As we move from COVID-19 as a pandemic, to COVID-19 as a virus, this week’s episode asks – what did we learn about pandemic response as a global health community? In particular, what did we learn about applying a global health response in middle- and low-economically developed countries? And what can we do better next time?
Our guests this week are Dr Bill Rodriguez, the Chief Executive Officer of FIND, the global alliance for diagnostics, and Dr Fifa Rahman, the Principal Consultant at Matahari Global Solutions, and a Permanent NGO Representative on the WHO Access to COVID-19 Tools Accelerator.
We discuss the successes of the international community during the pandemic, such as the unprecedented international coordination and the rapid development of health technologies have been vital to the pandemic response. But both guests point out that too often these measures were implemented without sufficient input from the people who are affected. We ask how we can work towards a future pandemic response that decentralises the decision making and control of the tools of global health and empowers people and communities to make decisions about their needs.
As we move from COVID as a pandemic to COVID as a virus, it’s incumbent on the global health community to take the lessons from this pandemic and strengthen our systems and processes for the next pandemic. This is the conversation is the first step in that process.
We hope you join the conversation @CentreHealthSec and follow Bill and Fifa’s work @FINDdx and @fifarahman.
Please note: We provide transcripts for information purposes only. Anyone accessing our transcripts undertake responsibility for assessing the relevance and accuracy of the content. Before using the material contained in a transcript, the permission of the relevant presenter should be obtained.
The views presented in this podcast are the views of the host and guests. They do not necessarily represent the views or the official position of the Australian Government.
Dr Bill Rodriguez 00:00
And the price has been an inability to connect to communities and understand what people need and the point that you made that it's been about the virus, and not about the people for a very long time.
[So] we would be really, I don't want to use the word criminally, but we would be negligent if we fail to take advantage of this opportunity and this awareness that we need to redesign our system so that there are people focused. So let's not let's stop talking about looking for COVID, let's start talking about people presenting with respiratory symptoms and what we do with them.
Dr Stephanie Williams 0:31
Hello, and welcome to Contain This. Today we're speaking to two people at the forefront of the global response to the COVID 19 pandemic, two people who bring very different perspectives to the discussion.
Dr Fifa Rahman is the Principal Consultant at Matahari Global Solutions, a Special Advisor at Health Poverty Action, and a Permanent NGO Representative on the WHO Access to COVID-19 Tools Accelerator.
Both bill and Fifa agree that unprecedented international coordination and the rapid development of health technologies, mostly diagnostics, have been vital to the pandemic response, but that too often these measures have been implemented without sufficient input from the people who need them. In this episode, Bill and Fifa shared their views on decentralising decision making in global health in order to empower people and communities to make the decisions they want to make about their health needs. I hope you enjoy the episode.
So I want to start with a question to each of you, if you could share some of your personal reflections from the past two years of the pandemic, in terms of your view Bill from within a global health organisation and yours, Fifa, really taking some of the more grassroots or country level perspectives. Let's start with Fifa.
Dr Fifa Rahman 2:10
So I think the first thing is probably about the value of the multistakeholder response. And I take CSO perspectives and bring them to the global, so I don't think I come from just one perspective. But one thing about a multistakeholder response is that you get to leverage upon the inherent qualities of each of these organisations. And that's reflected in a number of examples, but I'll make it brief. Some organisations simply aren't agile enough to respond quickly, and others are. And in a situation like a pandemic, it's incredibly important that you have these different actors to keep each other accountable. In the case of self-test, we had guidelines come out incredibly late. And I think that the agility of different members in the multistakeholder response, and I think brought up lessons for agencies that perhaps weren't used to doing things so quickly or were more bureaucratic. And there are some agencies who don't think trips flexibilities are important. And others like the WHO, who will, who will champion them. So there's, there's that. And, of course, even in in organisations, like the WHO the diagnostics expertise is just isn't as robust as FIND. So you have a real value in in organisations such as FIND being there.
