Examining Inequality: a look into the Gates Foundation Goalkeepers report 2019

How do gender and geography work against sustainable development? Neil Ford assesses the Gates Foundation 2019 Goalkeepers report, which examines the layers of inequality which work against a fair world.

The 2019 report from the Bill & Melinda Gates Foundation – Goal­keepers: Examining Inequality – in­dicates that despite progress in some areas, the gap between the poor and the better-off is still too wide globally, more so in Africa. The Report, also shows that someone’s place of birth and their gender – particularly if they are born a woman – are the biggest predictors of their future life chances.

“This year, given our theme, we have tried to emphasise the role of inequalities in blocking the achievement of the SDGs. We have also explored maternal mortality, stunting, and neglected tropical diseases (NTDs) in more detail, because those sto­ries provide insights about inequality and how to fight it,” say Melinda and Bill in their introductory remarks.

The Foundation began producing the reports to track progress towards meeting the Sustainable Development Goals (SDGs), which the member states of the United Nations committed to reach­ing by 2030.

Underpinning Goalkeepers is the premise that seeing where the world is succeeding will inspire leaders to do more, while see­ing where the world is falling short will focus their attention. The clear statisti­cal measurement of how much progress has been made towards meeting specific goals is designed to help keep pressure on the international community, including African governments, to achieve even better results.

The Bill & Melinda Gates Foundation, which was set up in 2000 and works around the world to reduce poverty levels and improve health, is only one actor in improving living standards among the world’s poorest households, but it has sig­nificant financial resources of its own and also attracts partner funding.

 

Sobering

The 2019 report introduces sobering new data about the “layers of inequality” and their impact on SDGs.

One of the main issues highlighted is a subject that has been addressed in previ­ous reports from the Foundation, but one that has also been a hot topic in the cur­rent global social and political narratives – how much gender inequality stacks the decks against half of humanity.

On average, girls in sub-Saharan Africa still enjoy two fewer years at school than boys; 21% are married before the age of 18; and they carry out three times more unpaid care work than boys. There is a long way to go before there is anything approaching equality of opportunity for boys and girls in poorer countries.

In particular, the report seeks to em­phasise the role of inequalities in making it more difficult to achieve the SDGs. It discusses maternal mortality, stunting and neglected tropical diseases in more detail, because those stories provide in­sights about inequality and how to fight it. Rather than merely presenting the prob­lems and then solutions, the report looks at real-life stories of the progress that has been made, in order to tell the stories behind the raw data.

While Goalkeepers and the SDGs relate to the entire world, sub-Saharan Africa is the focus of both of them because of the scale of poverty and the health challenges apparent in the region. This year’s report continues the focus on sub-Saharan Africa but also draws on the experience of other developing countries. The improvements in living standards that have been made in India and elsewhere can have great rel­evance for the region. As well as encour­aging investment, the Foundation places an emphasis on the role of innovation in improving outcomes, highlighting policies that have had a particularly significant or innovative impact.

The structure

The report looks at the big issues but on each, it narrows the focus to regions and countries, even looking at individuals living within those countries. It makes excellent use of graphs and other info­graphics, including to contrast the situ­ation in specific African countries with their counterparts in the industrialised world. Sections, introduced by a comment from Bill and Melinda Gates themselves, are written by experts in the fields con­cerned, including Dr Githinji Gitahi, the global chief executive of Amref Health Africa and co-chair of UHC2030, and also, people at the sharp end of development, such as Mitselal Tekele Tesfay, an Ethio­pian farmer.

The report has five main sections. It starts with ‘Examining Inequality’, em­phasising that where you are born has a bigger influence on your future than any other factor. Comparisons are made be­tween countries in poor regions and those in the industrialised world. For instance, more children die every day in Chad than die in Finland in an entire year.

It then looks at three areas where gen­der inequality is particularly pronounced: ‘Primary Healthcare’, ‘Digital Inclusion’ and ‘Climate Adaptation’. Finally, it dis­cusses the most recent global data about the 18 indicators most closely related to the work that the Foundation does.

Every year year, the Goalkeepers report charts the progress made on these indicators: rates of stunting, maternal mortality, neglected tropical diseases, agriculture, poverty, under-five mortality, neonatal mortality, malaria, smoking, HIV, family planning, vaccines, tuberculosis, universal health coverage, gender equality, education, sanitation and financial services for the poor.

Primary healthcare

Most improvement is made on average health outcomes by ensuring blanket provision of often basic services across a country rather than focusing invest­ment, even sometimes greater invest­ment, in urban centres. The best outcomes are achieved by targeting the most easily tackled health problems, through vacci­nations and better access to clean water and sanitation.

As governments invest more in pri­mary health care systems, overall health outcomes improve, but low-income coun­tries spend an average of just 36% of their health budgets on primary care. Yet some governments prioritise advanced health care for a minority of citizens, forcing the bulk of their populations to pay for their own basic health needs as and when required. This inequality feeds the vi­cious cycle of poverty and sickness, but more – and more efficient – investment in primary care can help break it.

When Universal Health Coverage (UHC) is achieved, all people in a country have access to essential health services with­out risking financial hardship. Although higher income countries are more likely than lower income countries to achieve UHC, the results of lower income countries vary enormously. While Rwanda and Ethi­opia are poorer than the other countries, both have invested heavily in community-based primary health care and so their UHC performance has improved dramati­cally.

