Episode 5: Good Health for All: How do we build equitable healthcare systems?

This is a challenging time for the social sector, which is reeling from global funding cuts. Organisations working in healthcare are particularly affected. In this episode, Vikram Patel, Paul Farmer Professor and Chair of the Department of Global Health and Social Medicine at Harvard Medical School; Dr. Balakrishna Korgaonkar, Associate Director at The Global Development Incubator and Diwakar Mittal, Senior Director of Corporate Affairs at Novo Nordisk, discuss how we can build affordable healthcare systems that serve those who need it the most and the role that technology will play in this endeavour.

Transcript

SPEAKER_05 0:04

If a delivery can be done by a midwife or a trained nurse, AM, does it need to be done by a doctor? On the midwife front, there is evidence that they can do better than the doctors in many settings in terms of providing more human-centered care and also better outcomes in terms of lower cesarean section rate, lower episiotomy rates, and so on, right? There is a lot of data around this.

SPEAKER_03 0:33

Welcome to Reorient. I'm Garov Gupta.

SPEAKER_00 0:35

And I'm a Nakshi Sopti. There's probably no better moment to talk about healthcare than right now. Global funding cuts have sent shock waves through health systems, especially in developing countries that relied heavily on US aid. The fear of an impending health crisis is quite real. So where does that leave the region and how resilient are we really when the world shifts around us?

SPEAKER_03 0:59

You're right. These impacts have been dramatic. And I know we're going to talk about this region, but let me just very quickly talk about sub-Saharan Africa, where I think it's the hardest hit. You know, external financing for healthcare for many of those countries represented close to a third or more of healthcare expenditure. And that's the funding that has been dramatically downsized, especially from the US. Now, in this region, especially in countries like India, we're a bit more insulated with respect to how much of our healthcare expenditure comes from outside, but we still have an enormous financing challenge in itself. We have our own challenges and we still don't have enough money that's actually going to a healthcare. So there are questions of how we can make the funding that is coming in more equitable. How do we prepare our health systems for an aging population? I know we've spoken about the demographic dividend. Actually, now we need to think about aging populations. And of course, what role can tech play? Is this going to be a leapfrog? So there's a good peg to talk about the region's own challenges. And I'll be speaking to Dr. Mvikram Patel of Harvard Medical School on his idea of decolonizing healthcare, Divakar Mithel, the Senior Director of Corporate Affairs at Novonordisk on patient behaviors, and Dr. Balakrishna Gorgaunkar on the idea of value-based healthcare.

SPEAKER_00 2:11

Now, value-based healthcare, what does it actually mean, Garov? Is it a mindset change from volume to value, from treating illness to improving lives?

SPEAKER_03 2:23

Well, wait for it. I have a tell-all monologue that kicks us off.

SPEAKER_00 2:27

Okay, so let's hear it from you, Garov.

SPEAKER_03 2:37

In this episode, we're going to be covering various aspects of the future of healthcare. And I thought it would be helpful to set the context. We're gonna start by focusing on the financing challenge. And there's I think two big trends that are really forcing the issue. One, of course, is something that's been going on for a long time, and that is that many countries have aging populations. The difference is aging populations have aged faster than anyone had predicted. These age pyramids are inverting faster than demographers had actually predicted. It is putting a lot of pressure on the healthcare system. At the same time, global funding for healthcare has been cut dramatically recently, especially coming from what's known as the traditional aid economy, right? The overseas development assistance, starting with massive cuts in the US, that has led to a conversation around a big long-term push that has been there around decolonizing healthcare in starting to find much more localized funding, localized protocols. And so this has in some ways supercharged that because the enormous amount of funding has been cup. What we will also discuss in this episode is then how do you think about funding, but then how do you get the most amount of value out of it? And what's interesting about healthcare is that healthcare has traditionally been an input-led model. It's a fee for service model. You're sick, you need to go see a doctor, and you present your sickness and you pay a fee to the doctor based on a consulting charge. You don't get charged on the basis of what your actual outcome is. Did you get better? Did you not get better? And there's very practical reasons for it. But this idea of a fee for service has pervaded the system where we're really paying for inputs. And there has been a big movement around what they call value-based healthcare, which is around how do you start financing things on the basis of actually outcomes, which sets incentives sometimes at the individual level or at the community level to start to actually make people healthier, prevent illnesses from happening in the first place, or to be super efficient with how we deliver healthcare because you're actually getting paid on outcomes. The other thing we'll also discuss, which is again related to the delivery of outcomes and quality in a resource-constrained environment, is of course AI, which again has a massive opportunity in terms of both scale and quality of delivery for the medical profession. So the whole episode is really meant to center around this idea of this pressure that we're feeling in financing. How do we therefore shift our mindsets towards delivering healthcare more efficiently in a more outcomes-oriented way? And how can you know technology also help us in that? Let's start by understanding this model of healthcare before we get to the funding challenge.

unknown 5:26

Dr.