And the second point, is probably that paternalism still exists in global health. And that's something that we really need to sort out because in access to self-tests globally, for example, and this translated to access to self-tests on the ground in LMICs, and the difficulty in tackling conservatism, visa vie PCR and self-test at home, is that at the highest levels, there was still there's still a lot of conservatism paternalism about, oh, we should only, we don't know if people in low and middle income countries will know how to read their self-test. We don't know whether they'll be able to link to treatment, which of course is really sort of colonial and also inaccurate, because people in Africa and Asia have been HIV self-testing for a while I've been pregnancy self-testing for decades. This isn't a situation where people don't know what they're doing. And that implication, as well as the concern that you know, the ideology that it's not your right to health to test which is wrong. Of course it is. It is our right to health to know our status, right. Those ideologies still persist at the highest levels and can be impediments to commodity deployment.
Dr Stephanie Williams 5:17
Thanks, Fifa and your reflections. Just remind me, I think we did start the COVID response thinking about a pathogen instead of people. And it changed quickly. But potentially, it's a learning for next time about where we start when we respond, Bill, over to you for your reflections.
Dr Bill Rodriguez 5;40
Thanks. I think both of those comments are on target. So let me give you my perspective from where I sit inside a global health agency. You know, I'd say the theme over the past few years that I've seen is this issue of centralised processes decision making activities versus decentralized and you can quickly relate that to colonialism and the legacy and echoes of colonial approaches to global health. You know, one, one point that the ACT-A principals in the hub is fond of making is that there's been an unprecedented degree of cooperation among the leaders of the major global health agencies. And they'll point to the fact that for the past two years now, two plus years, every Thursday night for 60 to 90 minutes, the principals of the major agencies involved in in the COVID response, will meet in and talk and discuss ideas. And every other week, it's open to the broader community and the CSOs like Fifa and others. And then every other week, it's a tighter group.
And the plus side of that is it has been unprecedented. There's a degree of communication and cooperation and a joint agenda among the principles of the global health agencies that has never been there before.
What's the downside? It's everything that Fifa just said, which is you've got a small group of people, mostly European, mostly white men, sitting in a room and trying to make decisions on behalf of the global community, without sufficient understanding of what's happening at community level without sufficient input. And so there's definitely been real pluses and benefits from having that ability to convene centrally on a regular basis. But the price has been an inability to connect to communities and understand what people need and the point that you made that it's been about the virus, and not about the people for a very long time.
And I think, you know, the self-testing agenda is a good one that Fifa brought up, because it's sort of highlights all of the successes of the COVID response and all the failures of the COVID response in one test. And I would say the most recent discussions around self-testing that are that are just as disconcerting as the fact that it took almost two years to get a policy recommendation out. That the discussion now is if people are using self-tests, we're not collecting data on what's happening to the pandemic. And again, there's a discussion that's coming centrally about that the collection of that data, to track the virus is more important than people taking control over their own health and knowing what to do and how to respond to symptoms and infection and protect their families and communities. And again, it's this sense that we have we have centralised decision making without sufficient input from people who are affected.
So I think we have to figure out how to take what we've been able to build and build on to really dramatically accelerate the availability of tools, and not just tests but vaccines and to some extent, therapeutics, but figure out how to embed it in what people need and what communities need and not in what health agencies like, like FIND and our partners need. And that's the challenge. It's a difficult one. But we need to figure out how to how to decentralise all of the activities in global health and not keep them centralised in a small group of people.
Dr Stephanie Williams 9:00
So, just to continue on that theme, then Bill, when you think about FIND as an organisation over the last two years, you've touched on being part of a important coordination mechanism. But how have you tried to overcome some of those, some of that disconnect that you point out about decisions, and then the people that are affected by them? How have you changed as an organisation?
Dr Bill Rodriguez 9:27
You know, find came into this into activity and the effort to respond to COVID as a much smaller organisation that was sort of less centrally involved in in major programmes and major decisions. And in part, that's because diagnostics have sort of been in the background behind vaccines and therapeutics and in health systems strengthening outside of diagnostics. And then COVID revealed, I think, to everyone how critical testing is for good decision making, for people to protect themselves, for resource allocation. So FIND was put in this new role of prominence because we have the technical expertise in in diagnostics, and as Fifa mentioned, we were small enough to be nimble enough, to be able to respond to the needs, maybe more than other agencies that are a little more bureaucratic.
