SAN FRANCISCO — Leadership will determine how much progress the world makes on poverty and disease, which are the clearest examples of solvable human misery, philanthropists Bill and Melinda Gates write in a report released Wednesday.
“Goalkeepers: The Stories Behind the Data,” was produced in partnership between the Bill & Melinda Gates Foundation and the Institute for Health Metrics and Evaluation at the University of Washington, which received $279 million from the Gates Foundation earlier this year, building on the $105 million grant that stood up the effort a decade ago.
The report, co-authored and edited by Bill and Melinda, features projections exploring three potential 2030 scenarios for 18 data points from the United Nations Sustainable Development Goals, featuring Gates Foundation priorities ranging from malaria eradication to vaccines to sanitation. These visualizations show what could happen if efforts continue without significant changes to approaches or spending; what could happen with strong leadership, innovation and investment; and what could happen if attention and funding decreased. They demonstrate that progress is possible but not inevitable. The report, which will be published every year until 2030, launches the week before the U.N. General Assembly, where the Gates Foundation will host two events that highlight the progress that has been made in reducing extreme poverty and disease while also warning that future progress is in jeopardy.
“We’re trying to document the incredible progress, including on key things like poverty and different disease areas. And we’re trying to look forward and see what the possibilities are. The possibilities to continue that progress, or, if the right things aren’t done in some of these cases, not only to have the progress stop, but also in some cases go backwards,” Bill Gates said on a call with reporters last Thursday.
Bill and Melinda note in the report — and the press release that went out with the report today — how this is a time when there is more doubt than usual about how committed the world is to international development. At the same time that the U.S. Congress is considering how to deal with cuts proposed in President Donald Trump’s budget, there is a similar “mood of retrenchment” across other donor countries, they explain. Gates has personally met with Trump to make the case for continued U.S. leadership in areas such as clean energy and global health. In this report, he and his wife aim to provide a data-driven look at the potential consequences of proposed funding cuts in the U.S. and elsewhere.
“We’re saying that progress is not inevitable. It is possible. There are heroes, there’s innovations, there’s exemplars. And there’s all, you know, the good will of all the people who are going to get together to discuss these things,” he said in reference to the U.N. General Assembly. “But the counter trends are that if countries do not think about these global problems, and you get cuts, or if you have setbacks, in terms of pandemics and things like that, you can have reversals.”
Factors that will determine whether millions fewer or millions more people die include rate of innovation, adoption of best practices, and government generosity, Gates said. That is part of the motivation for this data-driven report on the consequences of cuts, such as how a 10 percent cut to HIV funding would result in 5 million more deaths by 2030. In the call with reporters, he fielded questions from reporters around the world, and explained how .7 percent of gross domestic product is a level of substantial generosity he hopes all developed countries will achieve — but is by no means a ceiling.
From the pages of the report to the stages of their events, the Gates Foundation is working to highlight which approaches are working. The SDGs serve as a framework that can help leaders identify the problems that need solving, help funders and practitioners share best practices, and help the global community work together on solutions, Gates said on the call, explaining that the Millennium Development Goals and SDGs helped an industry that was traditionally about relationships shift its focus toward measuring humanitarian impact. The report features first-person accounts from leaders who speak to what has worked in countries such as Senegal, where leaders have increased the uptake of modern contraceptives, and India, where leaders have brought more women into the formal financial sector.
“We have spent a lot of our time recently speaking to global experts to learn more about stunting and its solutions. As development experts and practitioners continue to build the evidence base, however, countries need to scale up the set of health and nutrition interventions already proven to reduce stunting significantly. Peru’s story is impressive because they cut through a lot of that complexity and focused on what we know works,” Bill and Melinda write in the Goalkeepers report.
Peru demonstrates how stunting is a solvable problem, they said, with the prevalence of stunting among children under age 5 declining from 39 percent in 1990 to 18 percent in 2016. This largely due to the Child Malnutrition Initiative, a program that resulted from a program funded by the U.S. Agency for International Development and implemented by CARE Peru that delivered a package of interventions including nutrition, water and sanitation, and health investments rather than traditional feeding programs. The nongovernmental organization has since worked with the government across three different administrations to make nutrition a national priority, in a story told from two perspectives, Milo Stanojevich, the national director for CARE Peru, and Ariela Luna, Peru’s former deputy minister of development and social assessment.
One of the charts in the report demonstrates how much progress has been made and how dramatically progress could accelerate or decelerate depending on whether there is continued investment and research. The black line on the above chart is a projection that assumes no innovation, the report reads, explaining that the Global Fund and the development of new tools such as insecticide treated bed nets and improved antimalarial drugs have been responsible for much of the progress thus far. But while IHME projected that new tools and strategies could help the global community reach its targets for malaria by 2030, without this push for progress, the new cases of malaria per 1,000 people could climb.
“You know, areas like HIV and malaria … drug resistance can come along and actually that would mean that even the tools we have today would become less effective,” Gates said during the call. “And so one area that we always highlight is that we have to keep investing in the innovation.”
There is an exciting pipeline for new tools between now and 2030, Gates said, mentioning HIV protection, malaria vaccination and improved tuberculosis diagnostics.
“The big headlines would be to have a vaccine for HIV, TB, or malaria. And none of those are in a phase three state. So you know, we’d expect it’ll probably be five to 10 years before we’d get that,” Gates said. “We didn’t assume in our forecasts the very best case, which is that we get those new tools. We could actually do better than the best case we showed, if we got one of those breakthrough tools very early on.”
Melinda Gates writes that if she had to pick just one data point to focus on, it would be the number of children who die each year before they reach the age of 5. On the call, Bill Gates said this is like a report card for the world, explaining that 6 million more children died in 1990 than today, and while a lot of factors go into that, vaccines are the single biggest innovations to bend the curve. But the world should not be satisfied when a child is 75 times more likely to die if they are born in Angola instead of Finland, he continued. As there is a shift toward more births in poor countries, there is an even greater imperative to strengthen these health systems, he said.
At one point in the report, a chart demonstrates the decline of maternal deaths per 100,000 live births in Ethiopia. The proportion of women giving birth in health facilities, which has been identified as the most important priority to reduce maternal mortality, increased from 20 to 73 percent between 2011 and 2016, and Kesete Admasu, CEO of the Roll Back Malaria Partnership and former minister of health in Ethiopia, provided the story behind the data. The 3 million members of the Women’s Development Army, who meet with women daily, helps the ministry of health identify and understand problems and solutions, and now the focus must expand to making sure that the quality of care is uniformly excellent across those facilities, he writes.
“In general, the health results in a country track economic development. And so it’s always interesting to look at where you have outliers,” Gates said on the call, explaining that he is drawn to countries such as Sri Lanka and Rwanda that get much better health results than might be expected at that level of income.
But one of the challenges the Gates Foundation and other organizations working to accelerate some of this progress come up against is what Gates called “a systemic bias towards bad news.”
“For example, take the progress on childhood death, or literacy in Africa. It’s never clear what day it should be a headline, to say that those deaths went down,” he said. “But if you wanna make progress you’ve gotta be able to see what that overall picture is, and the important role that government generosity and innovation and the positive exemplars have played in that. And only by going to those exemplars and seeing what they did right are you able to push the frontier as fast as possible.”