Gates: Nigeria Needs Lot of Work to Address Malnutrition in the North

The Bill and Melinda Gates Foundation  through the annual Goalkeepers Report, is tracking progress made by countries across the globe as they push towards meeting the year-2030 Sustainable Development Goals. In an exclusive interview with Martins Ifijeh, the co-founder of the foundation, Mr. Bill Gates, made recommendations on how Nigeria can achieve target in areas of health, nutrition, education, human capital development, family planning, among others. Excerpts: 

Why is the Bill and Melinda Gates Foundation, through the Goalkeepers Report, tracking progress made on the 18 key Sustainable Development Goals?

The Sustainable Development Goals (SDGs) were set by the United Nations to improve human conditions. So what the Bill and Melinda Gates Foundation (BMGF) is doing, through the Goalkeepers Report, is to look at the SGDs every year, talk about where things are doing very well and then talk about the heroes who are doing the good job, with the hope of spreading the good practice. We also talk about where the world is falling short, and then remind everyone that there are decisions being made that will change the health, economics, and poverty level of developed and developing countries in the future.

So, the Goalkeepers’ idea is that there are a lot of people who have energy, who want to innovate and come together to share with each other. Hopefully, we will generate some broad visibility about sharing the best practices in such innovations.  The UN and a lot of world leaders will be participating in this year’s Goalkeepers event. We intend to focus more on health and agriculture because that is where we have our deepest expertise, but you will see this year, we are also talking a lot about education because that, together with health, is the key investment.  We use the word ‘human capital’ a lot because it is the key investment that will determine the quality of life and economic growth that can be gotten from large young generation, particularly in Africa, including Nigeria. How we invest in the young generation will determine the level of differences we make economically.

Women and girls are key to Nigeria achieving SDG, but cultural and religious challenges have become a major hindrance, thereby leading to unwanted pregnancies, maternal and infant mortality, illiteracy and poverty. Are there models suggested in the 2018 Goalkeepers Report that can be adopted to tackle this?

Well, of the projects that have happened in Nigeria, I understand the best is polio, and that was very successful. We think we are close to making sure there is no more case.  There is still work being done, but overall, it was a very impressive project. And part of that actually was working with the traditional leaders in a very intensive way.

I think the traditional leaders did a great job in all the things we asked them to do in the partnership we had on polio. So, I would expect, particularly in the North, for any changes you want to make, to engage them the right way.

I think there are people talking about whether Nigeria can have women’s groups, and whether it makes sense to get them together in a collective way. That, particularly in India and Bangladesh, has been ways that at the village level, the issue of best health practices, best agricultural practices, understanding about family planning can be achieved. And, of course, it will be decided by Nigerians whether that is a tactic they want to engage in or not. The most we would do is to be supportive of the leaders in Nigeria who think that that is a promising direction. There are some efforts along those lines already.

So, to get the word out about health, nutrition, and feedback on education system is not working well, I think there does need to be some innovation to accelerate the pace on these things, including on reproductive health, which is very important. Every country and even sub regions within the country should have different ways to approach these issues.

We are funding some new innovative tools like Syana Press, which a woman can use and inject on her own, which makes it more convenient. There are a number of tools available and making sure women know about those things, so that when they want to use them, they will have access to those. That has been an important tactic in a lot of countries.

Nigeria has almost 11 million stunted children with consequent implications for human capital formation and economic productivity. Within the context of the 2018 Goalkeepers Report, how can we turn this around?  

I would say the importance of reducing malnutrition is something that the foundation and the whole field of global health has started to focus more on because, we continue to measure and view as a primary metric, trying to make sure that the survival rate is super high, that is, the number of children’s deaths is reduced. And we still have a lot of work to do on that in the North of Nigeria. Over 10 per cent of the kids under the age of five don’t survive, and so the global average now is below five per cent, and so it is an outlier that includes not getting the vaccine coverage up at the levels that we should.

But for the kids who survive, the diet and health things that they have gone through really make a huge difference. And right now, the best way that is measured, is by height. That is, stunting, but we are also working to understand how that affects mental/brain development and if you are stunted, you are not only not achieving your physical potential, but also not achieving your cognitive potential as well.

And so, we do understand already that when a child falls behind in growth, that you need to get supplementary nutrition to the child. And building up systems where families see that their children have either some level of malnutrition and getting these supplementary foods to them, that is a very important thing.

I recently had a conference where I connected by video, and Aliko Dangote got the leading food companies in Nigeria together to talk about doing more in fortifying foods, that is, adding things like vitamin A to the various food products that are bought by all the people, including low-income families.  And that was a really great discussion about what are the barriers. What are the key foodstuffs to go after?  What are the current levels of compliance, and how do we get that up? So in that issue, as in many of the efforts the foundation does in Nigeria, Mr. Dangote was a huge help in getting the awareness.

So, I think on that food fortification front, there will be some real improvement and that is one element that helps a lot with nutrition and reducing stunting.

In the 2018 Goalkeepers Report, many countries were referenced to have made progresses so far. Why was Nigeria not cited? Does it mean we are not making progress? 

Well, certainly, Nigeria is making progress, but in the quality of the primary healthcare system, which varies state by state, it is not functioning nearly as well as I think Nigerians want it to work, because that is the key tool to not only reduce childhood death, but also to deal with these nutrition issues and make sure that that key element – that element of human capital – is fully developed.

So, because Nigeria has got a free press, elections, the opportunity to have these human capital issues and the funding of the education system and health system and the quality of those systems, is now. This is an opportunity to talk about this and its importance to the people.

I was pleased when I was in the country the last time that the discussion about whether we need to invest more in this next generation or not came up. There was at least some coverage, including your paper, THISDAY, which brought that issue up.

