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COVID-19 has set back public health efforts by years


Mark Suzman

The Bill and Melinda Gates Foundation (BMGF), on Monday, released the fourth of its annual Goalkeeper reports, which track the slow but steady progress the world has made towards more than a dozen health-related goals set by the United Nations in 2015. This year was unrelentingly grim. The Coronavirus (COVID-19) pandemic has scorched away years of work: More families are in dire poverty, malnutrition is increasing, far fewer children are getting immunised. Chief Executive Officer of the Foundation, Mark Suzman, in an exclusive interview with The Guardian among other things said that COVID-19 pandemic is an opportunity for Nigeria and many other countries in Africa to put in place some reforms in areas like primary healthcare, which has been delayed in recent years. NKECHI ONYEDIKA-UGOEZE writes. Excerpts:

What message does the 2020 Goalkeeper’s Report bring in a period like this?
The Goalkeeper’s Report, as I think you’re aware, is something we put out every year, and normally at the time of the United Nations (UN) General Assembly. The reason we launched this was to try and showcase where and how there is progress happening in global development towards those Sustainable Development Goals (SDGs), because it is often not understood just how much progress the world has made, over the last 20 years, and particularly in the last few, whether that is in reducing child mortality and maternal mortality, reducing poverty, and so on.

This year’s report, however, is the first time we are actually pointing to serious setbacks and saying that progress is now at severe risk because of the COVID crisis and the axillary impact it has had on social and economic issues. For example, on vaccinations, we have seen global vaccination rates dropping to 70 per cent from well over 80 per cent, which is basically taking our past 25-year global vaccination rates down in just 25 weeks. In total, in the global poverty rate, we have seen a steady decline.


Every year, for the last 20 years, we have seen a decline in absolute global poverty, but this year, we are seeing the first increase, with over 37 million people, a lot of them in Nigeria, being thrown into poverty. We are seeing setbacks in malaria, in education and in a number of other areas where we work.

And so this report is really trying to be a call to action, at the national and global level, and we are saying we really need global efforts to solve the COVID crisis, tackling the effects of COVID in a thoughtful and systematic way, so that we can get back on track for the Sustainable Development Goals.

Is Nigeria on a clean slate on Millennium Development Goals (MDGs) and to what extent do you think that the crisis in the Northeast, with COVID-19 as well as the corporate and government challenges going to affect our attainment of the SDG goals?
We have a long history of strong partnerships in Nigeria. Nigeria has experienced the most important global health success of 2020, which was the formal declaration of the end of wild poliovirus, and so it is an example of how, when the government, civil society, the private sector, the state and the federal level, all get together with global support, then we can see really important development outcomes.

And so, I think there is every prospect, for Nigeria being able to tackle the SDGs, more broadly, to tackle some of these wider health and development issues going forward, but the challenges are immense.

Bill Gates gave a speech in Nigeria a couple of years ago, to the president, the governor and others, where we talked about the human capital challenges faced by Nigeria. I think where Nigeria has made huge progress in key areas, and I keep returning to the polio one because that is an important signature achievement, which we do not want to lose sight of, but it is also true that, relative to its per-capita income and size, many of the indicators that Nigeria has, on extreme poverty to child mortality and maternal mortality, they are lower than you would expect.


And so, there is a critical effort that I think needs to be made. I think the government has put in place a broad and ambitious agenda around that, around investing in human capital, which can lay the groundwork for achieving the SDGs.

The COVID crisis has been a significant setback in that because it has both added to the pressure, and it has created new fiscal pressures, but it is also an opportunity for Nigeria, and many other countries in Africa to – put in place some reforms in areas, like primary healthcare reform, that have been delayed in recent years.

Are there new tools like the digital financial services that Nigeria can capitalize on?
Part of the message of the Goalkeeper’s Report, and part of the message that we would have for the people and the government of Nigeria is, that this is actually not a moment to lose heart, but a moment to redouble our efforts, to both reverse the setbacks that we have seen in the past six months, and see if we can really celebrate progress, and still meet that SDG target in 2030.

Obviously, because Nigeria is the most populous country on the continent, and it does now have the world’s highest proportion, or the highest absolute number, and they have very poor people, recently even becoming higher than India, there are significant challenges. We know those challenges are larger in the North and Northeast, but again, there are concrete programmes underway from the primary healthcare space, to digital financial inclusion, and in which we are relatively optimistic that these can be harnessed in order to celebrate progress.

How can we bridge the widening inequality gap that has been created by COVID-19?
That is a global problem, everywhere, where we’re seeing huge setbacks, and that is that – you know, I talked about the numbers in extreme poverty, but that is true at every level on the poverty curve. There are nearly 70 million, dropping down from the $4/day range in income, and certainly here in the United States, we are seeing huge setbacks among lower-income populations.


And so, to tackle that kind of inequality, you first need to tackle the COVID crisis, itself, making sure that you are not neglecting the other social and health issues at the same time. That is why the global efforts to develop a vaccine, to make sure that there is equitable global access to that vaccine, and treatments, which is something that we at the Gates Foundation are very involved in, is critical. But then you do need concrete steps at the national level, both to continue with the prevention and safety measures around the disease itself, and also the attendance issues of how do you try and ensure that basic primary healthcare does not get affected.

