An op-ed by Kate Kuo- Program Officer, Agriculture, Srivalli Krishnan,-Senior Program Officer, and Nachiket Mor-Country Director, India at Bill & Melinda Gates Foundation

In March 2018, Nature magazine published a groundbreaking 10-year study by China Agriculture University involving millions of smallholder farmers adopting enhanced practices. Through a scaled, countrywide effort, farm productivity rose by 11% while the use of nitrogen fertilizers — critical to increasing crop productivity, but also harmful to the environment when overused — declined by 14–18%. The profitability of the intervention, even before monetising the positive environmental impacts, was $12.2 billion.

The programme was an impressive marriage of knowledge workers, researchers, farmers, new technology, and businesses — all supported by a committed government that stayed the course. The result stunned the scientific community for its scale, success and impact.

The project was carried out under the sponsorship of the Chinese political leadership who aimed to transform agriculture at an unprecedented scale and speed. In December 2014, their central government shifted the focus of agricultural policy from high yields to sustainable production to achieve both food security and environment sustainability. In January 2015, a government document described the future of agriculture for the first time as efficient production, safe products, resource-use efficiency, and environment friendly. A month later, the government released a policy of zero-increase in chemical inputs by 2020. Collectively, these policies aimed to create a high quality, high efficiency, and environmentally sound agricultural sector without a dependency on subsidies.

Between 2005 and 2015, China Agricultural University led a nationally coordinated initiative for 20.9 million smallholder farmers in wheat, rice and maize to promote adoption of enhanced management technologies for greater yields and reduced environmental pollution. The project began by conducting over 13,000 field studies across all agro-ecological zones, from the subtropical south to the frigid north. Based on the trials, over 1,152 agricultural scientists from 33 agricultural universities collaborated with local farmers and experts to develop packages of recommended practices tailored to local conditions. The practices were based on a comprehensive, adaptable framework of integrated soil-crop system management (ISSM), which consists of cropping strategies (crop variety, planting date, and density) derived from the crop model simulations for optimal use of solar and thermal resources and strategies for nutrient and water application according to soil tests and crop characteristics.

The next step in the programme was to disseminate the ISSM practices through a national campaign in collaboration with 65,420 public extension workers and 138,530 private agribusiness staff. A variety of remarkably low-tech approaches were utilised to get the word out, including workshops for farmers to share experiences; in-person, on-site, timely advisory services; enhanced access to high-quality seeds, fertilizers and other chemicals, and demonstration plots.

Importantly, the outreach campaign recognised that changing a farmer’s behaviour required more than scientific recommendations. It required building trust and local capacity. Termed “participatory innovation,” field staff would engage with the most skilled and engaged farmers in the community through close dialogues and interactions. These “lead farmers” would help refine the recommendations to fit the local context, be the “early adopters” of the practices to influence others and serve as resources to answer questions and share experiences during demonstrations. Other local agents and experts would assist in translating the scientific content to common language more understandable to farmers.

A fascinating model emerged in parallel, the Science and Technology Backyard (STB), in which professors and graduate students lived in villages for two years, working shoulder to shoulder with farmers to carry out research centred on transferring scientific results into concrete knowledge and practices relevant for the local community. While carrying out research on improved practices, these students also developed deep bonds with the community through participation in local cultural events. The STB programme has become very competitive, attracting the country’s best students, and will soon be incorporating precision agriculture and agribusiness approaches.

Given the global birth rates, food production needs to be doubled by 2050. The large food producing countries will need to balance their growing national and global consumption requirements with the productivity and environmental challenges they face. This project shows that addressing the knowledge gap among smallholders can significantly improve productivity, farmer prosperity, and environmental sustainability all at the same time. The secret ingredient, though, is not the science. It’s coordinated and consistent action among agricultural players — government, academic institutions, private sector, and farmers.

The article was originally published in Hindustan Times on March 12, 2019

How India can increase its farm productivity was originally published in Bill & Melinda Gates Foundation on Medium, where people are continuing the conversation by highlighting and responding to this story.

An opinion piece by Nachiket Mor — Country Director, India at Bill & Melinda Gates Foundation

There are some interesting developments in progress within India. Extreme poverty is all but gone and by 2025 the prediction is that fewer than 1% of the population will be at that level of income. With the total fertility rate nearing replacement rate, population growth rate has slowed sharply and is expected to fall below 1% per annum by 2025, with several states already showing negative rates of growth. Total calorie consumption has fallen and there are now consistent food surpluses in the country. While each of these statistics is individually remarkable, taken together they paint a picture that is very different from the one that India woke up to on August 15, 1947. The India of naked, hungry, and homeless, teeming millions is all but gone forever, as are the fears of Professor Malthus, one of the earliest teachers of Indian civil servants at the East India Company College in Hertfordshire. As India looks ahead and prepares itself for the next decade, it will need to make room for this new India, and to think very differently than it has in the past.

