Further together: Insights from our India country office

At the Bill & Melinda Gates Foundation, we believe that all lives have equal value. That is why we focus on improving the lives of India's poor and marginalized.

We know, however, that we belong to a large and diverse ecosystem of institutions that share this focus, so we look for opportunities to work together and contribute our unique expertise.

In our partnerships, we play an important but limited role. This role is necessarily limited by the fact that our resources are tiny when compared to what Indian state governments, the Government of India, and Indian companies are already investing in their development priorities. Our objective, then, is to provide strategic support to help India get the best results possible from its investments.

This support begins with the technical expertise we are able to provide. Our foundation brings together leading local and worldwide experts to help devise innovative solutions to key development challenges. Should further expertise prove necessary, we also have access to a global network of problem solvers with experience in an even greater range of issue areas. Our convening power, our ability to marshal intellectual resources from every sector and every region of the globe creates unusual flexibility to adjust to needs as they emerge or evolve.

This year's letter gives concrete examples of the different kinds of collaborations we enter. We hope that telling these stories will help people understand how we fit into the dynamic ecosystem of Indian innovation. We also hope they convey a sense of the way partners and grantees organize creatively around challenges to make change happen. Finally, we hope that they make it clear how much exciting work is happening in India to make millions of people's lives better.

Working with the Government

More than a decade ago, the Government of Bihar made the decision to prioritize healthcare for mothers and children, and this focused effort has started to show impact. The child mortality rate in India's third-biggest state has declined since then by one third.

As part of this investment in its people's well-being, the state government sought partners who could provide technical support. Our foundation already had a team working on maternal, newborn, and child health, the area where Bihar wanted to focus, so in 2010 we started working together.

The public health system in Bihar consists of hundreds of thousands of health workers, from doctors and auxiliary nurse midwives in primary health facilities to ASHA and Anganwadi workers who provide basic advice and care to women in communities. We began by helping the government test new techniques and technologies to improve the quality of these providers' services in eight pilot districts. For example, to help frontline workers advise women about healthy practices like breastfeeding, we developed next-generation teaching aids based on digital technology. In facilities, we established a nurse-mentoring program that has, among other successes, doubled the number of nurses who wash their hands and wear gloves before and during procedures.

Though these interventions have led to successful outcomes, a careful review of the data revealed that by themselves they were unlikely to have enough impact on maternal, newborn, and child survival, which was the ultimate goal of the work. Therefore, the Government of Bihar, our foundation, and our grantee CARE India agreed to expand these investments in innovative methods and tools that solve specific problems to more districts and to augment them with investments in basic best practices that strengthen the underlying health system in general.

The partners are now working to bolster everything about Bihar's health system, from budgeting and procurement to management practices and data collection.

This two-pronged approach that layers technical solutions on top of a stronger health delivery platform promises to help Bihar meet its goals while generating lessons that will benefit other partners, especially other state governments interested in investing in the health and the human capital potential of their people.

Working with Corporates

One way to strengthen health systems is to ensure, as we have been doing in Bihar, that supply chains are working and that health workers always have the equipment and medicine they need. Another way is to develop new and better equipment and medicine. India has the technical know-how to be a global leader in this area.

The challenge, however, is that R&D is expensive, which is a particular problem when the products are intended for poor people and it's not clear how much demand there will be. Therefore, our foundation has worked with biotechnology and pharmaceutical companies in India to help remove some of this risk and uncertainty, either by subsidizing the development of specific products or by guaranteeing a certain level of demand for those products, once they become available. We hope that these collaborations not only save lives right now but also ensure that there’s a steady pipeline of high-quality, cost-effective public health solutions for the country.

We have worked with companies in India to develop affordable vaccines that protect children from the deadliest childhood diseases, including pneumonia, cholera, and enteric fever. We worked with BioE [Hyderabad] on a Measles-Rubella vaccine and with Bharat Biotech [Hyderabad] on the rotavirus vaccine, Rotavac, which is now being scaled up as part of the country's immunization program.

An organization we work closely with is Serum Institute in Pune. Founded in 1966, Serum now delivers more doses than any other vaccine manufacturer in the world. It is estimated that two-thirds of the world's children receive at least one dose of a Serum Institute vaccine.

A decade ago, Serum developed the MenAfrivac A vaccine with support from the foundation, which helped put together a powerful consortium of partners to help with this complicated project. The vaccine, which was used in the sub-Saharan Meningitis belt, has wiped out the dreaded Meningitis A virus. Now, we are working closely with Serum on the development of a pneumococcal conjugate vaccine.

We hope our support has increased the availability of lifesaving vaccines in the country, while helping the Indian vaccine industry thrive so that it can continue innovating to improve the lives of all Indians.

