Mumbai: Is poverty inevitable?

This is the key question Bill Gates & Melinda Gates, Co-Chairs of the Bill & Melinda Gates Foundation (BMGF), have posed this year in their annual Goalkeeper’s Data Report, a compendium of data and essays on work being done by the BMGF.

Eternal optimists both, they argue that decades of substantial progress--1.2 billion were pulled out of absolute poverty (below $1.90 or Rs Rs 138 a day) over 28 years to 2011, including 162 million in India--in the fight against poverty and disease may be on the verge of stalling. “Because the poorest parts of the world are growing faster than everywhere else,” said the Goalkeeper’s report. “More babies are being born in places where it is hardest to lead a healthy and productive life.”

If current trends continue, the number of poor people in the world will stop falling--and could even start to rise, the report warns in a grim preamble.

But there is good news too.

On many indicators, India, like many other parts of the world, is doing well. Globally, vaccine coverage has improved, maternal mortality, under-five mortality and neonatal mortality numbers have dropped.

Melinda, 54, has moved from a more 'behind the scenes’ role at BMGF to fronting several critical initiatives, particularly around gender and some of the Foundation’s most ambitious outreach efforts in continents like Africa and countries like India.

Every year, around this time, BMGF puts together an annual report of its activities and charts a plan for the future. The report is a comprehensive survey of efforts the Foundation has been putting in but backed at each step with data points to show progress--or not.

In an exclusive interview to IndiaSpend’s Govindraj Ethiraj, Melinda Gates discussed her Foundation’s successes, particularly in India, and the challenges she foresees in making the world a safer and healthier place.

The Goalkeeper 2018 report starts off somewhat pessimistic fashion but then it gets more optimistic as it spans the Foundation’s work in areas like health. Any reason, broadly, why you’ve chosen this approach?

Well, because we see that progress has been made, absolutely, if you look at the goals that were set. But we want people to keep an eye on those goals. Like in cricket, you have to keep your eye on the ball or any ball when we’re playing a game--if we don’t keep an eye on the ball then that progress will not continue to be sustained. That’s what we want people to see. We want them to see that progress is possible but not inevitable. We have to continue to make the investments like India’s making, or like different countries are making.

It appears from reading the report that most of the major problems, particularly leading from extreme poverty, seem to be now converging in Africa. Would that be a correct assessment?

What we talk about in the report is that there are particularly two countries in Africa where if we don’t make the investments we’re not going to get the progress.

But we can’t say ‘converging in Africa’ to be frank, because we also want to look at Ethiopia, the second largest country in Africa which is making enormous progress, so you cannot say at all that the focus is on Africa--as the hub of the problem--but there are two countries that we are particularly worried and what we’re trying to do is show that if you make the investments like Vietnam has made or like Brazil has made when they were more low-income countries, we will get the desired results if you invest in human capital.

With India there are so few states, I would say, that hang in the balance in India, both are very large states so we don’t want the world to take its eye off or India to take its eyes off the ball in its own country as well.

You’ve referred to the sheer economic growth in Ethiopia but preceded by China and India or rather China, India and Ethiopia almost in the same breath.

Right, what’s happening is that Ethiopia is following the model of countries like China and India. They are making the investments in maternal and child health and making the investments in innovation. India has really stepped up in the realm of family planning in the last few years as has Ethiopia because they’re seeing that if women can space the birth of their children, the women can get themselves educated and the family begins to be lifted out of poverty.

So, absolutely, China and India have become the role-models for the world and we are quite enthused by the investments that the Indian government is making across the country in innovation and maternal and child health. And, other countries look for what’s working so that they can apply it in their countries as well.

You have been working extensively in Bihar and Uttar Pradesh. As you look at the efforts made here and your reports on these regions in 2017 and 2016, what would be your key takeaways?

As a foundation, we always look at the data and see what the data tells us. So, the investments that have been made in Bihar and in UP around maternal and child health and nutrition, family planning, and some of the big diseases they have like lymphatic filariasis and visceral leishmaniasis, we try to see what are the trends there and how do we know that the states are making progress?

Here’s the way we know they’re making progress: In Bihar, if we go back to the period much earlier, and you look at the under-five mortality rate, it used to be 85 children dying per 1,000 live births in 2005-06. Now if you look at the period between 2015-16, that is now down to 58 children dying per 1,000 live births.

That is still too many but that’s substantial progress. A 45% decline in 10 years? I’d love to see that in any country. In terms of UP, we also see a reduction in infant mortality. Again in the same time period, between 2005-06, it would’ve been 46 children dying per 1,000 live births. Now it’s 43 in 2015-16, so they’ve declined by 7% in UP. Also, the maternal mortality rate is doing much better in both of those states.

What are the two or three key reasons that have driven this?

