Technically speaking: How the Gates Foundation governs ‘women’s health’ in India

Abstract

In global health, the ‘technical’ is viewed as scientifically and ethically superior due to the emphasis on quantitative methods, supported by international aid and philanthropy. This perceived objectivity and selflessness obscure numerous strategic decisions and practices through which donor-funded programmes shape the standards of women’s health. I argue that this unexamined belief in the technical approach is a key reason why ‘Reproductive, Maternal, Neonatal, and Child Health’ (RMNCH) remains dominant despite its conceptual limitations and uneven progress. An in-depth study of RMNCH projects in Uttar Pradesh funded by the Gates Foundation shows how technical interventions align with local social norms and political dynamics, creating an ideal-type female participant. In sum, this shapes the meaning and scope of women’s health.

Keywords:

• social determinants of health
• RMNCH
• Gates Foundation
• SDG 3: Good health and well-being
• SDG 5: Gender equality
• Uttar Pradesh

Introduction

In this paper, I argue that the underexamined trope of technical assistance obscures the diverse ways in which reproductive health programmes supported by the Gates Foundation influence the definition and scope of good health for women in India. ‘Reproductive, Maternal, Neonatal, and Child Health’ (RMNCH) is a global health paradigm representing a comprehensive and evidence-based array of interventions into major causes of preventable mortality for women¹ and children across the developing world. Among global health entities, RMNCH is more than an abbreviated cognitive shorthand. Kerber et al. (2007) present a comprehensive framework consisting of a long list of evidence-based reproductive and child health interventions bundled into eight ‘packages’, which could be delivered in a staggered format during adolescence, pregnancy, childbirth, the postnatal period and childhood, and across home, community, health centre and hospital settings. It is a well-established and portable conceptual category that shapes the ways in which the bulk of public health policy, research and investments on the females are organized (Stenberg et al., 2014).

RMNCH is a key segment of public health programming in India. In 2023, the government was operating six nationwide maternal and child health schemes namely, Janani Suraksha Yojana (Maternal Safety Scheme), Janani Sishu Suraksha Karyakram (Mother and Baby Safety Programme), Pradhan Mantri Matritva Abhiyan (Prime Minister’s Motherhood Campaign), Surakshit Matritva Aashwasan Yojana (Safe Motherhood Assurance Scheme), a midwifery initiative, and labour room quality improvement initiative called ‘LaQshya’ (Government of India [GOI], 2023). Additionally, state governments initiate RMNCH schemes regularly. These overlapping public health initiatives define healthcare entitlements for janani (mother) and matritva (motherhood), making maternity the bedrock of the state-woman relationship.

Framing ‘women’s health’ in terms of RMNCH has distinct limitations. The most recognizable issue is the uneven improvement in women’s health – ‘unfinished’ is the most frequently used word in describing progress under RMNCH (Askew & Brady, 2013; Brown et al., 2019; Khosla et al., 2020; Starrs et al., 2018; UNFPA, 2019). Multilateral organizations anticipate that the sustainable development goal (SDG) target for lowering maternal mortality will not be met by 2030 (WHO, 2023). The main causes of maternal deaths today – obstetric haemorrhage, infections, hypertension during pregnancy, illegal abortions – are the same as they were over a century ago (Loudon, 1986; Meh et al., 2022). The difference being that now over 99 per cent maternal deaths continue to take place in low- and middle-income countries (Suzuki et al., 2023). Within India, maternal deaths are concentrated in rural regions and among the most marginalized populations (Meh et al., 2022; International Institute for Population Sciences [IIPS], 2021).

