Thoko Moyo: Good evening, good day, wherever you are. We are honored to have so many people joining us. We have people joining us from across continents and time zones, and I believe we have people watching from across Africa. There are people watching in Asia, we have people in Europe, and of course, there are people watching right here in the US. Thank you for joining us on this chat with our CEO, Mark Suzman. My name is Thoko Moyo, and I'm the director of Global Communications here at the Bill & Melinda Gates Foundation.

Let me just quickly say thank you very much, first of all, for subscribing to the Optimist Newsletter. We appreciate your readership, and all of the updates that many of you sent us about your 2023 priorities. Thank you so much for your partnership in this work. When we get started into the content of today's discussion with Mark, I just want to note that we got a lot of questions from people who are watching today. We got over 100 questions and I don't think we'll be able to get through all of them, but I think I feel good that we've got a nice representative collection of the questions to guide our conversation today. So Mark, I hope you're ready.

Mark Suzman: All good.

Thoko Moyo: All good. So Mark, you've published your second annual letter as the CEO of the foundation last week, and you used that opportunity to tackle and reflect on some of the tough questions we get asked about the foundation and how it uses its influence. Why did you decide on that topic and why now?

Mark Suzman: Well, let me start with the news that I announced in the letter, which was first a new budget commitment that had been approved by our new board, and it is a record budget for the Gates Foundation. It's $8.3 billion, and it puts us on track to meet the commitment that our board has made to a move towards a $9 billion annual payout by 2026, which is by some margin the largest of any philanthropy in the world. Now, that is both a response to growing need, as I'm sure we'll cover a little bit more today. Many of the issues that we deal with at the Gates Foundation are seeing setbacks and challenges, although we think there are important interventions that can and should be done, and we want to do our part on it.

But also that size and scope of our budget, and the access that we do get to many of the global discussions and platforms that address the priorities of the Gates Foundation mean that there is appropriately a lot of scrutiny, sometimes some skepticism, sometimes just curiosity about who we are, how we operate. And I thought it was really important to just lay out a few principles, to use some examples from our budget of how we work, how we make our choices, because we really are trying to be as transparent and open as possible, because we think that makes us stronger and better. We want to encourage healthy dialogue about the best way to achieve the difficult goals we set. And so that really was the reason behind the letter this year.

Thoko Moyo: Well Mark, the scrutiny and the critiques of the foundation's influence, and of philanthropy in general are not new. I wonder from your perspective, what do the critics get right, and what do you think is missing from the conversation?

Mark Suzman: Well, there's a range of critics from some outright conspiracy theories unfortunately, and I think they get nothing right. That is outright misrepresentation of what we do, and it's quite damaging. But what is right and appropriate is the questioning of what is the appropriate role of philanthropy. Philanthropy is not government, it is not the private sector. We work to try and make it distinctively different, and think very hard about what the appropriate best use of scarce philanthropic capital, which does get tax advantages in the US, and so we have a duty to show that those tax advantages is being put to the highest purpose. In our foundation, that purpose is our mission, that every person deserves the chance to a healthy and productive life. And then we select areas where we think that there is a high leverage opportunity to really where philanthropic capital can take a risk, can fill a gap, can act as a capitalist, can generally be an enabler.

So whether it's in the fight against malaria, or the fight for food security in each of those areas, that's how we operate, and it's very appropriate that we should explain how and why we come up with the decisions we do, which is really based on how we think the best outcomes can happen, in terms of, we always talk about impact here at the foundation, in terms of lives saved and opportunities provided for the poorest and most vulnerable. And we do list every grant we make on our website, and it's listed in our reporting forms. And we also try to be transparent and open about how we've selected our priorities, how we move forward, and frankly our mistakes as well as our successes, and how we do cost corrections. So what's right in the debate is that there should always be a healthy, active, open dialogue about the best use of philanthropy, and we welcome that.