This new India faces some very different challenges. Very few people below the poverty line but close to 95% of the population being low-income, and not middle-class. Adequate total expenditure on health care by citizens but over 50 million people returning to poverty each year because of health shocks, having to once again claw their way back up. And, despite all this expenditure, a continuing burden of maternal and child mortality and infectious diseases alongside a rapidly rising burden of non-communicable diseases such as high blood pressure, diabetes, and mental illness which have a direct impact on the well-being and economic productivity of young Indians. Absolute hunger a distant memory for families but children with high levels of anaemia and malnutrition which hurts both their physical health and their mental abilities. To respond effectively to these new challenges, India may need to focus its attention and redirect its scarce tax resources towards building up its human capital and rely far more heavily on its well-functioning capital markets and private sector, to address the more traditional challenges of the lack of adequate capital and infrastructure and tools for risk management in the economy.

In a field such as curative health care , given the severe challenges that are inherently associated with it and its strong links to the productivity and welfare of its citizens, countries which have built well-functioning health systems have done so by strongly shaping and controlling their health care markets using all the tools at their disposal, and by so doing have effectively addressed the four concerns of health status, degree of responsiveness, financial protection, and equity. They have all, for example, used taxes (and other tax-like mandatory instruments) as the primary means of pooling current health care expenditures of citizens (currently estimated at over 4% of GDP for India) and have then used these pooled funds to pay for health care , instead of requiring their citizens to pay for them from their pockets when they need to use them. Additionally, all of them have found a way of keeping a strict control on both the quantity and quality of health care that is provided using a combination of their pooled purchasing power and the more traditional licensing and price control regimes, and have not allowed market forces to determine them in an unfettered manner.

India, while continuing on its journey to further strengthen its public health system, may also want to explore these ideas more carefully, to promote the orderly development of its entire health system and to address many of the challenges that it now faces. For example, in addition to allocating a significantly larger share of its annual tax budget for health care as many countries with similar aspirations have already done, it could also further strengthen its commercial health insurance markets and work closely with it to introduce products far more suitable for low-income families. It could also use schemes such as Employees’ State Insurance Scheme and Ayushman Bharat to garner additional resources from the public and in return offer all of them free and high quality health care . Additionally, while India could, over time, further strengthen its capacity to regulate the health care sector, since it already has a great deal of experience in operating strict licensing and price control regimes, it could very rapidly and effectively bring this to bear in health care markets.

This article was originally published in Hindsutan Times on Jan 2, 2019

India’s health care sector needs fresh ideas was originally published in Bill & Melinda Gates Foundation on Medium, where people are continuing the conversation by highlighting and responding to this story.

Joe Cerrell - Managing Director of the Gates Foundation’s Donor Government Relations team working across Europe, the Middle East and South Asia, and Nachiket Mor - Country Director, India at Bill & Melinda Gates Foundation

The world’s progress in improving health and development related outcomes for people everywhere is one of the greatest success stories of the past 20 years. Two decades ago, the infectious diseases that killed or harmed millions often went unchecked. Children born in poor countries were only vaccinated against a handful of the same diseases as children born in wealthier countries. There was no access to life-saving drugs such as antiretrovirals to treat HIV. But if we look closely at the trajectory of healthcare, we realise that since the 1990s, we have nearly halved the number of women who die in childbirth and halved the number of children who die before the age of five.

There are many reasons for these gains. As countries have grown wealthier, they have increasingly invested in their own healthcare systems, helping more of their citizens to live longer and better lives. Aid programmes from donor countries channelled either through their own agencies or UN organisations such as the WHO and UNICEF, have helped fill critical gaps. Large global charities such as CARE and Save the Children have raised funds from government and individual donors and with those funds have run large programmes in many poorer regions of the world.

An additional important reason the world has made such large gains in improving global health in the last two decades is the emergence of the ‘Global Health Funds’. These new and powerful mechanisms have made it possible for donor governments and United Nations agencies to partner with large private donors and civil society organisations (CSOs) to create very large pools of funds and technical capability to tackle some of the most pressing issues that poor countries face. In these funds, organisations like the Bill & Melinda Gates Foundation have contributed significantly, by way of money, deep expertise, and as catalysts, alongside other private and sovereign donors, allowing each one to multiply the impact they could have had if they had acted alone.

The ‘Global Health Funds’ currently comprise the Global Polio Eradication Initiative (GPEI); the Vaccine Alliance (Gavi); the Global Fund to Fight AIDS, Tuberculosis and Malaria (Global Fund); and the Global Financing Facility (GFF) and have had a remarkable impact: In 1988, there were an estimated 350,000 cases of wild polio every year, killing or paralysing its victims. In 2017, there were just 22, with a large and complex country such as India having entirely eradicated the disease, due to the joint efforts of domestic governments, CSOs, and GPEI.

