agriculture addresses both. The majority of Africans depend on farming for their livelihoods, and they are some of the poorest people in the world. With the right investment, though, farming and a robust farm economy can become a pathway to prosperity. And prosperous farmers will produce enough high-quality food to ease the heavy burden of malnutrition.

Our agriculture program’s vision is a sustainable agricultural transformation led by smallholder farmers. We work with partners to drive this transformation by giving farmers access to better tools and techniques, all the way from farm to table – that is, from the seeds they put in the ground to the markets where they sell their harvest.

African farmers’ yields are a fraction of what’s possible. There are many reasons for this lack of productivity: they plant unproductive seeds in poor soils; they contend with pests and diseases that can destroy their crop and weaken their livestock; and climate change is bringing more floods and droughts that can ruin growing seasons.

African agriculture has been geared toward mere subsistence.

A transformed agriculture will be a weapon against poverty and malnutrition, and a source of economic growth.

Through our partners, this is how we contribute to agricultural development in Africa: • We help research partners develop new animal vaccines and crop varieties that can withstand disease, pests and bad weather, keeping in mind farmers’ preferences about what they like to grow and eat • We generate locally relevant, cutting-edge information about agronomy and animal husbandry. For example, we’re investing in digital soil maps that analyze the nutrient content of farmland so that everyone from government policymakers to extension workers to individual farmers know what it will take to improve soil quality 32

• We work with governments to strengthen agricultural systems so that new tools and knowledge are delivered to the farmers who need them • We help link farmers to markets so that their increased productivity results in a better income, a better livelihood and more affordable food for everyone

“

Agriculture is not only a good investment for families, but a vital driver of prosperity and abundance. We invest in agricultural transformation because we have seen its power to reduce poverty, foster savings, create jobs and ensure that nutritious, healthy food is available for all.

”

Rodger Voorhies Executive Director of the Agricultural Development, Financial Services for the Poor, Gender Equality, and Water, Sanitation and Hygiene teams within the Global Development Program

A focus of our strategy is empowering women farmers, who do much of the agricultural work in Africa, but have even less access to good seeds and soil, information and markets than men do. As a result, women farmers can be as much as 40% less productive. Closing this gap will not only increase overall food production, but also give women more income and decision-making power, which has a positive impact on children’s health and education.

Mwanaidi Rhamdani works in an orange-fleshed sweet potato field in Mwasonge, Tanzania.

ONE OF OUR INVESTMENTS Babban Gona (“great farm” in Hausa) seeks to turn Nigeria’s smallholder farmers into businesspeople, and its small farms into profitable enterprises.

to loans so that they have some working capital; access to affordable inputs like improved seeds and to cutting-edge

training that will improve productivity; and marketing support so that they can store their crops safely and sell them at the right time for a better price.

Babban Gona organizes farmers into groups to help them benefit from economies of scale, the lack of which is “a key underlying structural problem that keeps Nigerian smallholder farmers poor”.

In just four years, Babban Gona has worked with 70 000

Once farmers are organized in groups, Babban Gona provides them with the services they need to become profitable: access

first time. Ninety percent of Babban Gona’s farmers plough their

farmers in Nigeria, helping them to triple their yields and

increase their incomes by more than a third. This extra income

leads to a virtuous circle – it allows farmers not just to reinvest in

their farms, but also to send their children to school, often for the profits into their family’s education.

33

PROGRAM STRATEGY: ENTERIC AND DIARRHEAL DISEASES

most common diseases

FIGHTING ONE OF THE WORLD’S

Sixteen years ago, Bill and Melinda read a newspaper article that appeared in The New York Times. The article was about the millions of children dying every year in poor countries from diseases that most people in the US don’t have to worry about. One disease in particular – rotavirus one of the main causes of diarrhea – caught their attention.

Rotavirus is the most common cause of diarrhea in Africa and around the world. Researchers in countries across the continent, including South Africa, Malawi and Ghana, have played a critical role in the development of safe and effective vaccines, which have been introduced into 31 national immunization programs to date.

To understand the full effect of rotavirus vaccines in children, the Center for Vaccine Development at the University of Maryland, together with collaborators in three countries in sub-Saharan Africa (CVD in Mali; MRC in The Gambia; and Kemri in Kenya), is enrolling infants and children with diarrhea to provide a detailed assessment of the changes in incidence, etiology and adverse clinical outcomes of diarrhea that emerge once the rotavirus vaccine has been introduced.

This knowledge won’t just help the struggle against rotaviral diarrhea; it will also help treat and prevent other forms of diarrhea across the continent.

Over the past 20 years, advances in vaccines and an increased emphasis on exclusive breastfeeding have done a great deal to reduce the impact of enteric and diarrheal diseases on children in the developing world.

But these successes have not ended the fight; enteric and diarrheal diseases still kill more children than HIV, measles and malaria combined in the developing world. The Gates Foundation’s Enteric and Diarrheal Diseases team focuses on saving and improving these lives by developing new vaccines and improving treatments for the various causes of these infections.

Though a vaccine for rotavirus, the most common cause of diarrhea in children, was introduced in South Africa in 2009 and in 30 other countries on the continent since then, there are other bugs for which vaccines don’t yet exist or for which they’re not yet safe for infants.

No licensed vaccines for shigella and ETEC exist, and the former is quickly gaining resistance to antibiotic treatment, so some of our partners are working on a portfolio of vaccine candidates against both of these causes of diarrheal diseases. Typhoid fever has also 34

emerged in many parts of Africa as a serious problem. There is progress in developing vaccines against typhoid that can be used in young children, and studies on the disease will soon be under way in Africa.

Thankfully, we’ve gained some traction in the fight against cholera: in 2013, the WHO launched a vaccine stockpile that has supported more than 30 campaigns covering around 3.5-million people worldwide.

Meanwhile, oral rehydration solution and zinc are very effective and low-cost treatments for diarrhea in children, but they are still not used in many communities. Furthermore, children who have recovered from moderate to severe diarrhea are still at significant risk of death for several weeks.

To help these children, we are working to make sure treatments are widely available in countries with heavy diarrhea burdens, and we’re also investing in research to improve treatment and case management, so that children who recover from diarrheal diseases are truly safe.

Diarrhea is the second leading infectious cause of death of young children in Africa after they have survived the first month of life.

By working to develop new and better vaccines, speeding up the introduction of those already available, and making current treatments better and more widely available, we can turn it from a killer into an inconvenience.

Diarrhea is a disease of the gut – one of the most fertile areas of science today, but also one of the most unexplored, and we are part of the effort to learn more. Our partners at the Malnutrition and Enteric Diseases Consortium are studying the complex relationships between nutrition, gut infection, gut physiology, immune function and growth. Other partners are working on a less invasive way to take pictures of the small intestine with a capsule that contains a microscopic camera. We are also beginning therapeutic trials to address stunting by treating the gut dysfunctions that underlie it.

Since 1990, millions of children who would have died from diarrhea have been saved, thanks to improved sanitation, simple hydration treatments and, more recently, new vaccines.

But hundreds of thousands of children still die from diarrheal diseases, many of them in subSaharan Africa.

The world knows how to prevent and treat these diseases, and we need to get these life-saving interventions to the children who need them, now.

Juliet Caroline Odhiambo (26) pictured with her son in Kisumu, Kenya.

Anita Zaidi Director, Enteric and Diarrheal Diseases

PROGRAM STRATEGY: FAMILY PLANNING

to choose

THE RIGHT Mothers bring their children to Laura's Maternity Home & Clinic for vaccinations and health checks in Accra, Ghana.

In 2012, an estimated 80-million women in developing countries had unintended pregnancies. How can having fewer children with better spacing between them pull Africa out of poverty?

Until recently, developing countries only conducted national health surveys every five years or so – meaning that decisions made today rely on old data. Performance Monitoring and Accountability 2020 (PMA2020) is a new smartphone-based data collection system that has started giving governments more data every six to 12 months. It also halves the time it takes to analyze the data, so insights reach decision-makers faster.

PMA2020 trains women to conduct interviews about family planning and other health issues in their local communities. The interviewers enter the data into smartphones and upload it to a central server, where it’s immediately available for analysis and reporting. So far, more than 1 100 women in eight African countries have been trained, and they’ve conducted more than 36

100 000 surveys that are already giving decision-makers the data to understand what’s working and what needs to improve.

For example, the Uganda Ministry of Health found from its surveys that younger women weren’t using family-planning services. As a result, the government made reaching these women a top priority in its national family-planning strategy. And instead of waiting five years to find out whether and how their strategy is having an effect, Ugandan leaders will know within a year.

