Melinda Gates: Innovation the right dose for Africa’s health and poverty symptoms

You are in Africa at a time the continent is hosting the Commonwealth Heads of Government Meeting. What message did you bring to this meeting?
 
My message was that there's incredible innovation going on on the continent, with a young generation that's up and coming with a lot of ingenuity. And, you know, so much progress has been made on the continent in the past 20 years.

Childhood deaths are down, immunisation rates are up … all of that progress. We need to maintain the momentum because some of those things went backwards due to Covid.

Malaria deaths are up, immunisation rates are down. And so my message is, let's keep what we call in the US the pedal to the metal - let's keep pushing forward all this progress and change that’s happening. When we invest in the health system, people grow up healthy, they don't deal with much malaria and then they can go on to get a great education and the job that they want and fulfil their dreams. And so my message is, let's make sure we keep focusing on health so that this amazing young population can live its dreams.
 
You were there when the Kigali Declaration on eradicating malaria and neglected tropical diseases was adopted. Now, looking at what is happening globally – with pandemics like Covid, wars and disruption of global supply chains - don’t you think it's too ambitious to achieve by 2030? 
 
We have innovation on our side. Ten years ago we didn't have a malaria vaccine, we didn't have any vaccine for a parasitic disease.

Now we have one, and it's being delivered in Africa. It's only 50 percent efficacious, but we have another vaccine coming very soon that should be more efficacious. Again, 15 years ago it was difficult for a mother to get a bed net. And then we started delivering bed nets. People now regularly use bed nets and, well, a next-generation bed net with a better insecticide is coming. So we have all this innovation. And we have people used to doing the right things like detecting malaria in the health system, detecting it quickly and getting on top of it quickly.

We have families that are now sleeping under bed nets. So it's possible. It certainly is an ambitious agenda, and a lot will hang in the balance with this war in Ukraine that's causing all kinds of problems in countries, including the continent of Africa. But we need to keep fighting because we're seeing many more people being healthy and not dying of malaria as in the past. 
 
Do you see more political will in the implementation of health and development programmes you've helped finance?
 
Definitely. I mean we're sitting here in Rwanda. They have invested in their primary health care system. I've just come from the telemedicine project, which is run by Babyl (an organisation using an app that uses artificial intelligence and machine learning with live health workers for consultation).

They’re taking the patient load off doctors and making sure that patients can call into a call centre, where there are nurses and doctors, and they go through their symptoms, and then they triage. Some of those patients need to go to the health clinic, but some can be treated over the phone or sent straight to the laboratory to get a test, then decide if they need to see a doctor, and so taking that load off the system so that the doctors can deal with the most serious issues.

Boy, that's a fabulous innovation! And they're doing it using feature phones, which are predominantly used in Rwanda and many countries in Africa.

But when you think of how that's changing the health system, wow! Just like M-Pesa when it was first created in Kenya, you could do a bit with it. But now when I see so many countries doing digital money and doing digital ID, people are able to save and to transact. If people save, if there's a health shock or something they want to invest in - like a business or their children’s education – they have the money. I'm seeing a lot of good change across the continent. You see a case like Rwanda, and you think, wow, this is really possible.
 
You have placed women at the centre of your programmes and that seems to be paying good dividends…
 
Put women at the centre and it starts to change things: They change their family, they change their community, they change a whole country. Rwanda is a great example. Over 60 per cent of parliamentarians are women. And when you go into the banking sector - you see a woman at the helm at the Bank of Kigali - and it's not, as some women have pointed out to me, unusual anymore.

The policies and laws have been changed and now it's got where the social norm is: you expect to see women in lots of high roles. I think that kind of change is possible when you empower women. I also know in the development community we have to do specific programming. So we can't assume that if there's one phone in the family, it's a woman who has it, you have to assume the man has it.

So, what's the extra mile we need to go to make sure the woman has an account on that phone, because the man will get the phone, he'll get a digital account, but she needs one too? Again, at Babyl they found that as soon as they got women signed up with a national ID, more women were calling into the call centre.  So, I know that empowering women makes a difference.
 
