‘Poverty, disease are solvable human misery’

Co-chair Bill and Melinda Gates Foundation, Mr. Bill Gates, in separate online and telephone interviews with The Guardian, ahead of public presentation of the Goalkeepers: The Stories Behind The Data and the United Nations (UN) General Assembly in New York, United States (US), spoke on the Foundation’s health system investments in Nigeria especially in strengthening the primary health care (PHC), polio eradication, maternal and child health (MNCH), family planning, vaccine delivery, and integrated medical services. Bill and Melinda Gates in their concluding note said, “Effective leadership is key to accelerating progress in fight against poverty and diseases.” Bill and Melinda Gates, who co-authored and edited the global report, released today, proffered more solutions to the “human misery” of poverty and diseases. CHUKWUMA MUANYA, Assistant Editor, writes.

A report by the Institute for Health Metrics and Evaluation (IHME), University of Washington, United States (US), Goalkeepers: The Stories Behind The Data 2017, has asserted that effective leadership is key to accelerating progress in fight against poverty and disease.

The report, which was made possible by Bill and Melinda Gates Foundation, selected 18 out of the 232 Sustainable Development Goals (SDG) indicators.

193 world leaders, on September 25, 2015, at the United Nations Headquarters in New York, committed to the 17 SDGs (or Global Goals). These are a series of ambitious targets to achieve three extraordinary things in the next 15 years: end extreme poverty; fight inequality and injustice; and fix climate change.

The 18 SDG indicators selected by the Goalkeepers report include: poverty, stunting, maternal mortality, neonatal mortality, under-five mortality, Human Immuno-deficiency Virus (HIV), tuberculosis, malaria, Neglected Tropical Diseases (NTD), family planning, Universal Health Coverage (UHC), vaccines, smoking, sanitation, financial services for the poor, education, gender, and agriculture.

Bill and Melinda Gates concluded: “People always ask us why we invest in global development. That is easy: Poverty and disease in poor countries are the clearest examples we know of solvable human misery…”

Guided by the belief that every life has equal value, the Bill & Melinda Gates Foundation works to help all people lead healthy, productive lives. In developing countries, it focuses on improving people’s health and giving them the chance to lift themselves out of hunger and extreme poverty. In the United States, it seeks to ensure that all people—especially those with the fewest resources—have access to the opportunities they need to succeed in school and life. Based in Seattle, Washington, the foundation is led by Chief Executive Officer (CEO) Sue Desmond-Hellmann and Co-chair William H. Gates Sr., under the direction of Bill and Melinda Gates and Warren Buffett.

The Gates said they are launching the report this year and every year until 2030 because they want to accelerate progress in the fight against poverty by helping to diagnose urgent problems, identify promising solutions, measure and interpret key results, and spread best practices.

“…We will publish this report every year until 2030 because we want to inspire leaders by showing what is possible and arm them with evidence and insights about how they might be more effective…”

The Gates explained: “As it happens, this report comes out at a time when there is more doubt than usual about the world’s commitment to development. In our own country, Congress is currently considering how to deal with the big cuts to foreign aid proposed in the president’s budget. A similar mood of retrenchment has taken hold in other donor countries. Meanwhile, most developing countries need to do more to prioritize the welfare of their poorest citizens.

“In 2015, the member states of the United Nations adopted the Sustainable Development Goals (SDGs), which together paint a picture of what we all want the world to look like in 2030. However, if we don’t reaffirm the commitment that has led to so much progress over the past generation, that world will remain out of reach. Leaders everywhere need to take action now to put us on the path we set for ourselves just two years ago.

“This report will track 18 data points included in the SDGs that we believe are fundamental to people’s health and well-being. To complement the data, we are also telling the stories behind the numbers—about the leaders, innovations, and policies that have made the difference in countries where progress has been most significant. In the charts, we include the agreed-upon SDG targets for 2030. Candidly, we are unlikely to reach every target—some are more realistic and some are more aspirational—but that doesn’t absolve us of the responsibility to get as close as we can.

“We asked the IHME to project the most likely range of outcomes on the 18 indicators between now and 2030….” The Gates said the decisions “we collectively make in the next couple of years are going to have a big impact on… whether or not millions or even billions of people will conquer disease, lift themselves out of extreme poverty, and reach their full potential.”