SPEAKER_03 5:27

Korgaonka, you describe value-based healthcare as the objective of your initiative, leapfrog to value. What exactly does that term mean?

SPEAKER_05 5:35

If we look at the health systems that we have currently in high-income countries, low and middle-income countries, you will see that the health systems are not necessarily working for people that they were meant to work for, right? In the sense that they're not delivering the outcomes that the patients need to see as a result of care that they are receiving. And still the health systems go on providing more and more care, not necessarily thinking about what's the optimal way to provide that care, what's the optimal way to make sure that the financing is oriented towards more human-centered care? And what is it that we need to measure to make sure that we are actually making progress in the right direction? So these are three buckets we really think about. How do we measure progress? How do we make sure that the care delivery is oriented in a human-centered way? And finally, the financing, does it create the right incentives in the system for the care delivery to be human-centered and create better outcomes for people it is serving?

SPEAKER_03 6:37

And if I interpret that, if you get these three things right, it feels like what you're saying is there's a lot of uplift that isn't simply about pumping more resources, but that these things get designed better. And then as a result, you actually get much better health outcomes for the same amount of money.

SPEAKER_05 6:52

Yeah, I would not undermine the fact that low and middle income countries, South Asian countries, particularly spend much less than they should be spending on healthcare. So I would not undermine that fact. But given the budget envelope that we have, how do we make the best out of it? Is the question that we are trying to answer. And how do we do it in a systematic way, not always looking at one individual intervention, but really looking at it from a system design perspective and answer that question of are we using available resources to the best possible extent? And are we delivering the outcomes that the people deserve?

SPEAKER_03 7:36

How do we measure outcomes in a human-centered approach to healthcare? What are the metrics? Well, there are broadly two kinds. Dr. Korga Unkar explained.

SPEAKER_05 7:47

So let's talk about the outcomes. I mean, typically for let's say a maternity program, what happens is what do you count? You count the number of ANC visits. That's the metric, which is an input metric. You sometimes count, you know, how many mothers visited more than four times or more than eight times during their ANC period. So all of these are metrics which are input-oriented. What you would track for outcome-oriented care is essentially how many women actually had a cesarean section delivery versus uh normal vaginal delivery. That's one.

SPEAKER_03 8:23

Which is, by the way, interesting because if you in these days with a lot of venture capital and private equity, more private equity entering, let's say, privatized hospital chains, I suspect that metric is in the opposite direction. There might even be a bit of an incentive to have more cesarean births. Then just an interesting example of also who's setting the metrics is also important.

SPEAKER_05 8:44

Right. Yeah, I mean, I'm definitely not against businesses making money. Businesses need to make money to survive and also need to make profits for their shareholders. But at the same time, I definitely feel like when businesses look at profitability, that is an important metric for themselves as definition of success, they need to look at like something like a balanced core card, where there are metrics which are long-term value metrics as well, which will tell them that the what are the right things to do as a business. But let's come back to the patient-level outcomes. So for the delivery, I said, you know, what kind of delivery did they have? What was their experience of care throughout the process? How did they feel treated by the doctor with dignity, with care, with so privacy was taken care of, et cetera? Was their pain handled during the delivery? So those are kind of like patient experience metrics. Then comes sort of a bucket which is more around quality of life metrics. For a new mother, what's quality of life? Whether they were able to feed their baby properly or not, brace feeding success, as they call it, right? Was there attachment between the baby and the mother as a result of care they were provided or the training that they were provided by the postpartum nurse, right? So these are metrics that we should be focusing on, which are more human-centered as well as, you know, take care of key clinical metrics. For tuberculosis, for example, bacteriological cure is a clinical metric. For diabetes, HB1C is a clinical metric. But there are metrics which are more patient-oriented and you know, a patient experience of care as well.

