New Delhi: Women continue to lose jobs even as men have regained most jobs they lost during the Covid-19 pandemic. Why is this happening, and what are the implications for women's empowerment and gender equity, not just in India, but for the rest of the world?

We discussed workforce participation in the context of gender equity with Christopher Elias, President of the Global Development Division at the Bill & Melinda Gates Foundation. Elias oversees emergency response, family planning, maternal, newborn and child health, polio eradication, nutrition and vaccine delivery. Earlier, he was Chief Executive Officer of PATH, an international health non-profit. Elias has an M.D. from Creighton University, Nebraska, United States, is a postgraduate in internal medicine at the University of California and has a Master's in Public Health from the University of Washington.

Edited excerpts:

Organisations like yours have been working on improving and increasing women's access to work. But the Covid-19 pandemic seems to have upset the applecart in more ways than one.

Covid-19 has been a shock to the world for the last couple of years and it's exposed some of the things we knew, which is that women's jobs are more vulnerable and less secure because they often work in the informal sector, so they're more easily pushed out of the workforce. As the Covid-19 situation is improving, it's also harder for them to get back into the workforce, partly because of the informal nature of many of their jobs, but also because of their significant burden of caregiving, with schools and childcare centres closed and eldercare weakened by the pandemic. There's this set of barriers that are gendered, that prevent women from being able to reenter the workforce. We've seen this around the world. The pandemic has shown us some of the vulnerabilities, how we undervalue the unpaid work women do, and how we need to redouble our efforts on women's economic empowerment.

As most jobs women have are informal, what policy interventions could address this, besides more formalisation of labour? What else could governments do to ensure that women have more formal employment?

Continuing the journey of creating economic opportunities for women in both the formal and informal sectors. Another key thing is providing a social safety net. I think this is one of the things that India, as I understand it, did very well in its Covid-19 response, by using women's groups--self-help groups and other women's economic collectives--as a way to facilitate early access to direct benefit transfers and really shore up the social safety net for women and their families. Because women play a very important role in the security of the family, and in general. Having that resilience that the self-help groups and others add to communities, as an avenue for providing that social safety net, has been quite important as well.

If we were to talk about overall gender equity, going back to pre-Covid times and the areas that you were working on, one of them is family planning. What are the determinants at work here?

The key goal in family planning programmes is to give women choices, to give women and their partners the opportunity to decide when to have children, how many children to have and to give themselves the predictability around how to safely time their pregnancy so that they're healthier. We know that having pregnancies too early, or too many, or too closely spaced, is bad for women's health and for the health of their children. So family planning gives women the opportunity to help plan the timing and spacing of their children. That's important because it benefits them individually, it benefits their family, it benefits their communities and ultimately, the nation. We've seen considerable progress.

This is my first trip to India in a few years because of Covid. I had the opportunity earlier this week to visit some of the work that we're doing in Bihar. I went out into the community and met with women in some self-help groups, who described how they used their networks to start making masks and providing them, how they were part of the Covid response, part of that resilient safety net for their communities.

In terms of empowering women in the context of family planning, is it a communication challenge, or a broader policy challenge?

There are several challenges that we've learned from family planning programmes around the world. One is providing accurate information about the availability of contraceptive methods. Also providing a range of contraceptive methods, because women will have different preferences, and they'll have different experiences with side effects. Then counselling women about side effects, what to expect and how to manage them. Further, providing services that are readily accessible by women. One thing we've seen is that as the frontline health workers, the ASHA workers and others have been able to provide more direct information and counselling to women in their communities and [as a result] we've seen a significant increase in the rate of contraceptive utilisation. The National Family Health Survey shows that, over the last five years, there's been a significant increase in contraceptive prevalence, particularly in some of the northern states, like Uttar Pradesh and Bihar.

As we look ahead, let's say family planning will bring about balance and gender empowerment. What do policymakers need to think about next in order to help people be more productive?

One of the core public goods, if you will, is a strong primary healthcare system. Because rather than focusing on one disease at a time, a strong and resilient primary healthcare system meets women's, children's and men's needs as they evolve. The recent efforts to expand the number of Health and Wellness Centres--I visited one earlier this week in Bihar--are the kinds of efforts [needed] to extend access and quality of services for the basic primary healthcare. Across the world, we see that most health problems can be prevented or treated early at the primary healthcare level. That then saves the system resources, because then that means fewer people are getting very sick and showing up at the higher levels of the healthcare system.