Beyond tracking progress on canonized metrics of female fertility, RMNCH also exhibits several axiomatic and epistemic flaws that remain underexamined within public health. The focus on maternal health is crucial, however, it has traditionally been approached as a pipeline for ensuring better health for babies (Starrs et al., 2018; Storeng, 2010). Further, it is secured at the cost of sidelining several other health issues. A study of public health publications in 2010 and 2020 found that research does not adequately reflect women’s disease burdens (Hallam et al., 2022). The share of publications on reproductive health increased from about 36 per cent in 2010 to 49 per cent in 2022. However, leading causes of female morbidity and mortality such as menopause, musculoskeletal and neurological disorders, and cardiovascular health remained underrepresented. While the discourse on gender as a determinant of health is improving, it has been primarily used with reference to women's reproductive health (Hawkes & Buse, 2020). From World Bank data sets to national population surveys, knowledge and intervention on women’s health continue to be organized with assumptions of a heterosexual, married, reproductive female.

Despite these limitations, RMNCH remains the orthodoxy governing female health in developing countries. In 2019, 35 per cent of the total development assistance for health was devoted to maternal and child health (including family planning) (Institute for Health Metrics and Evaluation [IHME], 2023). Even in the post-pandemic world, this category retains 22 per cent of the total development assistance for health (IHME, 2023). RMNCH is a key area of investment for the Gates Foundation, the largest private funder in global health (Bill and Melinda Gates Foundation [BMGF], 2009). In fact, the Gates Foundation’s annual budget for 2024 is $8.6 billion compared to the WHO’s biennial budget of $6.8 billion (Suzman, 2024; WHO, 2024). Between 1995 and 2023, the foundation spent at least $3 billion² in RMNCH grants. In 2021, 32 per cent of the Gates Foundation’s total expenditure on global health ($5.06 billion) was spent on RMNCH, consisting of grants towards neonatal and child health, maternal health, vaccines, family planning and reproductive health (IHME, 2023). With unprecedented capital and an international reputation of enormous success, Bill Gates commands a powerful role in steering the RMNCH agenda (Shaw & Wilson, 2020; Storeng & Béhague, 2017).

India is important for the Gates Foundation, with a long-held programmatic presence in the states of Uttar Pradesh and Bihar (BMGF, n.d.-c). The Gates Foundation describes its operations in India as ‘technical expertise’ and ‘technical partnership’ (Bhardwaj, 2015; Gates Foundation, 2010). More broadly, the Foundation’s global health division has invested in science and technology research and partnerships for drug and vaccine development, diagnostic tools, etc. (Birn, 2014). It acknowledges the impact of social practices and cultural norms on health, approaching these as part of the wider commitment to ‘innovations’ (Gates Foundation, 2010, 2017).

The technical stance is crucial in this era of global health practice. Since the 1990s, international health has undergone a ‘techno-managerial’ turn with the proliferation of public–private partnerships, short project-based interventions, the expanded role of the World Bank, and the establishment of the Gates Foundation (Kelly & McGoey, 2018; Porter, 2020). Unlike the WHO – the twentieth-century supranational institution for public health governance – private entities need to prove that they take objective action to advance public health (technical efficiency) and are best placed to do so (managerial effectiveness) (Kelly & McGoey, 2018). This analogous framing of social innovations and technical advancement has implications on projectified RMNCH interventions.

A core concern here is the techno-managerial turn in global health, which purportedly brings superior forms of scientific objectivity and social value. Scholarly critiques on the techno-managerial turn draw attention to power imbalances and the relative neglect of the socio-economic inequities that determine people’s health (see Janes & Corbett, 2009; Schaaf et al., 2021; Shawar & Ruger, 2020; Shiffman & Smith, 2008). This ‘depoliticization’ critique consists of a range of arguments. Scholars contest claims of impersonal decision-making based on RCTs and statistically significant data (Porter, 2020; Shiffman & Shawar, 2020). They shed light on the emotional and moral value of quantitative indicators such as maternal mortality ratio, which are subliminally linked to the value accorded to healthy motherhood as a locus of national honour and social development (McCoy et al., 2013; Oni-Orisan, 2016; Storeng, 2010). They examine the power and influence of pharmaceutical and philanthropic bodies, and new technical and financial institutions that inadvertently undermine existing bodies such as the WHO and national health ministries and employ opaque methodologies and operational practices (Shiffman & Shawar, 2020; Tichenor, 2020).