So, it is a real challenge. I think that there are steps that can be taken, but it is true that, until there is a sort of global response that is providing the vaccine on an equitable basis, it will be very difficult for any single country to return to normal.
Talking about vaccines, there are so many candidate vaccines that are going into trial, when are we likely to have success in this area?

Are there really efforts being made to ensure that there is equitable access for every continent?
Yes. We at the Gates Foundation have been strong supporters of an effort called CEPI (Coalition for Epidemic Preparedness Innovations), which was actually set up a few years ago, with us, and with the Wellcome Trust, which is a British charity, and some governments, to try and prepare for potential future pandemics. It creates and supports a basket of vaccines, because the point of the vaccines is that most of them do fail, in the final Phase 3 trials. So what you do need is multiple candidates, which is what we are having in the moment.

Now, we are cautiously confident that the first couple of candidates should be available and ready for approval and distribution by early next year. Again, you never know for sure, and so we are investing in a second wave of vaccines, as well, but that does not mean that they will be 100 per cent effective. There will be some effectiveness, and we hope that this can start.

Again, the size and scale of distribution means it will take quite a while to get the full global picture, but in terms of the equitable access, that is exactly why we have been engaging with this effort that included the GAVI vaccine alliance, CEPI, the World Health Organisation, called ACT-A (Achieving COVID Tools-Accelerator) and that effort, which we actually had a meeting yesterday.


This included President Matamela Cyril Ramaphosa of South Africa, in his capacity as Chair of the African Union, including the Prime Minister of Norway, Erna Solberg, and it included Ursula von der Leyen, the President of the European Union. That effort is exactly to try and make sure that there is equitable access, particularly, that you can make sure that high-risk groups and critical groups like healthcare workers, everywhere, do get access to that first wave of vaccines.

Nigeria has one of the highest child mortality rates in Africa, and one of the highest in the world. I want to find out, what are we not doing well, and what can we do to get out of this problem?
Well, there are a number of steps, and yes, it is relative to Nigeria’s per-capita income. Many of its health indicators are lower than comparable countries with similar per-capita incomes. And so, we think there are important steps that Nigeria can and should be making.

At a basic level, even in times of fiscal constraints, which we know this is one of those times; it means not cutting healthcare funding. Primary healthcare funding is an essential tool and vehicle to ensure that facilities are full stocked, that healthcare workers are available, and that is the best long-term investment in the future. The government has endorsed a strong human capital plan, investing first in health, and then in education, which is the key to any long-term economic growth, even when you are in the midst of a crisis like this.


And then, within that, there are specific interventions. Vaccination rates, particularly in the North, are really very low. In some cases, they are as low as 30 per cent, and that is the most effective tool. That is why we highlight the drop in global vaccination rates down to 70 per cent, but there are parts of Nigeria where, if they reached past that 70 per cent, that would be a massive increase, even for the rest of the world, that is a massive decline.

And so there are some key interventions, like that, like the basic provision of sort of basic healthcare facilities for primary healthcare, and that is why this sort of basic primary healthcare law, the new legislation, the new legislation in Nigeria, is so important to help with that funding. But those are the keys. It is the basic stepping-stone interventions that you need to put into place, and that will help tackle the critical first step to tackling those statistics you are talking about.

When most countries in the world are giving out stimuluses to their citizens to cushion the impacts of COVID-19 on their citizens, Nigeria is increasing the electricity tariff, and they are also increasing their full price on so many other things. Do you think that these measures will push more Nigerians into abject poverty?
Yes. So, first, on the stimulus programmes, that is. That is one of the constraints that developing countries like Nigeria face. Rich countries have committed around 22 per cent of their much larger Gross Domestic Products (GDPs) to stimulus, because they can. In aggregate, these developing countries have only been able to provide around three per cent of the GDP, of a much smaller GDP, and that is where support from institutes like the International Monetary Fund and the World Bank has been so important, with other steps like debt relief, and so on, for which there are global efforts.


So, the fiscal measures that you are talking about; there is the wider issue of what money is spent on. It is a matter of fact that Nigeria has one of the lowest, if not the lowest portion of the GDP that is taken as tax revenue, and so it is very low, by any standards, even by developing country standards. We certainly think there is scope within the Nigerian economy to sustainably increase revenue. But the key is, revenue needs to be spent and dispersed on services where citizens see concrete benefits to themselves, and so in something like the primary healthcare I just talked about.

If citizens see the results of their taxpaying coming back in the form of concrete benefits in health and education, in a reliable way, then they Are much more willing to pay for those services. I think that Is the key challenge for Nigeria and many other countries right now. It is translating the revenue that they do have into concrete services that actually help and alleviate the conditions for the very poorest.

What is your assessment of Nigeria’s COVID-19 response?
I think on that one, I would just simply say, I think, you know, Nigeria, like every country it has been a very tall order to try and confront both the direct COVID response and the underlying economic challenges. We are working closely to provide whatever support and advice we can to the government to tackle this, but we believe staying focused on those big-picture issues that I talked about, that’s the key to both the short- and long-term success.


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BMGFCOVID-19Mark Suzman
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