Impatient Optimists: A Field Visit to the Kuna Territory in Mesoamerica

Jeff Raikes (left) and Wolfgang Munar (red shirt) greet partners during a recent visit to the Kuna Territory. (©Photo Inter-American Development Bank)

Jeff Raikes, Wolfgang Munar

On a recent trip to Panama to look at innovative health investments, we visited the communities of Carti and Wichub-Huala, in the San Blas Islands archipelago, an autonomous territory of the Kuna Peoples.

The Kuna participate in the Salud Mesoamerica 2015 initiative (SM2015) that the Gates Foundation is jointly funding with the Carlos Slim Health Institute, the Inter-American Development Bank (IADB), the Governments of eight Mesoamerican countries, and the Spanish Bilateral Aid Agency. SM2015 is a catalytic initiative that uses an outcomes-based funding approach to support Mesoamerican governments in implementing pro-poor policies and programs that improve the health of women and young children in rural areas.

At the first community we visited, we were greeted by Mr. Gardi Sugdub, First Sahila (Chief) of the tiny islet of Carti, who was chosen by the community to lead their public affairs because of his proven wisdom and ability to articulate the People’s rich oral tradition as “keeper of metaphor.” Shaila Sugdub highlighted the high value the Kuna people place on protecting the health of their women and children. However, he also underlined the need for respecting Kuna traditions because, as he put it, “people who lose their tradition, lose their soul.”

We also met Ernesto Harris, Secretary of Carti’s Kuna Council. Ernesto went to college in the United States and, upon returning to the Kuna Territory, became part of the community’s leadership. Having “seen the world,” he felt his responsibility was to serve as a connector between his people’s needs and the external sources of knowledge that can benefit them. He reminded us that, in order to have lasting impact, investments in Carti’s local health system should not only consider valuable elements like a functioning infrastructure, available supplies, and well-trained personnel but, also, clean water and education.

Our conversations with these two local actors highlighted some of the challenges and opportunities faced by the SM2015 initiative in all eight participating countries and territories. We know, for instance, that traditions can be at odds with population health. The consequences of this conflict can be exemplified by delays in the management of complicated pregnancies which often contribute to the high number of maternal deaths among the poorest populations in Mesoamerica. To respond to these types of cultural challenges, SM2015 is taking into account existing social norms and behaviors of the local communities when implementing its health programs. 

Ernesto also reminded us that health is determined by many factors in addition to behavior – including the supply of health products and services. Like him, we believe that for the Gates Foundation’s work to truly act as a catalyst for change and have a lasting impact, we need to do a better job at putting together investments that integrate multiple sectors like water, hygiene, and health.  The SM2015 partnership is a great example of how to do this, as different sponsors have the complementary resources and knowledge to oversee a comprehensive program for maternal and child health.

At the end of our visit we spent time with Ernestina Scott, Carti’s local nurse who moved from Panama City to the Kuna Territory 20 years ago and never left. Ernestina has a true passion for her work, and this passion motivates her to stay despite obviously difficult conditions. Through our interactions with Ernestina and other local health care providers we got a glimpse into Carti’s primary health care system.

As we reflected on the interactions we had with local residents, community leaders, and health care providers, we were left with a strong sense of optimism as the local health system in Carti –and across the other seven countries involved in the SM2015 Initiative – start implementation of this unique program.

We believe that this program’s innovative outcomes-funding approach can create powerful incentives for improving the policy and financial environment across Mesoamerican health systems. However, its ability to drive lasting impact at scale will ultimately depend on the ability to effectively encourage local health care providers and households to improve their practices and behaviors.

We were genuinely impressed by the positive energy and the degree of commitment to improving population health that was evident among the people that we met in Carti. We were also humbled by the wisdom of this ancient community and their capacity to survive under conditions of extreme hardship.

Jeff Raikes is the CEO of the Bill and Melinda Gates Foundation, which first published this blog on April 30. Wolfgang Munar is Senior Program Officer in the Family Health Division comprising the Maternal, Neonatal and Child Health, Nutrition and Family Planning programs.

