Mark Dybul gave an interview to Felix Sassmannshausen of Health Policy Watch on October 30, two days after the Global Fund board appointed him executive director for the second time. He ran the Fund from 2013, and before that he led PEPFAR. I read the interview twice because it describes in the language of a multilateral financier what our company, owned in Kigali, is building.
His starting point is that the countries have grown and changed in population, and the quality of institutions and goals. Twenty-five years ago, when the Global Fund and PEPFAR were founded, the money came from outside and so did most of the technical judgment.
Dybul says the technical capacity of these countries, their financial capacity and their wish to own their health systems have all been transformed, and he gives the arithmetic: economies once measured in single-digit billions are now measured in hundreds of billions, a few in trillions. He estimates that 60 to 80 percent of current bilateral and multilateral health money goes to countries strong enough to move off it over time, and he says they want to.
I agree, and I can point to a balance sheet. Akagera Medicines is majority owned by the Rwanda Social Security Board, the institution that holds the pension savings of Rwandan workers. Those savings finance a clinical-stage company developing mRNA and lipid nanoparticle medicines: drug-resistant tuberculosis, nontuberculous mycobacterial infection, RSV, Lassa fever.
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When Dybul speaks of domestic financing, he mostly means ministries of finance taking over the cost of treatment. RSSB went a step further upstream. Rwandan capital is paying for the invention of the treatment.
The most useful sentence in the interview, for my purposes, is a short one: "Sovereignty is not just financing." Dybul extends the idea to data, to planning and to execution. I would add one more item, the one I have spent most of my working life on. Sovereignty includes the scientific and institutional capacity to make the thing itself. A country that pays for a medicine invented, patented and priced elsewhere has gained a great deal, and it is still a customer. A country whose institutions own the molecule has a seat where the price is set.
Our lead asset, AKG-100, has attracted the attention of the global multilateral institutions and large private pharmaceutical companies. It is a drug-candidate for drug-resistant tuberculosis. Its first-in-human Phase 1 trial ran at the TASK Clinical Research Center in Cape Town, and in July we reported with TASK that single doses were well tolerated up to 850 mg and held exposure above the target threshold for at least 14 days. These are early data from a small study; Phase 1 establishes safety and pharmacology and says nothing yet about cure. What matters for this argument is where the work was done, by an African-owned company at an African clinical site with African investigators.
Dybul also raises the point that should keep every founder of an African pharmaceutical company honest. Two of the best antiretroviral manufacturers in the world, he recalls, were in Africa, and both failed because they could not reach markets. I have no quarrel with that history. Capacity without a buyer is a factory waiting for its closing notice.
His remedy interests me more than the history. When he first ran the Fund, he says, procurement scored only the cost of goods. Once shipping and on-time, in-full delivery were counted, costs that had been invisible became visible, and the scoring began to favor regional production; locally made bed nets were the first result. Asked whether the Fund would pay a premium for African-made diagnostics and therapeutics, he declined to commit and said the question belongs to the board.
I find that answer more encouraging than a promised premium would have been. A premium is a subsidy, and subsidies end when budgets do. Honest scoring of total cost is a rule, and rules outlast the people who write them.
For a company like ours the lesson is to plan for that buyer from the first day: a medicine that is cheap to deliver, priced so that the Global Fund, the Stop TB Partnership's Global Drug Facility and national programs can buy it, and supplied from close enough that delivery time counts in its favor. We commit to equitable pricing for AKG-100 in tuberculosis, and I expect to be held to it.
Two other passages fit our work closely. Dybul welcomes the convergence of vaccines and treatments, citing malaria, where a vaccine and therapies now sit side by side, and the joint task force Peter Sands and Sania Nishtar built between the Global Fund and Gavi. Tuberculosis is heading the same way, and we are developing an mRNA tuberculosis vaccine candidate alongside AKG-100.
He also declines to spend his time on mergers of agencies in Geneva, New York or Copenhagen, because the attention, he says, belongs in the countries. A company whose board meets in Kigali and answers to Rwandan pensioners has no choice in that matter.
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His optimism I share, with one reservation. He says falling resources can force innovation, and he recalls how much was declared impossible in 2000 and has since been done. That holds where institutions exist to catch the innovation. Where they do not, falling budgets produce shortages and little else, which is why the quieter work of building laboratories, boards, regulators and investors in the countries themselves deserves as much of the Fund's attention as the grants.
The countries Dybul describes are the ones I have worked in since I was a Peace Corps teacher in western Kenya in 1979. He is right that they have changed. The test for the next decade is whether the institutions in the Global North that finance global health will buy from and invest alongside the institutions the Majority World is already building.
The full interview is at Health Policy Watch.
The writer is Chairman of Akagera Medicines, a Rwandan biotech company based in San Francisco, U.S.