While the ‘depoliticization’ critique is valid and necessary, it often lacks a clear definition of politics. In public health, ‘politics’ is typically invoked as the lack of political will, policy and operational bottlenecks, and poor fiscal commitments – these are also amongst the most quoted causes for poor RMNCH outcomes (Brown et al., 2019; French Gates & Gates, 2023; Khosla et al., 2019; Shawar & Shiffman, 2020). Lesser attention is paid to the ways in which large private foundations and research organizations are enmeshed with the political and therefore legible in the domain of who and what can and should be discussed as ‘the problem’ (see Cooper & Packard, 1997).

Reubi (2018) insists that the authority of powerful actors can be kept in check by the wider community of global health experts who scrutinize claims of impact and improvements and can raise concerns. However, the outsized presence of the Gates Foundation stands to compromise the scope and integrity of the critique. The Foundation’s technical stance consists of partnerships with reputable organizations, and a carefully crafted media image of the co-founders (Harman, 2016). It funds interventions, supports evaluation studies and is among the primary consumers of resulting data (Shiffman & Shawar, 2020; Tichenor & Sridhar, 2019). The Foundation is infamous for ‘gagging’ the intellectual and operational freedom of recipient entities such as the Lancet, IHME, Johns Hopkins University, Harvard University, the WHO, among others. Independent critique against the Foundation is thwarted by the fact that fund recipients would prefer to secure a piece of the pie rather than bite the hand that feeds them (Harman, 2016; Mahajan, 2018; McGoey, 2021).

To elaborate on the implications for women’s health, I begin by elaborating on the technical as a distinct manifestation of politics in this era of global health. Subsequently, I examine the sphere of the technical, elaborating on three distinct practices that shed light on its arbitrary, dynamic and inconsistent character: the technical can draw upon and perpetuate patriarchal values and casteist norms; it can also be aligned with local political and bureaucratic priorities; and it produces the female participant as the ultimate proof of objectivity and necessity of the current format of interventions. It is observed that the currency of technical intervention allows the Gates Foundation to embed itself in various social, economic and institutional nodes of power that ultimately guard the status of those at the top more than the well-being of those at the very bottom. This disappoints both the scientific rigour and social value of global public health.

Methodological note

The paper is part of a broader examination of participatory approaches³ in RMNCH programmes in India, and the ways in which this influences the meaning and scope of female health. To study this across the scales of global health practice, I employed participant observation, in-depth interviews, structured interviews, and a review of grey literature undertaken in New Delhi and Uttar Pradesh in 2020–2021. I conducted 68 in-depth interviews with female beneficiaries in Uttar Pradesh and 26 elite interviews with physicians, researchers, public health practitioners and private consultants. Additionally, recordings of interviews, speeches, panel discussions and documentaries available in the public domain were useful when an interview was denied or unfeasible.

This paper primarily draws on analysis emerging from key informant interviews and a review of grey material. I recruited key informants purposively, based on their professional roles in RMNCH programmes and in the field of public health in India. They were current and former bureaucrats, project managers from donor organizations and NGOs, epidemiologists, social anthropologists, private consultants, project staff, and experts on health advocacy, gender, individual and social behaviour change communication. All interview data has been de-identified and consistent replacement pseudonymization used in each instance.

Securing ‘technical’ boundaries

In global health, the ‘technical’ is the domain of experts (Cueto, 2013). It represents the qualities of homogeneity, standardization and consensus, which are hallmarks of both positivist knowledge-making and disciplinary specialization. RMNCH programmes are technical because of the use of biomedical and epidemiological knowledge of women and child health, rigorous research methods, and generalizable data on impact and change. At the same time, the vision and objectives of this segment of global health are anchored in the 1994 Cairo Programme of Action towards Sexual and Reproductive Health & Rights (SRHR). This implies a socio-political commitment to improving gender inequalities, empowering women and delivering interventions in a participatory mode, respectful of subjective circumstances, needs and choice. As discussed, RMNCH also represents a considerable mass of development assistance for health.