Right now, 225-million women in the world don’t want to get pregnant, but aren’t using contraceptives to delay or space their pregnancies. Fifty million of these women live in sub-Saharan Africa.

If they had access to reliable information about planning their families, a range of effective contraceptives and high-quality reproductive healthcare, their lives would improve in many ways – they would be healthier and wealthier, and their children would have a better chance at a successful life.

Our family planning program’s goal is to help women and adolescents make voluntary, informed decisions about their health and their future.

Melinda Gates has been a vocal advocate of family planning since 2012, when she co-hosted the London Summit on Family Planning.

The summit brought governments, businesses and philanthropic organizations together around a promise to ensure that 120-million more women around the world would have access to and use contraceptives by 2020. (The long-term goal is universal access, where every woman can access contraceptives if she wants to.)

Africa’s prospects for better health and prosperity would be limitless if every woman and girl had the ability to make decisions that affect their health and futures. When women have the education and services they need to time and space their pregnancies, the health and social barriers that keep so many families in poverty are diminished.

Kellie Sloan Director, Family Planning

The latest data show that 30-million more women are now using modern contraceptives, but we need to accelerate progress to keep our Family Planning 2020 promise.

As part of this promise, many African governments devised costed national family-planning strategies. Our program supports several of those countries as they implement their strategies.

In Senegal, for example, we’re working to further many aspects of the national plan – from educating women and girls about their health, to training frontline health workers and improving the quality of family-planning services, to improving the supply chain so that clinics are always stocked with a variety of contraceptives.

We are also investing in data and evidence that will help all countries provide better family-planning services. We are working with partners to develop monitoring systems that provide more information more regularly, so that countries can make adjustments and allocate resources more strategically.

We’re also gathering evidence about successes and sharing it widely, so that countries have field-tested methods to draw from. Part of this involves engaging young people in the design, research and implementation of new family-planning solutions to ensure that we’re investing in what actually works for them, not what we think might work.

Finally, we’re working with research partners to develop or adapt contraceptive technologies to meet more women’s needs.

Family-planning methods that are effective, reliable and readily available can help women build a healthier, happier future themselves and trigger a cycle of prosperity for their families and communities.

Research shows that when one additional method of contraception is provided to half of the women in a population, overall use can increase by as much as 4% to 8%.

For the first time in history, more than 300-million women globally are using modern family-planning methods.

The Family Planning 2020 goal is to ensure an additional 120-million women and girls have access to and use contraceptives by 2020.

37

PROGRAM STRATEGY: FINANCIAL SERVICES FOR THE POOR

of money

THE FUTURE

Itá¾½s safer, cheaper, faster. In this new digital world, the very poor are also benefiting from pioneering mobile payment technologies.

A rural mobile banking unit in Nkhoma, Malawi.

38

Two billion people in the world don’t have access to formal financial services. Instead, they have to use informal financial instruments like moneylenders and cash couriers to get by. But these tools rarely do exactly what people need them to do. For example, if your savings are in the form of a cow, you can’t use it to pay your child’s exam fee.

The Gates Foundation’s financial services for the poor program aims to help poor people unlock their resources so they can get the goods and services they need, when they need them, while investing in a better future. We do this by supporting new financial systems and tools based on digital and mobile technology. Digital financial services are safer, cheaper, faster, more convenient and more reliable than the informal tools they are replacing.

In some African countries, mobile money is already well established. M-Pesa has more than 20-million subscribers on the continent, while in Uganda 35% of the population has a mobile money account, compared with just 28% with a traditional bank account.

In these countries, we’re working with partners to develop a wider range of products and services to meet every customer’s needs.

Kenya’s M-Kopa, a company whose solar panels are affordable because they’re paid for in small daily installments using mobile phones, is a great example.

M-Kopa sells solar-power systems to Kenya’s rural poor. For the equivalent of about $200, farmers in off-the-grid places can buy a small solar panel, two lightbulbs and a flashlight, a rechargeable radio and a cellphone charger, all designed to last for about four years. It’s much cheaper (and cleaner) than the alternative, kerosene, which costs the average rural Kenyan household nearly $200 per year. But if a person who survives on less than $2 a day had to pay for the system all at once in cash, it wouldn’t be remotely affordable.

Ultimately, digital financial systems will be sustained by banks, telecommunications companies and other financial service providers. We are working with governments to make sure that financial regulations keep people and economies safe while allowing for the innovation needed to make mobile money work.

We are also collaborating with private companies and others to create a shared infrastructure for a fully digital economy.

In the long run, building an inclusive digital economy in which all citizens have a safe place to put their money and easy ways to use it will not only reduce poverty, it will also unlock the market potential of those who are currently excluded from the formal economy and lead to growth and prosperity for all.

“

The next revolution in financial services demands that transaction costs are reduced, security measures are increased for digital models, and systems function effectively across markets. The innovations we’re seeing now are already pushing us into new territory, and the foundation is committed to helping drive progress for the unbanked poor.

”

Rodger Voorhies Executive Director of the Agricultural Development, Financial Services for the Poor, Gender Equality, and Water, Sanitation and Hygiene teams within the Global Development Program

The big idea behind M-Kopa is that you don’t have to pay all at once. Instead, you put $35 down and pay 45 cents per day using your mobile phone. When you make your daily payment, a SIM card on the solar panel’s control box activates the system. If you miss a payment, the SIM card tells the system to shut down.

And power isn’t all M-Kopa sells. It sells lots of products using that same installment system: bicycles, rainwater tanks, fuelefficient stoves and even cash loans to pay school fees. As long as you have a cellphone account, you can participate in the new, expanded economy M-Kopa’s technology makes possible.

In other countries in Africa, however, the digital financial infrastructure simply isn’t in place. For example, in Nigeria there is a financial access point for every 2 500 people, compared with Kenya, where there is an access point for every 325 people. In these countries, we are investing with partners to help build the necessary infrastructure.

39

PROGRAM STRATEGY: HIV

Holy Grail

SEARCHING FOR THE

of medicine

Over the past 35 years, there has been huge progress in the fight against HIV. Medical breakthroughs have created new prevention tools, bringing down infection rates by 35% since 2001. Find out what’s on the horizon to address this epidemic.

African nations have made stunning progress in the fight against HIV. In 2000, just a few thousand people in Africa were receiving treatment. Now that number is more than 12-million.

But HIV is still a major crisis, and because the largest generation in history is entering the age at which they’re most at risk of HIV, there’s a serious danger that the rate of infection will start going up again. Our HIV program aims to save lives now and in the future by improving treatment for the people already living with HIV, and by bringing down the number of new infections faster.

One serious obstacle to improving treatment outcomes is the number of people who remain undiagnosed – of 25-million people living with HIV, half don’t know their status. We’re working to learn what prevents people from being diagnosed, and in the meantime we’re working with partners to improve testing programs and develop self-tests so people can find out their status without visiting a doctor.

For millions who are diagnosed, it’s difficult to stay on the daily treatment regimen long enough to entirely suppress the virus, so we’re helping to develop simpler, stronger therapies and more effective delivery programs.

To stop HIV in its tracks, we need to do more to prevent new infections. We need to understand how best to enable members of high-risk groups, including youth, sex workers and adolescent girls, to use prevention methods. We know that voluntary medical male circumcision (VMMC) is effective in reducing the risk of HIV transmission, but many national VMMC programs have not yet been fully scaled up. Daily oral pre-exposure prophylaxis (PrEP) and condoms are also effective, but only when people are able to use them consistently.

We’re working with governments and partners to expand delivery of PrEP, meet country VMMC targets, and increase condom use among those most at risk. We’re also partnering with PEPFAR to address the social and cultural barriers underlying HIV infection.

40

Through programs that address poverty, gender inequality, sexual violence and lack of education, PEPFAR’s DREAMS initiative aims to reduce HIV infections among adolescent girls and young women in 10 African countries.

Alongside efforts to expand access to existing tools, we need to invest in research to develop and deliver new prevention technologies. In the long run, we’re working with partners to develop improved prevention tools that fit better into people’s lives, including an HIV vaccine.

Finding an effective HIV vaccine has proven to be one of the most elusive goals in medicine. But in a 2003 trial, an experimental vaccine proved 31% effective against the subtype of HIV most common in Thailand. Since this was the first vaccine that had ever shown any efficacy at all, it represented a significant breakthrough.

