Levelling the playing field

It’s truly a case of arriving curious and leaving inspired. It’s a balmy morning in Seattle as we enter the 11,000 sq ft Visitor Center of the Bill & Melinda Gates Foundation (BMGF), arguably the world’s most powerful with over $40 billion in endowments. A brief walkabout inside the Center, which is divided into a series of six galleries, drills in how much we take for granted, the life of relative privilege that all of us have been born into. For instance, alongside the glass façade of the building is the Walk for Water exhibit that has footprints burned into the wood floor to show how far some people must go to get water to drink, cook and clean. Not only have Olson Kundig Architects and Studio Matthews put in a lot of thought into designing the entire experience, the layout is peppered with exhibits that comprehensively depict how the foundation is making life easier for the millions whose paths will never possibly cross that of their benefactors.

In India, whenever extended dirt-caked palms are thrust in our face, our response, depending on our frame of mind, is either to fidget for lower denomination currency or look away. Even if we give, it is with the unexpressed expectation of the return of some good karma. Seldom do we think and ponder: why? Doing that is too much trouble and way too much responsibility. But Bill and Melinda, after returning from a trip to Africa in 1993 and having encountered extreme poverty, did ask ‘why’ several times over and then consciously decided to dedicate the rest of their lives to remedy the inequity as best as they can. A piece in The New York Times in 1997 that mentioned how millions of children in poorer countries die from diseases eliminated long ago in the US was another important turning point that would eventually define their foundation’s priorities.

In order to understand the problem, Gates started to gather evidence of what was contributing towards these deaths. He saw a clear breakdown of the market mechanism that he had always believed in. He had not seen a failure of capitalism at such a large level, where only the needs of those who could pay were being addressed.

Given that almost every pharmaceutical major is driven by the lure of a life-saving blockbuster, many diseases that affect the poor get the same attention as a hyena from a lioness in heat. On second thoughts, maybe the hyena’s odds are better. This is the reason we haven’t had any new tuberculosis (TB) drug in decades. TB doesn’t affect the rich and that’s why there is not going to be much of a profit.

In 1943, Abraham Maslow postulated his hierarchy of needs that now seems like common sense. The needs start from basic physiological requirements and crest in self-actualisation. Most people with full stomachs must have gotten busy patting Maslow on his back or wherever because since then as a society we have really not succeeded in transitioning the vast majority from the bottom rung to the top. Set up in 2000, BMGF in its own way aims to do that across the world. It wants to ensure good health, act as an enabler to create conditions that sustain good health and simultaneously also provide financial tools to assist poor populations to break out of the cycle of poverty. HIV, polio, tuberculosis, malaria, hookworm, sickle cell disease, diarrhea… you name it, there seems to be no infection or disease that BMGF is not pouring resources into better understanding and treatment of. 

After realising that one in five of all children who die before the age of five lose their lives to vaccine-preventable diseases, it led to what is internally described as a passion for immunisation and the GAVI alliance. The Global Alliance for Vaccines and Immunisation was created in 2000 and its founding partners and permanent members include the World Health Organisation (WHO), Unicef, the World Bank and BMGF. Today, after the UK, the foundation is the second-biggest donor to the GAVI alliance, having made grants of over $1.5 billion. Committed to spending its entire endowment within 20 years after both the co-chairs are gone, the foundation has so far given away more than $30 billion cumulatively and that includes more than $1 billion for various health projects in India. 

Road to good health

Money in this hyper-connected times can buy you almost everything but health. Hence, compared with its home base, where it is working on improving access to opportunities, BMGF’s prime focus in countries such as India is on improving health and livelihoods. 

The foundation has been operating in the country for more than a decade now and most of its partnerships involve the community, NGOs, the government and its agencies such as the Indian Council of Medical Research, global agencies such as the John Hopkins University and various other national and international organisations. The foundation also taps into its reservoir of dedicated technical agencies like PATH (Program for Appropriate Technology and Health) and multiple in-house experts, one of whom is Jay Wenger, who leads the polio eradication initiative globally.