The technical is, therefore, the site of what is conceptualized as the most feasible, legitimate and desirable interventions for the well-being of populations. The technical has had strong connotations of depoliticization or anti-politics. This does not simply mean a rejection of power relations or socio-economic dynamics, rather it is a rejection of the corrupt, ‘self-serving’ and ‘exploitative’ practices associated with state bureaucracies and party politics in postcolonial settings (see Ferguson, 1994; Li, 2007; Venugopal, 2022). The ‘political’ is invoked as a ubiquitous albeit hidden, exogenous, and unpredictable social phenomenon. It mediates the success or failure of developmental policies and programmes.

However, politics is a distinct and autonomous reality for diversely stratified human societies (Mouffe, 1999). The political accounts for human behaviours and practices in ways that cannot be reduced to technocratic schemes (Venugopal, 2018). Defining a common good and pursuing improvements in the circumstances and conditions of human beings does not precede politics. It follows that technical interventions and those who fund these are not outside the realm of politics. Crucially, the argument is not that global health is political in addition to being technical. Rather, the technical itself is a distinct manifestation of politics. This necessitates a scrutiny of what is taking place under the technical. Exploring the political comportment of technical assistance enables us to see the motivations of funders, policymakers and researchers who govern the knowledge and interventions targeted at populations on the margins of socio-economic prosperity. It enables us to look at the dynamics of power in global health beneath the rhetoric of selfless charity and scientific enterprise.

To fully understand the political features of the technical it is helpful to employ the concept of boundary-work, in which certain qualities are strategically attributed to the scientific method, and the people and claims associated with it ‘for the purpose of drawing a rhetorical boundary between science and some less authoritative residual non-science’ (Gieryn, 1999, pp. 4–5). Boundaries need to be drawn and redrawn, to protect claims, to legitimize intervention, to absorb and mitigate different forms of critical contestations. Hence, all boundary-work is rife with tensions. For RMNCH, technical boundary-making can be traced in various instances: drawing on patriarchal and casteist norms that govern women’s social and familial roles; a conscientious entanglement with local beliefs and governance practices; and the recursive construction of the ideal-type female participant.

I. Checklists and changes

In 2014, the Gates Foundation granted $20.6 million⁴ to launch the BetterBirth trial across 24 districts in Uttar Pradesh covering over 300,000 women and children (Ariadne Labs, n.d.; BMGF, n.d.-b). This two-year cluster RCT examined the adherence and impact of the Safe Childbirth Checklist among attendants at primary health centres. The Checklist is a one-page quality improvement tool for birth attendants in low-resource settings and targeted at preventable causes of maternal and neonatal mortality (Ariadne Labs, n.d.; Semrau et al., 2017; WHO, 2015). It was co-developed by the WHO and Atul Gawande (surgeon, writer and public health expert). The BetterBirth trial was led by Gawande’s organization Ariadne Labs, a joint venture between Brigham and Women’s Hospital and the Harvard T.H. Chan School of Public Health.

Prior to 2014, results from small-scale studies indicated that the Safe Childbirth Checklist improved adherence to evidence-based childbirth practices. However, results from the Uttar Pradesh-based BetterBirth trial concluded that while adherence improved in the intervention arm, there was no significant impact on maternal and perinatal health outcomes (Semrau et al., 2017). Use of the Checklist also decreased after coaching ended. When the BetterBirth results were published in the New England Journal of Medicine in 2017, journal editors Robert Goldenberg and Elizabeth McClure published a critique of the trial. They argued that the negative results were not because of a failure to sustain adherence to evidence-based practices. Rather, they drew attention to the lack of trained personnel, standard and emergency obstetric tools and services at the health centres in Uttar Pradesh. The trial did not include the provision of supplies, improvement to facility or clinical training – features essential for reducing maternal and neonatal deaths (Goldenberg & McClure, 2017). Moreover, data was not collected on other factors that may have influenced the decline in adherence such as health and nutritional status of women or quality of antenatal and postnatal care (Semrau et al., 2017).