Could you illustrate that? Suppose you had a set of 10 medical conditions, what would be the ones that could be addressed through prevention rather than cure?

The number one example, and one that India has been particularly successful at, is expanding childhood immunisation, [through which] we can now prevent some of the most common causes of under-five child mortality, like pneumonia and diarrheal disease. In the last 10-15 years, new vaccines for these diseases have been developed and introduced.

One thing India has been very successful at, even during the Covid-19 period, is rolling out the new pneumococcal conjugate vaccine (PCV) which, again, I saw children receiving in Bihar this week. The PCV vaccine addresses the number one cause of under-five child mortality, which is pneumonia, where it's been rolled out at scale. The coverage rates of childhood immunisation have consistently improved in India over time, and India has introduced a number of new vaccines including the rotavirus and pentavalent vaccines, and now the PCV vaccine. By providing children with this full set of immunisations, you reduce the problems that were not only a source of mortality, but for many children resulted in the need for high levels of hospital care, etc. So immunisation is one [strategy].

Second is nutrition, another important area that primary healthcare can address. One of the things that we at the Gates Foundation work closely on with the government here is the Poshan mission, and the efforts to improve nutritional conditions around the country. Well-nourished children and young mothers who are healthier are less likely to get more severe illnesses that might recoil on the system.

Then, there are other new non-communicable diseases like hypertension, which we saw were a focus in some of the new Health and Wellness Centres. So there's a range of conditions, and rather than going after them one by one, build that resilient primary healthcare system as a way for addressing all of them, because different individuals will have different health challenges, and different communities will have more of one disease or another. Having that resilient system is the best investment.

Are you also seeing a rise in non-communicable diseases, because that's what the data show elsewhere?

Yes. That's generally true across the world. And it's true proportionately because we've made such good progress in reducing morbidity and mortality from infectious diseases, by preventing them in the first place through access to a wide range of immunisations and also by treating them quickly by having a stronger primary healthcare system.

As we've learned to cope with Covid-19, and to respond to it, what are the lessons that we can take away--in terms of the structure of the healthcare system, at the primary or secondary level, and second, in terms of anticipating future pandemics?

There's an important conversation starting about how to have greater preparedness, but not just for the next pandemic, because pandemics happen. Influenza causes pandemics. But even between pandemics, there are outbreaks of other diseases. So how do we begin to think about having better preparedness and a more rapid response?

There are a couple of elements that are important. One is having better surveillance, developing an integrated disease surveillance system, so that when a problem arises, whether it's a diarrheal disease outbreak or a pneumonia outbreak or a pandemic, we see it early [with dengue, for example]. The sooner we see it, the quicker we can have an effective public health response. So overall, improving our surveillance for diseases. Surveillance is a key component of a strong primary healthcare system, so that if a cluster of strange syndromes occurs, it's noticed and then notified up the public health system so that a response can be generated. One of the things that we've seen around the world is that the places that had stronger primary healthcare systems were more resilient.

Similarly, and this was very evident in my brief visit to Bihar, having that community organisation, the self-help groups here in India, have really been an important part of the resilience of communities to understand how to care for individuals when they were ill, how to support one another, how to get the additional food rations out to people, how to be part of that social safety net, as well as to then do important things like the mask production that I saw from the self-help groups up in Bihar. Build resilience both for the primary healthcare system as well as for community organisations and self-help groups. It's an asset that benefits the community every day, but it also is an asset when the community is under stress from an outbreak of disease or a new pandemic.

What more can be done in general for surveillance? What role can technology play in either collecting or disseminating the data faster?

There are a couple of ways to think about surveillance. One is to just have a well-trained health workforce that recognises when something out of the ordinary is happening, that can be then complemented by specific diagnostics. One thing we saw in my visit to Bihar is that the Health and Wellness Centres are introducing a broader range of simple diagnostic tests that can be done in the primary healthcare system. So technology has a role in terms of improved access to specific diagnostic testing.

The other thing that's revolutionary is having a digital information system that allows observations, either from the healthcare workers or from diagnostic testing, to be shared very quickly with decision-makers, who can then act upon that. That's where I think India has really been an exemplar for the world in building digital financial inclusion, the digital stack that has enabled mobile payments, etc.

