Helen Evans: a decade on the frontiers of global health
By Robin Davies
After working on Indigenous health and HIV/AIDS in Australia, Helen Evans rose to leadership positions in two of the world’s biggest and newest health funds, tackling some of the most significant health challenges of our time.
Visiting Kigali, in Rwanda, Helen Evans sat with a group of rural women who had formed a peer support network for HIV-positive women. The network was funded by the Global Fund to Fight AIDS, Tuberculosis and Malaria, of which Helen was then deputy head.
Many of the women were HIV-positive as a result of rapes committed in the course of genocide. Often their children, the products of rape, were also HIV-positive. Other women had acquired HIV from their husbands, who could not or would not acknowledge that.
The women spoke about their mutual support. They described their efforts to encourage other women in rural communities to be tested so that they at least knew their HIV status and could decide whether to seek treatment and support. Sometimes they were able to persuade women to take their husbands with them for testing, another step along the way.
“I was so impressed and moved by the courage and the strength of these women,” Helen says.
“It was a very profound experience. At the end, one came up and said, ‘I just wanted to thank the Global Fund for giving me back my life.’ She showed me a photo and said, ‘That was me, 12 months ago.’ She was skeletal, with advanced AIDS. But because of the Fund, she was now receiving anti-retroviral therapy, which turns AIDS, once a death sentence, into a manageable chronic disease. And she said ‘Now I can live a productive life, and what’s most important to me, I can live to see my children grow up.'”
Before joining the Global Fund, Helen inhabited the altogether smaller world of the Australian federal public service for some 20 years, albeit dealing with some of Australia’s most difficult health challenges. She was a long-serving head—for seven years—of the Office for Aboriginal and Torres Strait Islander Health. She managed the development and implementation of Australia’s second national HIV/AIDS strategy. She led the process to set up Australia’s first national childhood immunization register.
Helen came to international notice as Australia’s senior representative in the negotiations which led to the establishment of the Joint United Nations Programme on HIV and AIDS, or UNAIDS. She later served on its board. Then, in 2005, she was recruited to become the first Deputy Executive Director of the Global Fund. The Fund was at that time a relatively new and unusual creature in the multilateral menagerie, a public-private partnership that channelled large amounts of funding directly to developing country governments for defined purposes—a so-called ‘vertical’ fund.
Helen’s move to Geneva was a big step for her, but perhaps a bigger one for the Fund. Helen hadn’t worked in the multilateral system, but she had worked with it. She had learned much from her roles in public and indigenous health in Australia about working through partnerships to build and manage complex programs. She had learned also that, no matter what prescribed authority one might have, real authority has to be earned by building credibility, respect and trust. At the Global Fund, she fitted in much more quickly than many people expected.
She was, nevertheless and in her own words, ‘an unlikely appointment’. Even if the Global Fund was an unconventional mechanism, its senior ranks, like those of most multilateral organisations, were dominated by grey-suited, mostly white males. One of Helen’s direct reports, unimpressed that he was now reporting to a new layer of management, not to mention an Australian who had never worked in Africa, resigned soon after her arrival.
But other staff, and indeed the Fund’s board, saw the need for somebody with Helen’s skills to manage the fast-growing organisation on a day-to-day basis. The Fund’s founding Executive Director, Richard Feachem, was a visionary leader, but needed Helen to keep the show on the road. As he said, “Her skill set complements mine … Helen will play a crucial role in taking the Global Fund from a rapidly growing startup to a mature, major financing institution”.
When, in 2009, Helen was appointed as deputy CEO of what was then the Global Alliance for Vaccines and Immunisation (it is now simply Gavi, The Vaccine Alliance, or else just Gavi), the then CEO Julian Lob-Levyt described her role in very familiar terms. She would ‘oversee the performance and management of the Alliance secretariat as it strives to expand immunisation to developing countries’, drawing on her ‘extensive experience and strong management skills’.
The Global Fund, and also the Gavi Alliance, were both in a very real sense—to borrow Feachem’s term—startups. That’s why an important part of Helen’s role was therefore to introduce what might be considered more traditional practices into organisations accustomed to working informally, quickly and flexibly.
“There was a need for a little more consistency in processes and programs, and data collection, and accountability in people management practices, and so on. And there were some people who said, ‘Oh my goodness, we just going to be turning into a traditional bureaucratic organisation’.
“I have a very strong belief that processes and policies are there to give some consistency but, as importantly, to free people up to get on with the job. They absolutely should not be processes for processes’ sake. They should encourage initiative while ensuring consistency around decision-making and provide clear parameters for implementing countries.”
While Helen’s recruitment to the Global Fund, and later Gavi, was at least in part about bringing order to the management of these mechanisms, she didn’t go to Geneva simply to keep doing what she had been doing in Canberra. She was strongly attracted by the pioneering nature of the Global Fund’s work, as well as the dynamism, innovation and impact that characterise the work of Gavi.