India is among the handful of countries where BMGF has a dedicated country office, the other being China. The other notable feature of BMGF is that it does not seek to improve a few villages or a few blocks, but looks to catalyse change at the state and national level. When Girindre Beeharry joined the foundation nine years ago, it was still very much in its formative stage.

Now, director of the India country office, he says the biggest transition is in terms of how the foundation has built ground execution ability in addition to its lab skills. “Upstream, you are a big player and can easily invest and completely change the course of research. Downstream, you are a drop in the ocean and cannot have the same direct effect that you have upstream. Therefore, it becomes a question of working with the government and other partners who can scale solutions in places such as Bihar and Uttar Pradesh (UP).”

Given the foundation’s focus on improving conditions for the poorest populations, it has made significant investments in two states, Bihar and UP. Even Bangladesh, whose GDP is half that of India, has 20% lower mortality and 40% lower child mortality than UP. With a combined population of more than 300 million and a high burden of disease, their governments need all the help they can get. “We are working with the governments of Bihar and UP to scale up simple, proven maternal and child health interventions, such as skin to skin care, clean cord care and the early initiation of breastfeeding. Our data suggests that investments in the delivery of these interventions are working, despite the enormity of the task ahead,” says Beeharry. That’s quite evident in the initial success that the foundation has tasted in the country.

There are two notable success stories. The first is spreading awareness of HIV/AIDS and the second is polio immunisation. In areas such as HIV prevention and polio eradication, seemingly insurmountable challenges — such as reaching high-risk communities or children in remote rural India — have been overcome.

Right from its entry into the country, AIDS has been a focus area for the foundation. So far under the BMGF Avahan Initiative, about $350 million has been committed towards creating awareness and reducing the spread of HIV/AIDS. Launched in 2003, this programme runs across the six high-risk states of Tamil Nadu, Karnataka, Andhra Pradesh, Maharashtra, Nagaland and Manipur and was instrumental in preventing over 500,000 HIV infections over the past decade. Similarly, the foundation has been instrumental in eradicating polio from the country since 2011. 

Raj Shankar Ghosh, deputy director, vaccines, distinctly remembers the January evening when India was declared polio-free. “I was going to the market in a rickshaw. During our small talk, I mentioned this to the rickshaw driver and he told me with a lot of pride, ‘I have also been involved in this.’ I asked how? He replied, ‘Once, I had carried those boxes on my rickshaw.’” Clearly, everybody felt they had contributed to this pan-India mission in their own way.

Looking back, it seems pretty amazing that 20 years ago, there were 200,000 cases in India and there has not been a single case over the past three years. But the achievement was by no means a walk in the park as, historically, the biggest challenge has been getting the programme implemented on the ground. It is one thing for politicians to say that they are in favour of polio eradication and another thing for hundreds of workers to do the right thing, to make sure they actually reach every household and every kid really gets two drops of vaccine. 

Wenger worked in India from 2002-2007 and has painful memories of polio in its heyday. “It was always sad when the child had a limp leg and the mother would ask, ‘what can you do to help’. Having the mother say ‘help me’ and then not being able to do anything about it was very pitiful.”

Many believed it was impossible to eradicate polio in India because vaccination levels were quite low, sanitation was very poor and there was very dense crowding. Those are ideal conditions for the polio virus to spread easily. So, there were big obstacles to get over.

Beeharry says the last four major countries went by the acronym PAIN — Pakistan, Afghanistan, India and Nigeria. Now, India has dropped out and even Afghanistan seems to be making good progress. It has very few cases now and even those seem to be coming in from Pakistan. Afghanistan could be the only instance where warring foes, despite their differences, agreed to let the immunisation programme continue.