In 2000, 30 million children in poor countries were not being immunised, leading to millions of unnecessary deaths. Since then, Gavi has supported the introduction of 380 routine vaccines into the health systems of vulnerable countries and helped to immunise 690 million children, preventing 10 million future deaths.

Since the creation of the Global Fund, deaths related to AIDS and TB have fallen by a third, and malaria by half. GFF’s ‘In Support of Every Woman Every Child’ is today tackling the more than five million maternal, newborn, and child deaths that still occur among the world’s poorest people each year.

These spectacular gains made in human health need to be sustained and accelerated. Polio is only endemic in three countries, but until we get to zero, all countries will be at risk of polio re-emerging. Following the historic progress of reductions in malaria cases and deaths, we are on the verge of a resurgence that could see millions more at risk. And, despite more children being immunised worldwide than ever before with the highest level of routine coverage in history, increasing coverage rates with children in the world’s poorest countries continues to be a challenge.

To address these ongoing concerns, a massive replenishment effort for these funds is under way. As large philanthropists emerge both at global and domestic levels, these new forms of partnerships and alliances offer a powerful way forward. While donors and governments with the capacity to provide resources at a global scale can replenish these ‘Global Health Funds’, domestic donors can partner with their respective governments to set up similar mechanisms to multiply the impact that they can have working alone. These partnerships are essential if we want to create a world in which where you live does not determine whether you live.

This article was originally published in Hindsutan Times on Nov 1, 2018

Partnerships and alliances are the new mechanisms for savings lives was originally published in Bill & Melinda Gates Foundation on Medium, where people are continuing the conversation by highlighting and responding to this story.

An op-ed by Stefan Nachuk- Deputy Director, Global Development, and Nachiket Mor- Country Director, India at Bill & Melinda Gates Foundation

While much has been written about the universal healthcare models of high-income countries such as United Kingdom and Germany, it is generally not well known that Thailand achieved Universal Healthcare (UHC) in 2002, when its per capita income and health expenditures, and tax base, were comparable to what India has today. Post UHC while total health spending has stayed stable in Thailand at around 4 percent of GDP, the proportion paid out-of-pocket has dropped sharply to 12 percent, while the developing country norm is in the range of 40–60 percent, with large numbers of people returning to poverty for this reason in many countries, including in India. Health outcomes have also improved dramatically. The proportion of children dying in the first five years of life, for example, has fallen to less than 1.2 percent. And, on the chronic disease front, using its primary care platform and well-developed referral system, it has been able to increase access to standard care to about 50 percent of total depressive disorders and decrease its suicide incidence by close to 25 percent. Thailand’s success at making all this happen, even as the low middle-income country it was at that time, was considered nothing short of miraculous, and holds a number of relevant lessons for both developed and developing countries such as India, that are seeking to control costs and associated impoverishment while continuing to improve health outcomes.

One of the key lessons from their experience is the importance of being well-prepared for emerging opportunities. For Thailand this came with the election of a new government which had promised that it would improve the life of the average Thai citizen. By that time, within government and in domestic universities such as Mahidol, Naraseun, and Chulalongkorn, deep technical capabilities in health systems design had already been built, over a period of many years. This gave policy makers access to well-developed approaches and analytics, and allowed the government to move with confidence, and quickly, within weeks of its election, effect dramatic changes in Thai healthcare systems. With these changes Thailand could rapidly expand coverage to those who did not yet have access, while also saving money by shutting down or consolidating selected hospitals that had large government budgets but were seeing very few patients because of quality concerns.

Another powerful lesson is the importance of tight control within health systems. Because the Thais understood that they only had very limited resources at their disposal they initially excluded many high cost treatments such as renal dialysis and organ transplantation. They then went on to build a careful architecture which allowed them, through their Health Intervention and Technology Assessment Program, to clearly specify medically validated protocols and associated prices for all the available services, including diagnostics and medicines. Through their National Health Security Office, they designed a system in which primary care was given importance and patients were prevented from seeking higher levels of care without first seeing their designated primary care providers, and, only where necessary, being given a clear reference to a higher and more expensive facility. Through this office, purchasing arrangements were extended to both private and public-sector providers using payment and quality control approaches that gave priority to patient health and well-being, and avoided unnecessary treatments.

The third and perhaps the most important lesson was the value of being intensely pragmatic and politically astute. For example, they had very few physicians so they worked with nurses. Since did not even have a sufficient number of nurses they hired young women with high school diplomas and gradually ‘grew’ their health workforce by alternating intensive field experience for them with classroom training and certification. Once the reform was introduced and approaches to providing care were rationalized, the prescient decision on their part to include even the non-poor created a broad constituency in its favor which made it hard to reverse. Today, all the main political parties support the UHC scheme, as a result, while it will continue to evolve, it is highly unlikely that the basic scheme would ever be abolished in the future.