Digital inclusion

The benefits of digital inclusion are obvi­ous but although mobile penetration rates have increased rapidly in most less devel­oped countries, too many poor families are currently excluded from the benefits that access to the internet can bring. As Bill and Melinda Gates write in the report: “Some pessimists warn that technology will usher in a dystopian future. Some naïve optimists predict it will create a uto­pia. The truth lies somewhere in between. Technology is disruptive, and countries need to invest to maximise the positive disruptions and manage the negative ones.”

India provides an excellent case study of exactly what is possible because its government understood at an early stage that technology made it possible to con­nect directly with citizens instead of working through many layers of bureau­cracy. It then set about creating smart policies built around digital technology that improved both the quality and reach of government services.

For instance, Arshi Aadil, the manager for government and social impact at Mi­croSave Consulting, examines how digital technology helped the government of In­dia design a series of innovative policies in the gas retail sector that have empowered 75m marginalised women. The previous system of gas subsidies gave 700% more in subsidies to the wealthiest 10% of Indian households than the 10% poorest.

The Indian government launched a programme to couple new bank accounts launched for poor households and its ID system backed by biometrics to mobile phones, to transfer subsidies directly to those who benefit most. The government has saved over US$9bn since the scheme was launched in 2015 and has used the money to finance its Ujjwala programme to provide a 50% subsidy on the cost of a gas connection and stove for rural fami­lies.

Women are still overwhelmingly re­sponsible for cooking in India. Using cooking gas saves women the several hours per day that they had been spending gathering firewood, building and manag­ing fires that made them sick, and then cleaning up the ashes and dust.

Climate change

While international attention on climate change is almost entirely focused on how to limit carbon emissions, this is only one part of a much wider picture. The climate is already changing, with some of the most profound effects felt in the countries that are least equipped to deal with them. It is a terrible injustice that the people who suffer the most from global warm­ing are the poorest farmers in the world. Small-scale farmers did not do anything to cause climate change but the rainfall that they rely on is already becoming less and less predictable.

“These farmers already have no margin for error. They don’t have the resources to adapt to droughts and floods, disease outbreaks among their herds, or new pests devouring their harvest,” write Bill and Melinda Gates in the report. Dr Kaba Urgessa, the State Minister for Natural Resources and Food Security at Ethiopia’s Ministry of Agriculture explains how the government has worked with farmers to promote climate resilience in a country where there is 20% less rain than there used to be in some places.

It set up a disaster management policy and created food reserves to help people in rural areas cope when drought struck. The government also employs people to work on agriculture-related projects to create community assets, such as dams, trenches and terraces. At the same time, it gives people in rural areas a source of income that they can draw upon during difficult times, such as droughts or floods. Finally, agricultural extension agents are now employed to provide early warning of climate-related problems and to provide advice on how farmers can mitigate the impact.

Dr Urgessa says: “Our network of ex­tension agents is one reason why Ethio­pian farmers are more likely to use fer­tiliser, improved seeds, or irrigation than farmers in many neighbouring coun­tries.” He writes that the fact that the 2015 drought did not have anywhere near the same devastating impact as the infamous 1984 drought, despite being as severe in climatic terms, suggests that the policy is working.

The key indicators

Graphs at the end of the report highlight the rate of progress on each indicator, using forecasts made by the Institute for Health Metrics and Evaluation, giving rates in 1990, the 2030 target, the current projection for 2030 and 2030 scenarios if we progress and if we regress. Some of the targets are aspirational but oth­ers are clearly achievable. It is all too easy to view problems such as infectious disease and infant mortality as being synonymous with sub-Saharan Africa. Yet the industrialised world had to confront many of the same challenges in the past and had huge success in eroding their incidence.

Given the size of the remaining prob­lems and the impact that they have on billions of people, it is easy to overlook the progress that has already been made and in a relatively short space of time in historic terms. The rate of poverty – defined as the percentage of the world’s population living below the internation­al poverty line ($1.90/day) – fell from 38% in 1990 to 8% in 2018 but is pro­jected to fall by just another 1% by 2030. Similarly, the prevalence of 15 neglect­ed tropical diseases per 100,000 people dropped from 34,000 in 1990 to 16,000 last year and is forecast to fall to 13,000 by 2030.

However, the rate of progress on other indicators, while substantial in historical terms, is much slower. There were 29 new cases of malaria for every 1,000 people in 2018, down from 37 in 1990 and the figure is on course to remain at 28 in 2030. Similarly, the prevalence of smoking in those aged ten or more remained stubbornly high at 19% last year, down from 24% in 1990 but with just another 2% fall expected by 2030.

The report argues that huge progress could be made on many indicators rela­tively easily. Nearly 50% of the children who die before their fifth birthday suc­cumb to easily treatable conditions in the first month of their lives and another 30% die because they do not receive vaccines readily accessible elsewhere in the world. Similarly, the key to reducing maternal mortality is improved access to maternity care, because of the wide range of things that can go wrong during a birth. Severe bleeding, infections, hypertensive disor­ders in pregnancy, obstructed labour and complications following unsafe abortion, are all avoidable.

The Bill & Melinda Gates Foundation will continue to publish the report annu­ally in an attempt to track progress and identify “promising solutions, measure and interpret key results, and spread best practices,