What if all Indian children grew up strong and well-nourished?
What if each Indian household had access to adequate sanitation and hygiene?
What if every Indian had the opportunity to lead a healthy, productive life?
Sue Desmond-Hellmann, CEO of the Bill & Melinda Gates Foundation, recently wrote about the question that unites all of us who work at the organization: “What if?” What if we could solve, once and for all, the problems that prevent far too many people from leading healthy, productive lives?
The growth and innovation in India since the beginning of the 21st century has allowed the country’s leaders to take bold steps in the fight against the problems faced by the poorest among its citizens. We at the Gates Foundation are proud to have been a partner in this fight for the last thirteen years.
In India, there is no better moment to ask these vital “What if” questions, and deploy our collective will and expertise to change our collective reality. And, while our country faces significant challenges, they are solvable ones. Our leaders are committed to solving them and are taking decisive steps to do so, aided by some of the sharpest minds in medicine, engineering, the social sciences, information and communications technology, education, and research.
In many states across India, the foundation is proud to partner with governments to tackle critical challenges that affect millions of Indians. Our health-related efforts, for example, include maternal and child health, nutrition, vaccines and routine immunization, family planning, and control of select infectious diseases. Equally important are our efforts to integrate all of our work, including sanitation, digital financial inclusion and agricultural development, so that we can reach the most vulnerable populations with the services they need to live healthy, fulfilling lives.
Having joined the foundation just a few months ago, I find the scope and scale of the work we have been doing in India since 2003, and its genuine potential to have a positive impact, quite inspiring. I’d like to take this opportunity to discuss three initiatives that are having the desired effect: primary healthcare services for women and young children, tuberculosis diagnosis and treatment, and sanitation. It is my hope that the people of India and our government, supported by development partners including our foundation, continue to ask, “What if?” And if we all persist, I believe that together, we will achieve extraordinary advances in each of these areas.
In the last 25 years, the number of Indian children who die young has fallen by more than half, and it is still falling. Every baby born in this country deserves a chance, and a healthy, productive, fulfilling life.
Maternal and Child Health
India’s future depends on the health of her children. The status quo is unacceptable, the ‘what if’ scenario is something we must fight for. Every seven minutes, an Indian mother dies from complications of pregnancy or childbirth. Every two minutes, an Indian baby dies before she is a day old. In the poorest states, she is more than four times as likely to die as in the richest.
The plight of these mothers and babies should keep us awake at night. Not just because their deaths are tragic, but also because we actually possess the tools we need to help them survive, thrive, and brighten our country’s future.
Community health workers in Bihar and Uttar Pradesh meet regularly for training in how best to support mothers and their babies. Meanwhile, self-help groups offer mothers the opportunity to reinforce the practices they have learned from these workers. This integrated approach is already showing the potential to save more lives than any single change to the system.
Through the foundation’s partnerships with the governments of Uttar Pradesh and Bihar we are helping accelerate the use of these tools among health workers. Under the Nurse Mentoring program, Auxiliary Nurse-Midwives (ANMs) within the public health system receive mentoring support from specially trained hospital nurses for a period of six months while line listing and name based tracking systems help them keep track of mothers and babies in the days and months following delivery. Community Health Workers including ASHAs and Anganwadi workers come together as a team with the ANM leadership for regular planning, review and goal-setting sessions at health sub-centers on how best to support mothers and children, both before and after birth.
‘Mobile Kunji’, an illustrated deck of laminated cards, allows ASHAs and Anganwadi Workers to visually explain basic principles of maternal and newborn and child care to new mothers, and ‘Doctor Anita’, a pre-recorded set of persuasive messages addressing myths and misconceptions, offers additional advice in local languages - on-demand, directly through mobile phones. Additionally, through weekly meetings of self-help groups, women learn how important it is to give birth at a clinic, exclusively breast feed a baby for at least six months, and keep an underweight baby warm through skin-to-skin contact.
Data are still coming in, but we know enough to say that onsite nurse mentoring, improved clinical skills and better observation of clinical practices at primary health care facilities, are leading to reduced occurrence - and better identification and management - of maternal and newborn complications. The trends from government’s health information system (HMIS) data suggested a 22% reduction in still birth rate (SBR) from 18 to 14 per 1000 live births over a period of 12 months in facilities where nurse mentoring was implemented in Bihar. This reduction is two-times higher than the historic trend. In addition, improvements are being witnessed in identification and management of other newborn and maternal complications such as asphyxia and postpartum hemorrhage.
As the number of mothers who choose to deliver their babies at health sub-centers rises, the auxiliary nurse-midwives who staff these centers receive training and mentoring from hospital nurses to help provide better care to mothers and babies.
Similar practices have, in the past, reversed mortality trends in other Indian states, including Tamil Nadu and Kerala, and now need to be scaled up across the rest of the country.
India has the largest tuberculosis (TB) burden in the world. Every year, more than 20 lakh Indians contract tuberculosis and, on any given day, close to a thousand die. Tuberculosis continues to inflict the kind of damage in India that developed countries have been free of for more than a century.
The proportion of TB cases notified as against the estimated incidence of TB has stayed low over the years — sometimes even less than 50%.
Part of the problem comes from the way the private health system deals with TB. Many private doctors tend to treat for quick relief and do not order definitive diagnostic tests until several rounds of treatment have failed. As a result, a great many patients go from doctor to doctor, trying to get rid of their persistent coughs, while their TB goes undiagnosed for far too long.