As developing countries seek to pivot towards providing universal healthcare to their citizens, the three broad lessons from Thailand, of being prepared, exercising tight control, and being pragmatic and politically astute, could prove to be very valuable ones to keep in mind. In addition, while there will be a need for careful adaptation and learning, there are several other lessons from their experience that hold a great deal of value as well.

This article was originally published in Hindsutan Times on Sep 29, 2018

Thailand’s universal healthcare can be a model for developing countries was originally published in Bill & Melinda Gates Foundation on Medium, where people are continuing the conversation by highlighting and responding to this story.

An op-ed by Raj Shankar Ghosh- Deputy Director, Vaccine Delivery and Infectious Diseases, and Nachiket Mor- Country Director, India at Bill & Melinda Gates Foundation

Diseases that afflict humanity are of multiple types. Some present as outbreaks, such as SARS in Hong Kong and Ebola in the Congo, that call for a rapid response, while others, such as hypertension and cancer require a more planned and sustained effort. To guide their responses, many countries have established formal disease surveillance systems, which Public Health England defines ‘as the systematic regular collection, analysis, interpretation, and dissemination of data for a given population to detect changes on patterns of disease or disease determinants with action taken if a predefined criteria or thresholds are met’.

Surveillance data are collected either passively, where institutions and facilities routinely feed health data into a pre-designed system, or actively, where specifically assigned health workers scan health records from various data sources, including health care facilities, laboratories, and pharmacies. In countries with strong primary care systems as United Kingdom, Brazil, Thailand, and Rwanda, passive surveillance plays a major role, while in others such as United States, Japan, and Taiwan, more of a mixed approach becomes necessary, relying for example on a strong laboratory network. A strong model of active surveillance has been established for example by Canada where a network of reporting sites has been carefully located across the country to collect and report high quality data on prevailing and emerging diseases. These reporting sites in the Canadian Primary Care Sentinel Surveillance Network are supported by a robust laboratory network and well trained human resources. Many developing countries also have such networks and organizing them into a well-designed and fine-meshed surveillance network and equipping and staffing them well, as Canada has done, could be a highly cost-effective strategy for them.

With rapid advancement of communications technology, internet and mobile phones are becoming an important, even if not an entirely reliable, added source for data in many developing countries. While, given the high level of noise, drawing credible inferences from public social media, still needs more work, other avenues have proved to be more promising. HealthMap, for example, offers real time health surveillance data globally collected from news aggregators, eye witness reports, curated discussions, and validated official reports. In 2014, it was the first to report a rise in cases of a “mystery haemorrhagic fever” which was months later announced by the WHO, as the Ebola outbreak after laboratory confirmations. Canada’s Global Public Health Intelligence Network, using media reports of an increase in Emergency Room visits with acute respiratory illness in China, provided an early alert was for what was subsequently confirmed to be SARS. Another platform, ProMed-mail which relies instead on reports from medical workers, is credited with the initial alerts of the MERS outbreak. Several of these platforms have now come together to create a new rapid epidemic detection system, EpiCore, a closed virtual network of health professionals around the world who provide feedback on rumours and news stories for rapid action. These newer channels cannot form the primary basis of a robust surveillance system in any country but have the potential to provide early warnings and added feedback, which can further strengthen such a system.

Collection of relevant data, as stated in the definition, is only one component of surveillance. The other components are collation, analysis, triangulation, and dissemination of the data and its findings, and most importantly taking action. For this to happen it is very important that countries establish a single national focal point for disease surveillance. The United States, for example, has a single point of focus for disease information and action in its Centers for Disease Control and Prevention (CDC), which plays a significant role in alerting the health system and educating the community on significant findings from surveillance data. Additionally, in the face of outbreaks, CDC triggers its Emergency Operations Center, which in turn designs and implements specific, relevant measures to control and curb the outbreak. In China, the China CDC collates, analyses, disseminates, and acts on, relevant disease data collected from a web-based reporting system, the Notifiable Infectious Disease Reporting Information System, which has been in place since 2008 and reports approximately 5 million infectious disease cases annually.

Disease surveillance is key to strengthening the health care system of a country. Building such a system requires concerted action to establish both passive and active data collection capability; the mining of all available data from multiple sources such as news media and health workers; and, above all, building a strong single point of focus to aggregate, triangulate, analyse, and act on this information.

The article was originally published in Hindustan Times on Oct 15, 2018

Disease surveillance is key to strengthening the health care system was originally published in Bill & Melinda Gates Foundation on Medium, where people are continuing the conversation by highlighting and responding to this story.