In 2010, several public and private organizations joined together as the Pox-Protein Public-Private Partnership (P5) to help subSaharan African nations test whether they could use this vaccine to protect their citizens from HIV. The P5 modified the Thai vaccine to fight the HIV subtype most common in Southern Africa, and added a new adjuvant and vaccination boost to enhance the immune response and prolong protection. Last year, the P5 found that early-stage trials had met all criteria needed to move forward with a large-scale efficacy trial. In December 2016, P5 launched the Phase IIb/III trials of HVTN702, the most advanced of many clinical trials of an HIV vaccine currently in the field.

An HIV vaccine is the Holy Grail of global health. Thanks to the efforts of the African researchers and participants involved in the trial, we may be one step closer to this goal.

Africa’s progress against HIV is a major global health success story. Continued commitment to improving diagnosis, treatment and prevention will help young Africans stay HIV-free in the years to come.

The simple truth is that we’ve made tremendous breakthroughs in treatment and prevention of HIV, but they still benefit far too few people.

Emilio Emini HIV Program Director

HIV infection rates have dropped by

35%

globally since 2001.

17-million people are now on antiretroviral treatment.

In 2030, the largest ever generation of young people in Africa will reach an age at which they are most at risk of HIV infection.

Euaryste Tugirinshuru (32), stands with his family in a field near his home in the Kirehe district, Rwanda.

41

PROGRAM STRATEGY: INTEGRATED DELIVERY

mile

THE LAST

Over the past few decades, advancements in science and medicine have helped save and improve lives in Africa, and around the world. Yet many countries still struggle to provide essential health products and services to people, especially in poor and marginalized communities. Products that aren’t well designed for people, weak systems and undertrained health workers all contribute to healthcare delivery challenges.

Our Integrated Delivery team was created in 2012 to address the critical delivery challenges that slow health progress. Our goal is to ensure that life-saving and life-changing health products and services reach the people who need them most, when they need them and at a cost they can afford.

Our team takes a three-pronged approach to improving delivery, focusing on products and services, the systems that deliver them, and the people who provide, manage and seek care. We work closely with other foundation teams, country governments, and local and global partners to achieve our goals.

First, we invest in products and services that are affordable and easy to use. For example, we supported the launch and scale-up of the first rapid diagnostic test for sleeping sickness, a neglected tropical disease that endangers approximately 65-million people in sub-Saharan Africa. While the old diagnostic test was bulky and difficult to deliver in remote areas, the new test is a simple finger-prick blood test that health workers can use during doorto-door screenings. This test is helping to drive sleeping sickness caseloads to their lowest levels in history.

Second, we support efforts to strengthen health systems, especially at the primary care level. The 2014 Ebola outbreak showed the dire consequences of fragile health systems. In contrast, strong primary healthcare systems – people’s first and main source for care – can manage 90% of people’s health needs in a cost-effective way. Yet these systems are often under-funded, which means many people receive low-quality care, or don’t get any care at all. We work closely with the governments of Ethiopia and Nigeria and with various global partners to improve primary healthcare system design, financing and management.

Finally, we focus on people, who are at the heart of healthcare delivery. We aim to better understand and improve the healthcare workforce and patients’ interactions with the health system. For example, health system managers play a critical role – they support health workers, decide how to organize systems and are clearly committed to the work (a survey of primary healthcare managers in Nigeria and Ethiopia showed that 90% wanted to improve their skills). Yet these managers often don’t have the 42

training, information and support they need. We support efforts to better train health managers and workers, and to build evidence on patients’ health behavior.

While our work is diverse and spans complex issues, our ultimate goal is simple: increase access to quality healthcare, especially primary healthcare, for people and communities.

Hundreds of millions of people in the poorest and most marginalized communities lack access to even basic healthcare, which stands in the way of people living healthy and productive lives. We must overcome the challenges to help people get the quality healthcare they need and deserve.

Dana Hovig Director of Integrated Delivery

Nurse Birke Fisaha demonstrates how the passive vaccine storage device is used to keep vaccines cold for up to 30 days at the Achamo Health post in Ethiopia.

ONE OF OUR INVESTMENTS The Joint Learning Network (JLN) is a network of practitioners and policymakers in low- and middle-income countries working to strengthen health systems and achieve universal health coverage.

side of health-system reforms. Its members have access to

resources on strengthening systems, including guides, country briefs and case studies.

The JLN also works with the Primary Health Care Performance Initiative (PHCPI) – a partnership launched in 2015 by the Gates Foundation, World Bank Group and World Health

Over the past six years, the JLN has grown to include leaders from ministries of health, national health financing agencies and other key government institutions from 27 member countries, including 11 countries across Africa.

Organization, and supported by Ariadne Labs and Results

The JLN is unique in that it focuses on the practical “how to”

healthcare systems.

for Development – to measure the performance of primary

healthcare systems in low- and middle-income countries. The

JLN and PHCPI work together to ensure this data is available

for those in-country working to strengthen their country’s primary

43

PROGRAM STRATEGY: NEGLECTED TROPICAL DISEASES

FIGHTING THE

forgotten diseases

With names you can’t pronounce or have never heard of and with limited focus or support from many development players, neglected tropical diseases kill more people than you think.

More than 1-billion people around the world suffer from preventable, treatable diseases that many have never heard of – diseases like human African trypanosomiasis, onchocerciasis and schistosomiasis. Together, these are known as neglected tropical diseases, or NTDs. NTDs cause about 150 000 deaths every year, although this number vastly understates their impact. They also cause debilitating symptoms like blindness, chronic fatigue, anemia, and impaired cognitive and physical development. And sub-Saharan Africa alone bears 40% of the global burden of NTDs. Our goal is to control, eliminate and eventually eradicate these diseases – and a host of public and private partners are working together to achieve that goal.

In 2012, the Gates Foundation, the World Health Organization, the World Bank, and the governments of developing and developed nations agreed to the London Declaration on Neglected Tropical Diseases, to eliminate or control 10 different NTDs by 2020. As part of this declaration, nine leading pharmaceutical companies agreed to donate the necessary drugs free of charge – $17.8-billion worth by 2020.

But donated drugs don’t solve the problem by themselves, because the public health surveillance needed to find at-risk populations and deliver the drugs they need to stay healthy isn’t as strong as it needs to be.

We are working with partners to get treatment to the right people at the right time, using advanced data collection and mapping techniques. For some diseases, such as human African trypanosomiasis, optimal tools don’t yet exist, so we are working with partners to develop better diagnostics and drugs.

Because it is so challenging and expensive to reach at-risk populations, the NTD community also works to address other health priorities when working with these populations (it doesn’t make sense to travel hundreds of kilometers to deal with sleeping sickness while ignoring the other dozens of health problems people face).

44

That’s why we also look for ways to integrate NTD and non-NTD tools. For example, researchers are working on a diagnostic test for sleeping sickness and malaria, since both diseases look similar in the early stages. Similarly, since insects transmit more than one disease, controlling flies and mosquitoes will do more than help communities tackle just one illness at a time.

The places where these diseases take the greatest toll are the poorest in the world, with governments and health systems that have the least capacity to implement solutions. The result of successful NTD programs will be better health and a better life for 1-billion people.

Neglected tropical diseases are called neglected for many reasons. Most importantly, they affect the most vulnerable people in the world. Just a decade ago, they were also neglected because progress in stopping them was painstaking and slow. Now, though, these diseases are near the top of the global health agenda; resources are still limited but more available than ever, and advocates are starting to see the finish line.

Trevor Mundel President of Global Health

Yetagesu Alemu, a health extension worker at the Germama Gale Health Post in Ethiopia, takes a blood pressure reading during a house call to Adria Muste and her nine-month-old baby, Mohammed.

ONE OF OUR INVESTMENTS As part of the London Declaration, African nations pledged to control, eliminate or eradicate 10 neglected tropical diseases by 2020. The Expanded Special Project for Elimination of Neglected Tropical Diseases (ESPEN), a partnership with the World Health Organization’s Regional Office for Africa and other organizations, is helping them do this work.

enabling them to collect and share data, map the burdens of disease within their borders, and deliver treatments to sick people as efficiently and effectively as possible.

ESPEN will focus in large part on mass drug administration (MDA), which involves reaching entire at-risk communities annually with safe and effective drugs to treat and prevent NTDs.

ESPEN is dedicated to battling Africa’s five most prevalent NTDs: soil-transmitted helminths, lymphatic filariasis, schistosomiasis, onchocerciasis and trachoma.

Since 2013, 493.5-million people have been treated through

ESPEN’s goal is to provide technical and fundraising support to governments and health programs in affected countries,

36% in 2008. ESPEN will help finish the job, and achieve control

MDA. The scale-up of MDA across the continent has been a remarkable achievement. Of those that need preventive

chemotherapy, 43% are receiving treatment, an increase from and elimination targets.