SPEAKER_03 10:22

So let me ask you what may feel like a big question. If you did have this ability to say, let's say the Indian government, which I think you know, you've more experienced here, here are three things that would change overnight. I would like you to think about those three things as moving the trade-off from one thing to another, as in no new money, but just doing things differently. Where do you think there's the highest bang for buck at the moment sitting in our healthcare system, where there's a lot of disease burden we can lower or patient outcomes simply because of better systems design choices that are more patient-centric?

SPEAKER_05 10:53

Right. I would think about three types of interventions. One is interventions that allow frontline healthcare workers to do more. So, for example, if a delivery can be done by a midwife or a trained nurse, AM, does it need to be done by a doctor? So that kind of trade-off is one thing. But at the same time, you need to ensure that the midwife has the training to recognize when this case needs to be handled by the doctor and what cases they can handle themselves.

SPEAKER_03 11:25

And just on that, can I ask, is it more a practical consideration? Or are you saying, so either you could be saying, look, in reality, a midwife and a doctor are almost exactly the same? Or you could be saying, no, look, a midwife may be less capable, but is still capable enough that given our resource constraints, that's a better outcome than overburdening a system which has other things it needs to be doing. Is it one or the other?

SPEAKER_05 11:50

Actually, on the midwife front, there is evidence that they can do better than the doctors in many settings in terms of providing more human-centered care and also better outcomes in terms of lower cesare insection rate, lower episiotomy rates, and so on, right? There is a lot of data around this. This is just specifically midwifery example. So it actually could save money.

SPEAKER_03 12:13

And lives, could save money and lives and better outcome. This is a very free lunch in some ways.

SPEAKER_05 12:18

Yeah, exactly. And actually, the cost saving that I'm talking about doesn't come from the cost of the midwife versus the cost of the doctor, actually comes from the outcomes that they save, right? Second, I would say currently healthcare systems are quite siloed in terms of uh different programs, right? Verticalized programs. And I mean, because of the verticalized programs, it's the same healthcare workers who is actually delivering care, but they are doing work for from a program perspective. So I think there's an opportunity to bring it all together at a primary care level at least. So a comprehensive, integrated primary care, which is well connected to tertiary care so that the referrals can be managed. That's the second biggest opportunity from my point of view. A lot of care can be taken care of at a primary care level if done appropriately. Almost 80% of health problems can be taken care of at a primary care level. Last thing I would say is currently outcome measurement is not a focus. There is a huge quality movement, and the quality movement is actually focused on process measures, usually, like what kind of facilities exist. There is a checklist of things to do in each medical process, procedure, etc. And they focus on checklist, right? Which is great. But I think there's also the outcome focus which is missing. And the quality movement and the outcome movement needs to come together and needs to work together for it to really become a comprehensive picture. When you're trying to review the performance of a system, you review it from an outcomes perspective. But when you are performing care, actually, you can't think about outcomes because the outcomes are far off in the this is a time scale issue.

SPEAKER_02 14:04

Your quality inputs lead to quality outcomes.

SPEAKER_05 14:07

Yeah, exactly. And both of these things need to come together. That's our point of view.

SPEAKER_03 14:17

The idea that frontline workers like midwives are as capable, if not more, than doctors to deliver certain kinds of care is eye-opening. It was also interesting to learn that pharma companies have a similar outlook. I spoke to Devaka Mito from Novo Nordisk, and he too has interesting things to say about the need to support primary health care in the country.

SPEAKER_01 14:37

So, in fact, one change which we see which is coming slowly, is something called health-seeking behavior. So people do tend to take interest in terms of knowing about it. And what I've seen while traveling all across the country is the need is strengthening the primary care in our country. And I do see lots of focus coming in that direction in terms of taking chronic diseases, not just to the tertiary care, but actually to the primary care, because this is where people live. This is where the health has to play its role. So strengthening primary care is one very big opportunity which is there in front of us, especially when we look at uh chronic diseases like diabetes. When we talk about uh chronic care and when we talk about the primary care, I would also like to mention the role of community health worker, especially at the primary care. Because they play a very big role even in the behavioral part, even in supporting the local community over there in terms of health-seeking behavior and also providing the information which is relevant, which is local, which is very important. And one last point over there, which I could share with you, is uh influence really works in healthcare. And this is where I again go back to the polio example which I gave it. Uh, because our communities were involved, uh, because for so many years our community health workers were involved in that activity, uh, and they have a tremendous influence at the primary care, uh, we could really drive that to its final result. Uh so what I've seen is uh getting health-seeking behavior is one very important thing. But if we could also club it in our programs, and I see government moving in that direction, and many local uh state governments are also moving in that direction, where they are also bringing primary care into it, where they're also trying to bring the uh community health worker into it. I think that's a very, very powerful tool, especially for health-seeking behavior to turn into really taking an action on visiting a doctor or just uh, you know, knowing more about it, et cetera, et cetera. So that's something which is my understanding and my learning when I work all across, especially in chronic care.