In their conclusion to the report, the Gates noted: “… Take it from the point of view of justice, or take it from the point of view of creating a secure and stable world: development deserves our attention. We wish more people asked us how development happens. That’s the hard part. Working on this report—commissioning case studies and stacking charts next to each other—helped us reflect on the how question. To oversimplify the answer, the key is effective leadership.

“In one way or another, every story in this report is about a leader or leaders who decided to solve a problem, thought critically about innovative strategies and tactics, and kept at it. Some of the leaders we highlight work in government, some in local communities, and others at research institutions, but they are all focused on what it takes to make progress. Every time one of the curves takes a turn for the better, it is because a person or a group of people pushed to do more.”

The Gates said they are strong supporters of the SDGs because they help leaders be effective. “First, they help identify the problems that need solving. Every country now knows precisely how on or off track it is across a range of key priorities. Second, they help people work together on solutions. When one country is especially successful on a given indicator, it’s a good sign that there’s something worth learning from that country. Sharing best practices is so much easier when everybody agrees on the goals and how to measure progress toward them,” they said.

They added: “Above, we used the phrase ‘solvable human misery.’ We invite everyone to focus on the solvable part of the equation. It is a fact that this misery is solvable. We have it within our power to decide how much of it actually gets solved. Let us be ambitious. Let us lead.”

Bill Gates in separate online and telephone interview with The Guardian from his Seattle base in US threw more light on the Goalkeepers report as it affects Nigeria.

Basically, what message do you want to deliver to the world and indeed Nigeria through the Goalkeepers report?
Well, the first point we would make is that there has been incredible progress. And there are some countries that have made better progress than others, and so they are good examples.

You know, if you look at the progress often at the same income levels some countries are far ahead and other countries are not.

And so, for example, for Nigeria the primary healthcare system, there is an opportunity to improve it a great deal, so for example, the vaccinations are getting out there.

And we are very committed to work with partners in Nigeria on improving the primary healthcare. And so we are spending time working with a number of states, mostly in the North, where I talked with the governors about the various metrics and how they are organizing their primary healthcare system to work even better.

So people should have a hope that if we do the right things, there can be big improvements, and yet it really hangs in the balance that the government has to allocate the money and highlight the states and the people who are doing the work very well.

What are you recommending on how to boost healthcare in Nigeria?
Well, we can see — the partner we have is this International Health and Metrics in Evaluation (IHME). We are substantial funders of the project. And they have taken the per-country statistics, even broken them down at a subnational level.

So what hopefully the voters and the media in Nigeria will see is that relative to its level of economic progress, the health progress, particularly in the North, has fallen far behind where it should be. And you have countries that are quite a bit poorer like Rwanda or Tanzania or Ethiopia who have done a much better job of making sure the primary healthcare, that the people are doing the right thing, the right systems are in place, the money is allocated.

And so there is an opportunity literally to save hundreds of thousands of lives if we can get — you know, say you have just got the primary healthcare in the North to be as good as it is say in Tanzania that would be a very dramatic improvement.

And, you know, so hopefully as people are looking at governors or how the budget is allocated in parliament, these health issues get a lot more visibility.

Does your Foundation run any specific health-related programmes in Nigeria?
Yeah, so there are lots of things that we are doing in Nigeria. One is this partnership with the different states where Aliko Dangote, through his foundation, and we work with them to improve their primary healthcare.

Obviously, we have the polio effort, which is very substantial, where now making sure that the outbreak that we saw in August 2016, that we’re trying to make sure that doesn’t come back. And of course the big challenge there is up in the northeast, particularly in Borno. So we have a good relationship with both the Borno state and the military in terms of getting in to the stabilized areas and getting not only polio vaccine but also all vaccines out to those children, and helping them there.

We have work in digital financial services we are doing in Nigeria. We have work in agriculture we are doing in Nigeria. So Nigeria is super-important to us. Other than India, it is the country where we do the most work, where we spend the most money. And the opportunity for improvement in Nigeria is very, very large. If you take all the states and make them as good as the very best state in say health areas that would be a dramatic thing.

And so I personally have come to Nigeria a number of times and tried to make sure we’re doing our best to be a good partner.

