In an exclusive interview, mainly focussing on climate change, India’s health challenges, Microsoft co-founder and philanthropist Bill Gates spoke about introduction of newer vaccines in national programmes, investing in primary health and concerns about investing in an under-resourced health sector.The edited excerpts from the interview.

Did you speak about lack of budgets for health when you met the health minister?
That is a discussion I have, every time I come to India. I ask, “don’t you feel pressure from the voters?” My personal opinion is that the Indian health sector needs more resources. I believe it is under-funded.
After investing in HIV programme for years, how come the Foundation has been silent as the Indian national program disintegrates from drug stock-outs and budget slashes?
If they are cutting the budget, the Gates Foundation will be glad to raise our voice and say that is a mistake. I was told that the government has made a commitment to restore the HIV budget. In HIV, it is important to adhere to prescribed drugs. Drug stock-outs are a disaster for HIV- it affects other health outcomes quite a bit. There is no miracle here that the HIV budget can be cut and people can still get the treatment they deserve. That HIV budget should be preserved. If it has been cut, many, many, many people should speak out about that.
What is the thought behind the foundation supporting the Indian government to introduce the controversial Injectable contraceptives in the national programme.
This new policy is fantastic. Lot of rich women use injectables. Not in this country may be, but injectable contraceptives are not an inferior product. If you want to go for spacing, it is actually a very good product. Almost every country supports injectables, India has been quite unique in not supporting injectables. If anything, people should be worried about sterilization – which is very hard to reverse. If we really want to be sensitive, this is the country that does more sterilization than any other country. Of all the methods, that is the hardest to change your mind about.
The idea is to give women a choice. So far, other than sterilization, Intrauterine Devices (IUD) have been the main choice, but many women don’t like them. What we know from experience in other countries is that wherever women are offered lots of choices, you get more uptake. Women pick the one that works for them. Injectables fills a very important need where women don’t like the insertion and removal- it’s a jab- right now it requires a health workers to give you that. In some countries, you can just self-inject. There is a discussion about making that format sense for India.
What is your vision for India’s healthsector, ten years from now?
Today, in India, the out-of-pocket expenditures (amount spent on medical expenses that is not reimbursed by insurance) in each household is a real problem. Will insurance go up? Will the budget at the federal or state level be increased? The private sector in India has some of the best actors in the world and yet consumers don’t have a clear sense as to how they can find their way through the system. We see this best in tuberculosis- there are people who get diagnosed very quickly and then there are people who take years before they are properly diagnosed. Patients spend a lot of money before they are properly diagnosed- usually by the public sector. This is because a lot of people in the private sector conduct various tests that aren’t good for anything accept for the profit they generate for the provider. Everybody involved in this healthcare system needs to think what our vision is here. We have spoken to the health ministry about getting some people together- see where is this system going. It is not clear where the current design of health financing is taking us.
Is universalisation of health coverage on the cards?
That is just a word. At the end of the day, somebody has to make sure the system provides a certain quality of service and make sure it that is financed. There are many ways to go about that- various countries have tried different ways to evolve the healthcare system- mix of private & public, regulate to ensure equality. We want to help India have that dialogue. Today, in terms of quality and finance the system is nowhere near where we would like it to be
The Foundation loves funding big ideas and new technologies. Ten years after you started the grand challenges, few solutions have from it. Are you losing patience as research is taking more time than donors have?
Between, 1990-2015, we have been able to cut down infant mortality by half. India is on the verge of rolling out roll out the rotavirus vaccine, same for the pneumococcal vaccine- these are a result of great work by various Indian entities. These are dramatic things. Innovation is delivering some wonderful things. I am always hopeful that it will come faster. We don’t have an HIV vaccine for example but I continue to invest more than anyone else in it. We (the Foundation) are the biggest investors in Malaria, and tuberculosis. So, obviously I am very optimistic and not frustrated at all. I am hopeful they will come faster. Certainly, health products are more complex than solutions in Information Technology (IT) products. The turn around times are longer.
But there is no doubt that tealth is improving around the world, Id like to see it improve even faster.
What are the lessons to be learnt for weaker health systems from outbreaks like Ebola in West Africa?
Everyday there are more people dying than they should be. The Ebola outbreak was very scary and the foundation got very involved- in some ways the world’s response was too slow. The outbreak also showed that we haven’t thought about certain things-like testing drugs very quickly. If people offer their drugs (in such crisis situations), then do they have to think about some liability. Where do you get the medical expertise, the logistics, airplanes to go in - there are a lot of ways the world could have been better prepared for Ebola. But the end of the day, Ebola dint did not end up killing that many people. More people die of malaria in a week than those who died of Ebola crisis.