Samantha Power, US Ambassador to the United Nations in New York, has described the Global Fund as embodying a 21st-century model of development. Some would disagree, arguing that the Fund has too often bulldozed governments’ own investment priorities and swamped fragile health systems.
Helen does not accept this. She argues that the impact of the significant funding made available to countries to combat AIDS, tuberculosis and malaria over time actually freed up hospitals and health workers to focus on other health issues. It also demonstrated to donors and implementing countries that investments in health could achieve a real, measurable impact on the health and wellbeing of people, with consequent benefits for economic development.
She also saw a lot to like about the Fund’s emphasis on partnerships with developing country governments, combined with mutual accountability, performance-based funding and transparency. And she was very impressed by the quality and the diversity of the people who were interested in coming to work at the Global Fund, and later also at Gavi.
“We attracted an extraordinary group of people, a much younger profile, very smart, coming from all sectors including the financial sector, taking salary cuts, coming from NGOs, coming from countries, coming from governments, but all incredibly driven and inquiring.”
“There was a real buzz; it was very exciting. We made mistakes, there was no doubt about it. For example, we should have moved earlier to welcome work on health systems strengthening, on the underpinnings of the health system and where AIDS, tuberculosis and malaria fit within that. But the great thing was that we could say, ‘Yes, we haven’t got this right’. And we adjusted and tried to rectify mistakes as we went along.”
The governance arrangements of the Global Fund and Gavi were particularly innovative, if not to say challenging. Both funds are overseen by very diverse boards which include not only donor countries and recipient countries, as with UN organisations, but also private donors, civil society organisations and, in the case of Gavi, experts and, most controversially, pharmaceutical companies.
“To sit at a board meeting where they had donor countries and beneficiaries, but also civil society, on an equal footing, that was both exciting and quite challenging,” says Helen.
“I think for donor representatives it was difficult, because as a donor you actually have to refer back to your capital or stick to a government policy position that is not necessarily your own personal position. But on the whole, people found the mission and the approach incredibly stimulating and that formed a bond. The civil society representatives were incredibly active. This was really the first time in a global health forum that they were really sitting around the table as equal decision-makers, and they made great contributions.”
Dealing with donors became more difficult over time. Following the global economic crisis of 2008 and various instances of misappropriation—uncovered by the Global Fund’s own internal control mechanisms—donors’ enthusiasm for innovation began to give way to risk aversion. Both Funds accordingly moved away from a ‘light touch’ philosophy toward a much lower tolerance for risk.
At the same time, their boards professed an ongoing commitment to ambition and innovation. Meeting these sometimes inconsistent desiderata required, says Helen, “resilience, a high tolerance for ambiguity and a need to keep your eye firmly on the vision and strategic objectives of the organisation”.
Helen functioned, among other things, as a voice for the needs and concerns of the Asia-Pacific within the Global Fund and Gavi.
“One of the things that really struck me when I went to Geneva was that Southeast Asia in particular tends to fall off people’s agenda. The problems in Africa, and now the Middle East, are so huge.”
One of Helen’s final country visits as deputy CEO of Gavi was in fact to Indonesia in mid-2013, to participate in the launch of a pentavalent vaccine—a single-shot vaccination against the five diseases diptheria, whooping cough, tetanus, hepatitis B and Haemophilus Influenza type B—which was locally produced with Gavi support. Indonesia, like other middle-income countries, is in the process of ‘graduating’ from Gavi funding, though not everybody inside or outside Gavi believes that Gavi’s support should be tied simply to national income per capita.
“This launch was really exciting, because the vaccine was WHO prequalified, and Gavi only funds WHO prequalified vaccines. So that was great. But its launch had been very delayed, and rolling it out across some 6,000 islands in the archipelago was going to be a huge exercise.
“The health system in Indonesia is very patchy and has a long way to go, and that has a lot to do with the capacity and training of health workers. So Gavi is using the five-year transition period before funding actually ceases to try and look at where the big gaps are and what it is that, together with the Indonesian government, they can do to try and ensure sustainability.”
Helen takes a great deal of personal satisfaction in the achievements of both the Global Fund and Gavi. The Global Fund has supported prevention, treatment and care programs for AIDS, tuberculosis and malaria on an unprecedented scale and the results are measured in millions of lives saved and large reduction in the human suffering associated with these diseases since the year 2000. As for Gavi, immunisation arguably offer the best value for money in the public health arena, and the results show clearly in the data.
“I learned a huge amount from working in Aboriginal and Torres Strait Islander health and it was enormously satisfying to be able to then move to a global scale drawing on my experiences in Australia. The impact is much broader, with so many people living on less than $2 a day, though I don’t in any way undervalue or underestimate the need in Australia.”
