Despite impressive economic growth across Africa in recent years, the distribution of wealth has been uneven, and pernicious poverty persists. Few countries are expected to meet the United Nations Millennium Development Goals, aimed at slashing poverty, hunger and disease and achieving gender equity, educational, and environmental goals by 2015.
But many communities are defying that trend. Late last month, Melinda French Gates, co-founder of the Bill and Melinda Gates Foundation, traveled to Malawi to visit health and economic projects she calls innovative and effective. On 27 January she visited Benin with French first lady Carla Bruni-Sarkozy - an ambassador for the Global Fund to Fight Aids, Malaria and TB - to promote investments in women's and children's health.
Afterwards, Gates joined her husband and colleague, Bill Gates, at the World Economic Forum in Davos, Switzerland, where they announced they would spend U.S. $10 billion over the next decade to develop and deliver vaccines. That sum dwarfs the $4.5 billion the Gates Foundation allocated to vaccines over the past decade.
Among the initiatives Gates visited in Malawi is Kangaroo Care, a technique of wrapping premature babies against their mother's - or father's - bare skin. Research in both developed and developing countries shows that the strategy produces multiple gains, including less pain during medical procedures, better maternal milk supply and fewer illnesses and deaths - and is superior to incubators at regulating infant's body temperatures. She also looked at banking services she says are transforming the lives of rural families.
Melinda Gates spoke about her trip to AllAfrica's Tami Hultman by telephone from Malawi.
Your foundation is known for investing in science and advanced technologies in the service of its goals - in food security and the health sector, for example. Yet one of the projects you're visiting in Malawi - Kangaroo Care - is strikingly basic. Could you talk a bit about the kinds of effective interventions you're seeing in maternal and child health? Is a big piece of it changing common practices?
You're absolutely right that the [Bill and Melinda Gates] Foundation is focused on a lot of science and technology - but we do quite a bit, also, on the delivery side of things. You've brought up a perfect example, this Kangaroo Care. One of the things that I'm here to see in Malawi is: how is that working in conjunction with the government program?
The government here has been working on getting their child mortality rate down. That is the number of child deaths under the age of five. They've been working on that very consistently over the last 10-plus years. But one of the places where the rate wasn't coming down in childhood deaths was neonate - the first 30 days of life.
And so we came in with Save the Children as our grantee here on the ground, working with the government program. I was in a hospital out in one of the rural districts yesterday, called Doha, and today I was in the district hospital that's here in the capital in Malawi, really seeing how this Kangaroo Care program is integrated into the maternity wards.
The piece that we're linking up with is once the mother is there and is safe and delivers the baby. In many of these cases the babies are premature. We're there to make sure that they get this warm Kangaroo Care, where we literally teach the moms - and often the grand mom's there attending her - to wrap the baby and keep the baby warm on the mother's chest. It promotes breast feeding, it promotes the immune system, it promotes all the right things for the baby. Our goal here is to get this uptake across Malawi.
As they're getting women into these places of care, they also are working on saving these newborn babies. You're right that basic cultural practice is a big part of what's going to change births in these countries. It's not new science and technology for reducing child mortality.
For this kind of intervention, then, the science comes in through documenting successes and demonstrating their validity?
Absolutely. In malaria, for instance, we are very involved in the science and technology piece of malaria. We're very much behind getting a malaria vaccine. That's the ultimate tool. But in the meantime, while we're working on malaria vaccine, we're working on malarial medicines. Those combination therapies, the Artemisinin-based therapies, I'm seeing them in use on the ground here in Malawi.
But the other piece is in Zambia. We've been very involved the last few years in really measuring: "Okay, these bed nets that they're distributing across the country and indoor residual spraying [of walls with low-dose pesticides] - how is that working? What are the lessons learned?" And so we're doing the real measurement and effectiveness pieces and then spreading those to other countries.
For instance, here in Malawi, they're going to really [expand] the malaria program. We'll take all the lessons learned out of Zambia that can tackle these diseases and spread those to countries like Tanzania, Kenya and Malawi.
Malawi isn't alone, of course, in having something like 85 percent of its population in rural areas, while most of its health-care professionals are in urban centers. So how do you see health care being delivered in the coming years, in view of this reality? Is Malawi successful in having birthing centers like those you describe available to most people? How do you see African countries addressing this challenge?
Well, I think Malawi is doing a lot like Ethiopia is doing - they are trying to push it very far down. They understand that you've got to push it down to these district hospitals and health centers and rural health posts, and that means training a whole different workforce. In Ethiopia they call them health extension workers. In this country they call them "health surveillance assistants".
These are people who come from the local villages. They get 10 weeks of training, and they're the people who work in the villages to identify these pregnant moms, to make sure that the pregnant moms come for anti-natal visits. They actually give to the pregnant moms some of the things that they need and make sure the moms get into the health facility early. Three weeks out of the month they work out in the villages, but one week out of the month they work in the district hospital giving immunizations. They are part of the whole immunization program.