SPEAKER_03 17:01

I want to go back to the idea of measuring outcomes. Now, Dr. Korga Onkar has done a lot of work around tuberculosis, which continues to be a massive problem in India. What were his learnings from taking a value-based approach to patient care? What were the measures that reflected real outcomes?

SPEAKER_05 17:18

So, our tuberculosis work in the initial days, we also looked at collaborating with Dahlberg on this work, and we actually looked at what is it that can be done in the Indian tuberculosis space. It is driven by a government program, NTEP, and the National Tuberculosis Elimination Program. Basically, this program is trying to do tuberculosis elimination by 2025. That was the original goal. We haven't achieved that goal. And at the same time, we know that despite so many people actually coming to the government with the diagnosis of tuberculosis, from that point on, the main problem is only 40% of people actually complete treatment and achieve the bacteriological cure, as we call it, right? So there are drop-offs at each level. At diagnosis to treatment, treatment to you know, continuation of treatment, adherence to treatment, and finally, you know, basically bacteriological cure. There are so many drop-offs. And only 40% people actually coming to a bacteriological cure is a you know really difficult problem to solve. 60% people are being lost to the system. So that was the problem that we were looking at when we looked at tuberculosis. And how do you apply a human-centered approach to this problem? Because the government has done everything possible in terms of tracking people, individually, calling people. There used to be a program called as DOTs, directly observed therapy, right? And DOTs is literally watching people take the pill. You go to that extent and still 40% complete treatment or achieve bacteriological cure. That's a tragedy, right? Our hypothesis there was that what we are missing here is the social determinants of health. We are trying for behavioral change by monitoring people. You can't achieve behavioral change by monitoring people, but really deeply understanding what drives those behaviors and then providing some way to correct for those behaviors. The way we did it is basically first we need to know what is working for people, what is not working for people. So you need a way to tangibly measure what's happening. So we need three types of outcomes to be measured for tuberculosis. One is clinical outcomes, which is often well monitored in the government system. Second is the quality of life. How is it affecting quality of life for people and what aspects of quality of life is it affecting? Third is what's their experience of care, the patient experience of care. So these three things definitely need to be monitored for us to be able to actually understand what's going on and what's actually driving that 60% drop-offs, right? With tuberculosis, these drugs have side effects and it's not unexpected actually. But the patients are not well informed on what side effects to expect and what to do when they have these side effects. Second, the social determinants of health drive a lot of it. People don't have, I mean, the government already has a program for nutrition for tuberculosis. They get a direct benefit transfer for nutrition, but despite of that, um, nutrition is a problem for a lot of people with tuberculosis. With tuberculosis, there is weight loss and they need additional nutrition. So that's the second problem. And there are other problems such as somebody doesn't have access to somebody who can take care of them, somebody who can take them to the center. So there are social problems around this. Surprisingly, the stigma factor around tuberculosis has reduced quite a bit. I will also draw some attention from, you know, in tuberculosis, what we were able to do is really get that measurement piece right. We rolled out this questionnaire, really well-designed questionnaire, to about 13,000 people with tuberculosis in the you know states of Gujarat and Sharkhand and got these really cool insights from what is driving it, what does the cost side look like? What is the cost of care, not just from the system perspective, but also from a patient's out-of-pocket side perspective. So, what does that look like? However, it was a USAID-funded program, one-year program. We couldn't really get to actually acting on those insights. So, data to impact piece was missing in that one. However, we could do that in a program in Uganda in HIV. So what we saw really was really powerful for me. I mean, I personally experienced some of these conversations. And basically, most of the reasons why children with HIV, there were about 800 to 900 children with HIV who were enrolled into this program, the human centered HIV care program. And most of the time, and these were all people who have not achieved what is known as. You know, controlled viral load for people with HIV, right? Most of the time, the reasons were social. Children did not have access to education, were in some foster care kind of setup, they had poverty and hunger issues, they had some misconceptions about when to take medicines, when not to take medicines. All of these reasons were contributing to, you know, sort of some of these reasons for not taking medication and hence not achieving viral control. And these healthcare workers actually were able to connect some of these problems to existing NGOs, some other programs, social programs. And as a result of one year of doing this, 61% of these patients actually achieved viral control. So, which is an amazing number for me.