One of the toughest things Helen had to do was lead and manage Gavi as interim CEO, after the departure of Lob-Levyt, through a 12-month period when its future hung in the balance. Having made huge promises about scaling up the delivery of pneumococcal and rotavirus vaccines, and with a mountain of board-approved applications from eligible countries, Gavi was facing a potential fiscal cliff in 2011, just as donor countries were struggling with the impacts of the global financial crisis. Gavi’s biggest donors were at odds over the question whether, in these circumstances, Gavi should be committing funds to the strengthening of national health systems.
Helen managed to negotiate a compromise on the ‘systems vs vaccines’ issue, which brought all parties back to the fold. The United Kingdom then offered to host a pledging conference in June of 2011, in London, and the three biggest donors (the Bill & Melinda Gates Foundation, the United Kingdom and Norway) formed a political triumvirate to help drive fundraising. In the end, Gavi raised US$4.2 billion, as compared with a target of US$3.7 billion. Helen, with more than a little relief, handed over a fully-funded, well-functioning Gavi to incoming CEO Seth Berkley.
Something that gave Helen a great deal of personal satisfaction during her years working in global health was the the decision of Gavi’s board to approve a call for applications for the human papilloma virus (HPV) vaccine from eligible countries, taken at a meeting in Bangladesh in 2010.
Over a quarter of a million women die from cervical cancer every year and more than 87% of those deaths occur in low-income countries with limited or no access to screening and to treatment. The HPV vaccine, first developed by Professor Ian Frazer and colleagues at the University of Queensland, has been available in wealthy countries since 2006 and is highly effective in protecting against the two types of HPV that cause 70% of cervical cancers. However, its relatively high cost meant that, before Gavi stepped in, the countries with the highest burden of cervical cancer lacked access to it.
The decision to support HPV vaccination was difficult and heavily debated, for several reasons. The vaccine is expensive, even though Gavi was able to negotiate a dramatic price reduction from over US$100 to US$ 4.50 per dose (three doses were needed), and under Gavi’s business model all beneficiary countries must bear a portion of this expense through co-payments. Moreover, the HPV vaccine’s target group, pre-adolescent girls, is hard to reach. Immunisation teams in health departments work primarily in childhood immunization. Delivering the HPV vaccine requires working with education departments and also undertaking community outreach to the many girls who are already out of the school system. Also, some Board members were concerned that, since HPV is contracted through sexual intercourse, the vaccine would be controversial in certain countries.
“Some Board members felt that, while there was still so much unfinished immunisation business in the childhood realm, why put more burdens, both financially and logistically, on countries by introducing a controversial vaccine. ‘Let’s stick to our knitting,’ they said.”
“But the eventual decision by Gavi to support the HPV vaccine meant that we could start to address equity gaps for all girls no matter where they live. Now they can start to enjoy a future free of cervical cancer.”
“When a woman dies it is not just a personal tragedy. Her death has a generational impact on the family, particularly daughters who are often pulled out of school to look after the family. As they say, ‘women survive, families, communities and nations thrive.’“
Something else that gave Helen enormous personal satisfaction during her years in Geneva was the number of women who went to her and said how much it meant to them having a woman in an executive leadership role. It gave them confidence to have as a role model someone who seemed to be comfortable to be herself and had been able to combine a successful and varied career with raising children.
Having taken her Australian experience to Geneva, Helen eventually, in 2014, brought her international experience back home. The transition back to Australia was more difficult than she had expected.
For one thing the job she had left, as deputy at Gavi, was one that she loved. It was stimulating and rewarding and she was constantly working in overdrive. But also, the Australia to which she was returning was not quite the same as the one she had left. She had always talked about the Australian commitment to a ‘fair go’. Yet Australian political parties and individuals seemed to have become less tolerant, less open-hearted and less egalitarian.
“Tim Costello of World Vision says that really in Australia we have so little idea of how profoundly blessed we are. And I think that’s the case. I feel concerned about where we’re going, and I’ve found it quite a challenge coming back.”
Helen’s family were clear that it was time for her to slow down a bit so she resolved not to seek another full-time job. Indeed, she described herself as ‘retiring’ from Gavi. However, this has not prevented her from taking on board roles with the Fred Hollows Foundation and the Burnet Institute, as well as an honorary Associate Professorship at the Nossal Institute for Global Health in Melbourne. In addition, she is a member of the Advisory Council of the Pacific Friends of the Global Fund and has just been appointed as a member of the Global Fund’s Technical Evaluation Reference Group.
“I’m very pleased to be able to contribute back in Australia, where I can, some of what I have learnt over an extra-ordinary ten years in Geneva . I do think I have a pretty good grasp of how the global health and development architecture works and also how Australian bureaucracy works. I can also bring an understanding of the global trends that are impacting on global health and development, and I have a network there that can help.”
Too few people, especially Australians, move between the senior levels of national administrations and multilateral organisations. As Helen’s case demonstrates, all parties to such exchanges are enriched by them.