An op-ed by Marcella McClatchey- Program Officer, Agriculture, Anjani Bansal-Deputy Director, Agriculture, and Nachiket Mor- Country Director, India at Bill & Melinda Gates Foundation

Large numbers of low-income families the world-over depend on agriculture as their primary source of income. Agriculture is however a challenging sector and several issues prevent farmers, in particular small-holders, from realizing greater incomes. These include, low yields, weak market linkages, high price volatility, limited risk management, and poor price realization. Given the very large numbers of people involved, addressing these concerns of farmers is an important goal of public policy. For farmers’ incomes the keys to transformative growth are, among other things, the two areas of price and yield risk management.

Price risk management: Like other commodities market prices of agricultural products are highly volatile. Spot, futures, forwards, and options are essential tools which accurately transmit market signals to farmers and simultaneously allow them to choose the risk management approach that is best suited for them without relying on ex-post subsidies should markets turn adverse. A number of countries have focused on making these tools easily available to farmers.

In Australia for example, both farmers and buyers are able to purchase the necessary forward contracts and put and call options on agricultural products directly from their banks. Here cotton growers are the most prominent users of these tools to manage price risk and around 20% of wheat growers use market price risk management techniques such as futures contracts, options, and over the counter products like swaps. Easy access to these products and services has transformed the incomes and risk exposure of these farmers allowing them to respond to market signals by purchasing the level of protection that they need at market prices and altering their cropping patterns where necessary.

In Brazil, in response to a fall in bank finance for agriculture, the Bank of Brazil introduced an instrument called Сedula de Produto Rural (CPR), a tradeable product note, which represents a promise to supply a fixed quantity of agricultural produce in the future (tradable CPR, introduced in 1994) or its future financial value (financial CPR, introduced in 2001). Farmers are able to sell CPRs to raise financing. These instruments allow them to both raise financing at a competitive price, as well as transfer the commodity price risk to the buyer. CPRs in Brazil are deemed to be to be securities and are actively traded on the commodity exchange. Commercial banks are permitted to participate in these contracts as well. The quantum of finance being raised by farmers in Brazil through this route is to the extent of 40% of total financing whereas traditional bank financing amounts only to 30%.

Yield risk management: While effective management of price risk is essential, it is also equally important for the farmer to be able to effectively manage the risks to the yield that she is able to get from her farm. Crop insurance incentivizes farm investment and increases farmers’ ability to absorb shocks. However, to be effective at scale, technological tools like remote sensing and machine learning for better standardization and quality assurance of underlying crop data are needed to streamline decision making processes between insurance providers and farmers.

In the United States, where 90 percent of farmland is covered by insurance, companies have started to use drone technology to ather data on insurance claims following adverse weather events that affect production. Drone footage can be assessed using machine learning and computer vision software to increase the speed, reliability and targeting of claims processing and make payouts faster. In Europe, new agricultural technology companies are offering solutions in areas such as data intelligence and processing, farm mechanization, and robotics. By combining satellite data with artificial intelligence, weather information, and drone-based soil mapping, technology can, for example, be used to optimize planting periods, forecast crop yields, detect pests and diseases, and even help pin-point for the government where new irrigation projects need to be located for maximum impact. For example, a recent agreement between PartnerRe, a US based, diversified reinsurer, and Farmers Edge, an American decision-agriculture company, will allow farmers to access customized insurance products with integrated precision-farming capabilities. Insurers will also benefit from a more efficient loss adjustment process.

If farmers, the world-over, including in emerging economies such as India, are able to benefit from such approaches towards price and yield risk management, they will be able to build a great deal of resilience in their approaches towards agriculture while responding accurately to the signals from the wider agricultural market.

This article was originally published in Hindustan Time on Sep 13, 2018

Risk management is the way forward for farming was originally published in Bill & Melinda Gates Foundation on Medium, where people are continuing the conversation by highlighting and responding to this story.

Health systems around the world are benefitting from recent advances in supply chain technologies to deliver essential medicines to patients, more effectively. Traditional lines between public, private, online, and physical are starting to blur and, as a result, for example, direct-to-home and online pharmacy models have developed more quickly in emerging markets like India than many had expected. A commonly used supply chain architecture for essential medicines in most developing countries has historically been bulk procurement by the national or state/provincial government and then distribution to districts and health clinics owned by the government. This approach, even when well implemented, may suffer from many problems which are linked to, among other things, multiple levels of complexity, long resupply intervals, uncertainties in financing, and diffused accountabilities. Many countries, have therefore developed alternative supply chain models based on modern day supply chain science and technologies.

South Africa, for example, is now implementing a model in which the government negotiates prices and select suppliers, but the suppliers deliver the medicines directly to health clinics or district hospitals. In the past, such models were not feasible because of the challenges in verifying whether the supplier delivered the right quantity of products to the clinic. In South Africa, a new supply chain visibility platform enables supplier-direct-delivery by providing government procurement managers with unprecedented visibility into stock, receipts, and consumption at each health clinic.

One of the main sources of underperformance within supply chains stems from the lack of information capture and information sharing. Modern supply chains have adopted information and communication technology, such as the Electronic Vaccine Intelligence Network being used in public sector in India, to improve information flow and decision making across these supply chains.