Thoko Moyo: Fantastic. And so maybe let me pivot to a few questions that we actually got from our subscribers. And I think in keeping with the theme of tough questions, I'll start with this one from Waleed, and he's actually building on the point that you were making about the role of philanthropy coming up in some of the critiques that we hear. Basically, he wants to know, is traditional philanthropy failing?

Mark Suzman: Well, you first have to define what traditional philanthropy is. We believe philanthropy, as I said, has an incredibly important role. It's played an incredibly important role in many areas over the course of the 20th century, with different philanthropies playing that role. I think it has an important role going forward, but it's always to find what is the best way to do that, and there are multiple models. There are exciting new players in the philanthropy space like Mackenzie Scott, who has a model of giving broader, direct support to a range of organizations, in general operating support around some themes.

There's a model that we have, which is being more selective in terms of the specific priorities and issues and goals that we select, but we try and do that in a way that helps work closely with our partners in some respects, and take advantage of their expertise. And I think there is clearly a role for philanthropy always evolving, but whether it's traditional or not, it is filling those critical gaps that private and public capital cannot do. And at its best, it really provides very high leverage interventions that then can be scaled up and implemented by governments or the private sector. Because the one thing philanthropy can never do, even at the scale we operate, is actually achieve long-term sustainable results. Those have to happen within the communities, and the countries, and led by the local governments and the local partners. That's what sustainable impact is all about.

Thoko Moyo: Great. So then we have a question from Cathy Riley, and I think she's taken us back to the point that you were making about the foundation making a greater effort to be transparent and the accountability issue. So her question is, the Gates Foundation looks to be making more of an effort to open itself up to scrutiny, feedback, and accountability. Can you give examples of how the feedback that you've received and the accountability mechanisms have shaped decision making at the board level regarding the way the foundation delivers? And also, how are you encouraging this accountability among recipient organizations?

Mark Suzman: Yeah, it's a great question, and the answer is in multiple ways. Obviously our board is now, has been in place for over a year. This is the first budget that board has approved. The budget was shaped by lots of input from our board, who are a very distinguished group of deep experts and from a range of geographies and technical backgrounds, who have been offering Bill and Melinda and me very clear advice and pushes on how to be smarter and better about how we think of our resources, how we think about contingency planning, how we try and keep some of our powder dry for drive for action in the future. Really, the board has been a guiding force in urging us to continue to make efforts to be more open and transparent and receive that dialogue. And so this letter this year is partly response to that feedback.

So that's been one very critical new forum for formal governance and accountability. Actually, they have formal rights and responsibilities as board members. But then we are also trying to do it through other mechanisms. I've discussed on this call before that we've reintroduced a global partner survey, which is something we're going to continue to do on a regular basis, to try and get frank and open feedback from our partners because often that's difficult to do.

We know we operate in a position of relative power with funders. People find it difficult often to give us honest feedback because they're trying to make sure they get their grants or are concerned about how some of that might be received. And so mechanisms like a formal survey which allow anonymized responses that we can take action on and which came up with some valuable lessons for us about how we can and should be getting better and stronger about engaging our partners as more equal allies in terms of trying to meet the goals that we set.

And we try and do it through actions like publishing some of our goals and roles and strategies on our website. For example, laying out exactly what and how we try to operate during the ongoing fight against COVID, where there was a lot of misunderstanding and confusion about what our role was. And so we've laid that out very carefully and you can find that out on the website. And so yes, we're constantly looking for ways to create more feedback loops, more platforms for accountability and engagement from external partners, and frankly, internal dialogue as well.

Thoko Moyo: Mark, let me go back to the point that you were making about the power balance with our partners, between the foundation and our partners. And Jackie Wong actually sent a question around that. So the question was, will the foundation include individuals of diverse backgrounds and causes, grassroot advocates, leaders, to better serve the poor and the vulnerable? So speaking to the issue of power and speaking to the issue of diversity and how we incorporate that in the way that we work.

