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"Our desire is to act as a catalyst, not operator": Nachiket Mor, Bill & Melinda Gates Foundation
With presence in over 100 countries, India being one of its key geographies, the foundation aims to help find solutions to reduce extreme poverty and improve health.

With an endowment of $39.6 billion, and an annual grant support of about $4 billion, US-based Bill & Melinda Gates Foundation (BMGF) is one of the leading private foundations globally. With presence in over 100 countries, India being one of its key geographies, the foundation aims to help find solutions to reduce extreme poverty and improve health.

In an exclusive interaction, Nachiket Mor, Country Director, Bill & Melinda Gates Foundation, India, talks about the foundation's work in India. Edited excerpts:

Global funds are often criticised for pushing new vaccines that are perhaps non-essential. What is your approach to vaccine development?
All the vaccines that are globally available have already been fully approved for use in India quite a while ago and are already available in the private sector for those who can pay for them, so there is no question of pushing medicines that are not already locally available.

The real debate is about the feasibility of making these vaccines available through the public system for free to all the people of India.

This issue certainly needs careful thought before public funds are deployed, and it is for this very reason that the government of India has a well-structured process for making these decisions with very eminent scientists and administrators involved, who carefully weigh all the available evidence before making any recommendations.

Cost is only one of the many considerations. There are several other factors, too. Our support is provided to Indian partners only at the explicit request of the government and is designed to ensure that the best of the data and analysis is made available to Indian decision makers.
 
The government seems to be slightly critical of overseas funding. Is it true that the National Technical Advisory Group on Immunization (NTAGI) is reportedly distancing itself from BMGF, too?
NTAGI comprises a group of eminent India scientists and administrators, and has never been funded by our foundation or for that matter by any external donor, nor was there ever a plan to do so.

A government-appointed expert committee (the Mavalankar Committee) had recommended the formation of a technical support unit for immunisation, to support the work of the Ministry and NTAGI. Following this recommendation, the government decided that the technical support unit is needed to help with the technical analyses around supply, development of technical guidelines, and planning the roll-out, so that the data is available to the decision-making group at the Ministry of Health.

The Public Health Foundation of India, a joint effort of the government of India and other donors, was asked to set this up. They, in turn, approached us to provide them with some financial support and, at the request of the government, we gave them a $6.9-million grant for three and a half years to set up the Immunization Technical Support Unit (ITSU) to work with the Ministry.

While we remain committed to supporting the Indian immunisation program, it is our hope that over time larger and larger components of it will be funded entirely by the ministry, just like the Secretariat to NTAGI which was supported by ITSU will now be moved to National Institute of Health and Family Welfare under the Ministry of Health.

Are there any conditions or strings attached to the support you give?

In all our programs, our strong desire is to act as a catalyst and not an operator. We examine the issue of local context and need, sustainability, longer-term domestic funding and government ownership very carefully before we make our grants.

One of the major criticisms against international foundations in general is that their influence is highly disproportionate to the money they contribute. Do you agree?
I feel a statement like that is deeply disrespectful to us as Indians. It is as if we still have the colonial mentality and are afraid of outsiders because we are so gullible that we can be easily made to do whatever is being told to us by them. That is certainly not the case. We Indians have the full capacity to decide for ourselves what is in our best interests, and to accept or reject advice no matter what its source. And, while outsiders are welcome to help where they can, there is no dependency on any of them.  

How has the decade-long journey of Bill and Melinda Gates Foundation in India been?
The foundation started its operations in India 13 years ago. For a decade, it had a small office, and the focus was on a few specific disease categories in the health sector such as HIV and polio. Over the years, the range of activities has expanded to include additional health and non-health areas, but health remains one of the priorities. Agriculture, digital financial inclusion and sanitation are the non-health sectors in which we are engaged.

Gender is an issue whose impact cuts across all our work and is an area of increasing interest to us as a foundation globally as well as in India. And, if our initial approach towards solutions to health problems was much more product-focused, in the last five years we are engaging much more on the delivery end of these problems.

What has been the foundation's contribution to India's fight against HIV?
Our investments were focused on prevention in India - through targeted prevention interventions in the states with the highest HIV prevalence and among populations that are most at risk. Our India AIDS Initiative, called Avahan (call to action), worked closely with NACO and was a part of the broader National AIDS prevention response.

Our goals were to run an HIV prevention model at scale in India, encourage others, including government and communities to take over, replicate the model and foster and disseminate lessons learned within India and worldwide.

At its peak, the Avahan programme provided monthly prevention services to more than 220,000 female sex workers, 80,000 high-risk men who have sex with men and transgender people, 18,000 injecting drug users, and five million men at risk along the nation's major trucking routes.

An external evaluation estimated that Avahan has prevented about 600,000 new infections in the parts of India hardest hit by the HIV epidemic, indicating that such prevention programs that target key populations can reduce HIV rates in the broader population.

We also demonstrated a scalable model where over ~80 per cent of these populations sought HIV prevention services in the worst hit areas of India in a short period of three years. Our upstream focus, however, remains on discovery and development of biomedical prophylaxis for global application.

These are the various ways in which we contribute, but it is important to bear in mind that none of these activities are performed by us acting alone; we collaborate with both domestic and global partners to deliver the impact that is needed.

How much money is needed for vaccine procurement (for universal immunisation programmes) and HIV medicines?
The exact number will have to be computed, but it's my understanding that an estimated Rs 6,000 to Rs 7,000 crore, annually, should be sufficient to pay for the entire vaccine program.  This amount within the Rs 16 lakh-crore annual budget should be entirely feasible for the government to find.  

How receptive is the current government given the swadeshi influence it is perceived to have?
Our experience in India has consistently been that governments, both at the central and state levels, have a deep interest in the health and well-being of their people. They are willing to accept any offer of help from technical and a-political organisations like ours. This has been our experience not just in India, but all over the world.  

How much money do you spend on health? How big is your presence in agriculture and finance?
About 60 to 70 per cent of our allocations within India are in health-related projects across maternal, neo-natal, and child health, family planning, malnutrition, and infectious diseases. I am unable to tell you the exact amounts that come into India as they come from various sources since we fund several global agencies which, in turn, fund programmes here. The foundation spends about $4 billion per year on all its programs globally.  

In recent years, our engagement in agriculture in India has gone up considerably, where we work to strengthen programs that improve farmers' access to knowledge, tools and markets, to increase crop productivity, nutrition and their profitability.

There is also a surge of activities in sanitation because of the Prime Minister's Swachh Bharat programme. In digital financial services, we are involved in many projects where we can add value. We are also learning a lot from India and seeking to make that knowledge available to other countries around the world, particularly in Africa.

 

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