In Senegal, the government has started contracting private, third-party, logisticians for last-mile deliveries of all essential medicines from district warehouses to individual health clinics. Healthcare workers in clinics no longer have to determine order quantities for medicines or travel to district headquarters to collect medicines stock. The third-party logisticians deliver an assortment of 100+ medicine to each clinic and use tablet computers to collect stock and consumption data. This data coupled with advanced analytics allows for more precise forecasts of how much to ship to each clinic in the next round of delivery. As a result, medicine shortages have practically been eliminated in Senegal, that too at a reduced cost.

Around the world there is also a concern that distribution reach of the private sector is confined to more concentrated urban areas whereas those living in rural, remote regions depend on the public-sector medicines distribution system. Australia is one of the most sparsely populated countries in the world. Stocking products which are infrequently ordered and delivering them to remote rural pharmacies/clinics means minimal or no profit for private wholesalers and distributors. To remedy this incentive problem, the government of Australia runs an incentive pool which pays a small bonus to wholesalers who supply the full range of medicines to pharmacies in designated remote areas at or below the negotiated price. The Community Service Obligation (CSO) Incentive pool is overseen by an independent agency which monitors compliance and conducts regular audits of the distributors. Managing such an incentive pool requires strong government oversight and enforcement, but new digital technologies could also enable such structures in fragmented markets with lower enforcement capacity.

The private distribution network for medicines in China (not unlike India) is a complex multi-tier network with multiple middle-men between the manufacturer and the end-clinic. Some of the channel intermediaries charge additional markups adding to overall healthcare costs. The multiple product handoffs from one intermediary to another lead to the lack of transparency in the system and increased risks for fake products entering the supply chain. Modelling studies have shown the multiple benefits of reducing the number of tiers in the supply chain. Learning from them, China has now implemented a “two-invoice system” whereby only two invoices can exist between a manufacturer and a clinic. Each manufacturer sells to a distributor and that distributor sells directly to hospitals and clinics, eliminating multi-tiered distribution. In its phased implementation, rural areas which require “fine mesh distribution” would be allowed up to three invoices till national distributors can expand their distribution coverage to all regions.

As countries around the world, including India, attempt to ensure the timely availability of a full range of medicines to each and every one of their citizens, they would benefit greatly from studying some of these newer approaches that have been implemented, and developing appropriate solutions to their own challenges.

This article was originally published in Hindustan Times on 30 August, 2018

Overhaul the medicine supply chain was originally published in Bill & Melinda Gates Foundation on Medium, where people are continuing the conversation by highlighting and responding to this story.

An inseparable part of the human body, the complement of microorganisms living within our intestine, called the intestinal microbiome, plays a critical role in directing healthy growth and development, and preventing vulnerability to childhood illness. Research links the microbiome with better cognitive scores in one-year-old infants, and has identified brain and behavioural characteristics clustered by gut microbiota profile, in middle-aged adults.

We now know that the human gut microbiome impacts human brain-health in numerous ways, such as stimulation of the innate immune system and the production of hormones and neurotransmitters that are identical to those produced by humans. In this way it stimulates different neurons of the enteric nervous system, thus impacting architecture of sleep, reaction to stress as well as memory, mood, and cognition. To build physical-health, the gut microbiome allows appropriate nutrient absorption and defends the body from invading organisms. It directly impacts the body’s immunity and metabolism and determines our response to external medication and vaccines. The greatest load and diversity of microbial cells is believed to be within the gastrointestinal tract and any disruption in the balance of these microbes is also associated with a number of adult diseases such as diabetes, obesity, inflammatory illnesses such as arthritis, autoimmune conditions, and even psychological and neurological ailments.

Gut health is largely dependent on three factors: (i) the balance of the microbes present in the gut, (ii) the proper functioning of the gut barrier that separates microbes from the immune system, and (iii) the well-being of the gut immune system itself. When the gut barrier allows appropriate nutrient absorption and defends the body from invading organisms, it directly impacts our body’s immunity and metabolism. It also determines our response to external medication and vaccines. There are three main therapeutic approaches that might be used to address gut health: food, microbes, and medicines.

a. Food: It is critical that infants get an adequate supply of breast milk in the first six months. In addition to helping with the growth of good bacteria, several studies have shown that there is a mother-to-infant transfer of the required bacterial strains through breast milk. It is also important for gut-health that young children as well as pregnant and lactating women receive a balanced nutrition consisting of diverse ideally fresh foods with adequate protein, fat, carbohydrates, and fibre as well as other key micronutrients and bioactive molecules that help good microbes and the individual grow.

b. Microbes: A separate therapeutic class involves ingesting the microbes themselves, such as carefully chosen probiotics (e.g. Lactobacillus and Bifidobacterium), or more exotic healthy bacteria found only in the gut, that can help increase immune responses to oral vaccines and protect children from infectious diseases.

c. Medicines: A third approach involves delivering gut-targeted pharmaceuticals that act upon the lining of the gastrointestinal tract to help improve the gut’s barrier function and immune system.