When I interviewed a former senior representative of the Gates Foundation in India, they said, ‘Bill [Gates] likes this checklist approach, so they brought [it] to Uttar Pradesh’ (personal communication, 17 November 2020). Even if a billionaire philanthropist’s personal caprices may not have been the primary motivation for disbursing grants, Gates had defended the Checklist prior to the launch of the BetterBirth trial, arguing that it was ‘simplifying healthcare and saving money and lives … proving to be scalable without adding additional expense’ (Gates, 2012, para. 5). Here, the prospect of spending less on low resource health systems was a key attraction. The unfavourable results in Uttar Pradesh and the critique of the BetterBirth trial have not prevented the checklist from being implemented in over 30 countries (Ariadne Labs, n.d.).

One of the principal investigators on the BetterBirth study was Vishwajeet Kumar, who gained prominence in public health following the success of the 2003–2006 ‘Shivgarh trial’. This cluster RCT on modifying ‘high-risk’ birth practices was implemented in Shivgarh, Uttar Pradesh with the aim of reducing preventable neonatal deaths. It was observed that training on essential newborn care (birth preparedness, delivery hygiene, skin-to-skin care, breastfeeding, cord care) led to a decline in neonatal mortality by 54 per cent (Kumar et al., 2008). The study concluded that newborn care practices can create significant behaviour change and reduce neonatal mortality if intervention is ‘socioculturally contextualised, [and] community-based’ (Kumar et al., 2008, p. 1151). It was described as a success in innovative behaviour change management:

… based on trust, and developed as a participatory process of respectful engagement with the community to lead individuals and families from current towards improved behaviours through a path of least social, cultural, economic, and spiritual resistance to change … To minimise resistance to change, messages were designed to promote improved newborn-care practices to align with existing cultural values and traditions, so that they were not perceived as externally imposed … . (Kumar et al., 2008, p. 1153, emphasis added)

The trial team recognized that the success of the intervention depended on a supportive and receptive community environment. The social ‘innovation’ consisted of engaging respected and senior members of the community such as village heads, priests and teachers in monthly meetings. Behaviour change messages were incorporated into folk songs and locals were engaged as volunteers to embed the intervention into normative behaviours and practices.

The Shivgarh study team conducted in-depth mapping of the region’s gender, caste and class dynamics, as well as pregnancy and childbirth practices. At the household level, intervention uptake depended on men (and to some extent older women) who manage financial and care-seeking decisions. Mothers were identified as the newborn’s primary care providers but were inaccessible in the period of post-partum confinement – this ranges from 10 to 42 days after the delivery when both the mother and baby are considered ‘polluted’ by birth, making timely risk assessment challenging. To gain access, the study team engaged women from lower-caste groups in the village – the Domin and the Naun – because they could access the mother and the baby during post-partum confinement. Domin is a woman from the lowest caste, traditionally responsible for cutting the umbilical cord, and cleaning the baby and mother during the first week after delivery. Naun is also a woman belonging to a low caste, who massages and bathes the baby after the first week. The trial identified these women as ‘specialists and domain experts’, and ‘natural partners’ (Kumar et al., 2008, p. 1154).⁵ While successfully accessing mothers and babies, the study capitalized on and reinforced the subordinate and ‘polluting’ position according to these women in the caste hierarchy. This was different from the strategy of engaging untrained village doctors to impart better practices, or the village priest to offer amenable advice around breastfeeding – all of which relied on one’s reputation of respect and influence.

Kumar explained post-partum confinement as a form of community-based ‘quarantine’. The practice, admittedly, gives new mothers a period of recuperation and reprieve from resuming household chores immediately after birth. Nonetheless, it is also a period in which she and the newborn are regarded as impure and polluting for others. In not problematizing or challenging the stigma and pollution/impurity associated with giving birth, rather pitching it as native wisdom about quarantine, the trial circumvents the need to address gender roles, caste discrimination and class disparities. More broadly, the success of the intervention has been attributed to the fact that it was ‘culturally, socially acceptable and [did not] disturb the status-quo’ (TEDx Talks, 2011, emphasis added). The statistically significant results of the Shivgarh trial were derived from the fact that the intervention was socially conformist rather than innovative.