Can you quantify your efforts in Nigeria in terms of amount of money spent?
In 2016, we paid out approximately $110m for health investments in Nigeria. The strategy teams with the largest contributions to our health investments in Nigeria in 2016 were: polio, maternal and child health (MNCH), family planning, vaccine delivery, and integrated delivery.

We have investments in many states. Our focused delivery programmes are concentrated in Kaduna and Kano. We also have significant investments / engagement in Niger, Lagos, Borno, Yobe, Sokoto, and Bauchi.

We work across four key bodies of work at the federal level on health management information systems, health financing, institution strengthening, and supply chain.

Much of our health work is focused on eradicating polio, expanding / improving coverage for vaccines and routine immunizations, improving maternal and child health outcomes, expanding access to advanced family planning; and strengthening the primary health care systems at the state and federal levels.

Can you throw more light on your activities in these areas?
The majority of the foundation’s funding for routine immunization in Nigeria goes through Gavi, the Vaccine Alliance, to purchase vaccines and strengthen immunisation delivery systems. We also fund discreet bodies of work directly, including Memoranda of Understanding (MoU) collaboration with the Dangote Foundation and six governors in Bauchi, Borno, Kaduna, Kano, Sokoto, and Yobe states to improve routine immunisation systems and child health. The collaboration is guided by the states’ aim to gradually work towards fully financing and managing their immunisation programme, with all elements needed to run a strong programme in place—such as reliable vaccine supplies, good data and planning, and health staff trained, working closely with their communities, and with operational funds for key activities.

The foundation is also supporting the transfer of routine immunization data management from partners to the government. This was at the request of the government, and requires all districts/Local Government Areas (LGAs) to begin computerising their monthly health facility paper-based immunisation data into a national cloud-based health information system. The process will be finalized by the end of 2017, and will help the government to expand the availability and use of quality immunization data in Nigeria, which is one of the most complex and technically challenged immunisation systems in Africa. In the long-term, this project will establish an ongoing system for data analysis to inform decision-making processes for policy development, programme planning, and monitoring.

How much does the Foundation spend on Nigeria, Sub-Saharan Africa and Africa yearly?
In 2016/2015/2014, we paid out approximately $160 million/$248 million/$198 million respectively in investments located in Nigeria. For Sub-Saharan Africa these figures equal $730 million/$803 million/$723 million. For Africa they equal $732 million/$805 million/$730 million.

These figures do not include large multi-country / global investments that are funded through organizations headquartered outside of Nigeria, but with sub-grants in Nigeria (example Global Fund and GAVI). Similarly, they do not include investments that are not coded to specific geographies (example global health research and development, R&D, investments that benefit multiple countries and geographies and are therefore coded to world).
In Nigeria we have the challenges of high maternal and child mortality and also the issue of HIV and the family planning issues. What are the findings of the report on these?

Well, the key thing is to get the primary healthcare working so that the workers are there, the vaccines are there, they are located nearby, and there is a clear message to all the families that bringing your children in, whether it is for a prenatal visit or after birth, to get these vaccines, you know, that is super important.

You know, we have some other messages about exclusive breastfeeding where not giving the child anything but breast milk in the first year, not needing to add any water, is associated with the child doing much better.

In malaria it is the issue of getting the bed nets out and keeping those bed nets going. So I would say almost all of our health programmes, all these key areas we work in, Nigeria, because of its size and because there are examples of parts of Nigeria doing things well, that we are putting a lot of energy into trying to help out.

But I would say polio and primary healthcare, including vaccination coverage, would be the very highest priorities.

Bill, you have been very passionate around the issues of polio and you have visited Nigeria about three times especially because of this cause. Are you disappointed that Nigeria is yet to eradicate polio despite all the efforts?
Well, I think everybody is disappointed that after a period of almost two years where we did not have any cases, that then in August 2016 a few case
s showed up. And unfortunately, that is because of children who were in what we call inaccessible areas, the areas that Boko Haram had gone into.

And so Nigeria really did an amazing job on polio to stop it from being transmitted in all the other areas, but then it turned out in this Boko Haram area there were enough kids, and they were not getting the vaccines at all.