Medical science is rapidly learning how to manipulate gut microbes to address underlying disease vulnerability. There are several very promising gut-microbe-based clinical trials around the world that are evaluating interventions aimed at reversing the high rate of neonatal malnutrition and stunting. In a trial in Bangladesh, researchers are evaluating the role of rationally designed foods to repair the microbiome of 12–18-month-old children with malnutrition, in order to promote weight gain. Another trial in Bangladesh is evaluating a carefully chosen probiotic together with a special sugar microbes like to eat, in malnourished breast-feeding 2–6 month old infants, to improve their weight gain and healthy growth. Scientists in South Africa are working with older, 18–60 months of age, children with malnutrition, to see if microbial transplants from healthy guts can restore intestinal microbiomes and healthy growth.

Despite the dramatic progress in the last two decades, infant mortality remains one of the biggest health challenges faced by the world today. Focus on the microbiome and gut are now at the cutting edge of scientific research on infant health and malnutrition. It is heartening to note that there is emerging evidence that the microbiome dramatically affects nutritional status and this approach has the potential to overturn traditional approaches. Promoting the development of healthy gut bacteria through appropriate nutritional interventions could go a long way in boosting overall health.

This article was originally published in Hindustan Times on Aug 16, 2018

Gut microbes are critical enablers was originally published in Bill & Melinda Gates Foundation on Medium, where people are continuing the conversation by highlighting and responding to this story.

The first few hours and days of life are critical for the survival of a child and most of the factors that need to be addressed during this period are clinical in nature and are under the control of the attending nurse or physician. However, these factors are responsible for only about half the under-five deaths, because the rest of the deaths take place once children return home from the hospital. Recent research has identified that the greatest danger to children under 5 is not acute illness, but prolonged, and as yet poorly described, forms of vulnerability that produce worse-than-anticipated outcomes, particularly when combined with other childhood illnesses. This research thus raised the question as to whether there is a set of underlying factors which are not biological or clinical that make these children far more ‘Socially Vulnerable’. This vulnerability arises in and from familial and wider community contexts in which these children are placed. The concept of Social Vulnerability captures the environmental, socio-cultural, and temporal dimensions of childhood vulnerability and describes stages prior to clinical vulnerability and well prior to morbidity. It defines a family’s ability/inability to respond to child care needs during the three stages of: (i) everyday care and exposure to risk factors in the home, (ii) care seeking pathways and the variation in the time taken to seek care, and (iii) nursing and follow up during the recovery phase.

More recently, using tools from anthropology, careful research at the family level has allowed the field of public health to more deeply explore what factors lead to social vulnerability. In many countries, including Ethiopia, Tanzania, and India, community health-workers play an important role in the delivery of primary healthcare. They often work for years in certain locations, and have an instinct about which children are more vulnerable than others. Using this instinct or social knowledge, it has been possible to co-design a Social Vulnerability Identification Tool which can help them quickly identify different family types according to the unique barriers they face (diagnosis), and to more sharply tailor their engagement with these families to target specific categories of vulnerability (treatment).

One such effort, for example, groups families into five types: (i) Survivors: experience enormous paucity of income; (ii) Conservatives: are rigidly bound by strict traditional norms of behavior; (iii) Strivers: are perpetually short of time and need to balance multiple commitments; (iv) Potentials: have specific critical-knowledge gaps; and (v) Pilots: balance every aspect of their lives in an optimal manner. In this characterization, the children of Survivors live in unsanitary conditions, on the remote fringes of a village making getting access to care much more difficult, and are unable to properly care for the child once she returns home after an episode of illness. In a Conservative family, tradition defines the kind of care a child receives and the mother has little power to decide when to seek care. For the Strivers, the mother has no time to follow the given advice and often delays seeking care until the child is seriously ill. The Potentials, make repeated mistakes in taking care of the child because they fail to recognize the specific risks that they are exposing the child to.

Once a health-worker identifies the closest type to which a family belongs, she is able to rapidly deploy the tools necessary to address the specific social vulnerability being experienced by the family. In this example, for Survivors it is clear that income support from the government is a must, for the Conservatives identifying the true decision makers within the household and then working with them to develop new norms of behavior would be essential, for the Strivers offering them time efficient tools and social support is key, whereas for the Potentials drawing their attention to specific risks associated with their existing childcare practices would be very important instead of offering generalized advice. The Pilots can be relied upon to act as role models where appropriate, and to support the health-worker in helping to address the specific challenges being faced by the other families.

This is only one example of a grouping that could be employed in the field. The key here is to offer groups of community health workers sufficient training and support so that they are able to create their own typologies and related heuristics, allowing them to respond rapidly with targeted guidance instead of taking a more generalized and uniform approach towards families under their care.