The problems don’t stop there however. Once TB is diagnosed, treatment is time-consuming and complicated, and few patients are able to finish the six-month course of treatment. Diagnosis and treatment of TB is effective and free in the public health system, but the fact is that a majority of Indians seek private care. The imperative, therefore, is to fight TB with the help of providers that Indians actually seek out.
Subsidies make it much easier for poor Indians to afford the test that diagnoses tuberculosis. As a result, those who are sick get healthy sooner - and stay that way.
Innovative public health experts in some cities, it turns out, have started doing just that, by making the benefits of the public health system available to private doctors—and, through them, to their patients. In these cities, subsidies for tests at private labs mean that TB diagnoses are far more affordable. Private doctors offer patients government e-vouchers for free medication. Call centers and mobile-based notification systems are getting quicker diagnoses to more people and helping more patients remember to follow treatment regimens that don’t disrupt their lives.
The response has been extraordinary. Doctors test their patients for TB early, and patients go on medication until their course of treatment is complete. In the Mehsana district of Gujarat, where we have partnered with the government on this initiative, fully 85% of privately treated TB patients have become part of the new system. Likewise, in Patna, the number of patients notified about their TB has increased over four fold.
The government is studying these results. If effective private engagement is scaled up, together with discoveries researchers are making on new tools, we can slow the needless loss of Indian lives and resources to this age-old disease, and put the country on track towards ending TB.
Digital vouchers redeemable at any chemist give patients access to free medicine, while new call centers help them remember to take that medicine and track their recovery in ways that are convenient and respectful.
The people of India produce 1.3 lakh tons of human waste every day, and over 1 lakh tons of this waste ends up back in the environment, untreated. This means that human waste is in the land where we grow our food, where our children play, and the water which we bathe in and drink. Each gram of this waste is toxic and contains thousands of parasites and viruses. As a result, over 2 lakh young children die every year of infectious diarrhea, and many more are stunted for life.
The majority of this waste in India comes from the practice of open defecation in fields, bushes, and bodies of water. More people openly defecate in India, than in the rest of the world combined. The Government of India’s ambitious Swachh Bharat campaign aims to eradicate open defecation by 2019. As important as the use of toilets is to the success of this campaign, equally critical is the effective disposal of the waste that emerges from these toilets. Currently, most of that waste is sucked up by sewage trucks—or collected by hand—and then dumped into the same fields and bodies of water that Swachh Bharat is trying to keep safe.
With “Clean India,” the government aims to eliminate open defecation entirely by the 150th anniversary of the birth of Mahatma Gandhi, but that solves only half the problem. If waste in toilets and pits is improperly disposed of, it just as dangerous to our health and the health of our children as open defecation.
Traditional solutions for safely collecting and disposing human waste, through a vast water- and energy-intensive infrastructure of sewage pipes and treatment tanks, are no longer the most appropriate options for today’s cities. More effective are decentralized solutions, such as innovative modern toilets that directly treat the waste and state-of-the-art community level sewerage treatment plants. We are working with the central government and state governments in places like Tamil Nadu, Andhra Pradesh, and Odisha to support the development of city-wide models that will combine universal access to hygienic toilets with local solutions to contain, treat, and safely dispose of human waste. These solutions are already being piloted in cities such as Bengaluru and Tiruchirappalli, and could eventually become a reality across the country.
The technology exists to treat and dispose of waste locally, without having to rely on extensive underground sewer systems. Cities across the country are piloting programs to make sure our children are no longer exposed to the parasites and viruses in untreated waste.
But there are other, more practical, ways to dispose of waste. Our world-wide call to Reinvent the Toilet – with solutions that can run without water, electricity, or plumbing; that leave waste 100% pathogen-free; that cost no more than ₹ 3 a day per user; and look nice enough for people to want them in their homes, saw over one hundred applications. Some of the most promising toilet models are now being tested in the field to make sure they are both functional and appropriate for people’s real lives.
Our ultimate goal is to create truly clean cities in which every part of the sanitation system is safe. These waste treatment and disposal innovations, along with the Swachh Bharat campaign, offer us the potential to make life more dignified, more pleasant, and healthier for almost a billion Indians.
India’s social problems – from health to sanitation to financial empowerment - are inextricably interconnected. Consider for example a woman who doesn’t have a bank account; she is more susceptible to tuberculosis; she needs support during pregnancy; and she lives close enough to an open-defecation site that her children suffer frequent bouts of diarrhea.
The solutions are interlinked too; and this is why we believe so strongly that working together with the people and the government of India, we can succeed.
Our mission at the Bill & Melinda Gates Foundation is to help all people live healthy, productive lives, and India - and the world - are closer than ever to realizing that goal. While much work remains to be done - and it will take time - we at the foundation are optimistic that we will get there. We believe that a different India is coming into view.
An India where women and children get the support they need, where someone who contracts tuberculosis is swiftly cured, and where fatal infectious diarrhea is a thing of the past.
As India continues to take bold steps towards social development and progress, the lives of the Indian poor will continue to improve - every man, woman, and child in India will have the chance to live a healthy, fulfilling life.
An India that answers the question “What if?” by taking all of her people to a thriving, prosperous future.
Nachiket Mor, PhD
Director, India Office,
Bill & Melinda Gates Foundation