The Gates foundation has gone from HIV to Vaccines, and now taken up funding Climate Change…
The main focus of my work is on health and that’s the area in which were investing a lot of money, we have expertise, partnerships. We also do work in agriculture, in finances, but the biggest work remains health. If you want to uplift the poor then you have to ensure agriculture is not impacted, and that climate is conducive for farming. But my main focus, as you can see through our funding remains on malaria, diaorrhea, pneumonia. Climate change could interfere with uplifting the poorest so everyone should care a little bit about that too.
This week you have launched the Breakthrough Energy Coalition in Paris, spoken to world leaders about Climate change. How optimistic are you that there will be a sustainable, binding declaration out of COP21?
I’m no expert on whats going on in Paris. My whole life has been about innovation, from my work on personal computing to the IT sector, and even health and agriculture has been helped by people getting together [to innovate] and use that little miracle. In health, like inventing new vaccines, that’s innovation. In energy, I feel whats best is strong innovation and that’s why I was so excited that 20 countries including India and US and China agreed to double their energy R&D budgets. If we are going to make the cost of clean energy as inexpensive as hydrocarbons, or coal energy today, which will need innovations. That will mean you won’t have to think about this huge trade-off between “Should I be clean” or “Should I electrify”?
We do want to speak about your focus on innovation, but you mention this trade-off. That is the basis for India’s position at COP21, when it calls for ‘climate justice’, the idea that the developed world wants the developing world to cut emissions, while it is desperately trying for economic growth. Do you then support the Indian position? Can your coalition be a bridge for this?
I can’t comment on climate justice, I don’t know what the definition of that is. I think while the premium cost of clean energy is very high, you force an almost impossible trade off between two very important goals. My belief is that if you increase the R&D that will lower the price of energy. A poor person is buying fertilizer, fuel, materials. The price of energy is affecting their life in so many ways, we need to find anything that can bring the cost of that down.
The Breakthrough Energy Coalition (BEC) you have set up says: Technology will help solve our energy issues. What kind of technology and what kind of energy has the best chance in your opinion?
The beauty of the commitment at BEC is that a diverse set of things will be tried. We can try hydrocarbons and hydrocarbon sequestration, there is nuclear fusion and fission. There’s wind energy, but that’s very high up. Instead of solar energy to make electricity we want to look at making gasoline directly, so we don’t have the storage problem. So I would say we have about 15 different paths, so we should back all of them between the various countries.
But India has made it very clear. They want to increase renewable energy to 175 GW, of which atleast 100 GW will come from solar energy. Is India going down the wrong path then?
Well, wind and solar energy will be a big part of the mix, but the intermittency makes it unviable. Energy has to be reliable, and when the sun isn’t shining and the wind isn’t blowing, you still need energy. If youre running a factory 24 hours a day.
So the whole system designed in terms of storage and transmission gets quite complex. You still have other substantial sources of energy that are reliable. So wind and solar can be a part of your mix, but you cant do much with them without a storage miracle.
Many also feel that the push for technology as you have spoken off is the wrong path…that it is in conservation, emission cuts that the world has to push instead of waiting for some elusive miracle, as you term it?
I don’t think you can say to somebody who doesn’t have lights or a refrigerator that they should cut down on energy usage. We want people to have these services, basically the world will use more energy in the future. Even if the US used 1/3rd of the energy it uses today by some…’virtuous behaviour’…the increase in energy demand out of Asia will be far greater than a 2/3rds reduction by everyone in the US. So yes, we shouldn’t waste energy, but we should also be realistic. When you speak of cutting greenhouse gas emissions to zero, you cant conserve your way there, you have to have new energy innovations in order to make up for it.
I do want to ask about a term your critics use, which is philanthro-capitalism…where they say that whether it is climate change or health, your foundation funding is tied to technologies or companies that you have an interest in…how do you respond to that?
The notion that we do what we do out of self interest is….you know somebody should and see if that’s legitimate. We don’t benefit in any way from this. If you think the way to make money is to come to India and help people get healthcare (laughs) that is one strange way to make money. I find it amusing someone can say that. The healthcare system in India is under-funded , and we give money away to it, not make money. We give hundreds and hundreds of millions of dollars to help children get nutrition. We don’t get some benefit back from that.
Mark Zuckerberg says you were his hero…and looks like he is following with you his philanthropic announcement 99% of his shares…you haven’t always been complimentary about his priorities….what do you think of the announcement?
It’s fantastic! Mark is starting at a younger age than I did, he will do things smarter because he wont make the mistakes I did. He is younger than me, but we do partner on many things, his commitment is phenomenal, he is a great person.
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