SPEAKER_03 22:50

Now that we have an understanding of value-based healthcare, let's come to the funding challenge. India, as we know, still has a huge shortage of healthcare finance, even though most of it is funded by the government. I was curious to know Dr. Korgaunka's thoughts on the financing models that are most suited for a value-based approach.

SPEAKER_05 23:09

I think when we think about financing for healthcare, there are two levels there, right? One level is you need some funding for innovation. And then there is funding for ongoing operations. And my fundamental belief here is that the innovation can be funded by aid, but operational funding should not come from aid because that has to come from indigenous sources, domestic sources. Only then will it be sustainable. It can be from taxpayer money, it can be from out-of-pocket, it can be from insurance, doesn't really matter. Sources of financing don't matter, but they have to come locally for sure. The innovation part sometimes is a big investment for figuring out something small. But if you fix that really well, then it can create long-term ROI for the system. And hence that is something where philanthropy needs to play a role. So that's how I see the dichotomy when it comes to financing. The second part, the operational part, I would say the way currently financing is organized is a problem. Currently, the financing is fee for service, right? So you provide a service, you get a fee for that service. In the government systems, it's usually budget lines, right? And it's always optimized for budget lines. So from there, we need to move towards creating incentives for more human-centered outcomes. So linking incentives to actual on-the-ground patient-level outcomes is an important thing to do when it comes to financing.

SPEAKER_03 24:41

It's impossible to talk about healthcare today and the future of healthcare without bringing up AI, which is going to be transformative for the sector. It has the capacity to deliver healthcare advice at scale, but also at a high quality. And we really need to be thinking about embracing this technology. And I wondered what do medical professionals like Dr. Patel think about this opportunity? One provocation for you about, you know, medical doctors is today, if you're a lower-income country, especially, should you be training doctors? You know, doctors are anywhere from 15 to 50 times more expensive than a community healthcare worker. And a community healthcare worker with an iPad might outperform that doctor. And I would argue that some of the latest technology can do that better than a university-level conversation because they'll have a much closer sense of the data in those communities and what is actually more locally relevant is obviously dynamically updating. Is there a real provocation that we need to think not just decolonize, but actually really lean into innovation and get away from even that old mindset of, you know, we need doctors who often have to some extent a kind of monopoly play on the healthcare field, et cetera, and really think differently about how you deliver that primary healthcare capability.

SPEAKER_04 25:56

Absolutely, Gauda. I completely agree with you. You know, I'm a physician myself, but I do think that the doctor-centric, hospital-focused approach to healthcare has been the most expensive, certainly the least efficient, and not necessarily the best quality of care for people in the population. So I completely agree with you that the future of healthcare must look that like one where there is a team and where medical practitioners, physicians play a role, but they're neither kings nor emperors. They just play the role that they're equipped and skilled to play. And I also agree with you that technology is going to transform the way healthcare is delivered. And so I am bullish about technology, but at the same time, I think we should also bear in mind there are certain things that a person wants when they're sick that cannot be addressed by a computer or a chatbot. They often need the kind of healing relationship that doctors, nurses, and community health workers can offer that cannot, I think, at least with my understanding of modern technology, be replaced by no matter how sophisticated your large language model is, it does not establish that kind of therapeutic warmth and rapport, which by the way, Gaurad, is also extremely important to the healing process. But yes, some kind of new way of health workers, human resources and health interacting with technology to enhance the coverage of high-quality healthcare, I do believe that that's going to be the future. And that future will not be necessarily about doctors and hospitals. And I'll say one more thing. You know, the one country that I believe has been a pioneer in this approach is India. You know, India already has more community health workers than any other country in the world, and I'm saying per capita, not just absolute numbers. There are many different cadres of community health workers. This has been going on for decades. And the foundation of India's government or public healthcare system is entirely led by non-physician health workers.

SPEAKER_03 28:11

If he had the opportunity to tell the Indian government how its health priorities need to shift from where they are today, what would he say to them?