So we've had to, we've had to grow that muscle, we've had to build that muscle of how to engage globally, all at once on a daily basis. And that meant hiring new people with new skills and focusing more on some of the downstream activities around. You know, identifying community-based needs, identifying novel strategies for uptake of tests in different settings and working closely more closely with partners on the ground, then we'd had to do in the past at FIND.
To be able to make sure we didn't get caught up in the wave of sort of centralised decision making, we've had to rely heavily on our country teams and our partners. And so I think we just didn't have the staff in the in the presence to be able to know what was happening and what government officials needed, what community based organisations needed, what was happening at clinic level, other than in a few settings. So one thing we did is we lot we relied heavily on our India team, which is are by far our biggest country team who do have a lot of local operations, mostly in tuberculosis and hepatitis C, and AMR control. So that informed a lot of our thinking. And then we really tried to identify what are the equity issues, we try to maintain an equity framework around all the aspects of testing, from R&D, to manufacturing, to regulatory authorization, to training to market development and demand generation.
And that led us to, we certainly relied on CSO organisations and other partners to help us understand what they were seeing on the ground. We tried to track equity in different ways about who has access to tests, and is that an equity issue? But also where does manufacturing take place? And is that an equity issue? And then we tried to make investments to improve equity. And that included not just, you know, cash investments in new programmes, but to try to put our time and people to address, you know, regulatory barriers that were equity issues, policy barriers, that were equity issues.
And, you know, honestly, I can't say that we succeeded. But that was the effort we made to make sure that as a small organisation that was moving in a in a rapid way into a new role, that we didn't lose sight of what the what the goal was, which is to help individuals and people and communities lead healthier lives, and in this case, to get through the pandemic.
But it's, it's hard when you're when you're sitting in Geneva to make sure you're listening to what's happening on the ground. I think that's a problem we all face.
Dr Stephanie Williams 12:49
And Bill just to help us with a bit of perspective, when you say a small organisation in global health, roughly how many people work for FIND at the moment?
Dr Bill Rodriguez 13:00
Yeah, before the pandemic, I think we had 80 people, 85 people or so in Geneva, and about 60 or 70 in India, and now we have over 200 people across a number of countries based out of the Geneva office, but sitting in working in multiple countries, and about 100 people in India 80 to 100. So we've sort of tripled in size in the past two years. And now we're you know, $150 million organisation with 250 or 300 global staff.
Dr Stephanie Williams 13:31
Fifa, you've been an advisor, civil society advisor to ACT-A, but you've also been in the field or overseeing some work assessing access to rapid antigen tests and the degree of integration between COVID and TB services. What are some of your standout reflections on key findings of barriers to access or what has overcome them in the places that you've been working?
Dr Fifa Rahman 13:57
So probably going to start with the fact that the WHO recommends that people seeking a test for screening for TB screening also are offered a COVID test. And we found that in our work, you know, across a number of countries in Africa and a couple in Asia, where there wasn't really any momentum after that piece of paper was issued. So that piece of paper was issued and nobody really took up on it. So it makes me think about the value of advocacy and the value of civil society funding to pressure governments to go like, okay, look, WHO has issued this document, and we need to integrate. So, everybody, I think a lot of donors are concerned about tracking advocacy, because how do we do it? We don't know how to plot but there are lots of ways how to monitor impact from advocacy, and I don't think that should be an issue excuse to not fund advocacy.
I think the next thing is about sort of conservatism about PCR is better. Like we've seen that in a number of places. And, and I think the arguments need to be pushed through more with more clarity that, yes, of course, PCR is more accurate. But in, in some of the areas we're working in, it's taking four to five days or more for PCR results to reach the individual, from time to time of collection of sample. And in that time, and these are educated lab experts or technical experts who, who should really know better, right? In those four to five days, while someone's waiting for the result, they could have infected a bunch of other people. So there's, there's a greater value in doing a rapid antigen test, or whether professional use or self test, and the public health value of that is something that needs to be communicated more to maybe conservative decision makers on the ground.
