‘It’s Always Personal’
Priya Agrawal on her mission to end preventable maternal deaths & why she's the luckiest person in the world.
Whenever Priya Agrawal went to sleep, she thought of the women whose lives she had not been able to save during her work in India and Africa. “You close your eyes and they are on the inside of your eyelids,” she recalls. “Every single time I wasn’t able to get the blood in time for the woman dying in childbirth, there had been five, ten opportunities to prevent her even getting to that stage.”
Dr Agrawal is Executive Director of MSD for Mothers*, which is the pharma manufacturer’s $500 million, ten-year commitment to ending preventable maternal mortality.
Maternal mortality unacceptably high
Every day, approximately 830 women die from pregnancy or childbirth-related complications. “Two Jumbo jets of women dying per day is just not acceptable,” Agrawal says simply. An obstetrician and gynecologist by training, her CV in global women's health could hardly be more impressive: after training at the universities of both Oxford and Cambridge, she went to the Harvard School of Public Health on a Fulbright Scholarship. Since then, she has worked in countries such as India, Kenya and Nigeria for bodies ranging from the World Health Organization (WHO) to social enterprises before choosing to help MSD.
MSD for Mothers seeks to identify and develop solutions to tackle some of the most critical obstacles that stand in the way of delivering quality care that could reduce the number of women who die during childbirth. Agrawal understands better than most that prevention is the key: it is no surprise to find that her motivation is personal. “It’s always personal,” she says. “I grew up in the UK, my dad’s family living in London, my mum’s family in India – both sides had diabetes. My dad’s side were living with it, my mum’s side were dying from it.”
We have to do something for people in the greatest need.
The contrast is stark. But she knows that she has a challenge. “I’m competitive,” she laughs. “People always say to me that prevention is a hard sell so I want to be able to pitch prevention over treatment and that’s one of the reasons I agreed to come to Merck.”
Why maternal health?
She admits to being slightly suspicious of the company’s motives at the beginning. “When I first started, I questioned why MSD was doing maternal health,” she admits. “They’ve done global health in the past – river blindness, HIV – but both times they had a relevant product. It made sense. I said to them: ‘There’s no quick fix, no drug - why this?’”
The answer, it turns out, is simple: moral obligation. “We have to do something for people in the greatest need,” she says. At the WHO or Harvard, she says, “our intentions were never questioned, whether they were right or wrong”. That is not something you could ever say about pharma – and this raises two interesting points: one, since Agrawal, herself, was skeptical before immersing herself in Merck, she understands that pharma suffers from a reputation problem; and two, she has now seen things from the pharma side of the fence.
“I have been incredibly impressed by the people that make up the company of MSD,” she says. “Our core team is incredibly small by design, but we’re really leveraging MSD’s business and scientific expertise to tackle this challenge.”
Truly mission driven
This gives Agrawal a simple mandate: 70,000 employees and their experience are at your disposal, so use it to save women’s lives. “That’s meant that not one manager – and it’s not an easy economic environment right now - has said no when their employee has said they want to work with MSD for Mothers,” she continues. “Employees spend between 10 and 80% of their time with us and that expertise is what is making us different from any other global health foundation donor body. It shows me that inherent in the DNA of people in the company is that they want to do more – they are truly mission driven.”
At MSD for Mothers, if we don’t have a certain percentage of our products failing, then we’re not taking enough risks. A failure is the first attempt at learning.
But pharma is hampered by negative perceptions from outside and a lack of willingness to take risks, she believes. “Organizations are made up of people – and if they feel they are always being questioned, I understand why they might interpret rules and regulations more strictly. Because they might not be given that second chance. It’s such a shame.”
Of course, compliance, ethics, and integrity are vital, she goes on. “But let us innovate! Allow us to actually partner with the people we’re trying to care for as opposed to putting a lot of paper and processes between me and the person we want to help. So it’s about speed of innovation and the ability to fail. At MSD for Mothers, if we don’t have a certain percentage of our products failing, then we’re not taking enough risks. A failure is the first attempt at learning.”
The importance of failure
She returns to this intriguing idea of failure more than once. Her point is that it is challenging for pharma, in general, to innovate quickly enough to improve the health of the population. “[Look at] the number of diseases that have increased since I was at medical school,” she points out. “We need innovation to be as fast as the diseases we’re discovering.”
To solve this, digital innovation is one of the pegs on which MSD for Mothers is hanging its hat. In addition to that, its approach is based on three core areas: the first is that patient-centric solutions must be designed with the patient in mind; two, decisions on what will work need to be data-driven; and lastly, using a platform approach improves the ability to connect technology with what is required on the ground.
It’s TripAdvisor for care, allowing women to rate the care that they have received at the time of delivery, helping to hold the care system accountable.
Agrawal believes that disruptive innovation through digital technology has the power to transform the quality of maternal health care services being delivered around the world. However, to be successful, there must be an appetite for risk, an understanding of the value of ‘failing fast’ in order to learn, and an environment which makes quick adoption possible.
“It’s not easy to be patient-centric,” Agrawal says. “You know there’s a need, you develop a product and spend millions of dollars - and I’ve seen it fail again and again across industries and government organizations”. Instead, she suggests that MSD for Mothers starts with ‘demand discovery’ and thus develops products that people actually want and can use. To this end, it is critical to bring ‘user design’ to bear on the project from the off, as on mobile phone platform Care to Share. “It’s TripAdvisor for care, allowing women to rate the care that they have received at the time of delivery, helping to hold the care system accountable,” she explains.