They're also working very creatively out in the village to get the village to do planning and to look at itself and say, 'Okay, what is the cultural practice that's keeping women away from the hospital? Is it about the mother-in-law, or the husband? Or that we don't take the women [to hospital] earlier?' They're the ones driving all those messages down at the village level with the chiefs, because they know the chiefs really well.
Malawi, from what I'm seeing, is one of the best countries in terms of linking the village all the way up to the different levels of care - actually doing a pretty incredible job of training these people and then linking them to the health system. I do think that's what you've got to do to make substantive changes in maternal and childhood deaths.
Whether you're talking about maternal and child health or HIV/Aids or malaria - that kind of training of people who can reach the local level, where the people are, is really pertinent, isn't it, to the whole question of how health care is delivered and by whom? I think it was health journalist Christine Gorman who cited a BBC report in 2003 that Malawi graduated 60 new registered nurses that year but 100 registered nurses left for other countries, half of them to the United Kingdom. And, of course, anybody visiting a hospital in the eastern United States is likely to be cared for by African nurses and med-techs. Have Malawians or other Africans been expressing concerns about this nurse and doctor brain drain to you?
Yes, they absolutely do. They're asking: 'Who else can we train in the system?' They have health officers now, in the hospitals, that have a certain level of training. They're actually kind of between a nurse and a doctor, but they can do an awful lot of things that a doctor can do. For instance, they can perform a Caesarean section! At one of the hospitals I was in yesterday there are nine different people in that unit. If you add up all the people between the midwives and these health officers - all the people who can do Caesarean section - there are nine people on a rotation.
They are saying, 'Look, there's only one doctor in the entire hospital, but this is how we're starting to address the other pieces. You don't have to be a medically trained doctor to do a Caesarean section.' That's how they're training these different levels.
Even these health surveillance assistants - they call them HSAs - can already give a shot to a woman. So they're starting to say: 'Well, they can give her family planning services, they can do Norplant, they can do Depo Provera [for birth control]. That ten weeks of training - if we extend it by two more weeks, we can start to put more things in their hands, and they can deliver out at the local level, before you even get the person into clinic.'
Ethiopia has trained 30,000 health extension workers and they are putting them in 15,000 posts out in these super-remote areas. So when you see a country like Ethiopia tackling that or Malawi attacking it the way they are, those are some of the creative ways they are going to get to this problem of not having enough doctors and nurses in the country.
I saw in November, in a rural clinic in Kwara state, Nigeria, that non-doctors were performing C-sections, and I was amazed. They're having a very good record of success, of saving lives, these non-traditional health officers.
Very.
On another topic, when we interviewed Malawi President Bingu wa Mutharika late last year, he indicated that improving the lives of the majority of people, by achieving food security, for example, is as important as overall economic growth - without, of course, suggesting that the two aren't inter-related. I'm wondering if you see that approach to development spreading in Africa - rather than looking solely at economic growth, which can be very unevenly distributed.
Yes, we are starting to see that. Some of the ways are innovative things going on in the banking sector. I'm seeing that in places like Kenya. I'm seeing it in places like Tanzania, and I'm certainly seeing it on the ground here in Malawi.
One of the specific reasons, besides the maternal and child work that I wanted to come out and see, was a grantee we've been working with for a number of years called Opportunity International Bank of Malawi (OIBM). They're saying, "Okay, this country of 13 million people, 85 percent live in the rural areas, but the banks are all in the big towns." Their entire focus is: how do you push banking services out to this rural population?
We passed a sign today on the highway as you're leaving the capital that says, "Next bank is 96 kilometers away." As if they're proud of it, right? Well, this bank is not even touching most of the population!
So what OIBM is saying is, 'How do we be really innovative to get banking services out to the poor, to the people who want to bank a dollar a day, $2.00 a day.' So they've done something incredibly innovative.
Right now, in most African countries, you have to present a driver's license and a letter of reference and a couple of other letters to open a bank account. Well, there's no way somebody who lives on $2.00 a day has anything close to that kind of documentation. The way they solve that problem in Malawi - this bank - is they have a biometric reader. The woman or the man comes into the bank and shows their fingerprints. They put it on a biometric scanner. They put that on a smart card. Anywhere that person presents that smart card, they now have access to their bank account.
And then the bank is taking these mobile units out, and they'll show up two days a week in these super-remote villages and bank all the poor people. I was in a village today where they are now banking 3,000 people. They're saying, 'Well, once we get up to almost 5,000 people we can open a teeny, tiny little satellite branch and - by the way - the way we do it is: we drop a container in there, and we bank, literally, out of a cargo container!' That's the kind of innovative thing you've got to do to really reach a whole segment of the population.
When you talk to the people who are standing in line at these banks, they understand that they have a huge benefit - a safe place to store their money. They don't have to go on a bus to store their money. It's not being eaten by a rat. They're not hiding under the mattress. When it's time to pay the school fees, guess what? They have a place to go access the money, and it's been saved over the year. I'm seeing the government really supporting this, supporting the right regulations in the country and moving this in the right direction.