Well, several things. I think the investment in vaccines, in innovations. The country has really started going after pneumonia deaths, diarrhoea deaths--those are the two biggest killers of children, particularly in those states.

Going after the two diseases like lymphatic filariasis and visceral leishmaniasis but also the investment in the health system.

Telling women that the right thing to do is to not give birth at home but to come into clinics to give birth and making sure that those clinics are stocked with the right supplies, the workers there are trained, delivery of the baby, taking the mother’s blood pressure right away.

If she hemorrhages, having the medicines there to stop the hemorrhaging, so having high-quality health facilities makes enormous difference. Both in the baby’s life not being lost but also in the reduction maternal mortality which is down about 30% in UP just in the last ten years.

You have personally and frequently visited these regions. Are there any personal experiences that come into mind over the last year?

I love to visit the families and really talk to the women about what’s life like for them. Two of the women that I’ll say I met more recently when I was in Kamrawa in Uttar Pradesh, a woman named Anita and another named Sushila.

They were amazing because I had them in a group of about 10 women with whom I was there to talk about life with their children, their lives, if they used contraceptive pills--it’s so interesting because Anita was only 40 years old--I feel that she was slightly younger than that but that’s about how old she thought she was and she got married as a teenager and she had five pregnancies.

We asked her what’s like it to raise that number of kids and she said, “It’s hard, it’s really hard. I’m constantly working.” The thing that was striking is that the other woman we met, Sushila, is a 28-year-old mom who used to be a teacher and she said, “Look, I know we’re having two kids. That’s all my husband and I have decided.”

She has a five-year-old and a two-year-old, and she said that when her two-year-old gets to be five, she was going to go back to school and teach again.

So her future was open to her and as she talked, it almost made Anita more sad because Anita could see that she was basically trapped in this life of raising too many kids and trying to provide for them and here, Sushila has this very bright future for her and her kids because she could space the birth of her kids and had a made a decision of just having two children.

This was, for me, just a very striking example in that period: Two women who led very different lives just because of contraception.

What’s your experience been in working with government of India to achieve the objectives you have set out with? What are some of the challenges you face, if any?

Working with the Government of India--well, we’ve been doing this for many years as a foundation, and I think that they listen and they are responsive. They have really looked at pneumonia and diarrhoea deaths and said, okay what can we do to bring them down and to do it the right way keeping in mind the Indian context.

They’ve worked over many years to ensure that vaccines have been absolutely safe for the populace, and they’ve rolled the vaccines out first in a couple of model places and then rolled them out at scale. They’re always thinking about the Indian context and I think that’s the right thing. What we’re also seeing is the momentum gained.

The Indian government, after having seen the numbers of deaths of children, deaths of mothers coming down is willing to make more investments, and that’s smart business.

The fact that they’ve stepped up and made such a strong commitment to contraceptives because they know the difference human capital makes, that if a woman can space the birth of her children and limit the number then she can educate both children, that investment in contraceptives in fundamental.

I think there’s still some challenges, to be frank, in moving money from the central government to the states. The states aren’t always able to pull that money through in health.

And I think they’re still working that out, but we’ve been quite encouraged by working with several different administrations in the Indian government and we’ve been quite pleased with how they are learning, listening and applying it to the Indian context.

Lastly, about new solutions and approaches, some may work and some may not. I came across this report where one of the approaches towards diarrhoea and pneumonia did not quite work in Bihar and there could be others as well. So, what do you take away from these failures or relative failures and how do you change strategy?

One of the most important things to know about the Foundation is that we are a learning foundation. We are always learning and evaluating and we’re also being transparent so we’re not trying to hide things that don’t work.

When we try something, we take a risk and that is the role of philanthropy--to take educated risks and see what might work.

We always follow up with the data and numbers and then publish it so everybody can learn from it. So, the example that you’re citing--absolutely! We did not get the results we wanted.

I think the intention was right. We wanted to hook up patients with high quality healthcare with doctors but those specific implementations didn’t work. So, we’re learning from that and we say: Right goal, wrong tactics, what needs to happen next?

But if we’re not willing to take risks and if we don’t plan to take risks, we won’t learn new ways of doing things. We have all the strength and digital technology that we’re seeing people benefit from but we’re always looking at how they could benefit more and how could we make it more cost-effective.

The last thing I’ll say separate from that is, just that the other thing that we’ve been working on for 15 years along with the Indian government is having affordable vaccines and India has become the largest vaccine manufacturer in the world for affordable vaccines.

Here you’ve benefited not just one country but also people from Ethiopia and all over the world. I look at India and I look at the Indian lady there and I look at that market economy and the way it’s now working not just for India but also the rest of the world--to me that’s actually really exciting, and it’s great to be in partnership with the Indian government in the private sector.

(Ethiraj is the founder of IndiaSpend.)

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