Dr Bill Rodriguez 16:22
Can I follow up on that with just a comment? I mentioned earlier, this tension between centralised processes and decision making decentralised. And, I think one of the key lessons of the COVID, era, hopefully it's ending soon for as an acute pandemic, but will be with us for a long time as a virus. I think one of one of the lessons is everything, almost everything we do in global health, the policies, the financing mechanisms, the agencies and structures, the approach to addressing health is, is vertical, right? It's disease focused and not people focused.
And, and just this comment about TB and COVID testing that Fifa made, I think we've learned, yeah, maybe there's a role for that in the kind of pandemic and what we saw in the first year of COVID. But had we built systems that were people focused from the beginning, and worried about when a patient comes in with symptoms are concerned or sick, how do we respond to their needs, with the right set of tools, including tests of various kinds, maybe we would have moved faster on self-testing, maybe would have moved faster to say you have respiratory symptoms, we're going to look for all the things that could cause your respiratory symptoms, whether that's TB or COVID, or RSV, or influenza in a comprehensive way, based on understanding, what's going on around us.
And everyone has talked for years about integrating HIV and TB, at the at the molecular platform level, let's use the same platform to test for HIV and TB, and it just hasn't happened. But that's because the systems are designed this way. So we would be really, I don't want to use the word criminally, but we would be negligent if we fail to take advantage of this opportunity and this awareness that we need to redesign our system so that there are people focused. So let's not let's stop talking about looking for COVID, let's start talking about people presenting with respiratory symptoms and what we do with them. And that's going to be different than sending them to a PCR lab to test them for COVID. If we're if we're if we're designed on a people-centred approach.
Dr Stephanie Williams 18:37
So let's take that a bit further than because when we when we step that idea out a bit, it does force us to come and think about, well, what does that look like from an institutional support? Now we're in the realm of talking about universal health coverage, basic packages of care, robust levels of health service delivery, and integrated diagnostics as an example. So I’m just really interested in your candid reflections on the practical next steps towards that type of change, given the organisations that we are all supportive of and a part of?
Dr Bill Rodriguez 19:12
Yeah, so our Head of Global Health Security at FIND, she's fond of saying, people talk about pandemic preparedness. That's what we hear is kind of the term that everyone talks about these days. Those of us who've been working in pandemic preparedness for 20 years, we use a different term - we call it primary health care strengthening, right. It's the same thing.
And I think what it looks like is essentially to say if we want to prepare for the next COVID, whether it's SARS COVID three or some other virus, we need to actually invest in primary health care.
So what does that mean? It means actually coming up with a basic social insurance mechanism for every country so that there's a plan to fund it. There needs to be essential packages around disease areas, but more specifically around what treatments need to be or what tasks need to be available. How do we integrate prevention programmes, whether it's screening programmes for cervical cancer immunisation for childhood diseases, we need to have that approach. And we need to recognise that if we do that and we consider what are the implications for surveillance and response to the next pandemic, we'll be in a much better position. So we have to have that discussion instead of talking about pandemic funds and where the money is going go for new vaccines for disease X, which are hugely important. But the priority needs to be how do we improve primary health care with the right financing the right mechanisms, and the right approach so that all of these agencies that have their different tools, can develop them toward that end?
And that's a discussion that I mean, I think Tedros tried to begin it before the pandemic and then was derailed by the pandemic. But I'm hopeful that we'll see a global leadership focused on that issue and a frank discussion around what are the costs? How do we fund it? What comes from global agencies? What's funded domestically? How do we make sure the tools we're developing are geared toward that? How do we train staff and make sure that the community-based treatment programmes and the community based clinics have what they need to be the true frontline of primary health care? While in the background being ready for the next pandemic? We have to have a different conversation, I think is the answer.
Dr Stephanie Williams 21:26
Fifa, what's your perspective on that question?
Dr Fifa Rahman 21:30
I agree completely on the health systems primary health care point. And in fact, it's one of our demands that we're making to the G20 and, and to the WHO, in these discussions on the future pandemic response is that health systems and primary health care and universal health coverage need to be central to any future response, and not ancillary, which is what we saw in the COVID response.