Mark Suzman: So one of the major efforts we have underway, and it's an ongoing effort which I launched shortly after becoming CEO and is very much a work in progress, is what I call our how we get diversification and strengthening of our partner landscape. That means both identifying newer and more diverse partners, particularly those from the communities and countries directly affected and impacted and living the challenges that we are working to try and address. And we try and do that fairly systematically, but it looks different strategy by strategy.

So the way our malaria strategy might go about trying to identify one set of partners and that forms to strengthen capacity of tracking malaria bed net distribution in Africa might look a little different from the way our K-12 education team in the US might be working more closely to develop stronger relationships and identify new partners in the school districts and the communities where the students we're most trying to support are background and low income students who tend to have greater challenges and worse educational outcomes are.

And so in each of those we've been making some progress. We're trying to put in place new metrics of how we track that, to make sure that we're constantly learning and moving forward. But again, it's very much a sort of journey that we're in the middle of, rather than something I think we've achieved.

Thoko Moyo: So here's another question, and this one's again sort of thinking about partners and trying to get into the idea of partner autonomy and accountability. So David Lubinski is asking, so can you give or describe some examples that show how to balance partner autonomy and accountability?

Mark Suzman: Yeah, well that's also a good question that we'll look at a little different sector by sector and depending on the goals, but maybe for this let me use the example of the evolution of some of our work in India, where we've been operating for close to two decades now. And there, the evolution of our work, for example in the states of Uttar Pradesh and Bihar, which are the two largest states by population in India and traditionally have had some of the most challenging health and development outcomes. Our work there has ended up growing and deepening very much in direct partnership and being guided by the priorities set by the governments in each case.

We've signed memorandums around standing with the state governments of Bihar and Uttar Pradesh. And they set the goals and priorities. And what we then come and do is we can work with a range of grantees and other partners, often with key technical expertise on something like how you might improve vaccine supply chains or better training for community based health workers and nurses or in the COVID response, better tools for how you can identify and distribute the vaccines.

And what we'll do is work to pull together a sort of coalition of those experts and supports to be then guided by very clearly the priority set in dialogue with the government. And that would be true when we are working, say at a national level there also, where we work there with, for example, their department of biotechnology around different ways we can help support, improve livestock and climate adaptation related to livestock, which is a critical tool where, again, we'll be guided by their priorities, but we'll then come in and say, well here are areas we have some particular expertise or partners that we think can add value.

And that will look similar in, say, our work in agricultural development or financial inclusion, where we might work in a particular country like Kenya to help on the distribution. We've worked on the development of a drought resistant form of maize, which is being rolled out there with full support of government. We might have helped with the development, working with, again, global and national organizations. In this case, the CGIAR system, which is a global group mostly located in global south that does research and development for crops that might most benefit the poor. And then you'll work with each national government and national agricultural research services to figure out the best way to roll those out to make sure that they're actually meeting the needs of local farmers, getting the inputs of local farmers, thinking about market development. Again, it's given the range of things we work on, the exact way it operates looks a little different field by field, but we're very much trying to balance that where we're following and guided by the priorities being set at the national and community level in the countries and communities we work with, and then bringing what we hope is some distinctive expertise and risk capital.

Thoko Moyo: I'm just looking at the time and I want to make sure that we get to some of the questions that we've got about our program priorities. Maybe let's pivot to those. We got questions about our programmatic work in areas from global health, agriculture, to gender. Let me start with this one on our global health priorities. It was submitted anonymously, but it's a great question. What are the foundation's global health priorities and opportunities for collaboration among the different stakeholders?

Mark Suzman: Yeah. Well, this is one of those areas where this is a call for the optimist and and while there are huge challenges and setbacks that we've seen, for example, the first increases in incidents of death from malaria and HIV and tuberculosis, some of those curriculars over the last two years during the Covid era, after nearly two decades of very steady declines. And so at one level, there's a... And as to redouble, some of the work we know can be successful, such as with the Global Fund to fight AIDS, TB and malaria, which I cite in the letter, and we made a significant increase in our contribution as many other funders did because we know that's a very effective mechanism for getting lifesaving vaccines, bed nets and other, and antiretroviral treatments to those who most need them.