The article was originally published in Hindustan Times on Aug 1, 2018

To save lives of children, diagnose and treat their social vulnerability was originally published in Bill & Melinda Gates Foundation on Medium, where people are continuing the conversation by highlighting and responding to this story.

Costs relating to healthcare have a feature that is very different from that of virtually all the other services such as education, food, and clothing. This is the extremely high variability associated with these expenses. There are long periods when most individuals have predictable expenses which can be planned for through savings. However, there are times when some individuals face very high levels of expenditures, such as when they get cancer or are severely injured in an accident. An important question that all societies need to answer is how will these expenses be paid for?

Economic theory indicates that expenses that have such an uncertain character are not best financed through savings and loans because those tools ultimately are limited by the lifetime income and other expenses of that particular individual. Instead it suggests that since all individuals, including those that are completely well, face the possibility that they may need to incur such expenses at a moment’s notice, they will be better off if they paid a fixed sum of money into a pool on a regular basis, and relied on this pool to pay for these unpredictable expenses. Theory also argues that since almost all individuals don’t like risk, participating in such an arrangement will reduce the level of risk that they experience, and even if they never need to draw on the pool, they will feel better. However, despite the strength of the argument, the global experience is that most individuals do not spontaneously choose to participate in such an arrangement. There are a number of reasons for this, including poverty, and potentially the fact that evolution designed the human race to give little or no importance to the risk of falling seriously ill or dying sometime in the future. This is a core problem with which countries around the world have grappled.

In upper income countries, the most popular solution has been to use payment of taxes as a pooling mechanism and then to offer free healthcare services to individuals when they need them. Unlike in India where only 15–20% of the health expenditure is met out of tax resources, in the US the number is 50% and in Canada and the UK it goes up to as high as 80%. Others, like Germany and Japan, require employers to compulsorily deduct a certain portion of the employee’s salary and pay this into one or more pools of funds. These countries then use their tax resources to pay into these pools on behalf of those that are not able to pay because of poverty or unemployment, and to shore up pools themselves if, for some reason, they run out of money. Compulsory deductions account for close to 60–65% of health expenditure in these countries. India’s Employee State Insurance Scheme has a similar character but currently accounts for less than 1% of annual health expenditures.

Costs relating to healthcare have a feature that is very different from that of virtually all the other services such as education, food, and clothing. This is the extremely high variability associated with these expenses. There are long periods when most individuals have predictable expenses which can be planned for through savings. However, there are times when some individuals face very high levels of expenditures, such as when they get cancer or are severely injured in an accident. An important question that all societies need to answer is how will these expenses be paid for?

Economic theory indicates that expenses that have such an uncertain character are not best financed through savings and loans because those tools ultimately are limited by the lifetime income and other expenses of that particular individual. Instead it suggests that since all individuals, including those that are completely well, face the possibility that they may need to incur such expenses at a moment’s notice, they will be better off if they paid a fixed sum of money into a pool on a regular basis, and relied on this pool to pay for these unpredictable expenses. Theory also argues that since almost all individuals don’t like risk, participating in such an arrangement will reduce the level of risk that they experience, and even if they never need to draw on the pool, they will feel better. However, despite the strength of the argument, the global experience is that most individuals do not spontaneously choose to participate in such an arrangement. There are a number of reasons for this, including poverty, and potentially the fact that evolution designed the human race to give little or no importance to the risk of falling seriously ill or dying sometime in the future. This is a core problem with which countries around the world have grappled.

In upper income countries, the most popular solution has been to use payment of taxes as a pooling mechanism and then to offer free healthcare services to individuals when they need them. Unlike in India where only 15–20% of the health expenditure is met out of tax resources, in the US the number is 50% and in Canada and the UK it goes up to as high as 80%. Others, like Germany and Japan, require employers to compulsorily deduct a certain portion of the employee’s salary and pay this into one or more pools of funds. These countries then use their tax resources to pay into these pools on behalf of those that are not able to pay because of poverty or unemployment, and to shore up pools themselves if, for some reason, they run out of money. Compulsory deductions account for close to 60–65% of health expenditure in these countries. India’s Employee State Insurance Scheme has a similar character but currently accounts for less than 1% of annual health expenditures.

Economic theory makes it clear that some form of pooling is essential for all countries to meet the highly variable components of health expenditures and to make them affordable. Experiences of different countries, however, suggest that each one will have to approach it based on its own unique context. For India, it is very likely that a combination of the Asian and African models will be the most relevant because it does not have either the tax base or the formal sector employee base of the Europeans and the Canadians.

This article was originally published in Hindustan Times on July 12, 2018

Health spends can’t be left to chance was originally published in Bill & Melinda Gates Foundation on Medium, where people are continuing the conversation by highlighting and responding to this story.