Also simple things like being able to verify immunisations. We have now been talking to countries in Africa and elsewhere, about how they might build on and use a similar application that was developed for Covid-19 immunisation here in India. This is a good example of India being on the leading edge of innovation, not just for this big country, but also for producing public goods that are going to be helpful elsewhere in the world.

How could we use our learning from Covid-19 to improve our overall public health response? Surveillance and immunisation are two critical components, but what else are you looking at?

Covid-19 has been such a challenge for every country over the last two years. You have to try and find whether anything that comes out of it would be a lasting benefit. My best example of that has been the efforts to build stronger systems for oxygen support. Prior to Covid-19, the number one cause of under-five child mortality around the world was pneumonia and many of those children's lives could have been saved with more ready access to oxygen systems. We were making some incremental progress in expanding oxygen systems before Covid-19.

What Covid-19 did is it stressed the entire system. Oxygen systems were in short supply in most countries and that helped to get the political awareness and commitment to strengthening those systems in the short term to respond to Covid-19. But if, coming out of the pandemic, we can build stronger and endurable oxygen systems, that will then serve not only to deal with the next pandemic of respiratory illness, but also to save children's lives from pneumonia every day.

This is one of the areas on which the foundation has been working with the Government of India, both at the federal level and at the state level in Uttar Pradesh and Bihar, on strengthening oxygen systems. Just as we come out of the pandemic knowing we have to do better at surveillance and strengthening primary healthcare systems, as a component of that, [we need to be] thinking about how to strengthen oxygen access. That's complicated. It's more than just [providing] a tank of oxygen. It's how do you produce oxygen, how do you move it, how do you make sure hospitals and primary healthcare centres have enough of it, etc. That [kind of] systems thinking about a critical life-saving commodity like oxygen is another important learning that we'll take out of this pandemic.

Anything on the research that goes into creating a vaccine at this speed?

I think that's one of the things to step back and celebrate out of Covid-19, how quickly science came up with tools to help us manage the pandemic. It was just over a year from when Covid-19 began that we had effective vaccines. That's never happened before. I think the fastest a vaccine had ever been made before was four or five years. So science was on our side.

India played a very important role because India is the largest producer of high quality and affordable vaccines for the world. I think about 60% of the vaccines used in the world are actually manufactured in India. Indian vaccine companies responded quickly with new science to produce Covid-19 vaccines, not just for India, but for the world. Indian vaccine manufacturers, have been a critical part of the response both nationally and internationally. The largest supplies of Covid-19 vaccines to Covax, which is a global vaccination initiative focused on low and middle-income countries, has been coming from Indian manufacturers. India was very successful in taking a remarkable capacity for vaccine manufacturing, harnessing new science and producing vaccines at scale very, very quickly.

Producing vaccines, however, isn't enough, you also then have to deliver those vaccines. And that's been one of the more impressive things in India, how quickly the government organised to work with many different partners to actually get vaccines from the factory into people's arms very quickly. That progress built on having had a strong immunisation system, with good systems like the CoWin system for tracking vaccines through the cold chain, etc., to get them out to people wherever they live, to provide them for people at different hours. I heard in Bihar about a programme to make vaccines available from 9 a.m. to 9 p.m., so people didn't have to take time off of work to be able to go and get the vaccination. So India has been an exemplar of harnessing new science and getting it [vaccines] out as quickly as possible. That's played an important role in being able to address the latest wave of the Omicron variant that's been surging, [with] lots of cases, but much fewer cases of hospitalisation or mortality.

Back to the question on women and empowerment. Looking ahead, what kind of thinking do policymakers have to do to address the challenge at home, ensuring that women are able to provide the right immunisation for their children, and how more of them could join the workforce? What's the forward thinking in this area?

Continuing that journey of women's economic empowerment is even more important now, as we come out of the pandemic, than before.

There are many elements to it. One is education, if you think about the pathway to a job. We know that educated girls and women marry later, they have children later in life, they are more likely to be established economically, they ultimately have fewer children and better-spaced children which is better for their, their children's and the broader family's health. So continuing with interventions around expanding girls' education.

Further, encouraging access to family planning so that women have control over the number and spacing of children, and giving them the choices to be healthy and economically active. Also, working to create jobs that recognise that women are equal in being able to do those jobs, and to give them greater social benefits in terms of when there is a challenge and they have to be out of the workforce, for caregiving responsibilities, etc.

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