Don’t reinvent the wheel
Mobile technology pilots “are often useless”, she concedes. But MSD for Mothers is convinced it can do better. “It’s about being strategic,” Agrawal goes on. “We do need to reach out and see if there are other platforms we can leverage and build on. Don’t reinvent the wheel. Every time you innovate, you start small.”
There is no substitute for getting into the field. “You need to be on the ground to work these things out, you can’t do it from New York,” she insists. This might involve using what is already available to women rather than getting them to buy something else.
Data is the new currency. The more data we have, the more we can target. Real-time data is what it’s about, and that’s what we can get using digital technology in these countries.
Denmark’s Maternity Foundation is rolling out the Safe Delivery App, an mHealth tool designed to enhance antenatal care and emergency obstetric care in Sub-Saharan Africa. A text-based system links pregnant women to the health system, while videos allow birth attendants to better recognize and manage complications, such as postpartum hemorrhage and newborn resuscitation.
“We got amazing data,” she enthuses. “Skills around stopping women dying from bleeding improved by 40%. The government of India wants it scaled up after seeing data from Ethiopia. Data is the new currency. The more data we have, the more we can target. Real-time data is what it’s about, and that’s what we can get using digital technology in these countries.”
In Kenya, MSD for Mothers is developing a mobile phone-based system called mPango to help improve women's access to contraception. At the FT Digital Health Summit in June, Agrawal spoke of a “transformation in the way that labor and delivery services are delivered”. She added: “We are going to build it in India and Kenya and then we are going to bring it back – reverse innovation.”
This is no idle suggestion: it's not only the developing world which has a problem with maternal mortality. Women from aboriginal populations in Canada and Australia, for example, have a higher chance of dying than women in those countries from other ethnic groups, she says. The same is true for migrant populations in Europe, while rates in maternal mortality have even risen in the US in some populations. “For deaths to be happening in the US with all the resources they have is absolutely unacceptable,” she adds.
There have been unexpected knock-ons from MSD for Mothers’ work, such as helping to strengthen health systems in countries where there is a high cost of doing business. She takes Senegal in West Africa as an example. “There’s no reason why pharma companies should not consider countries like Senegal for their products, but the transactional cost when infrastructure is weak, for example, lack of functioning supply chains, is often too high,” she states. “At Merck for Mothers, we know that contraceptives are the closest to a silver bullet that you are going to get to when it comes to fighting the scourge of maternal mortality.” In Senegal, the problem was not the availability of contraceptives, she explains, but that they were not getting to people.
“They had 85% stockouts so there’s no way these products are being used,” she goes on. “We came in working with government and NGOs, used private sector principles, and in less than two years, we managed to do a nationwide scale-up of a supply chain model.” Stockouts were slashed to less than 2% for every single facility in the country, giving 3.2 million women reliable access to contraceptives, thus reducing unintended pregnancy rates.
Taking more risks
“The government now wants to put all products through the supply chain – which will benefit all companies with new products,” she insists. “Initiatives like ours are not just ‘here let me write a cheque’ if they are truly leveraging expertise within the company – and strengthening systems that will lower transactional costs for other companies.”
As we have seen, if Agrawal could change one thing about the pharma industry, it would be to make it less risk-averse. Rules and regulations have obviously been created for good reasons, but some actively prevent responsiveness, she thinks. “It’s blamed on the industry but it’s not their fault alone – we’ve created a situation where this happens,” she goes on. “I’d like regulators and society to allow those pharma companies that want to do so to be able to be responsive to customer needs in real time, to allow them to be nimble enough.”
But pharma has to help itself too: “Pharma needs to do a better job at speaking in the customers’ language about the incredible products which are out there – they’re very shy about their accomplishments. Looking after patients, I’ve used a lot of MSD products to save lives – but I had no idea they were MSD products.”
Business in the developing world
Not surprisingly, she has a clear view of her own next steps and insists that pharma can do more. “Either I’m going to learn every single thing about what makes companies like ours successful on the business side and bring it to population health and global health in terms of real private sector engagement and not just cheque writing; or I’m going to be part of taking Merck’s amazing life-saving products to more people in developing countries like in Africa and South Asia. We can do business and save lives in the developing world as successfully as we can in the US – I know it’s possible and if I can be part of that, then that would be success for me.”
She has learned a lot, but one of the most surprising is perhaps her realization that private companies have a major role in public health. “MSD for Mothers has made me realize I was foolish all this time,” she admits candidly. “You cannot have real progress when it comes to population health with just governments and civil society. We need accelerated progress to achieve the sustainable development goals (SDGs) and for that, you have to have the private sector at the table.”
She generously praises eyeforpharma’s role in attempting to help the pharma industry change to meet its obligations to patients. “Telling people’s stories and motivating people is critical,” she says.
But for all Agrawal’s considerable achievements, she is adamant that she would not be able to function so successfully in her current role without the support and encouragement of senior management. “I could not be this honest and this open if not for the CEO,” she concludes. “I’m the luckiest person in the world – if we had more leaders like that we would be in a better place.”
*Since this interview took place, Dr Agrawal will be taking on a new role leading Vaccines & Women's Health business units in MSD's UK office.
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