45

PROGRAM STRATEGY: NUTRITION

of life

THE BUILDING BLOCKS

In Africa, malnutrition is a silent epidemic that is killing children. But now the world is listening …

Children eat lunch at Dome Experimental Primary School in Accra, Ghana.

46

Nutrition is one of the smartest investments African leaders and their partners can make to ensure the next generation thrives. Better nutrition will advance every single priority in global health and development.

Shawn Baker Director, Nutrition team

foods starting at six months. We also try to make sure older children and adults, especially women and girls, are getting the nutrients they need by breeding healthier crops and fortifying staple foods.

Unfortunately, our existing tools will only address a portion of the malnutrition burden. Therefore, we are working with other partners to help fill in the gaps in our understanding of what causes malnutrition and how to address it.

Our partners are doing research to better understand just how much damage malnutrition does to children’s cognitive and physical development. They’re also developing new solutions, such as improved nutritional supplements. And they’re trying to identify the most effective combination and timing of interventions, so policymakers can ensure children get what they need when they need it.

There is no priority in global health and development that doesn’t depend on nutrition in one way or another. It is exciting that the world is finally giving it the attention it deserves; it will be even more exciting to see the results.

ONE OF OUR INVESTMENTS

Malnutrition is known as the “silent epidemic”. It reduces the immune system’s ability to fight infection, stunts growth and inhibits brain development, and makes it difficult for children to perform well in school – usually while displaying few visible symptoms.

The problems it causes affect hundreds of millions of children – malnutrition was the underlying cause of 2.6-million child deaths in 2016 – but because the connection is hard to see, malnutrition has long been a neglected part of development.

This is finally starting to change – funding for nutrition has been increasing globally. And the Gates Foundation’s nutrition program is part of this movement, with a doubling of our budget in 2015.

Our goal is to make sure that all women and children have the nutrition they need to survive and thrive.

Breastfeeding may be the most important health intervention there is. It helps babies grow and develop, it protects them from diseases and it even reduces the risk of breast cancer in mothers. In fact, nearly half of all diarrhea episodes and one-third of all respiratory infections could be prevented with increased breastfeeding in lowand middle-income countries.

In many communities, though, mothers either don’t breastfeed or don’t breastfeed effectively. Because breastfeeding practices are deeply ingrained, and because mothers and health workers often don’t have the resources they need, it can be hard to encourage families to change their behavior.

So our partner, Alive & Thrive, started its program to promote breastfeeding and healthy complementary feeding by listening to mothers, health workers and policymakers to understand where the challenges lay.

Based on this analysis, they developed Smart and Strong, which reached millions of families in Ethiopia through radio programs and home visits, training for fathers, and counseling tools and reminder cards that are now being used in government programs throughout the country.

Some of our partners apply the knowledge that already exists about how to improve nutrition. The 1 000 days between the start of a mother’s pregnancy and a child’s second birthday are the most critical period for brain and body development, so we work closely with countries to ensure that women and children are getting the nutrition they need during that window.

By relying on volunteers trusted by their communities and early adopters they could offer as models, Alive & Thrive has seen great success. Ethiopia’s breastfeeding rate rose by eight percentage points in just four years in program areas, and dietary diversity more than doubled (though it is still much too low).

We encourage mothers to breastfeed their babies exclusively for the first six months of life and to provide the right complementary

The success of the program in Ethiopia, as well as Vietnam and Bangladesh, has led Alive & Thrive to expand into Burkina Faso and Nigeria.

47

PROGRAM STRATEGY: MALARIA

mosquito THE MIGHTY

“If you think you are too small to make a difference, try sleeping with a mosquito.” This is a well-known quote that keeps the Malaria team awake. Malaria is one of Africa’s biggest killers, but we are winning the fight.

Since 2000, malaria deaths worldwide have gone down by an

astonishing 57%. It’s a great global health success story, and it’s particularly good news for Africa, where 90% of malaria deaths occur.

But a child still dies from malaria every minute. And hundreds of

thousands of deaths, along with hundreds of millions of cases of

severe illness, are standing in the way of health and prosperity for the continent.

Our malaria program’s goal is not just to reduce malaria deaths,

but to eradicate the disease altogether. The alternative – trying to

control a dynamic disease like malaria in perpetuity – is untenable.

Biologically, the mosquito that transmits the parasite and the

parasite itself continuously evolve to resist our efforts to fight them.

Logistically and politically, it may be impossible to maintain the level of effort and commitment to keep the disease permanently at bay.

We are helping to develop the strategies and tools that African

health systems will deploy to make progress toward elimination.

For example, since most people infected with malaria show no symptoms but still transmit the disease, health systems must

move from just treating clinical cases to detecting and curing all infections.

This requires not just a shift in approach, but also new tools,

including highly sensitive tests to diagnose the disease and drugs

that don’t just treat symptoms but clear all parasites from the body, including the forms that reinfect mosquitoes. There are already

new drug candidates in advanced clinical trials for a single-dose, complete cure for malaria.

Also, because the mosquitoes that transmit malaria are developing resistance to the insecticides we use to fight them, we’re investing 48

While we are heavily invested in developing new tools for malaria elimination, in the near term our focus is accelerating the gains made over the past 15 years using current tools and new strategies.

These gains form the basis for increased commitment to eradication efforts. The next three to five years are crucial to putting the world on a trajectory to achieve eradication in our lifetime.

Bruno Moonen Deputy Director, Malaria team

in new insecticides for bednets and house sprays, and other

The E8 countries also operate mobile clinics that diagnose and

partners on some long-term solutions, such as malaria vaccines or

to another, lead to cross-border transmission. Finally, the E8

innovative vector control methods. Finally, we’re working with

genetically modified mosquitoes, which will help the world get to zero cases a generation from now.

Deploying these strategies and tools will require the leadership

of countries whose people are affected by the disease, especially

because the malaria community needs double the current funding over the next 10 years to stay on the path toward eradication.

We support African leaders through organizations such as the

African Leaders Malaria Alliance and the Elimination Eight Initiative (E8), and we spread the message about the benefits of eradication so that African governments and other funders step up to meet the challenge during this critical time.

treat people who, by moving from one country in the region

countries are harmonizing their disease surveillance systems so that they can understand these cross-border patterns of

transmission, and make strategic decisions about where to deploy their resources.

The success of the E8 won’t only shrink Africa’s malaria map

– it will also serve as an important source of lessons for other

countries that commit to eliminating the disease in the future, as we move toward global eradication.

SUB-SAHARAN AFRICA ACCOUNTS FOR

90% OF GLOBAL MALARIA CASES.

ELIMINATION EIGHT INITIATIVE (E8) No country in sub-Saharan Africa has ever eliminated malaria.

The E8 aims to change that. Its goal is to eliminate malaria from

eight Southern African countries: Botswana, Namibia, South Africa and Swaziland by 2020; and Angola, Mozambique, Zambia and

Zimbabwe by 2030. We support the E8 because it demonstrates how strong partnerships and government commitment lead to

IN THE PAST 15

YEARS, MALARIA

MORTALITY RATES FELL BY ALMOST

60% AMONG ALL AGE GROUPS, AND BY 71% AMONG CHILDREN

rapid progress toward elimination, even before new tools become

UNDER FIVE.

These countries are running their own national malaria strategies.

33 COUNTRIES HAVE BEEN

available.

But since no country can eliminate malaria in a vacuum –

national borders don’t stop the spread of disease – E8 takes

CERTIFIED BY THE WORLD HEALTH

a regional view of the problem. These countries’ ministries of

ORGANIZATION AS HAVING OFFICIALLY

implement new policies, and fast-track the introduction of new

ELIMINATED MALARIA.

health collaborate with one another to share data and evidence, malaria-fighting technologies.

49

PROGRAM STRATEGY: MATERNAL, NEWBORN AND CHILD HEALTH

miracle of birth PRESERVING THE

One of the most important days in a person’s life is the day they are born – but in Africa it could be one of the most dangerous. The Maternal and Newborn Child Health team is working on solutions to save more lives.

Until 2013, Ethiopia didn’t register maternal deaths. When a woman died during pregnancy or childbirth, there was no record of it – or why it happened. This made it difficult to prevent maternal deaths. To solve this problem, Evidence 4 Action (E4A) partnered with the Ethiopian government to develop a maternal death surveillance and response (MDSR) system.