And so we have to maintain very high vaccination levels thought about the country, particularly in the North, while we go and get the vaccines to those children up in the North. And that is where we are really pleased it is being given a lot of priority, and we have had very deep engagement with the Ministry of Health, with the army and with the authorities up in Borno to try and get to those children as quickly as possible. And so we are not sure that it is gone, but we are hopeful, and we are doing everything possible to get over that setback.

Child mortality
Co-chair, Bill & Melinda Gates Foundation, Melinda Gates, noted: “If I had to pick just one data point to focus on, it would be the number of children who die every year before reaching the age of five… What is more fundamental than keeping children alive so they can thrive and build the future? Based on global child mortality data, the world is on the right track. In the years I have been working in global health, the number of child deaths has gone down tremendously every year. Six million fewer children died in 2016 than in 1990. That is more than the total number of children in France.

“Children are 75 times more likely to die if they happen to be born in Angola instead of Finland. Warren Buffett calls this the ovarian lottery. The work of this generation is to make the ovarian lottery fairer (and save millions more lives) by addressing child mortality in countries like Angola, Nigeria, Democratic Republic of Congo, and Pakistan where children are most at risk.

Bill and I began investing in health and development because we believed it was possible to eliminate gross inequities. We’ve seen many poor countries prove the point. Take Malawi. In 1990, one in four children there died. Now, it’s one in sixteen. This is great news, because Malawi is closing the gap between itself and Finland. It’s also a call to action, because now there’s a big gap between Malawi and Angola.

“To answer the call, the world must spread best practices from exemplars like Malawi. Fortunately, we know a lot about how to save children’s lives.”

Melinda Gates said close to half of the almost five million children who will die next year will die in the first 28 days of their lives. She said most could be saved by a few simple interventions: for example, resuscitation if they can’t breathe, antiseptics that cost pennies to prevent infection, and breastfeeding to strengthen their immune systems.

Melinda Gates said countries like Cambodia and Ethiopia have shown what happens when a country prioritizes its newborns and that the challenge is reaching the most vulnerable people in the world with basic information and services.

She said about 1.5 million of the children who will die next year will die from diseases that can be prevented with vaccines; and many countries, including Bangladesh, Honduras, and Tanzania, immunize more than 90 percent of their children, but there are still nearly 20 million children in the world who are not immunized at all.

Melinda Gates said this explains why measles, preventable with a vaccine that costs less than 20 cents, still kills almost 150,000 children every year.

She said it is a huge challenge to reach children in countries in conflict or in remote regions hours away from any infrastructure whatsoever, but it is doable, and it is more doable now than ever before.

According to Melinda Gates, consider how difficult it is to deliver a vaccine that needs to be kept at a specific cold temperature to a child who lives in a vast desert, but now, new coolers using insulation developed for spacecrafts can keep vaccines cold for a month and help reach millions of children currently being missed.

She said in 2000, Bill and Melinda Gates Foundation joined many partners in launching what was then called the Global Alliance for Vaccines and Immunizations (now Gavi, the Vaccine Alliance). The co-chair said since then, Gavi has helped more than 70 countries vaccinate 600 million children.

“It has helped dozens of countries add new vaccines against leading childhood killers such as diarrhoea and pneumonia to their immunization programmes. It has saved more than seven million lives. We know what it takes to give millions of children the opportunity to thrive. The question is, do we have the commitment?” Melinda Gates said.

Maternal mortality
Bill and Melinda Gates said: “If you were trying to invent the most efficient way to devastate communities and put children in danger, you would invent maternal mortality.

“So the fact that the number of mothers who die has been cut in half in the past generation is one of the more important successes in global health. It is all the more impressive because reducing maternal mortality is really hard.

“Statistically speaking, it is rare compared to, say, child mortality. That is why maternal mortality ratios are rendered per 100,000 live births instead of per 1,000. Therefore, for every new solution that saves a mother’s life, you need to deliver 100 times as much of that solution to have the same impact.”

Luckily, solutions already exist, they said. Bill and Melinda Gates said to deliver those solutions to all women, the most important priority is persuading them to deliver in health facilities, where they can get skilled obstetric care, instead of at home.

Minister of Health of Ethiopia, Dr. Kesete Admasu, wrote about how his country created a health infrastructure that helped women make this decision.