But at the same time, we need to bend the curve. We need to have new innovations that are actually going to accelerate or transform the fight against say, malaria. And there, example, we've been doing some work on things like whether you can digitize bed nets, you can make sure you can customize their distribution into higher risk areas. We've been working in a country like Benin on that and that's been a very successful pilot. We've got new tools like monoclonal antibodies, potential vaccines and others that could be transformative interventions. New diagnostics, ways in which you can tell whether a child is suffering from malaria when they present with a fever very quickly so you can provide the right treatment. All of those are areas now, as we develop the tools, are areas that are primed for collaboration and partnership at both the global level with partners like the Global Fund, and at the national level and right down to the regional level because we're getting much more sophisticated. By we, I mean the global community, and picking and prioritizing particular geographic areas where you have the highest incidents.

And that's true whether we are looking at nutrition and great search into the microbiome in times of treatments and supplements and other tools that can help mothers either before or after giving birth to give birth to much healthier children. It's a long list, so I don't want to go through the laundry list, but I think it's a very exciting set of areas and innovations across all of those areas we work where even if we're facing setbacks right now, there is genuine potential to see a dramatic acceleration going forward, but it requires resources in partnership from far more than philanthropy.

Thoko Moyo: Maybe let's now talk about gender equity. The foundation has outlined a focus on gender equity and female empowerment. What are the funding priorities for the foundation related to gender equity, to female empowerment, social inclusion for the next couple of years? And where does the foundation think it can make the most impact in those issues?

Mark Suzman: Yeah. Well, that's a great example of how we've evolved over the last decade really, decade plus, since Melinda really put us front and center first in the family planning discussion back in 2012 with the London Declaration she co-hosted there, but it's evolved with our role in health, in economic empowerment and other tools. And that culminated really in the formation of the Gender Equality Division, which is a standalone division that I set up shortly after becoming CEO. And that division has now mapped out some comprehensive strategies around our area in women's health, in women's economic empowerment, around women in leadership, where we have particular efforts working with other philanthropists to try and encourage women leadership in areas like economics and health and law.

And the women's economic empowerment is perhaps the most exciting of the new areas where we've just developed a new strategy. There's significant increase in our budget that we just approved for it, and it really is about looking for interventions and platforms that we can think have very high potential from better targeting of women entrepreneurs to better helping ensure that women have control and ability to use, maintain, and grow financial and other assets and tools. And so, expect to hear a lot more about our work in this area in coming months.

Thoko Moyo: We only have a few more minutes, so maybe we'll just take two more questions. In your annual letter, you mentioned the SDGs. Here's a question that was submitted that's asking about SDGs that require sustainable solutions at scale. With the debt crisis or distress in many countries, in Africa and in South Asia, for example in Sri Lanka, how might we make investments or engage to shape or generate revenues, so countries can be more autonomous?

Mark Suzman: Yeah, that's a fundamentally important question. We're at a critical inflection point as a world on it because as I said, we have seen the greatest setbacks in SDG trajectories since the SDGs were announced in 2015. And really, since the MDGs, their predecessors, were launched in 2000. As our Goalkeepers report, which I encourage all subscribers if they haven't looked at it to please look at it, maps out across multiple indicators. We've seen the trend lines get seriously set back on nearly every major sustainable development goal that we work and prioritize. And so that is a massive call to action as far as, how do we generate more resources for?

Some of that needs to be at the domestic level and really is about how countries in the global south can better raise revenue, target that revenue. We think it's not just a matter of raising revenue, but making sure you are investing in the human capital, the education, the health, the gender equality, because that's the basic building block of human development. And then galvanizing actually more global resources, and there is a promising set of discussions which has been forced open a little bit by the COVID debate about whether we can have some ambitious reforms to what's called a somewhat arcanely the multilateral development finance network, but it's basically the big entities like the World Bank, which do great work, but we really think there's an opportunity to both expand their balance sheets, find new ways of targeting their resources against some regional and global public goods. There's an exciting debate going on that I think we'll see a lot of this year, and I'm hopeful we'll actually see some concrete outcomes that raise genuinely new resources for our issues because they're desperately needed.

