Exemplars in Global Health: Q&A with Dr. Niranjan Bose

Gates Ventures—in partnership with the Bill & Melinda Gates Foundation—just launched the Exemplars in Global Health platform, which is available at www.exemplars.health. What is Exemplars in Global Health?

Just like in any field, it’s important in global health to learn from positive outliers: Countries that have outperformed their peers. Having an objective assessment of what led to one country’s success helps other countries discover replicable lessons and improve their own performance.

Exemplars in Global Health is an international research collaboration for doing just that. Working with partners, we have researched exemplars in several topic areas like stunting and child mortality reduction and created a web platform where our content is curated and kept current. Beyond the web platform, we also work directly with global health leaders around the world to help them adapt lessons from exemplars to the context in their country.

For any given topic, we start with a topic overview: Why is it a global challenge? Who are the positive outliers? We then go into the stories from each country, from what was achieved, how was it achieved, to who played a role, and what gaps still exist today.

Since we have half a dozen or so countries for each topic, we also provide cross-country synthesis that outlines the “no-regret” things to do if you're a region or country and plan to embark on this journey.

We’ve always looked at what works in global health. For instance, the Lancet Nutrition Series tells you what interventions to use to get really good outcomes in nutrition and reduce stunting levels. But it doesn't tell you how countries that have succeeded actually did it. Every country in the world knows about the interventions and has programs built to deliver them, but some countries seem to be achieving faster health gains than others. We need more understanding of the implementation elements of success: How is one country getting these interventions to work so well when their neighbors might not be?

A lot of interventions proposed by the global health community are derived from randomized control trials.

But when you flip the question and say, let's just look at 10 years, 20 years of progress in the real world, you might get slightly different answers.

For instance, in our stunting reduction research, water, sanitation, and hygiene (WASH) comes up as a key intervention. But when you do a randomized control trial, WASH doesn't come up partly because of the time-limited duration of these trials, which usually last only three or four years. When you look at a decade or two decades worth of progress, additional insights come out.

For funders, this means you can't measure the impact in just three years or four years. You might have to have a program that's more holistic over the course of a decade.

The platform is not a one-stop shop, where we expect somebody to go in and then become an expert. The platform is just one part of our toolkit.

We have a suite of tools to help users get the most out of the content. The country comparison tool helps you decide if you should be learning from country A, B, or C. The data explorer lets you build your own visualizations. And the Report Builder allows you to customize the content you want to read or share with others.

There are also community-oriented tools, which allow users to ask questions of our expert network and even to contribute to the platform via annotations. We believe this interactivity is really important.

Offline, we can connect decision-makers to global and in-country experts in our network so they can dig deeper into research and think about how it might apply to their situations.

We started studying stunting about three years ago. The reason we chose stunting reduction as the lead topic is the multifactorial nature of the problem. It's not a single intervention, it's not a single sector that can drive the interventions.

We then added child mortality reduction and community health worker platforms, and now we're researching a total of seven topics. On the nutrition side, we're expanding to maternal anemia outliers. We've also expanded to vaccine delivery, neonatal, and maternal mortality reduction. The most recent addition is health systems, which is just starting.

Given the COVID-19 crisis, we also felt that the Exemplars methodology could reveal some of the positive outliers in epidemic preparedness and response. So, we did a sprint on that topic.

Part of that project is looking at pandemic preparedness in general and past outliers, such as Uganda for the Ebola outbreak. But secondly and more relevant to our current crisis is if there are positive outliers when it comes to the COVID-19 response. (It’s too early to call any country a true “Exemplar,” since the pandemic is still going on.)

In this case, we highlighted Vietnam, South Korea and Germany. Germany, in terms of keeping the case fatality rate low. Vietnam, in terms of just sheer low numbers of cases. And South Korea, how they tightly contained it with rapid testing and innovative testing models. And we know that there are other countries—and states like Kerala in India—that appear to have effectively addressed COVID-19.

Bill and Melinda often ask the program teams at the foundation, “Who are the positive outliers and what have they done differently?”

I remember almost 10 years or so ago, I got a call about a trip that Bill and Melinda had taken to Zambia, where they saw the MACEPA malaria program. They came back and asked, "How do we help Zambia’s neighbors know what MACEPA is so they can replicate its lessons?”

Eventually, we decided to try to address this question systematically.

One of the biggest things we wanted to avoid is an exercise where a group sitting in Seattle is commenting about Rwanda, Peru, Nepal, Bangladesh. So right from the outset, the key word has been partnerships.

For every single topic, we have a research partner, an academic, or a group that is deeply immersed in the subject matter.

In addition to the research partners, each of the topics has a technical advisory group, which includes experts from around the world. They play a key role in the country selection process. Once the countries are chosen, there's yet another level of partnership that kicks in, identifying local academic research partners or organizations who can be the eyes and ears on the ground.

We try to fill any gaps with a community of in-country experts who have had direct experience with the policies and programs we’re studying.

Exemplars is not a single organization. It's a plethora of partners with the common goal of getting the most rigorous and objective analysis of a country's progress.

Five years or so from now, I hope we are not pushing for this content to be adopted. I hope there is a pull from the community, including funding agencies, in-country decision makers, or implementation partners. I hope they want to use this content and actually co-create some of the content with us.

True success for the program would be when the concept of Exemplars is just part of any decision-making process in the field. We don't have to ask the question, “Have we studied the Exemplars?” It’s just the norm.