Kesete suggests, as this shift from home to facility births continues, the maternal health community must make sure that the obstetric care provided in facilities is of the highest quality.

Bill and Melinda Gates, however, said with many more mothers delivering at facilities, it puts new pressures on health systems—they need more equipment, more staff, and more training. “If the world provides those, then we will continue to drive down maternal mortality at the accelerated rates of the past 25 years.”

Family planning
Bill and Melinda Gates said perhaps the best way to describe the importance of family planning is this: achieving the family planning goal makes it more likely that we will achieve virtually every other SDG. Poverty. Maternal mortality. Child mortality. Education. Gender Equity. The Gates said they all get better when women can plan their pregnancies so they are physically and economically ready when they have a child.

They, however, said norms around sex and family life are powerful; and in many countries, families have not typically planned the work of giving them options is not just technical—raising more funding, developing new products, and repairing broken systems. “It is also deeply cultural,” the Gates said.

Bill and Melinda Gates said despite these challenges, many developing countries have started to prioritise family planning because they understand the impact it has; and in the past several years, more than 40 countries have launched rigorous national family planning plans.

In the report, two people instrumental in one of the most successful family planning programmes, in Senegal, wrote about their experience. Fatimata Sy is director of the coordination unit for the Ouagadougou Partnership, an alliance of the nine francophone West African countries committed to reaching more women in the region with family planning services. Imam Moussé Fall, a founder of the Islamic Network on Population, helps his fellow imams think about how family planning fits into their theology.

According to the 2017 Goalkeepers report, Senegal revamped its supply chain to make sure that a woman seeking contraceptives never got sent home empty-handed.

“Together, Mrs. Sy and Imam Fall demonstrate both the breadth and depth of work necessary to make sure families can unlock their full potential,” Bill and Melinda Gates noted.

HIV/AIDS
Co-chair, Bill & Melinda Gates Foundation, Bill Gates, said starting in the early 2000s, the world made a huge investment to address the HIV and Acquired Immune Deficiency Syndrome (AIDS) crisis, including the Global Fund to Fight AIDS, Tuberculosis, and Malaria and the United States President’s Emergency Plan for AIDS Relief (PEPFAR); and in the history of global health, there’s never been an increase of that magnitude in getting products and services to people who need them.

Bill Gates said with 35 million dead, AIDS is the worst humanitarian disaster of my lifetime. But when you consider what would have happened if the curve had stayed on its original trajectory, the fight against HIV also has to be counted among our greatest successes.

He, however, said it is a success at risk because: governments in both donor and developing countries that responded so aggressively to the crisis 15 years ago are now focusing on other things; and funding for HIV control has been flat, and now there is talk of cuts. Bill Gates said in a world of competing priorities and limited resources, these conversations are mandatory, but he wants to be sure that the people having them are clear about the consequences.

Bill Gates said he is not advocating for a blank check for HIV treatment, because he does not think they need one. He said the Foundation asked the IHME to develop a simple model to help her think about the potential impact of a 10 percent annual cut in donor funding for HIV treatment. “As you can see in the chart, it could cost the lives of 16.6 million people. Given the current tenor of the global discussion, an even bigger cut to global HIV funding is a very real possibility,” Bill Gates said.

He said people could now be treated more efficiently. Some countries, such as Zimbabwe, Bill Gates said, have implemented what is known as differentiated care. Most patients adhere to the treatment regimen closely, so they receive longer-lasting supplies of drugs and go to the health facility less regularly. He said more than two-thirds of Zimbabweans on treatment visit a health professional only once every three months. However, patients who are less likely to stick to the regimen get extra support. In this model, no one is wasting money by getting more services than they need, and no one is risking getting sicker by getting less than they need.

Second, Bill Gates said, the key to solving the AIDS crisis over the long term is prevention. He said the fewer people infected in the first place, the fewer who will need treatment. “We don’t want to control a disease when we can end it.”

According to Bill Gates, in 1990, there were 94 million people on the continent between the ages of 15 and 24, the age when people are most at risk of contracting HIV; and by 2030, there will be more than 280 million.