In 2015, 11 000 Ethiopian women died during pregnancy or childbirth, and the Ethiopian government knows exactly who each of them was and why they died. In 2016, Ethiopia launched its first-ever national MDSR review, revealing that the leading causes of maternal death were hemorrhage and preeclampsia. As a result, the Ministry of Health recommended regular training on managing these two conditions.

Specifically, we align with the targets for reducing maternal

and neonatal mortality that were laid out in the Sustainable Development Goals.

There is a lot of good news: maternal deaths are down by almost half since 2000, and child deaths are down by more than half.

Unfortunately, approximately two-thirds of all maternal deaths

occur in sub-Saharan Africa, and the risk of a child dying is higher in this region than anywhere else in the world. And newborns

represent a rising share of child mortality – almost half of children who don’t live past the age of five die in the first month of their lives.

There are relatively inexpensive and simple ways to ensure the

E4A’s work with the Ethiopian government is doing more than just triggering national-level policy changes.

health of mothers and babies. The challenge is delivering solutions

The staff at local health facilities now meet every two weeks to discuss maternal deaths and consider improvements to care, such as acquiring an ambulance so that pregnant women who live far away can get to the facility safely. And for deaths that take place outside of facilities, E4A conducts verbal autopsies, which helps raise awareness in communities about the risks of childbirth.

and tools, our highest priority is collaborating with governments

A healthy birth is an exceedingly complicated event because it depends on so many factors.

These factors include a woman having access to high-quality primary healthcare so she can seek family-planning information and services and prenatal care; a birth attendant skilled enough to recognize warning signs and administer the right treatments; and, since babies need to not only survive birth but thrive, a strong health system that prioritizes immunizations, nutrition, and other key elements of healthy growth and development.

All of these factors together are called maternal, newborn and child health (MNCH), and they form the basis of a flourishing society. The Gates Foundation’s MNCH program aims to help all women and children – and, by extension, all societies – flourish.

50

to women and children across the continent. Though we work with research partners to continue developing new and better methods and other partners to improve primary healthcare using life-saving interventions for mother and baby that already exist.

At least 75% of maternal deaths are preventable. For example, oxytocin and misoprostol, which cost less than $1, prevent and treat postpartum hemorrhage. And simple practices like early

and exclusive breastfeeding and skin-to-skin care could prevent 1-million newborn deaths every year.

One of the best ways to help save mothers and newborns is to

encourage women to give birth at health facilities, where the staff are trained and equipped to deal with complications, instead of at home. But this only helps if the training and equipment are

indeed in place, so our strategy now prioritizes the quality of care at facilities. We also invest in frontline health workers who bring health advice and basic services into communities.

Childbirth promises hope for the future, but it is also risky. Our

partners seek to reduce that risk and help all women and children fulfill their potential.

When mothers and newborns have access to the quality services they need to survive and thrive, we can achieve long-lasting benefits for families, communities and countries.

Hugh Chang Director, Strategy Planning and Management for Global Development

The number of children under five dying from preventable and treatable causes has been halved since 1990.

According to Unicef, deaths in the first month of life, which are mostly preventable, represent 45% of total deaths among children under five.

A newborn in the discharge room for new mothers at Dowa District Hospital in Dowa, Malawi.

Approximately 500 000 women die annually while giving birth in the developing world.

51

PROGRAM STRATEGY: PNEUMONIA

Jade Nelson is held by her grandmother Veronica at the TC Newman Clinic in Paarl, South Africa.

THE WORLD’S MOST NOTORIOUS

child killer

The race to find a vaccine to prevent children dying from pneumonia is on.

Pneumonia is the world’s leading infectious cause of death among young children. Half of those deaths occur in sub-Saharan Africa, where pneumonia killed almost 500 000 in 2015. Our pneumonia program’s goal is to save those lives.

The key to doing so is vaccination, but since pneumonia is caused not by a single bacterium or virus, but by many different ones – pneumococcus, influenza and more – it takes many different vaccines. Some of these vaccines exist, but millions of children in developing countries aren’t receiving them. Other pneumonia viruses, like respiratory syncytial virus (RSV), don’t yet have effective vaccines.

52

Our key partner in increasing access to vaccines is Gavi, the Vaccine Alliance, an organization that helps the world’s poorest countries buy vaccines. Since 2010, Gavi has helped more than 25 African countries introduce the pneumococcal vaccine (pneumococcus is the most common cause of pneumonia).

We also support research into an RSV vaccine, long complicated by the fact that the virus is most fatal to children under the age of six months, which makes it difficult to conduct clinical trials.

But vaccines can’t help children until they’re old enough to be inoculated, which means that we have to find other ways to protect

newborns. For these infants, our partners are looking into the exciting new field of maternal vaccination.

There is strong evidence that when pregnant women are vaccinated against a disease, they pass a significant degree of protection along to their babies. So far this approach has only been widely implemented to prevent neonatal tetanus, flu and pertussis, but with more research our partners hope to use it to protect infants from many more diseases, including pneumonia.

Finally, we are working with other partners to improve diagnosis and treatment of pneumonia for children who do get sick. If properly and quickly diagnosed, childhood pneumonia can be effectively treated with a three-day course of antibiotics at a cost of less than 50 cents.

Further, the world still doesn’t know enough about which children are likely to get pneumonia in the first place, so we’re also supporting research into environmental and physiological factors that contribute to infection.

Astoundingly, pneumonia continues to be the number-one infectious killer of children worldwide. Fortunately, we have the tools and know-how to prevent and treat most pneumonia cases; what we need is the collective will to prevent these deaths, and to make sure these solutions reach the children who need them most.

Keith Klugman Director, Pneumonia team

The global health community has adequate tools and is developing better ones to fight pneumonia. There is no better way to save children’s lives than to deliver these tools to all the children who need them.

ONE OF OUR INVESTMENTS A history of longitudinal studies of pneumonia in rich countries has given us a very clear idea of what makes children more likely to get pneumonia, but no similar study has been conducted in the developing world, until recently.

The Drakenstein Child Health Study, conducted in a poor community of the city of Paarl, not far from Cape Town in South Africa, has been enrolling pregnant women in their second trimester and following their children from birth through to the age of five to investigate the risk factors and long-term impact of pneumonia on young children.

The data that researchers are compiling has already begun to yield results that are in many cases applicable to children with pneumonia all over the world.

They have learned, for example, that early-life pneumonia infections impair lung function (in addition to impaired lung function predisposing children to pneumonia). They’ve also found that children whose mothers smoke or are HIV positive are more likely to fall ill.

This information – and more like it – will help health workers devise more effective ways to prevent and treat pneumonia in children throughout Africa.

Pneumonia has remained the world’s leading cause of death among children under the age of five.

Medicines for diarrhea and pneumonia cost less than US 50 cents per treatment.

Only one-third of children with pneumonia receive the antibiotics they need.

53

PROGRAM STRATEGY: POLIO

a disease

THE ENDING OF

The world is on the verge of wiping polio off the face of the Earth and, despite the setback in Nigeria, the fight continues.

When new polio cases were detected in Borno State in Nigeria in 2016, the government of Nigeria, the governments of neighboring countries and the GPEI partners immediately mounted an emergency response to stop the outbreak.

In just three days, health workers vaccinated approximately 1-million children in the areas directly surrounding the detected cases. Shortly thereafter, they reached 10-million at-risk children in Nigeria and four neighboring countries. By the end of 2016, 40-million children in Nigeria, the Lake Chad area of Chad, northern Cameroon, southern Niger and parts of the Central African Republic were immunized.

Thirty years ago, Polio was paralyzing 350 000 people in 125 countries every year. But in 1988, the countries of the world set a goal of eradication, and the Global Polio Eradication Initiative (GPEI) was launched.

Since then, millions of volunteers have immunized billions of children, driving the number of cases down by more than 99% and saving more than 16-million children from paralysis. There are only three countries in the world where polio is still circulating: Afghanistan, Pakistan and Nigeria.

After nearly two years without finding a case, Nigeria announced in 2016 that four children in the north-eastern state of Borno, which has been plagued by violence and insecurity for years, had the disease.

The area where the polio virus is circulating is currently the focus of a major humanitarian crisis, with 2-million displaced people in Nigeria’s Borno, Yobe and Adamawa states. In 2015, as many as 600 000 children in Borno were inaccessible to vaccinators, and the polio program was unable to enter half of all settlements in the state due to the security risk.

The outbreak in Nigeria is a sobering reminder of how difficult it is to eradicate a disease, and how fragile progress can be. Until we get to zero cases everywhere, any country is at risk.