Further, this technical intervention exhibits myriad conflicts of interest. The Shivgarh trial was funded by USAID and Save the Children through a Gates Foundation grant. Peer-reviewed publications on the trial state that funding sources did not play a role in study design, data collection, analysis, interpretation, or report writing (Kumar et al., 2008, Willis et al., 2009). However, the corresponding author for Kumar et al. (2008) is Gary L. Darmstadt who at the time was the Deputy Director of the Global Health Program at the Gates Foundation (2008–2010) (Stanford University, n.d.), participating in the trial from the conceptualization of the study to the submission of the paper. He was also the corresponding author for Willis et al. (2009), however, this time his affiliation is listed as Johns Hopkins University. Not explicating the extent to which donors influenced research design, implementation and analysis is a disservice to scientific rigour.

When the priority is to satisfy the donors and/or policymakers’ idea of social change and scientific objectivity, researchers are not likely to be vigilant against the intrinsic ideological schema that binds class, caste, ethnic, gendered and racial privilege across space and time. A systemic and wilful ignorance prevails towards the fact that gender inequality does not have a clear start and end point, and evades neat quantification. This is reflected in both the quantum and scope of key RMNCH measures.

On average, female sterilization is the main contraceptive method across India (37.9 per cent). In Uttar Pradesh, the figure is 16.9 per cent (IIPS, 2021). A chief attraction underlying the health department’s continued promotion of female sterilization is that ‘[It is] very quantitative. You can count that so many women have had tubectomy’ (personal communication, 30 September 2021). Officials in the state family planning programme acknowledge that spacing methods such as intra-uterine devices are not as ‘effective’ because women can ‘go to another health clinic and get it removed’ (personal communication, 30 September 2021). It is similarly difficult to convince donors about the gravity and urgency of addressing mental health or geriatric care – socio-structural issues that lack standardized indicators. As a Uttar Pradesh-based consultant working for the Gates Foundation put it, the emphasis was on gathering data to showcase improvements, ‘so, you need to have a problem that you can measure’ (personal communication, 12 January 2022). In a classic instance of putting the cart before the horse, the impetus to count social change is setting the parameters around what counts as social change.

II. SMART politics

Since 2014, the Indian government has cancelled the FCRA license of thousands of research, advocacy and civil society organizations, preventing them from receiving foreign funds (Reuters, 2024). The Modi-led government justified the move by arguing that foreign developmental aid exercises undue external influence on domestic policies and processes (Alam, 2023). Such dichotomization of external versus internal obfuscates the fact that in practice, the local and global are mutually reinforcing. During the 2014 FCRA crackdown, the Gates Foundation was accused of promoting political lobbying via public health grants. However, this disciplinary move was followed by mutual reconciliation. In 2015, the government honoured Bill Gates and Melinda French Gates with the Bharat Ratna, one of the highest civilian awards in India. In 2019, the Gates Foundation awarded Modi with the Global Goalkeepers Award, a humanitarian honour. The Foundation maintains several engagements with the central health ministry and state health departments, in addition to grants made to research and advocacy organizations, and NGOs. Sinews of power extend across international and subnational domains even as they may manifest in different forms. One must, therefore, examine the interstitial space of reciprocal and bidirectional influence.

Day-to-day project operations rely on various social networks and relationships, making it imperative to understand the prevailing power dynamics. These ‘adaptive management’ tendencies are not simply about customizing technical interventions to better acclimatize to the local political dispensation. Rather, intervention is itself political (Whitty, 2019).