I mean, in the ACT-Accelerator, there was so little funding for the health systems connector, which is the sort of pillar that that was which to tackle health systems issues. But also, there was a lack of organisation around health systems, right. And, and those conversations didn't happen. And they should have because we saw health systems decimated during COVID. And it's definitely something that we want more centrally featured in the future pandemic response. But we also want to see financing change, because what the situation is now with, with health systems and primary health care is that they're, they're being funded through disease specific funding. So governments and donors give HIV funding and expect that’s addressed through there. And I think it needs to be, I mean, that could still happen. But there also needs to be funding specifically for primary health care and health systems and named as such, to place the emphasis there. So I'd like to see that that change.
And in terms of, what best practices we need to bring is, is it really feeds upon what Bill said about structuring things around people and bringing services to people. And whether that means, the sort of boxes that they had in Malaysia that had a pulse oximeter as in, masks in, rapid test in, and, and send those out to people. And whether that should be combined with other health services as well. Or through community health workers in rural parts of Africa. And we know that 14% of, only 14% of community health workers in Africa are salaried. So whether it means creating funds to be able to salary community health workers who know the culture, who know the nuances on the ground, to be able to go to the elderly lady who lives in a rural area and say, hey, have you ever been vaccinated? Do you want a COVID test? What other problems are you facing? These are all things that we need to seriously tackle in the future pandemic response.
Dr Stephanie Williams 24:16
And I think we also have, we haven't really got the best mechanisms on the financing primary health care and the domestic resource mobilisation and what's the right type of system support, be it loans be it grants, be it long term health system strengthening projects, all of these ideas force us into a conversation of better solutions where the donor dollar is tiny compared to the resources required for primary health care, but it's one that I agree we shouldn't be shying away from trying to improve our collective approach to it.
Can I take a turn left to go back to technology, which feels like an odd turn to be taking now, but it comes back to the idea of innovation in FIND’s title, about some of the exciting or novel developments that maybe interests a bit closer to a patient centred approach, at least at the diagnostic interface.
Dr Bill Rodriguez 25:18
When you think about why Primary Health Care has been under invested in and under supported part of it, either as a cause or a consequences, most frontline health workers at the community level or at the clinic level, just don't have the right tools, right, they don't have enough tools to be able to understand what's happening to the patient in front of them. And they're left with a lot of difficult choices about do I use an antibiotic or not? Is this COVID or not? Is this TB or not? And what do I do?
So what we've seen in the past two years is when you put resources into R&D, how fast you can develop new products, the first PCR based test for COVID were available commercially, within six days of the virus being identified, right, which is unprecedented. The first rapid tests within eight months. And that's unprecedented if you think about malaria tests and HIV tests. And then multiplex molecular tests, I could find COVID, and something else were available within the first 12 to 14 months. So when there's funding available, and the and the products are clear, the needs are clear, we can do a lot very quickly.
What that's also meant is we've seen two major investments in two different platforms that have that have really borne fruit. The first is, in molecular multiplex testing, well, what does that mean? Taking the power of PCR and being able to say from a single sample from a patient who's presenting in front of me, I can identify from between four and in the most promising platforms, 27 pathogens, at a low price point, somewhat below $10 at market launch, and ideally, getting down to roughly $5 per sample, or per test. At volume production, I can say, what does this patient have in front of me? And I can make that assessment in a simple instrument that's used at primary care. The next generation of the GeneXpert platform for those familiar with that or similar platforms.
So that's incredibly exciting and potentially transformative for primary care to be able to manage infectious diseases by saying, I have a patient with respiratory symptoms, I'm going to run a test for roughly $5 and identify a pathogen, I have a patient who looks like they may be sick with a febrile illness, I'm going to draw blood and see if they're sick. And run that here, if I have the ability to draw blood and processed blood, all of that getting a result back in minutes to an hour instead of, days, two weeks. So those technologies are entering the market. A few are on the market now.
We'll be seeing more and more of those technologies enter the market 2023, 2024. And by 2025, ideally, we should see a competitive marketplace for affordable tasks that can make those determinations at the primary care level, frontline clinics, and certainly level one, facilities and hospitals that have a basic laboratory that do glucose testing now or HIV testing now. So that's really an exciting investment that is poised to pay off. And now the question is, can we integrate that that kind of technology in our primary care system.