He said what that means is pretty clear. “If we only do as well as we’ve been doing on prevention, the absolute number of people getting HIV will go up even beyond its previous peak.

“We have to do better. Part of that is more funding, not less. And, as with treatment, we need to identify and promote the best prevention practices so that we can get maximum impact from every dollar we spend.”

Bill Gates said Kenya has been a leader in this area, emphasising both voluntary medical male circumcision and pre- exposure prophylaxis, or PrEP, two of the most effective prevention methods currently available. He said other countries could learn a lot from Kenya’s experience.

Bill Gates said over time, there will be need for better tools, such as long-acting drugs that prevent HIV infection and, eventually, a vaccine. But, he said, the pattern with research and development funding is the same as with delivery funding: it is been flat, and now it is targeted for cuts.

He further explained: “That is a scary prospect. Without R&D investments, we would not have the new discoveries that will make it easier to prevent transmission of HIV. In the meantime, if we do not spend more to deliver the tools we have now, we will have more cases. If we have more cases, we will need to spend more on treatment, or people will die.

“But this chain of causation works in the other direction, too. If we invest more, if we are more efficient, if we share what we learn, if we show more leadership, then we will write the story of the end of HIV as a public health threat.”

Financial services for the poor
Bill and Melinda Gates said poverty is not just the lack of money and it is also the lack of access to basic financial services that help the poor use what money they have to improve their lives. So, they said, the development community has been trying to promote financial inclusion—that is, to connect the poor to bank accounts and services like credit and insurance—for decades.

The Gates said the problem is, it has been too expensive to do it at any kind of scale, given that almost two billion people live completely outside the formal financial system.

They, however, said with mobile phones, it is easier and cheaper to reach the poor with financial services. “The number of people with accounts is going up quickly, and we are starting to see the impact.”

According to the Gates, in particular, there is exciting new evidence that digital financial services like payments and savings do indeed help people lift themselves out of poverty.

They said India has been especially innovative about investing in the building blocks of digital financial inclusion and Aadhaar, a nationwide biometric identification system, makes it simpler and more secure for poor people to do business with banks.

According to the Gates, India’s regulators have made new rules to provide flexibility for different types of financial institutions to provide a wider variety of services. They further explained: “For example, a new class of banks called payment banks brought in new private sector players to the market and opened millions of new accounts. In 2014, the government launched a programme called PMJDY to help the poor open accounts in huge numbers, and it recently started providing benefits to them through these accounts.

“One of the development community’s hypotheses has been that inclusion could be especially revolutionary for women who traditionally have been excluded from making economic decisions. Now, researchers are starting to test it.”

The Gates said, last year, a landmark study in Kenya by Tavneet Suri and William Jack established a clear link between financial inclusion and women’s empowerment. This year, Rohini Pande and her colleagues added to the evidence base with fascinating results. Melinda Gates talked to Dr. Pande about her research, what financial inclusion can do for Indians and India, and how to speed up progress. The excerpts are in the Goalkeepers report.

Stunting
Bill and Melinda Gates said stunting is one of the most powerful, but most complex, measures in global health.

They said stunted children are defined as children who are short for their age by a specified amount but it is not actually a child’s height they are concerned about; rather, stunting is a proxy for something much more important: how children are developing cognitively, emotionally, and physically.

The Gates said stunting is the opposite of well-being, which is why they say it is such a powerful measure, but its complex because it is caused by multiple factors that accumulate over a period of time— everything from a mother’s health to a child’s diet, disease history, and environment. The Gates said they do not yet have a complete picture of the root causes—and there is no single intervention to prevent it and they have to mix and match a variety of interventions.

The Gates said they have spent a lot of their time recently speaking to global experts to learn more about stunting and it is solutions; and as development experts and practitioners continue to build the evidence base, however countries need to scale up the set of health and nutrition interventions already proven to reduce stunting significantly.

They said Peru’s story is impressive because they cut through a lot of that complexity and focused on what they know works. The Gates said Peru proved that stunting is a solvable problem when leaders are committed to following the evidence.

Milo Stanojevich, the country director for CARE Peru, and Ariela Luna, Peru’s former deputy minister of development and social assessment, wrote short essays explaining how the country made so much progress in such a short time. The essays are contained in the Goalkeepers report.