At a 2019 event on India’s adolescent health programme, Medha Gandhi, the Gates Foundation country lead on family planning, was asked about the organization’s partnership dynamics with the government. She said:

… we are a very data-driven organization. So, for us, what current data tells, and what data trends show define to a large extent [the things that] we are going to prioritize. And sometimes what does happen is that … data becomes more important than people itself, which I guess tends to happen in a large organization … And numbers tend to tell a bigger story than what people probably do … And for us, strong declines, elimination, these are huge priorities … We are a very technology-driven organization … . (Observer Research Foundation, 2019)

A colleague of Gandhi’s defended the statement, adding that the foundation’s priority was to avoid creating parallel streams and work with the government in an ‘integrated and aligned’ manner (personal communication, 8 July 2022). In Uttar Pradesh, perhaps the most prominent aspect of this relationship has been the establishment of the Uttar Pradesh Technical Support Unit (UPTSU) to facilitate RMNCH programming. The UPTSU was set up in 2013 and is operated by the University of Manitoba in partnership with the India Health Action Trust, a charitable entity. With time, the unit also began assisting the government on nutrition and health system strengthening. Between 2015 and 2023, the Foundation granted University of Manitoba over $178 million⁶ for its operations in Uttar Pradesh (BMGF, n.d.-b). Perhaps due to the extensive investments and embedded operations, interviewees hesitated to speak about the Foundation and RMNCH programming in Uttar Pradesh.

In 2021, the state government introduced a Population Control Bill on the eve of World Population Day (11 July). This bill pushes a two-child policy through promoting sterilization and capping two children as the condition to avail government employment, job promotion, subsidies and contesting local elections (Mukherjee, 2021). How does the Gates Foundation reconcile its ethos of gender equality and women’s empowerment with the prevailing political ecosystem in Uttar Pradesh? An employee working on the foundation’s family planning projects in the state responded, ‘See, it’s unfair for me to comment on that [pause] given the position I am in … there is a fair bit of alignment to national priorities as well as women’s health agenda … I know I am not giving you a clear answer, but this is what I can say’ (personal communication, 12 July 2022).

Priya, is a senior officer working on family planning with the UPTSU. She sees the unit as a technical partner with a three-pronged role, namely, responding to the needs of the government, actively informing state policy, and creating new evidence. She attributes the successful partnership to the culture of ‘evidence-based decision making’. Initially, the health department staff was sceptical about the UPTSU, regarding them as resource flushed consultants peddling ‘fancy ideas’. Senior government officers wanted to ‘see numbers’:

During high-level reviews, all that was asked was the number of Caesarean-sections, the number of institutional deliveries, the number of maternal deaths per facility. On [women’s] choice, they would say, ‘What is that? Why do you need contraceptives? Sterilizations are happening, we are doing so many sterilizations’. (Personal communication, 28 July 2022)

The UPTSU started by winning trust, by supporting the department with ordinary tasks such as data analysis reports and making quality PowerPoint presentations – skills and competencies that were deficient. They refrained from branding deliverables with the UPTSU logo because ‘we are like background dancers; we are not here to take credit’.

They focus on creating a seamless supply of RMNCH services and commodities to facilitate individual choice, especially through expanded private sector participation. Priya maintained an unwavering confidence in young women’s ability to decide for themselves given the improvement in awareness, better education and enhanced aspirations for a good life. She argued that young couples are smart, they know what they want and prefer private facilities. As an example, she added that it is easier to buy condoms at private chemists because one is treated as a client undertaking a financial transaction, without harassment, judgement, or resistance. Priya viewed contraceptives as a solution to give women more time for themselves, and to look after children, ‘If you are going to … be pregnant all the time [laughs], you are never going to have the time to focus on your health, on the health of the child or [your] own nutrition status, not get the required rest’.

There is merit in acknowledging the intelligence, agency and independent decision-making of women in rural communities. However, the characterization of smart, assertive women ignores economic and educational deprivations as well as the normative expectations from the female. The logic of birth spacing for individual rest and leisure does not explore whether the beneficiaries even possess the time, space, resources to reflect and make choices. Further, there is an inescapable condescension in the remark about targeted beneficiaries being ‘pregnant all the time’.

