Our Center Director Gavin Yamey is chairing the Advisory Board for the new Lancet Commission on Hearing Loss. Yesterday, at the first meeting of the Commission, hosted by Duke University, he gave a 10-minute talk on what makes a successful international global health or development commission. Below we post his talk.
Last year, I led the writing of a peer-reviewed paper published in the journal Health Policy & Planning called “How to Convene an International Health or Development Commission: Ten Key Steps.” The authors were all involved in Global Health 2035: A World Converging in a Generation, aka the Lancet Commission on Investing in Health (the CIH). Three of us—myself, Larry Summers, and Dean Jamison—were commissioners and one of us, Jessica Brinton, was from the Bill & Melinda Gates Foundation, a major funder of the commission. I hope this doesn’t sound too self-serving to say: I think this commission did make a bit of a splash and as a result, we kept getting asked by other newly launched Lancet commissions to share our ideas on what worked and what did not.
So here are our ten steps—more or less in chronological order.
Step 1. Identify and clearly articulate the very specific gap that the commission will address. In other words, why is a commission needed?
My sense is that some commissions didn’t catch fire because it was never clear in the first place what they were for.
For the Commission on Investing in Health, we saw a giant, deadly gap: first, health had fallen off the radar of the development community. We thought this was dangerous and we thought a commission was needed to show the value, for development, of investing in health. We wanted to show to policymakers the powerful evidence of the value of public financing of health—not just for improving health but also for protecting the poor from the financial ruin caused by out-of-pocket medical expenses.
Step 2: Choose a chair or chairs who will be super-engaged, and energize and inspire the commissioners
The chairs will set the agenda, help frame our analytic work and hopefully run the commission meetings in ways that get the most out of the discussions. They’ll also leverage their personal and policy connections when it comes to policy engagement and outreach. It helps to have chairs who are well known worldwide and are key opinion leaders. For the CIH, we were fully aware that Larry Summers had a reputation for being controversial provocative and someone who has ‘embraced the role of a provocateur,’ which carried risks. To me, I’m 100% certain that a huge part of the CIH’s success was due to him pushing us to think in new ways, to take risks, and not to stay inside what he called the “UN-speak comfort zone.”
Step 3: Secure dedicated financial and human resources
It’s extremely difficult to pull off an impactful commission without funding and people who have protected, paid time to write and protected, paid time to serve as a secretariat. A strong secretariat is needed to help with logistics, timelines, meeting venues, etc. The commissioners themselves are unlikely to have a ton of free writing time. Universities can be very helpful in providing in-kind support.
Step 4: Start at the end and then work backwards
Ask yourself: when do you want to publish, what can you hook the publication date to, how can you maximize impact? Previous commissions have done themselves a huge favor by piggybacking the launch to a high profile global health event like a World Health Assembly—the Lancet Commission on Global Surgery was even able to get a new resolution passed at this assembly. For the CIH, we timed ours to feed into the discussions about the new Sustainable Development Goals (SDGs). In our commission, we conducted modeling showing that with the right investments, by 2035 the world could achieve what we called a “grand convergence” in global health—a universal reduction in avertable infectious, maternal, and child deaths. We were then able to feed the results of our analysis into the SDG process itself. We did around a dozen different UN briefings.
If you don’t have this kind of end point as a “tether,” you can drift and lose focus. Once it is set in stone, you can then establish your work program, your commission meetings, and your interim milestones.
Step 5: Choose commissioners based on expertise, diversity of viewpoints, diversity of people, and ability to be or connect with change agents
Diverse groups bring more innovative ideas and help to avoid group think. For a commission to effect large scale, sustained change, you need experts in the topic, sure, but you also need economists, policy experts, epidemiologists, social scientists, civil society voices, affected communities and others engaged. I think this new commission on global hearing loss has done a spectacular job on this front.
Step 6: Use in-person meetings of the Commission wisely and effectively
You, the Commissioners, are all supremely busy people. Getting you here was a massive logistical undertaking. There may be three or four more of these. In-person meetings are crucial. You can’t pull off a commission with conference calls alone. They have to be in person: you need face-to-face time to get to know each other, to go in depth into the content, to spar and debate. Bringing outside speakers in can work really well, as can live streaming parts of the meeting to help build a sense of inclusion. We did that with The Lancet Commission on Global Surgery at our Harvard meeting: one day was open to the public and live-streamed, the second day was closed.
With the CIH, we found that producing an annotated outline early in the process was super-helpful, i.e. getting down the basic structure of the paper. Why?
- It helped as a focusing tool
- It helped to build consensus among Commissioners around key themes
- It made the writing of the final paper easier.
Step 7: Say something new, unexpected, and controversial and say it using simple messaging
Don’t produce something safe that makes everyone feel warm and fuzzy. Warm and fuzzy won’t bring about change.
Don’t be bland.
Disrupt orthodoxies, challenge readers, push them to think in new ways.
Distill out three or four key messages and make them simple and punchy:
- For the CIH, our key message was: ‘with the right investments we can end premature mortality within just one generation.’
- For the Lancet Commission on Global Surgery, our key message was: “five billion people lack access to safe, affordable surgical and anesthesia care when needed.”
Step 8: Generate new research
Of course, for any commission, you must synthesize the best available evidence and tell readers the state of the art. But if you can commission new research as well, there are lots of advantages:
- New research findings can be a ‘hook’ to galvanize policymakers to take action.
- You can “test hypotheses” in real time. For example, at the start of the CIH process, we had an early hypothesis that in middle-income countries that were graduating out of health aid, high levels of avertable mortality may be concentrated in ‘pockets’ of rural poverty. We commissioned a rapid analysis using demographic and health survey data from 37 low- and middle-income countries that did indeed show a clustering of child deaths in rural regions of middle-income countries.
- Given that resource mobilization is at the very top of the political agenda when it comes to the SDGs, including the health-related SDGs, our experience suggests that policymakers are particularly ‘hungry’ for research on the costs and financing of the SDGs.
Step 9: Develop an action plan as soon as possible: the report is a starting point and a tool, not the end point
The report should have forward-looking, actionable recommendations. It’s a tool for change, but effecting that change needs a plan. It’s very helpful to also create short policy briefs in multiple languages, slide decks for the Commissioners to use—you as Commissioners are the ambassadors of the report’s recommendations. For the CIH, we created a short video. We had a press strategy in place at the launch of the report. We developed a detailed calendar of events post-launch to maximize the reach of the report findings and reinforce the messages, and to reach specific policymakers. Different voices within the commission were also highlighted to reach different policy audiences depending on whether the goal was reaching a group of health or finance ministers or a set of high-level donors.
Step 10: Use the final report to lay the groundwork for future work
A great commission take on a life of its own post-launch, and one way it can do so is by catalyzing new studies. We have an opportunity with this commission to help lay out a research agenda on global hearing loss.
So, in summary:
Say something fresh, with simple messaging, timed for maximum impact; generate new data; be forward-looking and actionable; have a policy engagement and outreach plan in place that reaches a diverse set of policymakers through different channels; and, above all, be provocative.