We need to understand not only 'what works, but what it takes to work': Chris Elias

As President of the Global Development Division at the Bill & Melinda Gates Foundation, Dr. Chris Elias spends his days working on high-impact solutions. Whether it's emergency response; family planning; maternal, newborn, and child health; nutrition; Polio eradication; or vaccine delivery, he leads a team whose work has the potential to touch hundreds of millions of lives.

A common theme of Dr. Elias' programs is innovative and integrated delivery, including the strengthening of primary health care systems. Exemplars News spoke with him about the importance of extracting lessons from delivering essential care in the world's most resource-constricted settings.

Why did you become involved with Exemplars in Global Health?

Dr. Elias: Responses to even the toughest global health problems exhibit some variation, with some communities and countries showing better progress than others. Examining this variation by looking for the “positive deviants” or “exemplars” often helps identify the critical elements of successful policy and programs – elements that can be replicated in less well-performing settings. I also believe partnerships are the pathway to transform global health and development. Exemplars in Global Health does just that – by bringing together diverse stakeholders to uncover what made a given country successful and then adapting those lessons learned for policymakers in other country contexts, EGH functions as the pathway for a more connected, more informed global health community. It has been an honor to be a part of this work over the past three years.

What has been the biggest surprise this work has revealed?

Dr. Elias: A very welcome surprise has been how broad the interest has been in EGH’s analyses and recommendations. This has been especially evident among country policy makers and program managers who are trying to achieve more impact within highly constrained resource environments. EGH’s research model also underscores the inherently interdisciplinary nature of global health – e.g., EGH consistently shows that there is no single sector that can drive the uptake of an intervention. This is especially important in encouraging actors to look beyond their silos to broader collaborations.

Prior to EGH, tell us about a time in your career when EGH research would have been useful?

Dr. Elias: In the mid-1990s I was working in Southeast Asia on reproductive health and HIV prevention programs throughout the Mekong region. Thailand, where I lived, had one of the world’s most successful HIV prevention programs, a major component of which was the “100 percent condom policy" – a structural intervention characterized by a unique model of collaboration between public health authorities and law enforcement that aligned the incentives of brothel owners to insist on 100 percent condom use on their premises and empowering sex workers to refuse clients that would not use condoms. This successful program may have prevented a highly concentrated HIV epidemic from becoming more widespread in the general population and was widely recognized as an exemplar. Initial attempts to replicate the program in neighboring countries, however, met with mixed success. Had I had access to the type of in-depth analyses that EGH has produced we would have accelerated the replication of this high-impact program within the Mekong basin.

How have exemplars (from EGH or otherwise) contributed to the work you're currently doing?

Dr. Elias: The work of EGH has informed a broad range of the programs within the Gates Foundation. Examples include the family planning program, the nutrition program, and our emerging work on primary health care. Indeed, increasingly we are collaborating from the earliest stages to help identify potential exemplars and conduct the analyses. Not surprisingly, a strong partnership has developed between BMGF and the EGH team.

Not every solution is one-size-fits all. How can one best discern scalable lessons and apply them to individual circumstances?

Dr. Elias: I’d suggest looking at it from an implementation management perspective. First, it is important to test whether the enabling conditions are in place – does this solution have the necessary fiscal, political, policy, and/or organizational support? If not, what are the barriers to achieving these enabling conditions? In parallel, asking what external forces are in play, e.g., is there market demand or an economic or political crisis? Are the proper incentives and accountability mechanisms in place? Most importantly, is there a clear vision and are there champions for this solution? In short, we need to understand not only “what works," but “what it takes to work.”

What makes sharing data across country lines so challenging?

Dr. Elias: There are so many challenges to cross-border data sharing – the expense, the time, the issues with data security and protecting personal data – the list goes on. There is also a fear that the data will be used to publicly embarrass particular countries or communities; or that better funded international researchers will rush to publish papers before national authors. The benefits of data sharing are also not always widely appreciated. The COVID-19 pandemic has brought to light the need to share data more easily across borders. In the early days of the pandemic, sharing data allowed researchers to access the virus’s genomic sequences which was one facet of accelerating vaccine development at a historic pace. Sharing data on emerging variants of concern helps improve everyone’s response.

EGH research comprises literature reviews, qualitative and quantitative analysis – none of which are completely inaccessible to experts. Why has studying positive outliers not been a systematic practice in global health?

Dr. Elias: It’s a good question – to be able to study positive outliers requires a suite of resources, resources that might not be available to any one practitioner alone. This is why the EGH model serves such an innovative purpose – to bring together the experts to look at those positive outliers in a holistic, comprehensive way. And, of course, no one is shy about having their successes highlighted and widely acclaimed!

EGH research is different from a randomized controlled trial (RCT). What can the EGH approach identify/find that a traditional RCT might miss, and vice versa?

Dr. Elias: RCTs are the gold standard for the efficacy of interventions. They are critical for helping us understand whether a product or intervention approach works. RCTs require highly controlled environments and relatively small numbers of participants, who are often screened by specific “eligibility” criteria. Once we know something works in these environments, we need to then look at the effectiveness of the intervention in more “real world” settings. Intervention research helps us in that regard. Knowing whether an effective intervention can reach impact at scale, however, requires examining successful programs with a range of qualitative and quantitative tools, which is what EGH brings.

What is the best starting advice you would give to experts seeking to improve a given health outcome?

Dr. Elias: Take the time to really listen and understand the experience of the populations most affected and use that information to discern your course of action; interrogate the variations in impact achieved by similar program; and don’t be too tied to any one hypothesis and be open to changing your mind.

In the long-term, what is your hope for this work?

Dr. Elias: GH has shown the importance of and need to highlight positive outliers in the field of public health. My hope is that this model will not only deepen and expand the global health knowledge, but broaden and advance the global community’s work on other intractable global issues of our times, such as climate change and education.