Then the second investment has been in digital health and digital tools. And so the ability to not only be able to generate information at the primary health care level, but to connect that information with deeper expertise, whether it's specialists in paediatrics, or in gastroenterology or in neurology, who can immediately provide support to a frontline worker and what to do with that information, clinical decision support tools, databases, where now you can track what's happening in different parts of the health system with better surveillance and allocate resources, all of that investment in the past few years. And it started pre-COVID, but was accelerated by COVID, now are really available so that frontline workers can be connected in a different way to health systems. Again, we need to manage that, that that tool and the power of that tool in a way that supports the needs of patients and health workers. But that investment will also transform primary health care.
I'll say there's been a third investment in genomics and sequencing, which has allowed unprecedented tracking of COVID variants worldwide, it's now being applied to monkeypox variant monitoring. That's another tool that maybe has a role, I think in surveillance and maybe someday will be appropriate for clinical case management for drug resistance for TB or other diseases. I think we're not quite there yet with that technology. And we have to not overestimate what it's capable of doing on a day-to-day basis. But that's a third technology that in the future, I think is going to be transformative. But those other two molecular multiplex testing and digital tools are currently tools we need to plan for their immediate use at the primary health care level.
Dr Stephanie Williams 30:13
So, coming to you, then Fifa. Bill’s left us with three innovations to be hopeful for I wonder if you could close us off today about what you're hopeful about, taking forward from the pandemic, from your perspective.
Dr Fifa Rahman 30:30
So I'm hopeful that that diagnostics is now sexier to donors. I think that I think we've made a lot of noise about how it was just vaccines, vaccines, vaccines, vaccines, vaccines, and I think, I hope that consciousness is there or at least is nascent.
And, one of the things that I feel we have sort of needs more attention going forward and I feel like the seeds are being planted as we speak is that with innovation and of course, digital health is is is so important going forward, that the human element be retained. And the example I'm thinking about is with thermal ablation cervical cancer in some of in Zimbabwe, Mozambique in particular, that these are important tools, they the not just thermal ablation, but the diagnostics also for cervical cancer, right, they take a picture of the cervix, and they send it to the, to the AI tool for analysis and, and it sends back the result to the mobile phone to tell you whether you you've got precancerous cells or not. The human element in community health workers and the role of them in understanding the cultural acceptability of tools, the, the whether the mobile phone is owned by the male of the family who might get upset if he's, if his wife has precancerous cells, all of that, the sort of human element of knowing the cultural nuances of a community and the risks to a woman of that, that's quite important. And the same applies to COVID. Right? The community health worker will know. And in Zimbabwe we had, we had community health workers working, holding tablets, and putting people's HIV self-test results in in this tablet and sending it away for surveillance. All these tools are incredibly important, but also to emphasise on the value of the humans behind it.
Dr Stephanie Williams 32:45
So we, at the Centre for Health Security had always found diagnostics sexy, because I think we had been a partner of FIND pre-pandemic, and admire the nimbleness of the organisation. But we were an early partner there. But can I thank you both for your time and perspectives today, across so many important and current discussions, were having now about what we need to keep and what we need to improve, both from how we work from the field right up until the organisations and the places we work to continue to improve the chance that next time we do it better. So thanks so much for joining us today.
You've been listening to Dr Fifa Rahman and Dr Bill Rodriguez about global health lessons from the COVID pandemic. I'm Stephanie Williams, Australia's Ambassador for Regional Health Security. On this season of Contain This we have talked to a number of guests about what the global health community got right and wrong during the pandemic. A recurring theme has been focusing too much on the virus instead of the people. As Bill said, we would be negligent if we fail to take advantage of this opportunity and this awareness that we need to redesign our system to be more people focused. He and Fifa gave a number of suggestions for how this can be done in the future.
Contain This is produced by the Indo Pacific Centre for Health Security, hosted by Australia's Department of Foreign Affairs and Trade. You can follow us on Twitter @CentreHealthSec.