SPEAKER_04 28:19

Well, you know, I can say that over the last five years, I have been leading the Lancet for the Lancet Medical Journal, a commission that is seeking to address this very same question. You know, we're in the final stages of the publication process of that commission, which we hope will be launched in January 2026. The commission is called the Commission on Re-engineering India's healthcare system to be person-centered. That's not the exact title, but essentially that's the focus. And I think that really is at the heart of our message is to convert a healthcare system that has been largely run on bureaucratic administrative mechanisms, such as, for example, how many doctors do we have, how many clinics do we have, to one that is focused on outcomes. That is to say, what is the experience of individuals who are in that healthcare system in terms of the quality of care that they receive, in terms of the equity with which care is delivered, in terms of the cost that is borne by the individual patient, and ultimately in terms of the health outcomes you achieve. And so, in a nutshell, Garov, moving from a focus on the system to the person and making the system person sensitive. And of course, we can go into details of what that might look like practically, that is the clarion call of the commission. And I'll tell you why we need to do that. We need to do that because India is in the midst of a dramatic transition in its population structure. So people will be very familiar that there are now clearly the population time bomb that we were told about in the 70s has flipped. Yeah, we've got an aging population. Exactly. The new time bomb isn't that we have too many babies, but we have too many older adults who, of course, are another kind of dividend for our country rather than being seen as a burden. However, the healthcare system is nowhere near prepared to address the health needs of older adults which are going to be dominated by chronic diseases, chronic conditions. And the healthcare system for chronic conditions has to be person-centered because one size does not fit all when you're treating diabetes or when you're treating cardiovascular disease or you're treating neurodegenerative conditions. You've got to actually provide person-centered care, care that is highly community-centric, care that incorporates addressing social determinants of health and disease. All of this needs to now become the mantra of the future of the healthcare system.

SPEAKER_03 30:53

Finally, I want to address the issue of the major funding pullback that has happened in the aid sector around healthcare. You know, we experienced a seismic moment when USAID's funding was pulled back. Now, Dr. Patel has spoken about decolonizing healthcare. And I wonder if this is the moment to push that idea, given that people are talking about reforming existing institutions and building new ones in the healthcare space.

SPEAKER_04 31:17

Gaura, this is a great question to ask me because I am a full-time senior faculty at Harvard Medical School, which has been at the epicenter actually of some of the dramatic changes that are being announced by the US administration right now. For example, you know, we have lost all our federal funding. So of course, I'm extremely seized by the question of how the withdrawal of the US from global health more specifically and global solidarity more broadly is affecting the architecture of institutions, of governance, of financing for global health. And so I think to your point, this is a historic moment. I do believe that changes that were happening already are going to be catalyzed. By changes, I mean changes in the organization, the architecture of institutions that are concerned with global health. For countries like India, which are middle-income countries, those changes already began more than two or three decades ago as the proportion of financing that was devoted to the health sector and the social sector was becoming increasingly borne by the taxpayers in India itself. And so the reliance on foreign funding was already significantly reduced. I believe that there's going to be acceleration of some of those changes. Yes, you're right. Some of the institutions that we relied on, like UACID, will no longer look the same, at least in the near future. And therefore, I wouldn't consider them as being absent, but reformed. And I think that reformation at the heart of that reformation will be a far greater emphasis on multilateralism and a far greater emphasis on self-reliance. And the latter is extremely important for decolonization because the moment you become self-reliant, you then set your own priorities. You're guided by your own people's needs and you finance, therefore, what you think is important rather than what the donor tells you is important.

SPEAKER_03 33:18

I'm curious though, because a little bit of what you're describing, there's optimism, right? There's optimism in that. And I think anyone who undertakes, I know you're sitting on some commissions that are thinking about what the future of health institutions could look like. But I guess one question I have is global intentionality, right? We're also in a moment where the idea of belief in we can do better together is fading to some extent in different geographies. It's obviously uneven. And you know, when we had these institutions first come out, and not just healthcare institutions, they came at a time of post-World War II where there was this sort of uniform sense of never again. And so intentionality, while of course, we can argue about whether it was very biased and globally north, and all of those things are true, there was still at least some level of shared intentionality and values that were driving the creation of the next set of structures. Where are they now?