However, despite the challenges, the outbreak in Nigeria can be stopped. The Gates Foundation is supporting a massive emergency response in northern Nigeria and the entire Lake Chad region, led by the WHO, Unicef and country governments. We are also continuing to plan for the final stages of the eradication effort, 54

after the Nigerian outbreak is stopped and there are no cases in Afghanistan and Pakistan.

The polio community has made it a top priority to transfer the lessons learned and infrastructure from the 30-year fight to end polio to other global health efforts. The world previewed this legacy of the eradication program during the 2015 Ebola outbreak, which was stopped quickly in Nigeria thanks in part to a well-developed, polio-fighting infrastructure that was adapted to respond to Ebola quickly and effectively.

The progress against polio across Africa and around the world is one of the greatest success stories in global health. The ultimate success will be the relegation of the disease, and all the misery it has caused, to the dustbin of history.

The recent discovery of polio in Nigeria was disappointing, but it was also a challenge to us. We cannot sit back and wait; we have to use every tool at our disposal to find the virus where it is hiding and stop it forever so that no child ever again is paralyzed by polio.

Jay Wenger Director, Polio team

Ahead of World Polio Day on 24 October 2016, the “End Polio Now� logo was projected onto the Bill & Melinda Gates Foundation headquarters in Seattle.

For every 200 people infected with polio, only one will have symptoms.

A global network of 20-million volunteers and health workers has been mobilized to conduct polio immunization around the world.

1.5-million childhood deaths have been averted through polio immunization campaigns.

Polio eradication will result in global savings of $50-billion, mostly in developing countries.

ONE OF OUR INVESTMENTS It is critical to strengthen disease surveillance across Borno state and the Lake Chad region to ensure that partners have the information they need to direct immunization efforts and eliminate the virus totally from these areas.

To that end, we are supporting GPEI partners to retrain frontline health workers, introduce new rapid reporting technology, collect stool samples from children in the most at-risk areas, and search carefully for cases of paralysis.

Insecurity continues to pose a major challenge in northern Nigeria, but we are employing time-tested strategies for meeting that challenge, such as setting up permanent vaccination posts at the edges of inaccessible areas to vaccinate people traveling in and out.

55

PROGRAM STRATEGY: TUBERCULOSIS

deadly duo

TACKLING THE

South Africa is home to the world’s largest HIV/TB co-infected population, which makes it a key country for the TB team. Find out how better data and better tools will help the fight against TB.

A group of patients relaxes after lunch in the grounds of the Brewelskloof TB Hospital in Worcester, South Africa.

56

Tuberculosis affects 10.4-million people every year, killing 1.4-million. The majority of cases are in Asia, but there are still 2.7-million cases and 450 000 deaths in Africa annually. Our TB program impacts on countries across the continent, but we focus especially on South Africa, which has 20% of the cases in Africa. In addition, South Africa also has many of the leading TB researchers in the world and a strong government commitment to protecting its citizens from the disease.

Though treatment for TB exists, only about half of South Africans with TB are treated successfully. Our strategy, which is strongly aligned with the country’s national TB program, aims to identify the key junctures where people encounter barriers to quality care – some are never diagnosed, some never start treatment, and some aren’t able to complete the long treatment course before it is done – and fill those gaps.

At the same time, we are investing globally in new tools, including better diagnostic tests, simpler drug regimens, and, eventually, an efficacious vaccine. Together, improved TB control systems

South Africa’s TB initiatives hold tremendous promise to save lives. They offer a model for how to identify and keep track of more patients who need care, introduce and encourage uptake of new innovations, and ultimately reduce the number of people who fall ill or lose their life to TB … Success in South Africa means success for the world – and it is within reach.

Gilla Kaplan Director of the Tuberculosis team

and advanced TB prevention and treatment tools can lift the heavy burden of the epidemic.

One of the best investments to help make sure more people are able to successfully complete treatment is a strong data system.

Unfortunately, although knowledge exists about the numbers of patients who fall through the gaps at the national level, there is nothing comparable at the district or facility level. As a result, South African policymakers and health workers do not have the information they need to pinpoint the best strategies for saving lives.

We are working with partners to help create such a data system.

We are also focused on bringing the country’s strong research community together with the clinicians who care for patients, to make sure cutting-edge knowledge is put into practice as quickly as possible.

One unique aspect of the TB epidemic in South Africa is the prevalence of HIV/TB co-infection. South Africa is home to the world’s largest co-infected population – of the 98 000 people who died of TB in South Africa last year, a staggering 73 000 were known to be HIV-positive. The lessons learned from our work on HIV and TB co-infection with partners in South Africa will help other countries tackle this crisis.

In the long run, the world is developing better tools to fight TB. For now, though, it is possible to save lives using the tools we already have, if we succeed in delivering them to the millions of Africans who need them.

ONE OF OUR INVESTMENTS With Gates Foundation support, South Africa’s Department of Health established the TB Think Tank, a group of TB experts from clinical and research communities, in 2014. Since South Africa produces the world’s sixth largest research output related to TB and also has the world’s sixth highest TB burden, the Department of Health saw both the need and the opportunity to improve scientifically based, strategic decision-making about TB policies and programs.

The TB Think Tank has been a valuable resource to the government, helping make its TB control program one of the most innovative in the world. The Think Tank contributed to South Africa’s first-ever TB investment case, which led to additional funding for TB control. It also guided the development of South Africa’s new five-year TB strategy (2017 to 2022).

Finally, the Think Tank has facilitated the evaluation of a variety of new TB treatment methods and tools, including a new TB drug and a shortened treatment regimen for patients with multidrug-resistant TB. Given the success of the TB Think Tank, the Gates Foundation is currently awarding a similar HIV Think Tank grant.

57

PROGRAM STRATEGY: TOBACCO

change

ADVOCATING FOR

A young man smokes a cigarette bought from a kiosk in the streets of Nairobi, Kenya.

58

Not many people know the foundation has a small but mighty team that is working to prevent a tobacco epidemic in Africa.

Every year, more people die from the effects of tobacco than from tuberculosis, AIDS and malaria combined; this century, scientists predict tobacco will kill 1-billion people.

As smoking rates fall in rich countries, tobacco companies are turning to markets in developing countries. Without strong protections, tobacco epidemics will ravage these countries in the decades to come. Our tobacco program’s goal in Africa is to help countries stop this health crisis before it starts.

Our priorities differ by region, depending on local conditions. China, for example, is already the world’s largest producer and consumer of tobacco. In African countries, however, the tobacco epidemic is still at a relatively early stage, so our primary goal is prevention.

The good news is the world knows what works: 180 countries have signed a treaty, the WHO Framework Convention on Tobacco

Control (FCTC), that outlines evidence-based policy, and there is no debate about the path forward.

We work with a well-coordinated network of strategic partners to support governments as they implement public policies that will discourage tobacco use. The policy changes our partners work toward include tobacco taxes that increase the price of tobacco products, bans on tobacco advertising, graphic warning labels and smoking bans in public places.

And they’ve made real progress. For example, Uganda has put in place the strongest tobacco-control law on the continent, including 100% smoke-free public places, graphic health warnings, and a ban on all tobacco advertising, promotion and sponsorship.

We pair this policy work with social marketing efforts to change consumers’ attitudes and perceptions about tobacco use.

African countries have already made significant progress in stopping the tobacco epidemic in its tracks. We are proud to lend our support to the efforts to prevent hundreds of millions of tobacco deaths and debilitating illnesses.

ONE OF OUR INVESTMENTS

Tobacco kills up to half its users and exacerbates poverty. But the policies in the WHO Framework Convention on Tobacco Control are proven to work.

Africa is the only continent in the world that has the power to prevent a tobacco epidemic.

Cynthia Lewis Deputy Director, Global Policy and Advocacy

Kenya is one of Africa’s most progressive leaders in the area of tobacco control. This is because of the government’s deep commitment to protecting its citizens from the epidemic, but also because of the strong civil society organizations that work alongside the government to further this agenda.

We are proud to partner with the International Institute for Legislative Affairs (IILA), an organization begun in 2004 by a group of Kenyan lawyers and their colleagues who believe that they have a duty to use their professional abilities to improve society around them.

In the years since then, the IILA has provided policy expertise, worked with key government officials to advocate against tobacco, and supported anti-tobacco research. The IILA’s tobacco-control advocacy goes back to the 2004 ratification of the FCTC by Kenya, while it also played an important role in the campaign for the 2007 Tobacco Control Act. The IILA’s leadership on tobacco control continues today, including generating evidence on the impact of tobacco tax, conducting an analysis on the illicit trade of tobacco products, and providing significant recommendations on implementation and enforcement of the Tobacco Control Act. With the decentralization established by Kenya’s Constitution of 2010, the IILA is now developing model legislation and engaging with county executives for health in an effort to explore how tobacco can be controlled at the county level.