Wenger says, “The government agreed to do the campaign in their areas and the Taliban in theirs as they both wanted to protect their children. Even though they were fighting each other, an arrangement was made so that the vaccine could be sent to both sides. Everybody did their job and got rid of the virus in places where it has never been eliminated before.” Except for Afghanistan, Pakistan and Nigeria, every country has been declared polio-free and the aim is to make the world polio-free by 2018. 

The only danger is that the virus may travel from these still-affected countries and pop up in a mutated form in India. Hence, the foundation is taking measures to guard against that by going all out to ensure full immunisation. Then, the oral polio vaccine is being replaced with injectable polio vaccine. Along with Acute Flaccid Paralysis surveillance, it also does extensive environmental surveillance, which includes sewage sample testing, to check for wild polio virus. In India, no sewage sample has tested positive for a number of years. 

Tropical battle 

Having reined in polio, BMGF is now aiming for measles elimination in southeast Asia by 2020. Unfortunately, the sense of urgency prevalent during polio immunisation is no longer visible for other immunisation campaigns. Ghosh points out that in some districts where the polio campaign covered around 93% of the district, routine immunisation coverage for Japanese encephalitis is abysmally low at 14%.

“Half of my job is about working with state and central governments and ensuring that whatever it is that we are learning, they are learning, too, and it gets baked into the fabric of the system,” says Beeharry.

Incidentally, GAVI financially supported India’s immunisation programme from 2002 and it is only recently that the Indian government decided to commit $4 million over four years to the alliance. The irony is that despite India being the largest supplier of vaccines to the GAVI alliance, it has the largest number of unimmunised children in the world.

In India, almost 2.3 million children in the age group of one to five die every year. Along with neo-natal deaths, diarrhea and pneumonia account for about 300,000-350,000 and about 400,000 deaths, respectively. And of the 300,000-350,000 diarrheal deaths, about one-third of that is due to the Rotavirus, an infectious agent that thrives in unsanitary conditions — another area of concern that the foundation is looking to address.

Down the drain

While access to affordable vaccines through existing health systems of the country is one part of the problem, the affected community also needs to have access to clean drinking water and toilets for addressing the hygiene aspect. Ghosh says, “Introducing the Rotavirus vaccine will not have the impact unless we address issues such as unavailability of sanitary facilities and effective communication to mothers to utilise these services.”

Today, one in every two Indians, or 630 million people in the country, don’t have access to toilets and the biggest pollutant in water is our own waste. Open defecation is a particularly severe problem in south Asia, especially India and sub-Saharan Africa, and it is these two regions that are the focus of the foundation’s Water, Sanitation and Hygiene (WSH) efforts.

Half of all hospitalisations in the developing world are the direct result of poor sanitation and there are more people dying as a result of poor sanitation than AIDS, TB and malaria combined. That being the case, why has it not gotten much attention?

“One reason is that it is taboo as people don’t really want to talk about it in much the same way as it was a serious challenge to get people’s attention on HIV early on. People don’t really want to talk anything related to sex,” says Brian Arbogast, director, WSH. 

A foundation of BMGF’s size brings its own convening power. As the foundation has driven a lot more focus on non-sewage sanitation, there is a growing understanding about the problem of open defecation. The hitch is, there aren’t any great models than the traditional flush toilets with sewer systems that go to treatment plants and can’t be scaled up for growing cities.

“Nobody was actually challenged to reinvent the toilet until a few years ago. We believe there is a billion-dollar opportunity in reinventing toilets. We know people who don’t have toilets in their homes will buy it so long as they don’t smell, are easy to clean and are affordable,” says Arbogast.

The quest is to build a toilet that doesn’t require water, is not connected to a sewer system and everything that comes out of it is safe. Arbogast says the foundation’s quest could give birth to a new industry called decentralised sanitation.

“Over the next couple of years, we will try some of these technologies and find the companies out there that are willing to be pioneers in this new industry. We are going to figure out how we can help reduce the risk that they would be taking, so that they are more likely to jump in wholeheartedly.”