Thoko Moyo: Well, we've come nearly to the end of our time, but I do want to end with a question that actually fits in quite with the idea that the foundation is a learning organization, and we got a question from Saskia Verbunt, I apologize Saskia if I've mispronounced your name. But the question is, what has been your most eye-opening and unexpected learning in the last year Mark?

Mark Suzman: Really good question because we're all about trying to learn. But I'd say maybe in the last year, it's a slightly counterintuitive ones, so maybe I can sort of close with challenge and sort of call to action is, we really thought, I genuinely thought, that having the world go through a global pandemic, which caused trillions of dollars of economic damage, which killed many millions of lives, would be a wake-up call to the world about why investing in global health is one of the best investments that can be made, because the consequences of not doing so are so profound. Both in pandemic preparedness for the future, how do we make sure we never go through a pandemic like this again?

And I was part of a report that made recommendations to the G20 and other bodies that saying, if the world put together 10 billion a year, which is a tiny fraction of resources of the trillions of dollars were spent on COVID, we could put in place an infrastructure that could both identify new diseases, work on recession terms, so we're ready to have vaccines and other treatments within a hundred days of a new breakout. It's been amazing to me that funding has not been forthcoming, that the world has not taken action. What you get is a lot of grand statements and commitments about, yes, we want to work on this. Yes, we learned the lesson.

We need to strengthen health systems. We need to invest more in research and development for global health. But the profound lesson is it's very difficult when governments and other partners in the private sector are focusing on short-term issues, from inflation to energy grid. They're just not rising to the challenge. On the flip side though, I say that's a depressing learning because we thought we'd be moving into an expansion year, but as I was citing with some of the exciting innovations we've learned, we've learned from the innovation of mRNA vaccines, which we were very early investors and supporters on, which we now think have great potential for diseases like HIV and TB and malaria.

We have some of the other tools I was citing in disease like malaria, which still kills hundreds of thousands of children every year. Many, many, many, many more than COVID ever killed. And yet we've got these powerful new tools coming on stream and these powerful interventions, and it just requires some political will and energy and resources. And so even if the world has not risen to the challenge right now, all our efforts this year and really that's why we double down in our own budget against these needs and now continue to expand because we think the critical time is now to invest and tackle these issues. And that if we do it right, we can actually bend that curve and make sure that we start the recovery towards achieving those sustainable development goals which guide all of our priorities.

Thoko Moyo: So all is not lost. I mean, that's actually really great to hear.

Mark Suzman: Oh, definitely not. Definitely not. No. No. Again, this is the Optimist broadcast. Not only is all lost, but we are on the cusp being able to actually have some kind of, I didn't even talk about the exciting increases in digital financial tools that link in with the women's economic empowerment and with agriculture across all the areas we work. There's some very exciting potential and that I think show the power of philanthropy in trying to show some of these models. But again, the difficult work, the way to make it actually reach the people most in need has to be about the communities, the countries themselves, taking it, seeing these as their own priorities, putting their own resources in. And that's very much what we've been working to build and accelerate in the months to come this year with our new budget and then the years to come going forward.

Thoko Moyo: Terrific. Well, thank you so much for sharing your time and your insights today. I know you're in Seattle. I'm in DC. I'm looking forward to seeing you in person soon, and I want to say thank you to everyone that joined us today for sharing their questions and very importantly for being Optimist subscribers. And I want to invite those of you that are not subscribers to join by visiting gates.ly/optimist. What I can say is Mark and I truly appreciate your interest, your engagement. We've recorded this conversation today, and we'll share the link in an upcoming email. Thank you so much for joining. Enjoy the rest of your day or your evening wherever you are. Thank you so much.

Mark Suzman: Good.