SPEAKER_04 34:13

Well, I mean, I think what you're speaking to is what troubles me the most, which is the loss apparently of global solidarity. But let's caution ourselves a little bit here. Let's step back for a moment. There is one country that has sought to change the equation of global solidarity. And I think we need to keep that reality in mind. In fact, what I see happening as a consequence is a growing need for other countries to begin to strengthen their historic partnerships or develop new partnerships. I also want to say one thing about, I mentioned perhaps the word opportunity. I don't want to in any way diminish the cataclysmic impact that the sudden withdrawal of the United States from some of its key instruments of supporting the poor in the poorest countries in the world. For example, UACID and PEPFA, which finances HIV AIDS treatment programs for millions of people in Sub-Saharan Africa. So I do think this is an urgent crisis for many of the poorest countries in the world. And if there was one example of solidarity that I wish we would see quickly, is those countries that have the resources that includes all the other OECD countries, but also, I would say, wealthier middle-income countries, and there are many of them now, to step up and to fill the breach.

SPEAKER_03 35:36

And it's interesting because I think you're seeing signals in both directions, right? One level, you're absolutely right. There was some, you know, the US has led the way, but it has also created permission for others to then sort of follow, right? And you're actually seeing that in some of the announcements on ODA funding that have gone well beyond the Americans as well.

SPEAKER_04 35:55

Well, I mean, yes, Gardon, that's, for example, the US's monumental, outsized role in supporting science. You know, I mean, it's there's no question, not only the science ecosystem within the United States, but also supporting science globally. And for this, we must be extremely grateful to the American taxpayer. Now, the changes that are happening now mean that humanity will suffer if that science ecosystem isn't now supported by other actors, other players. And I'm praying and hoping that we will see countries around the world increasing the share of their GDP that they're investing in science, but also that they will take this kind of outward approach that American institutions took for so long, which is to say science is a public good. And by public good, we don't only mean the public in our respective countries, but the public everywhere. Let's not forget the pandemic was a global phenomenon. Infectious disease that begins in another country could very well come to your own. And therefore, it is in our interest to support a global network of health research institutions.

SPEAKER_03 37:08

Could you give us a little bit of a sense of the direction of travel that, you know, especially healthcare institutions and bridge building are going towards, different from what has happened in the past? Are we seeing decolonization coming up as an opportunity? So I think it's early days.

SPEAKER_04 37:24

Let's not forget. And so it might feel like a lot has happened and a lot has happened, but you know, it does take time for a new global architecture to be formed. But I do see signals that there is a new alignment taking place. Um, one which in the long term will be good for people everywhere. A good example of that is in March of this year at the University of Global Health Equity in Rwanda, an institution that my medical school is very deeply associated with, hosted a convention of deans of African medical schools. Now, it turns out that over the last two decades, the numbers of medical schools in Africa has exponentially increased. And more than 100 deans from around the continent met in Kigali and declared that they would now collaborate as a consortium on fundamental questions. For example, what should the curriculum of medical students be? And I think this is a great example of decolonization because when your curriculum for the future doctor is based on local realities, local context, on the felt experience of disease and sickness in your communities, that is the hallmark of decolonization rather than what has historically been the case. And this is also true of India, where so much of our medical curriculum is still very similar to what might be taught in the United States or in Europe.

SPEAKER_03 38:53

So what you're describing is a broader idea of decolonization, not just in terms of becoming independent from a funding perspective, but also ensuring that protocols, processes are localized and they have that localized nuance. And I think that wraps up a fantastic discussion. Thank you.

SPEAKER_00 39:14

So, what were your takeaways, Goro, from the discussion? I was interested to hear Dr. Kor Ganker say that midwives are often more effective than doctors when it comes to deliveries. But existing incentives are tied to surgeries. And I wonder how healthcare can be incentivized in a way that drives change.

SPEAKER_03 39:32

Yeah, and that's really the heart of it, but also just an incredible conundrum. You know, like imagine, would you pay a doctor in a village more because they see more patients? Or do you pay them more because he or she sees less patients? It's really tricky because both of those reflect different realities. It feels like someone's doing a more of a job. And in the other, maybe they're preventing, doing what a doctor should be doing, which is looking at overall healthcare. So I think getting this stuff right is so critical because you get the incentives wrong, you can end up having very, very perverse outcomes. And I worry at a moment in which more private capital is starting to flow in, what is private capital optimizing for?

SPEAKER_00 40:09

Well, moving on, we're going to be taking a step back and looking at the bigger geopolitical canvas. Where does South Asia sit in the political and economic currents reshaping the world? We'll be joined by Temur Beg, chief economist at DBS Bank, and foreign policy analyst Si Raja Mohan, Rory Daniels, Farva Amer, and Bhagia Senaratne. You won't want to miss it.