Jeff Raikes on Philanthropy

This blog post was originally published on Impatient Optimists

Jeff Raikes on Philanthropy

Welcome to my new blog series on Impatient Optimists, where I’ll be sharing my thoughts on the Gates Foundation and philanthropy. Every six weeks I’ll be posting a new blog discussing a pressing issue at the foundation or addressing some of the challenges and opportunities facing the philanthropic community. More than anything else, this is a space for a conversation. So please submit your questions, share your feedback, and let me know if there are any topics you would like to hear about.

For my first post, I want to discuss a challenge at the foundation that’s been on my mind lately. It’s called the “innovation pile up”. Let me explain.

At the Gates Foundation, we believe in the power of innovation to improve lives. That’s why over the last decade we’ve invested in one of the fattest pipelines of lifesaving technologies the health and development world has ever seen. A new, rapid diagnostic test for tuberculosis that will help reduce transmission of the disease. Better tools to enable women to plan their families. Even improved toilets that provide clean sanitation for the world’s poorest people. In all, the foundation and its partners have developed more than 100 new innovations that are available today or scheduled to be introduced by the end of the decade.

That’s the good news.

Here’s the bad news:  None of these innovations will make a difference if they can’t reach the people we aim to serve. 

Many obstacles stand in their way. Some public health systems in the developing world lack staff, training, or infrastructure to take advantage of these new tools and technologies. Regulatory agencies can be slow to approve new drugs and devices. Market forces may make it difficult to introduce these new products. Then, there are actual roadblocks. Transportation systems and roadways may be so bad – or nonexistent -- that just getting these new tools safely to the people who need them is a challenge. Finally, even if new drugs and tools arrive in remote villages, cultural practices may dissuade people from adopting them.

That’s why we need to get smarter at delivering these innovations. If we don’t, we risk not improving and saving as many lives as we could. 

At the foundation, this challenge has been dubbed the “innovation pile-up,” and solving it is one of my top priorities. As part of the re-organization of our global programs, which I outlined in my 2011 Annual Report letter, we are now balancing our research and development efforts with a greater focus on how these innovations will get delivered. Chris Elias, our new president of Global Development, brings decades of on-the-ground experience in heath and development. He is leading our work to better understand the obstacles to introducing and scaling access to new tools and technologies and how we can overcome them.

We’ve already learned a lot about effective delivery from our work on vaccines. We have a better understanding of the best funding mechanisms for new vaccines and the most reliable ways to deliver them safely to the remotest health clinics. Thanks to these efforts we are on track to significantly scale up the delivery of lifesaving vaccines in developing countries and prevent the deaths of millions of children under 5 by the end of the decade.

Now we need to build on this success and ensure other promising technologies reach the people who need them the most. We are exploring ways to integrate some of these new innovations into existing delivery systems. For example, a new, easy-to-use injectable contraceptive that would provide women living in remote areas a simple, effective family planning tool will likely be introduced through family planning programs already operating in these countries. 

Other existing innovations will require new delivery systems and business models to be successful. Consider the challenge of expanding access to a simple, lifesaving product like the mosquito coil. The spiral-shaped, insect-repelling incense has the potential to protect families from malaria-carrying mosquitoes. But the cost – even at pennies per day – remains out of financial reach for many of the world’s poorest families. Donors may be able to help drive down the costs for these families, but there hasn’t been much interest in this solution without more data on the impact of wide-scale coil use. That’s why we’re working to fill this knowledge gap by funding new research studies. We’re also exploring next-generation mosquito repellents that would last for months, cost less, and not require burning. All of these solutions will require the cooperation and partnership of governments, the private sector, and consumers to be successful.

These are tough challenges. But I’m confident we can overcome them. We now have a team dedicated to speeding up the delivery of existing innovations and finding new system delivery models for entirely new innovations. More importantly, we will be listening closely to the people who will benefit from these innovations. By understanding their needs, we can design the best solutions and most effective ways of delivering them. Working together, we will realize the full potential of these innovations, and, in doing so, help the people we serve realize the full potential of their own lives.

Jeff Raikes is the chief executive officer of the Bill & Melinda Gates Foundation.

Click here to view the Bill and Melinda Gates Foundation Annual Report.