Working with Communities

Organizations, both in the private and public sector and governments, provide products and services to people all over India. However, by far the most important agents of change in the country are the people themselves. We work closely with dozens of community-based organizations doing innovative work to empower citizens in villages, towns, and cities across the country.

Many of these organizations are building off the work of self-help groups. Largely an Indian innovation, self-help groups now receive government support because evidence proves that community members working together empower each other and improve each other's quality of life.

In 2012, Project Concern International (PCI) ran a pilot project called Parivartan to learn how to encourage the members of self-help groups to adopt healthy behaviors even when unhealthy behaviors are deeply ingrained. They focused on hygiene, nutrition, and sanitation practices, because customs around food and feeding are very difficult to change. The Parivartan project found that the key was providing a range of healthier options instead of prescribing a single solution that might not work for everyone.

Now PCI is using what it learned in the pilot to work with thousands of self-help groups supported by the Jeevika program in Bihar, and it is seeing progress even with behaviors that are traditionally slowest to change. Studies show, for example, that women exposed to PCI's approach are more than twice as likely to feed their toddlers diverse and healthy diets, which means their children are less likely to suffer from chronic malnutrition and more likely to survive and thrive.

In many of the very same communities where PCI is working, an organization called Digital Green, created in 2007, is disrupting agricultural extension services as farmers have known them for decades. Typically, advice about agronomy comes to farmers, when it comes at all, from a far-away bureaucrat unfamiliar with local conditions. Digital Green turns this model on its head by training local people to film and screen training videos showing local farmers teaching about local crops in local languages. This approach is not only a much better way to convey information to large numbers of farmers spread out across the subcontinent; it also empowers farmers by giving them a greater say in planning their own futures.

In the past decade, Digital Green has trained more than 11,000 extension agents to use more than 4,000 videos in 18 Indian languages to provide instruction to 1.3 million smallholder farmers. In one study in Bihar, rice farmers who watched Digital Green's videos adopted 50 percent more improved practices and increased their yields by more than 20 percent than farmers who didn't.

Now, with our help, Digital Green is experimenting with a pilot program that helps smallholder farmers aggregate and transport their produce so that it fetches a better price in the market. Everything Digital Green does is based on the conviction that farmers and their families prosper when they have more control over their lives.

Working with Institutions

The beauty of all the partnerships described above is that they are sustainable. They are producing new knowledge and skill that organizations will use to keep on improving people's lives. Digital Green, PCI, Bharat, BioE, Serum, and Indian state governments will be building India's future for years to come.

One other role we play is helping build capacity so that organizations and institutions are able to respond to challenges as they arise. We believe in the importance of technical expertise, and when we don't have enough to share on important topics, we invest in those who do by supporting centers of expertise.

Consider the paradigm-shifting goal of the India Sanitation Coalition, which aims to replace an old technology (expensive sewer systems) with something cheaper and better. To accomplish this, it needs access to the very latest ideas about how to design and implement innovative sanitation systems and technologies. We have helped by investing in the Water, Sanitation, and Hygiene Institute (WASHi), which provides technical assistance to governments, conducts training, research, and advocacy, and implements WASH-related programs in communities. WASHi, which works closely with the Ministry of Housing and Urban Affairs, has trained more than 100 sanitation professionals at Madurai Kamaraj University and developed groundbreaking toilet and fecal sludge management technologies. For example, the Sunidhi toilet solves a range of problems that prevent many women from safely using public facilities. It includes both an Indian and Western-style water closet to cater to the needs of rural and urban women, it comes with a sanitary napkin dispenser and an incinerator for used sanitary napkins, and it is equipped with a wash basin and mirror for handwashing. On top of that, it is affordable and the whole unit takes just two days to install.

Thanks in large part to WASHi, Indian urban sanitation is not only on the cutting edge; it is making the country's cities much safer. We have worked to create expertise in a number of areas that are important to India's development organizations, from how to communicate about social and behavior change to how to collect and analyze data. These investments are building knowledge that makes us all more effective.

Conclusion

This very small list of the organizations we collaborate with makes one thing clear: India is overflowing with ambition and innovation. If innovators from every sector work together, all adding their special skill sets to the mix, then we are more likely to achieve our ambitions faster.

At the Bill & Melinda Gates Foundation, we see our role as supporting governments, private companies, civil society organizations, and the communities they represent, in their efforts to be as effective and efficient as possible. Partnerships with different organizations allow us to draw on the unique talents, resources and know-how of industry, academia, and the public sector to better serve the most vulnerable communities. We are more likely to build a better future for India if we do it together.