And so Nigeria has some strength. It is better off economically than a lot of the countries in Africa. It has got a lot of very capable, college-educated people in the country that care about these issues. But today, the performance in a number of states of the health and education system definitely falls short. And in order to have this bargain where you say, ‘Hey, we are going to raise tax levels,’ people will have to get a sense that the money is being spent in an effective way. And that bootstrap where the taxation levels are fairly low because the expectation of what you get is low, getting from that mode, they will say okay we have more resources and we see that in terms of how teachers are hired or healthcare workers are hired or how the delivery is measured to make sure it is working well, there is a lot of work to go on there.

I am hoping that this discussion about the number of kids there will be turned into an asset. The key work is all domestic and it touches on political issues like holding the government at federal, state, and local levels to account so that you are picking the most competent people to improve the education and health system, as well as the agricultural help provided to farmers.

Has the world made significant progress when you compare the 2017 Goalkeepers Report and the 2018 Goalkeepers Report?

Not absolutely. Whether it is reducing childhood death or reducing extreme poverty, the progress continues. In many areas, the goals that were set for 2030 are very ambitious and so in that sense, you can say for a number of things, we are not on track.

But every year, more kids get vaccines, every year the attendance in school go up, which is a fantastic thing, because on that attendance issue, we have made enough progress. It is fantastic that now we can focus in on the quality of learning there and really see that, okay that will be a very critical thing. So, this is a very hopeful story. You know, in fact, the book that I have been asking people to read and was sent out to everybody who is attending this event is the Hans Rosling book, ‘Factfulness’ and I hope that lots of people in Nigeria look at that book because it tells what might surprise people about human development effort and the amazing successes we have had. And the roadmap of how countries are moving is actually fairly clear. That as the years go on, we do get more innovation, so we get some additional tools, whether it is better seeds or new vaccines or techniques for training teachers in the classroom.

But, yes, we are making progress, but then again, we are not going to achieve a lot of these goals unless we really accelerate the sharing of best practices, which is one of the key goals that we have as we get together in September 18 for the Goalkeepers event.

The 2018 Goalkeepers Report recommends more dynamic ways of farming, as a way to cutting poverty by half, and creating new jobs. What are those ways that countries with large numbers of poor and subsistent farmers like Nigeria can emulate?

Agricultural productivity is maybe the first step a country needs to take. If farmers can get better advice on agricultural extension, advice about which seeds to use, when to plant them, and how to access credit for fertiliser, you can get more than a doubling in that productivity. And, of course, the benefits of that are very dramatic because poor farmers make up such a huge part of the people in developing countries.

Historically, the strongest examples come from Asia where China reformed its agricultural sector in 1989 and then had almost a tripling of output because they went to the better seeds and they developed the credit system, they also figured out where they should do irrigation and where they shouldn’t. Today, African agriculture, including Nigeria’s, basically has a productivity level similar to what China had before those reforms.

Now, in Africa itself, we have seen strong agricultural growth. Ethiopia, off of a fairly low base, did a lot of reforms and has had very substantial growth. Rwanda, post genocide, has had pretty dramatic growth, and even Nigeria has had some growth, but nowhere near what’s possible, particularly in the Northern region of the country, where the productivity levels are still well below what is possible to achieve. So, there is a key role for the government.

One of the harder things, though, is to have some level of infrastructure.  Things like roads are another part of that investment that has to be done well.

India, Vietnam and a host of other countries are getting it right in the area of curbing illiteracy. What are the key traits Nigeria and other countries in sub Saharan Africa can adopt to address this?

There are really two dimensions to the education sector. The first dimension is raising the revenue to fund it, so you can have the schools, hire enough teachers and have those salaries be paid on a dependable basis; and the second issue is the quality of the education system, making sure that the right teacher-training and the right feedback on the teacher-quality is taking place.

On the first issue, Nigeria does probably need to raise a higher percentage of Gross Domestic Product (GDP) and taxes in order to be able to fund some of these key human capital issues, but there are a lot of countries where the second issue, the quality issue is still a huge challenge.

In fact, you know, in health, you have some real exemplars at fairly low levels of wealth, where they run very good health systems. There are a few exemplars of people who run high-quality education systems, but less than in health. It is a challenge to really run that personnel system very well.

In the Goalkeepers Report, we talked about Vietnam because it is a pretty substantial outlier where they did the agricultural piece super well, then they focused on the other issues around health and did that very well, and then not only did they get access to schools, the kids, including the girls, are in school. But they, more than most countries at a fairly low level of wealth, actually did a really good job on the quality of those teachers.

And so, it is a funding issue to start with, and then it is a personnel quality issue. In fact, the World Bank does a yearly human development report, and this year, it focused on this issue of education and its access. A lot of countries, including in Africa, have made huge progress on the access to education, but the quality of what is going on in those school rooms still needs a lot of work.

How can this improve our human capital development?

Well, certainly, when we say human capital development, the quality of the diet that comes from agriculture reforms, the attendance in schools and quality of schooling, overall health and nutrition, are the magic elements that really determine how youth-bulge will benefit a country or be a challenge. If countries don’t make those investments, level of employment, level of wealth, and food security can actually go down.

And given the rate of population growth that is going on throughout Africa, which is particularly true in Nigeria, which is more than a doubling, which is will be pretty amazing by 2050; if you really look at that number and say, ‘Okay, that is a lot of kids to feed and to put in school,’ then the challenge of getting that quality of governance that includes the education and health sector, you know, it is a big deal.

And, if there was one country that its path I think will influence other countries and be a huge deal just because of the size of the population, I would put Nigeria at the top of the list because it is super important not only for Nigeria and for the region, but for all of Africa, because this would set an example for making these investments.