You have had messaging around reproductive health. How has that gone?
 It's gone actually well, and we're seeing more places across the continent where women are asking for contraceptives, whether you're in Niger, Senegal, Kenya or Rwanda, women are saying “this is a tool I need and want to use”. I think the message has been well received, but we still need to do more to have more supply of contraceptives.

One thing they do here in Rwanda, which is what countries that are farther along on this journey do, is to offer a basket of contraceptives, you know, long-term and short-term; long-term being an IUD (intrauterine device) or an implant, short-term being the pill or condoms. When you offer that basket, women are more likely to use and stay on a contraceptive.

And then you add something like telemedicine, where there's no bias, they feel it's private, they can get counselling. When women can time and space their births, they're healthier, their children are healthier, and the family is wealthier.
 
There has been a discussion around equity in terms of access and supply of medicines and vaccines between the rich countries and poor countries. How can this be resolved?
 
Covid exposed the inequities and injustice in health. The fact that the high-income countries were in line first for medications and vaccines, that's not okay. And so, the countries that couldn't get them were outraged and they should be. But I think one of the silver linings coming out of Covid was making sure that more vaccines are created in more places.

On the continent of Africa, there should be probably three regional hubs. Before coming to Kigali I visited the Institut Pasteur de Dakar, Senegal, where the Foundation has been investing since 2012. They've been around almost 100 years, they make yellow fever vaccine of very high quality. Well, guess what?

There's still a shortage of yellow fever vaccine, so they're ramping up production. And Russia has just dropped out of the equation.  So Institut Pasteur de Dakar are going to create much more capacity. They are also readying to create a measles and rubella vaccine. So it doesn't have to be created somewhere else; it can be created on the continent. Other vaccines with this mRNA technology are coming along. If we invest now, which you just saw BioNTech do here in Rwanda, then as mRNA comes along, it may eventually help us deal with malaria and tuberculosis.

And Institut Pasteur in West Africa will also move to mRNA vaccines over time, and then I think we’ll probably have one other hub on the continent, likely in the south. That’s going to make sense for Africans.

 
We’ve seen a move from grants to partnerships. What next? Do we foresee in the near future sub-Saharan Africa financing its own health programmes? 
Yes, the goal should always be helping low-income countries become middle-income countries and middle-income countries become high-income countries.

That’s where everybody would like to progress. So, our job is to have deep partnerships, understand what's needed and what our partners want, and then we do a mix of grants and investments. We are all about trying to make sure there is innovation, but that the innovation is shared equally. Some 95 percent of malaria cases are in Africa and 96 per cent of the deaths happen here. So, we felt that there needed to be more innovations. That meant having to put in a whole bunch of scientific grants to incentivise scientists to do it. And it means investing in things like mRNA. So when it comes along, we can use it for malaria.

I think African governments want to be self-sustaining, right? So we try to be in deep partnerships to make sure governments are on that path. We're trying to connect the dots and help people see all the innovations that are going on so that they can be shared.

So as I mentioned, at Babyl in Rwanda, we made a grant to help them get up and running. Today it is run by Rwandans and they don't need continued grants from us; they're on a path where they will break even in a couple of years. 
 
What makes you lose sleep about global health?
Let’s just take Covid as an example. I was outraged to see that there were healthcare workers in Africa who couldn't get a vaccine when we were giving it in the West, you know, essentially to everybody.

That didn't make any sense. So that kept me up at night. I've been in and out of lots of health clinics in Africa and I know how tough those environments are. And those are the people doing the hard work - the frontline work. So, that certainly kept me up. I did a little better, personally, when I started to see the women going out and the health care workers giving the right messages, making sure people hand-wash, making sure they wore masks, I was like, okay, they're doing the real work until they get a vaccine.

But what keeps me up at night is just knowing there's still needless maternal deaths, just because we haven't helped fix health care clinics in the right way and children are dying. I've been in situations where I've seen babies sucking on oxygen, with pneumonia, where there's not enough oxygen to go around, you know, a little premature baby. That’s tough.

And so it still keeps me up at night that we haven't got further. We’ve done well on infant and child mortality, but we need to do better. We really do.

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