59

PROGRAM STRATEGY: VACCINE DELIVERY

than lives

SAVING MORE

A young child is vaccinated during a vaccine outreach in Agordiebe near Accra, Ghana.

The life-saving power of vaccines is reason enough to make delivering them a priority, but it’s not the only reason: it is estimated that every $1 invested in vaccines saves $44 in healthcare costs and lost productivity for a country. Find out what the Vaccine Delivery team is doing to get vaccines to those who need them most.

Vaccines save millions of lives every year, but 1.5-million children will die this year from diseases that vaccines could have prevented. Our Vaccine Delivery team’s goal is to help countries save those lives by immunizing as many children as possible.

In Africa, immunization coverage (measured by how many children get the DPT3 vaccine that protects children from diphtheria, tetanus and whopping cough) has increased from 57% at the turn of the millennium to 80% today. That’s one reason for the historic 60

declines in child mortality across the continent, and for the fact that the world is on the verge of eradicating polio.

Even with this progress, however, one in five African children remains unprotected by vaccines, while many more don’t receive recently developed vaccines against leading killers like diarrhea and pneumonia. Many of these unvaccinated children live in hardto-reach areas, or in countries with weak health systems.

It will take more investment and innovation to reach universal coverage, a goal endorsed at the groundbreaking 2016 Ministerial Conference on Immunization in Africa.

African countries have not only improved coverage, but also introduced additional vaccines to protect children from more diseases.

The Gates Foundation works with many organizations in the area of vaccine delivery, including Unicef and WHO, and with many critical country partners and civil society organizations across Africa. Perhaps our most important collaboration is with Gavi, the Vaccine Alliance, a global partnership that helps 73 of the world’s poorest countries buy vaccines and build strong immunization systems.

For example, haemophilus influenzae type b (Hib) caused approximately 180 000 deaths in Africa in 2000, when just two countries vaccinated against the disease. Now, though, every single African country provides the Hib vaccine as part of the routine immunization schedule.

Since 2000, we have committed $4-billion to Gavi – the foundation’s single largest investment. With Gavi’s help, many

Every year, vaccines save millions of children from devastating yet preventable illness and disease. And they are an excellent investment in the economic health of communities. We need the continued commitment of governments, donors, vaccine manufacturers and communities to rise to the challenge and extend the benefits of immunization to all people, regardless of where they are born or where they live.

Orin Levine Director, Vaccine Delivery

In addition to our work with Gavi and specific countries (we work directly with the ministries of health in Ethiopia and Nigeria, and with many others), we invest in innovations that can help all countries build strong, sustainable immunization systems.

For example, we are working with countries so they can generate the data they need to run efficient immunization systems that protect more children. We are also working with research partners to develop new ways to store and transport vaccines, since it can be challenging to keep them cold in places without reliable electricity.

These innovations include technologies like refrigerators that use hydro and solar power, and portable thermoses that can store 300 vaccines for more than a month using a single set of ice packs.

ONE OF OUR INVESTMENTS The Better Immunization Data (BID) Initiative’s slogan is “better data + better decisions = better health”. Led by PATH, a leader in global health innovation, BID is collaborating with ministries of health in Tanzania and Zambia to focus on three data-related priorities: building an electronic immunization registry; improving stock management; and fostering a datause culture.

The registry ensures that the health system can track all children from birth and make sure they don’t miss any vaccinations.

In Tanzania, facilities with electricity and internet enter data electronically, and facilities without use modified paper forms that are scanned into the system at the district level. Home births are also captured in the registry through SMS. BID is also working to increase visibility of stock at each facility and district-wide, so that vaccines are available when and where people need them. And it provides mentoring and training to help health workers use data as part of regular planning, supervision and performance improvement.

The BID Initiative is also designed with a peer-to-peer learning network, the BID Learning Network (BLN), that brings countries together to identify shared problems and solutions.

Currently, 17 sub-Saharan African countries participate in the BLN through webinars, a virtual community forum and in-person design collaborative meetings.

61

PROGRAM STRATEGY: WATER, SANITATION AND HYGIENE

the toilet

REINVENTING

In urban areas especially, it’s not enough for only a few people to gain access to toilets.

To increase health and prosperity, and thus create the model cities of the future, private- and public-sector stakeholders must come together to ensure that toilets are part of a sanitation system that is safe, effective and sustainable for everybody.

Sub-Saharan Africa’s urban population is the fastest growing in the world, with many people now living in densely populated informal settlements.

Usually, sewer systems fail to reach these communities, leaving them few choices for containing and disposing of fecal waste safely. In poor settings, an estimated 90% of fecal waste travels untreated directly into the environment, contaminating water, soil and food.

Inadequate sanitation is more than just an inconvenience; it’s a toxic catastrophe. Children are especially vulnerable. Worldwide, nearly 1 000 children die each day from diarrhea-related infections and endemic disease caused by pathogens that thrive in fecal sludge. Many others survive but suffer long-term effects on their physical and cognitive development.

The Gates Foundation’s water, sanitation and hygiene program takes a holistic approach to help people lead healthy, productive and dignified lives in an environment free from fecal sludge, especially in areas of the world where decentralized, often informal sanitation systems and practices remain by far the most common options.

ONE OF OUR INVESTMENTS Until now, most of the 8-million people in Kenya’s slums haven’t had access to sanitary toilet facilities; they’ve had to use pit latrines that empty into waterways and farmers’ fields, or “flying toilets” (old plastic bags filled with waste and tossed into the street).

Because of this, some 4-million tons of fecal waste are released into the environment every year.

But one of our RTTC partners, Sanergy, is ready to change that. Sanergy’s prefabricated Fresh Life Toilet (FLT) is small and convenient, easy to keep clean, and – most importantly – affordable.

Sanergy is a franchise, which means that people who live in Kenya’s informal urban settlements can buy a Fresh Life Toilet (using financing from Sanergy, if necessary) and charge their neighbors a fee to use it.

Institutions like schools, churches and health clinics can also buy FLTs, which makes it possible for the community’s most vulnerable people to have regular access to private, safe and sanitary toilets.

We focus our investments on developing transformative, usercentered technology solutions; catalyzing urban sanitation markets; building demand for sanitation services; advocating for pro-poor sanitation policies; and conducting relevant monitoring and evaluation to see how these interventions are working.

Every day, Sanergy employees go from FLT to FLT and swap the toilets’ used “cartridges” for empty ones. They carry the waste away from dense residential settlements to a central warehouse, where it’s converted into clean, organic fertilizer for purchase and use by farmers.

In 2011, our Reinvent the Toilet Challenge (RTTC) invited engineers and inventors to devise safe and effective sanitation solutions that work without sewers, electricity or running water – especially in regions where shortages of water and electricity are already a concern.

As organic fertilizer products are in short supply in East Africa, there’s a high demand for them – and Sanergy is able to reinvest its profits in the communities it serves.

Since then, foundation partners from around the world continue to make progress on off-the-grid sanitation products, facilities and services with the greatest potential.

62

So far, there are nearly 800 active FLTs in Kenya, which get used more than 40 000 times per day. They’ve kept nearly 10 000 metric tons of sewage out of the environment. It’s not enough, but it’s a great start.

We believe it is possible to bring affordable sanitation solutions to people who need them. With innovation, fecal sludge may also soon be converted into something that has real value, such as clean and organic fertilizer for farmers’ fields and healthy protein-rich food for livestock.

But much work remains.

Brian Arbogast Director of the Water, Sanitation and Hygiene team

The Reinvent the Toilet Challenge is a worldwide competition by the Bill and Melinda Gates Foundation, encouraging innovative thinkers to develop “nextgeneration” toilets that will deliver safe and sustainable sanitation to the world.

Washing hands in the Chongwe District, Zambia

90% of childhood

deaths from diarrheal disease are in South Asia and sub-Saharan Africa.

2.5-billion people

around the world still lack access to improved sanitation.

63

Yudaya Sekisambu is a successful cassava farmer in the Nakaseke district, Uganda.

MEET THE

foundation’s

leadership

Bill Gates

These are the people who direct the foundation’s vision.

