India has taken a giant leap in improving people’s access to toilet, yet there are challenges like quality of infrastructure and water supply. You have talked of technology resolving such issues…
We are doing two kinds of innovations: One is the ability to process fecal sludge with a lower cost plant. That still requires you to collect the fecal sludge and move it to the plant, but we will have plants of different sizes and lower cost than what’s existed before. We have companies that are actually delivering those, and that’s a reality.
The actual toilet that does the processing itself, the so-called reinvented toilet, that’s still a work in progress. We have lot of prototypes, but there’s not a product there. Even when we get it, which we are optimistic we will in the next five years, it will take a lot of time to get the adoption.
You are a technophile. Do you think that technology can solve some of the big problems that are confronting us like climate change?
Technology has helped improve the human condition. Our lifespan is better than 200 years ago — electricity, transport, better seeds, vaccines for things like measles, and other childhood diseases. With every advance, you get challenges. Fertiliser’s a good thing, but you can’t overuse it. Now, we have social media, which has a lot of pluses but also some minuses, in terms of the political dialogue. Overall, I am a believer that most technologies can be shaped to have more benefits than negatives. Climate change is a particular challenge where India is a good example — should it build more coal plants, or can it get its electricity from other sources? I am very involved in trying to accelerate breakthrough ideas in climate change. I can’t prove how easily that will go, but I do think it is great that we are getting a lot of smart people involved in these challenges. I see technology, as if we shape it in the right way, very positive.
In your recent lecture in Cambridge, you talked about the ability to predict the future, at least in the health sector. Could you elaborate how it would work in the Indian context?
The India health story is a glass half full; that is, there’s been huge progress. Childhood deaths have been brought down dramatically. Life expectancy is 10 years greater now than it was back in 1991. India has rolled out some of these new vaccines, the rotavirus vaccine, and over the next few years, we will figure out a plan to roll out the pneumococcus vaccine.
Despite all that progress, and on some of the fronts, like nutrition, and in some parts of India, such as vaccine coverage rates, there’s still work to be done. And our partnership with the government, the ministry of health, and some specific ones in states such as UP and Bihar, is about continuing to improve the health system. We can get the childhood death rates down even more, likewise the maternal death rates.
Inequality seems to be increasing across the world. And on other hand, governments are stretched for funds. Do you think it is a good idea, like India has done recently, of taxing the super-rich to gather resources?
I do, in many cases, think taxation systems can be more progressive; that is, you can make it so that the rich are paying an even higher share of the taxes. Exactly how you should do that, what works, practically, without creating disincentives for innovation will vary by country. But as countries like India take on more healthcare responsibility, whether through the state primary healthcare system or through an insurance-type system, you are going to have to collect more in taxes.
Should there be a cap on salaries of CEOs, as there seems to be an increase in inequality there?
I think the key tool is taxation. If somebody starts up a company, they will have equity ownership. And so, a cap, I don’t know any country that’s done, a cap on CEO salaries. If some country tries that out, will they discourage companies from being there, or will CEOs find other ways of having more stock options? So, I have not seen any country with a specific plan on that. My general view is that taxation can be more progressive in most countries, certainly in the US, which is the one I know.
What is your view on Ayushman Bharat programme?
Well, we have been in a dialogue with the government to see where we can be helpful in bringing in experts, as they develop their insurance plan, and as they put more resources into it, and as they broaden the coverage capability.
As counties move up to middle income, like India is, most countries do make sure that lots and lots of people are covered by health insurance. And PMJAY is a positive step in that direction. We share our thoughts with the government, just providing technical advice so that they can look at accelerating this as a benefit, and making sure it’s efficient, and figuring out how to finance it.
How do you see the private sector delivering public health in a country like India?
Well, most countries, as they provide better health coverage for their citizens, the actual workers and delivery is in the private sector. But that’s not true of all cases. Like, the UK’s NHS manages to do it where it’s almost entirely government controlled. But for a country that wants to grow health availability quickly and drive for efficiency, some way of getting the best of the public sector and private sector probably makes sense. An area that we have learned about this is in tuberculosis where a lot of the increased coverages come from a way of getting the government and the private sector to work together to both diagnose people, and then provide them the medicine.
What do you like most about India and what frustrates you most about the country?
Well, India is this amazing democracy with 1.3 billion people and incredible depth of talent, people coming out of places like IIT. And it’s a country with incredible potential, whether it is in the health sector, or the IT sector. India supplies about half of the units of vaccines that get made in the world, and our foundation’s had great partnerships with many groups in India about doing new vaccines. We are impressed with the ambition in the nutrition programme, National Nutrition Mission.
We are impressed with the ambition about improvements in sanitation. Democracies aren’t always all that predictable, but I see so much opportunity for improvement. India is the place that the Foundation has done the most work, more than any other country in the world, and we feel very good about the results of that work.