Given the magnitude of the problem, the solutions also need to be radical. That is why the foundation launched the Reinvent the Toilet Challenge (RTTC); the Toilet Fair earlier this year was an opportunity to showcase innovative technologies and share best practices around safe sanitation. Eram Scientific Solutions, based in Kerala, which develops off-grid, self-sustained public toilets, was among the six Indian winners this year. 

Inclusion for real

The final piece in the foundation’s attempt to level the playing field is financial access. Through Financial Services for the Poor, the foundation wants to decrease the cost and time needed for the poor to access financial services and increase their ability to withstand financial shocks. To address these deficiencies, the Indian banking system does have priority sector norms and no-frills accounts but there has not been much credit flow to the poor. That is why there is still a thriving informal sector, both for lending as well as domestic remittances.

BMGF entered the space of financial services for the poor six years ago because nearly 2.5 billion people around the world, largely in east Africa and south Asia, did not have access to financial services and this inequality did perpetuate economic hardship. Rodger Voorhies, director, Financial Services for the Poor, says poor people are not statistically poor but are rising and falling in and out of poverty based on shocks that happen in the household or opportunities that they can or cannot take.

“The foundation’s approach is to provide the ability to capture those opportunities or the ability to buffer them against risk. If you could make small changes to the buffering or make meaningful changes to the opportunity capturing, it makes a real difference in their poverty level.”

In the beginning, it did help the micro credit industry gain scale but soon BMGF realised that micro credit through self-help groups was reaching only a tenth of the 2.5 billion people who did not have access. Therefore, like in WSH, an equally disruptive approach was deemed necessary to push financial services for the poor. 

The answer was a digital payment structure that piggybacked on the mobile phone network. Not only would transaction costs fall but the need for a minimum transaction size and minimum balance could be completely done away with, as a daily-wage labourer did not deal in large amounts. Voorhies says that the biggest positive for the poor is the digital footprint or credit history that gets generated. “Good low-risk borrowers can get emergency loans when they need it or school fee loans for uniforms or buy a cow based on past data. Instead of costly micro credit loans, they should be able to borrow cheaper than high-risk borrowers.”

While a small-value electronic payment system like M-Pesa has been a hit in African countries such as Kenya and Tanzania, in India, adoption continues to be hobbled by onerous regulation and low rural connectivity. The Interbank Mobile Payment System mandates that a mobile service provider not only has to have a partnering bank, only those outlets that are within a 30-km radius of a partnering bank branch can be used for withdrawals. The need for withdrawal through a bank comes in as the platform can only be used for deposits. 

 regulation only permits mobile transactions linked to a bank account, Voorhies feels there is a need to be flexible with KYC norms. “While we all want robust KYC, do we want it so robust that just because I don’t have a drivers’ licence or a passport or an identity card, I don’t have access? Why isn’t a SIM card registration enough? Or if I am already receiving a health payment in Bihar or UP, why doesn’t that qualify me to open a bank account? Isn’t it better to actually have people in the system rather than out of it?”

Along with improved health, sanitation and education, embedding people in a financial system builds resilience and increases their ability to take advantage of opportunity. What the foundation is ceaselessly working on is to provide an enabling environment to help those without access manage their lives better. The task ahead is mammoth and Beeharry is aware of it. “We are a small player. All the outside donors, including public multilateral organisations like Unicef, WHO, World Bank and USAID, account for only 1.2% of health spending in India. That means every day, you have to persuade other people that this is something that you need to do.” 

While UP and Bihar keep Beeharry busy, about two to three times a year, he along with his staff makes it a point to visit a project that BMGF is not funding and is in a geography that it is not operating in. “We are constantly in learning mode because we don’t necessarily believe what we have today is what we are going to end up with three years from now. We are making a bet based on the best information we have today, not knowing whether it will work or not,” sums up Beeharry.