india

Updated: Sep 18, 2019 06:03 IST

Bill Gates speaks on why the Gates Foundation is awarding Prime Minister Narendra Modi for improving sanitation at the Goalkeepers Global Goals Awards in New York on September 25 and 26. And why toilets, vaccination, gender equity and ending poverty are the highest priorities on the to-do list of the Microsoft founder and the world’s second richest person, who has a real-time net worth of $105.4B, according to Forbes. Edited excerpts:

Why is Prime Minister Modi being awarded for sanitation over other initiatives, like universal immunisation and Ujjwala (cooking gas for the poor)?

The vaccination improvements in India are quite fantastic and we have congratulated the government, they’re definitely on the right track there.

Sanitation was chosen because in a lot of countries, it is not discussed, it’s an almost hidden thing. The quality of life and the number of diseases caused by poor sanitation are terrible and yet a lot of governments are unwilling to talk about it because it isn’t easy to fix and it takes time. It’s a topic people just don’t want to talk about.

India, over the last five years, has allocated resources and really talked about the need to clean up. We have a lot of innovative approaches on which we’ve partnered with government [in India] because in the sanitation area, there is always a challenge of quality. People don’t use toilets that are not maintained. India is an exemplar on this and so it’s very appropriate to have an award for something that is not as visible as vaccine coverage.

Goalkeepers 2019 focuses on inequalities of geography and gender. What is the bigger driver of inequality and how can it be removed?

The gender differences are quite stark both in health and education, with the actual ranking being different country by country. In villages in India, a lot has been done by women’s groups, who get together for a variety of purposes such as savings activities, educating each other about health behaviours like prenatal care and vaccination, and to speak out as a group about the quality of education and health services available to them. Our foundation works with self-help groups and measures impact. It has worked very well.

Another gender thing we’ve tracked very closely is financial services, where India has made very good progress on reforms in money transactions. Women’s access has gone up from 40% to over 70%. So that gap is closing quite a bit. The Gates Foundation has always focused in the parts of India with a large burden and where the health services needed the most improvement, specifically in Uttar Pradesh and Bihar. And there has been improvement. With increased government resources going into these systems, the capacity is increased and the out-of-pocket expenses are not nearly as high.

India is a place for some very good examples of what’s been achieved. For example, in the vaccine area, India has countrywide adoption of the new vaccines, we have the second measles dose and the actual execution of that’s been pretty good. And that’s why the childhood deaths continue to come down.

Can the world meet any of the Sustainable Development Goals (SDGs) by 2030?

Yes. It’s quite amazing how the child death rates have reduced. The death rate in the 1990s was about 9 million, and last year it was about 5 million even though there are more kids aged zero to five years old. It’s fantastic that we’ve got new vaccines getting to more children. We understand how to work primary health cost in a strong way. And the key point we’re making at Goalkeepers is that some countries are doing well even with a low level of GDP on these key issues and we can learn from them. Within countries, some parts are doing a lot better (at the sub-national level), and we can learn from them. There are great achievements in some parts of India [like in Kollam district in Kerala], where 1% children die before the age of five and the majority are getting the chance to go to college. The current trend line is that we have a lot of countries and lot of districts within countries not meeting the SGDs.

The SDG targets are very ambitious for the reduction of infant mortality, and the aim is to reach the specific goal as close to it as we can. We are making good progress. India should be proud of the part it has played... but there are lots of inequalities within the country.

What are the key interventions that prevent maternal and child deaths?

The key interventions are getting women to go to prenatal care, getting them to deliver in a facility, and making sure the quality of that facility is very good. There are a variety of things in the first 30 days, including keeping the baby warm and if the baby is not doing well, to get her back to healthcare. And then you have vaccination. When you implement all those things in a strong way, you can cut death rates — and there is actually data out of India — by more than a half. The hard part is often the quality of the primary healthcare service. If you take the district that does the best, you have great primary health centre, high quality training and execution. The quality is still not up to the level it needs to be, and that’s where the foundation has partnered with India. We have dashboards to look at hiring, trainings and to understand why any child is still dying.

Vaccine denial had led to the re-emergence of vaccine-preventable diseases, like polio and measles. How can misinformation on social media be countered?

The key is [identifying] whom people trust and making sure they hear from the people they trust. Sometimes, it will be religious leaders, sometimes people in the medical profession, sometimes it will be politicians.

The people with the bad information are speaking out a lot in a kind of outrageous way and the other people are not speaking up for vaccines, to explain they save more lives than any other tool that mankind has ever invented. We also need to see where the negative stuff about vaccines is coming from. Some countries ban it because it causes childhood deaths, others don’t ban it. Then you just have to overwhelm it [rumours] with correct information.

India’s ‘JAM trinity’ — Jan Dhan Yojana for bank accounts, Aadhaar for unique ID, and mobile phones — is showcased in the report. Does the foundation have plans for similar projects in other countries?

The foundation is very involved in working with the Reserve Bank of India to create the so-called payment banks, where, because they’re not making loans, the regulatory complexity is greatly reduced. That was a key reform until mobile phone companies and others came in and created a lot of competition with very, very low deals.

The India work built on the experience in other countries like Kenya, which had m-paisa. Now, with the continued success in India, we do have a group that spends over a US$ 100-million a year to get a bank account for very one it the world.

We have projects in Nigeria, Pakistan, we continue to do work in Tanzania, Uganda. So, we are basically taking the digital money concept to everyone in the world; we focus on poor countries. There has been incredible progress.

How would you rate Ayushman Bharat-PM JAY health protection scheme in India?

I’m a big believer that as India is doing a better job collecting taxes, the health sector needs to be a beneficiary. And that’ll be a mix of the things that you just go to the health sector and get for free, like child’s delivery and vaccines, and insurance-based services, where the government wants to make it less expensive for some people. India needs to strike at the health system in both respects: stronger insurance offering and the services that should be free to everybody.

The current insurance scheme, as I understand it, is of a modest scale but it’s off to a good start. In terms of the overall health system, it will be important that both government-subsidised and purely private insurance options are merged to provide for health needs that go beyond basic services.

Prime Minister Modi recently launched the Fit India campaign to promote physical activity. What do you do to stay fit? Any yoga?

No, my wife (Melinda Gates) does yoga. I exercise a fair bit. I play quite a bit of tennis. Even when I took a vacation in India in Rajasthan, I got to play. I’m lucky I enjoy playing tennis and it’s not a chore for me, and I hope I can keep playing for decades to come. I do specific exercises to keep myself fit three or four times a week and then I play tennis a couple of times a week.

You travel a lot. Do you take every recommended vaccine before travel?

I absolutely do. No one promotes vaccines more than I do.