Co-Chair and Trustee

Melinda Gates

William Gates Sr

Sue Desmond-Hellmann

Jim Bromley

Connie Collingsworth

Christopher Elias

Allan Golston

Geoffrey Lamb

Leigh Morgan

Trevor Mundel

Steven Rice

Mark Suzman

Co-Chair and Trustee

Chief Financial Officer

President, US Program

President, Global Health

Co-Chair

General Counsel and Secretary

Chief Economic and Policy Advisor

Chief Human Resources Officer

Chief Executive Officer

President, Global Development

Chief Operating Officer

President, Global Policy & Advocacy 65

in Seattle

WIDE AWAKE

American artist Janet Echelman’s new artwork “Impatient Optimist”, commissioned by the Bill & Melinda Gates Foundation and installed on its campus, is unveiled at the Bill & Melinda Gates Foundation in Seattle on Tuesday, 10 February, 2015.

When the Gates Foundation opened its iconic Seattle campus in June 2011, the event was attended by the chair of the Duwamish tribe (known as Seattle’s First People).

It was an important, symbolic moment, in which the tribe gave its blessing for the foundation to do its work on the sprawling piece of Seattle real estate. The land was a wetland meadow, and then a parking lot, before it became the main home of the Bill & Melinda Gates Foundation.

66

2.

What stands on that piece of land is now iconic: more than 81 000m2 of office space encased by towering glass walls. Why glass? Simply because philanthropy should be transparent, the foundation believes, and the see-through walls are a daily reminder of that principle.

Another principled piece of design is the outdoor plaza at the heart of the campus. The open space provides tranquility amid the bustle of Seattle, but it also serves a more important purpose – the restoration of the original wetland ecosystem. Guides say that since the foundation moved to the spot in 2011, birds have begun returning to the area, attracted by the open water and the replanted wetland vegetation.

In fact, the sense of a building working in harmony with its natural environment is a design thread that runs through the Seattle campus, in ways that sometimes aren’t immediately visible. Run-off water from pavements and the courtyard feeds into a storage tank that flushes toilets. Daylight sensors measure light levels and adjust electrical lighting according to what’s needed. And rooftop solar hotwater panels provide 50% of the hot water needed in the building.

Hanging above the plaza is what’s perhaps become the foundation’s most well-known piece of art: an outdoor aerial sculpture suspended between two buildings called Impatient Optimists. It looks like a giant floating net hovering above the campus. The piece is made of ultra-lightweight fibers, which hold and reflect light, changing shades with the color of the sky.

Inside, the art is no less arresting. Among the pieces is one of former South African president Nelson Mandela’s distinctive “Madiba” shirts. The story goes that someone from the foundation admired Mandela’s shirt, and so the elderly statesman, who was well known for his sense of humor, gifted it to the foundation, joking that he was giving Bill Gates the shirt off his back.

Another prominent feature within walking distance of the foundation is the Museum of Pop Culture, known until recently as the Experience Music Project (EMP) Museum.

Dedicated to science fiction, fantasy and music, this is a must-see for all geeks.

3.

Three great things to do in Seattle:

1.

If markets are your thing, take a stroll down to the bay, and take in the Pike Place Market, where fishermen throw their catch from stall to stall and foodies will find everything from seafood to teas, spices and cheeses from around the world.

Just across the road from the Gates Foundation is a recognizable landmark, the Space Needle. Take a trip to the top of the Needle, where on a clear day you can see across Washington state.

67

OUR YEAR IN PICTURES

2

1 3

4 5

1. Gates Foundation CEO, Sue DesmondHellmann took a learning trip to Ethiopia in 2016. She visited healthcare sites and met scientists and public health officials during her visit.

2. Emir Muhammadu Sanusi II with Nigeria

68

advocacy against child marriage.

3. Melinda Gates meets the press in the

6 facilities during a child-health scoping mission in Kano. “Advocacy with community leaders is

Seventh-day Adventist school in Kangemi,

most effective when they identify you as one

Nairobi in June 2016.

of them – especially in communities that are

4. Gates Foundation Nigeria country representative Mairo Mandara speaks during

conservative,” Mairo says.

5. Gates Foundation CEO Sue Desmond-

country representative Mairo Mandara. The

an advocacy visit with Hisbah community

Hellmann met with scientists and researchers

emir is sparking constructive discussions in

members in Kano, Nigeria. She discussed

from around the continent in October 2016,

conservative communities with his strong

the importance of taking children to health

to talk about how the principles of precision

7 9

8 10 medicine could be applied to public health systems in Africa.

6. Buhle Makamanzi, Moky Makura and Siobhan Malone at the launch of the

11 8. The Bill & Melinda Gates Foundation

and Amsale Mengistu on a site visit to the

disease in Kazungula, Zambia in April 2015.

EthioChicken poultry farm in Mekelle region,

9. Melinda Gates with women who’ve been

dubbed “Female Food Heroes� in Tanzania.

Soshanguve, South Africa.

The competition was established by Oxfam

Udale Daba Kebele health post in the Afar

10. Sue Desmond-Hellmann, Lia Yeshitla

Malaria team celebrates progress against the

historic #HVTN702 #HIV vaccine trial in 7. Orin Levine speaks to children outside the

12

to highlight the critical role that women farmers play in East Africa.

Ethiopia.

11. The Africa team celebrate a soccer victory in Nigeria.

12. Bill is met by Aliko Dangote on arrival in Nigeria.

region of Ethiopia.

69

counting?

WHO’S

Mark Suzman, chief strategy officer and president of Global Policy and Advocacy at the Bill & Melinda Gates Foundation, reflects on 10 years at the foundation.

If you had told me 10 years ago, when I took a job at the Bill & Melinda Gates Foundation, that I would still be there today, I would have been skeptical. Yet I am still at the foundation and excited to stay, which maybe is a lesson about how experience can prepare you in unexpected ways for wonderful opportunities (and challenges) you never anticipated.

70

I began my career as a journalist in my native South Africa during the latter years of apartheid. Among other things, I covered courts for The Star in Johannesburg, getting an up-close look at the mechanics of injustice under that horrendous system of racial separation and oppression. Later, as a correspondent for the Financial Times, I reported on the run-up to the election of Nelson Mandela as president. I had the opportunity to meet and interview Mandela several times — a true highlight.

way of a better life for the world’s poorest people. When my time at the UN came to an end, the foundation felt like a natural next step.

I was a little nervous, though, because the foundation’s culture has always been rooted in scientific and technical expertise. I, on the other hand, am a policy wonk and very much a generalist. Unsure I would fit in, I thought I would stay a few years, contribute what I could, and move on.

My qualms dissipated quickly, especially once I met the foundation’s co-chairs. Bill was a little intimidating at first, but soon I realized that he and Melinda both want to have a rich, fact-based dialogue on any issue before they decide what to do. That sounds simple, but it’s rare, and it makes the foundation a more dynamic and impactful place.

Today I lead the foundation’s efforts to build strategic relationships to increase awareness, action, and resources devoted to global development and health. My role reflects Bill and Melinda’s belief that smart policymaking and advocacy, as well as science and technology, are key to making the world a better place.

It’s true. Public will combined with technical resources can produce amazing results. A prime example is the success of the United Nations Millennium Development Goals, which I had the privilege of helping develop and implement, and which contributed to an unprecedented era of progress in world health and well-being.

Child mortality has been reduced by half since 1990, while maternal mortality is down almost as much. In little more than a decade, deaths from HIV, TB and malaria have decreased by 40%.

Mark Suzman visits the Digital Green agricultural training program in Ethiopia.

As much as I loved journalism and its capacity to shine a light on inequity, I began to feel that shining a light is not enough.

The prospect of helping bring about real change is what led me to go work at the United Nations, as policy director in the UN Development Program and later as an advisor to the Secretary General. It was a great experience that gave me perspective on how to work effectively with governments and policymakers to try to solve complex, global problems.

While at the UN, I began hearing about the Gates Foundation and its unusual role in bringing together governments, business and civil society to tackle some of the big challenges standing in the

Continuing such progress is central to our missions at the foundation, and we’re in a unique position because the foundation is recognized as offering deep expertise on the issues we care about, from education in the US to global health and development, with no political agenda beyond helping those most in need. Our ability to help foster public-private partnerships and gather support was demonstrated again recently at Davos with the launch of an innovative coalition to combat future epidemics.

All of which is why I’m still passionate about my work after 10 years. As the global political landscape changes in the months and years ahead — with issues like migration and security coming to the fore — we at the foundation will continue to advocate for the coalitions and innovative approaches to development that represent our best hope of ensuring a healthy, secure world for people everywhere.

Mark Suzman is Chief Strategy Officer and President for Global Policy and Advocacy at the Bill & Melinda Gates Foundation.

71

Bill & Melinda Gates Foundation www.gatesfoundation.org/where-we-work/africa-office