When I traveled in November with Dr. Jennifer Riria of Kenya Women Finance Trust, which provides loans, and, now has launched Kenya Women Holding - which is moving aggressively into banking for the poor - I met their rural women clients. My job as a journalist is simply to find out what's happening and to report it to the largest possible audience, but I must confess that their enthusiasm about the difference the availability of financial services was making to their families was infectious.
It totally changes their lives! And, when you think about it, the people are so ingenious. If you're running a half-hectare farm - do you know how hard that is to do in Africa, to run it well, to have enough to feed your family and put something out on the local market? These women and men are ingenious. As soon as you start banking them and you start talking about a loan, they are thinking about a new business and how to expand it, as you've seen! It is really quite something. So you give them the means to lift their own lives out of poverty, and that's life changing.
It always seems to me that the people who are most pessimistic about the prospects for development, and Africa in particular, need to spend some time with very poor people - especially poor women, but also poor men - and see the creativity and intellect that people bring to their pursuits.
Totally. That's the reason to come out to Africa and see it. I think a lot of people can sit back and criticize or look at the statistics. When you're here on the ground, you start to see what's actually possible. And, yes, there are lots of barriers. But when I go out and visit this OIBM bank, I see the amazing innovations that they're doing. They say, 'Well, we have this hurdle but this is how we change it. We learned.'
They are learning about when they build a branch that's too big: 'Okay, we can't spend that kind of money. We have to do it in this way.' Or: 'What are our clients asking us for? They need crop insurance. How do we begin to explain to people crop insurance?' Well, it turns out, it's not that hard! These are farmers and they understand weather, right? So, yeah, you've just got to get out and see it, and you see what's possible.
I know that the [Gates] foundation has a reputation for being aggressive about measurement, about tracking results, about effectiveness. So I wonder if you could address an idea that gets lots of media attention - maybe spearheaded at the moment by the book Dead Aid, but the idea's been around for a while - the critique that aid has been not only misspent but, going further, argues that you should essentially curb aid and encourage entrepreneurship and trade. Could you just parse that a little bit - how you see it, as a grant-making foundation whose resources come from an entrepreneurial enterprise - and then thinking about what you've learned in Africa over these last few years. What is your answer to the people who say, "Forget about aid. Focus on economic and business development."?
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Well, I would say, look at the statistics. I mean, Bill and I are investing our own money. This is our money that we could spend on other things. We certainly wouldn't put it into aid if we didn't think it was effective!
When I look at health statistics, I see the GAVI Alliance, the Global Alliance for Vaccine Initiatives, and I see that there are 3.4 million children that are alive today because of the hundreds of thousands of vaccines that have been delivered.
I look at the immunization rate in Malawi, and I see that 86 percent of the kids are vaccinated. There are children that are alive because they're vaccinated. How can you stand in Malawi and say aid isn't effective? I just don't understand the argument.
Look at [another] Malawi statistic, on child mortality. They used to be one of the worst in terms of their under-five mortality rate. It's something they have been trying to tackle. Well, they've made progress year over year. They have had four percent decline each of the last 10 years. Now, they are one of the better African nations.
Their infant mortality rate is down to 72 deaths per 1,000 live births. They are probably going to be one of the African nations that makes MDG4 [reducing child mortality] by 2015. Or look at the maternal death rate. It's still high, but significantly down over the last six years, because they are tackling it. And that's because people come in and do aid alongside government programs.
It has to be done in conjunction with the government. At the end of the day, it's sustainable by the government in the country. But the GAVI Alliance has spent about $116 million in this country. You wouldn't have the vaccination rate or the number of children alive from these vaccines if that alliance didn't come in with the money - or if you didn't have NGOs coming in and UNICEF in here working alongside and saying, 'Okay, the government is committed to getting the child mortality rate down. What is it we can do alongside the government, with the programs they are initiating, to make sure the supplies are there?'
Or look at Save the Children, teaching Kangaroo Care. When Save the Children leaves Malawi in whatever year that's in, let's say it's in the next five years, Kangaroo Care will be left behind. The mothers know how to do it, the clinicians know how to do it, the hospital knows how to do it. It's not very expensive and that's saving newborn lives. I say it's absolutely effective.
Where do you see the major development challenges in this next decade. Where do you see the major ways of addressing them coming from?
One of the major development challenges is around food - food security for people. That's why we have such a substantial investment in this Agra [Alliance for a Green Revolution in Africa] program - taking the lessons from the Green Revolution and making sure that those really start to come to Africa and that they are regionally based, so that the farmers have the seeds they need to grow drought resistant crops, legumes that reinvest into the soil, all the things they need. Or, if they want to grow potatoes, [that they have] a drought resistant type of potato. That's one of the things they're doing here in Malawi. The issues around food - making sure that people have food for their families, food they can put on the world market and sell, and that they participate in that world market - I think that's one of the big development issues over the next 10 years.
Finally, a quick follow-up to what you just said earlier that seemed to be alluding to the quality of governance as a factor. Is that something you see as important?
Absolutely. Where you have good governance, it makes all of these things that much easier to do and that much more sustainable.