The flipside of the argument that consumers prefer private sector facilities is that the public sector remains a comparatively hostile place for women to buy condoms or seek sexual health care. ‘Private’ is a catch-all category, encompassing everything from an unregulated supplier of pharmaceuticals to multi-speciality hospitals. Given that the public sector remains the only source of affordable care for the majority of the rural population, it is curious that greater effort is not made to contest and reform the rigidities around gender norms and dignified care in the public sector. While it is positioned as a self-effacing ‘background dancer’, the UPTSU successfully installs a vision of reproductive health that is founded upon a market-friendly gender-equality agenda and a vacuous rhetoric of individual choice.

It is acknowledged that fostering women’s decision-making – albeit divorced from structural change – is not easy. However, one must remain vigilant on the assumptions and modalities of pursuing this agenda. Here, RMNCH programming harbours an implicit consensus on remaining an ally to bureaucratic and political power. The UPTSU avoids transgressing the state government’s authority by first embedding support within seemingly ordinary operations (making slide decks) and moving to more higher order strategy around reproductive choice and market-based innovations. This makes technical support both innocuous and indispensable.

To say that large foreign-led health projects ‘are situated in and rely on local regimes of economic, cultural, and social capital’ (Biruk, 2018, pp. 26–27) is not a novel conclusion. Through huge investments and myriad modes of intervention (e.g., memorandum of understanding with the government, funding research trials, issuing grants to local NGOs), the Gates Foundation commands unprecedented influence over the RMNCH landscape of Uttar Pradesh. The reference to its investment and omnipresence is not intended to raise alarm over undue subliminal influence, pressure tactics and covert persuasion – that all of this occurs is tragically incidental. The point is, whether they seek it or not, Bill Gates and Melinda French Gates empower a narrow mode of pursuing gender equality and women’s well-being in developing countries.

How private foundations give away their money is shaped by how they earned it (Horvath & Powell, 2020). For the Gates Foundation, the legacy of Microsoft also pervades how the co-founders intervene in gender-based inequities in health. I interpret this using Microsoft’s infamous ‘Embrace, Extend, Extinguish’ strategy.⁷ The strategy was publicly discussed for the first time during the 2001 antitrust case against Microsoft for trying to gain an illegal monopoly on personal computer markets: ‘Microsoft planned to “embrace” existing Internet standards, “extend” them in incompatible ways, and thereby “extinguish” competitors’ (United States v. Microsoft Corporation, 2001, p. 202). It can be argued that this is an incommensurable analogy between issues of social policy and technology markets. However, the co-founders endorse this techno-managerial stance themselves. At a townhall event in India in 2015, Bill Gates was asked about why the Foundation did not take credit for public health improvements in the country. He stressed that the government bears the ultimate responsibility on this front:

… the system that works is largely a capitalistic system and no one really believes in a 100% capitalistic [sic]. You can’t run a police force or a judiciary capitalistically. And even in domains that you can run capitalistically like food, you need food standards, you need laws to make sure the pricing is done in a fair way, and you need to fund research … so you want the market to extend pretty far. Different countries draw the boundaries differently. The more socialistic things are, the less you get this incentive system and measurement system that works very well … part of the reason we don’t want to take credit for something is that in basically all of our programmes, we are a partner with the government. Or actually, our partners are partners with the government helping them get smarter faster. (Bhardwaj, 2015, emphasis added)

Here, Bill Gates is demarcating aspects of human life that can and cannot be entrusted to market forces. Law and order cannot be government ‘capitalistically’, however gender norms and public health – domains in which the Gates Foundation intervenes – can. At the townhall, the co-founders positioned philanthropy as a ‘catalytic wedge’ to make the Indian government smarter, that is, increasingly market-friendly. In this role, the Foundation is not the primary guarantor of structural transformation and so while it does not take credit for impact, it also evades accountability for failures which on balance are more complex.

The emphasis on making governments ‘smarter’ is part of the corpus of technical assistance seeking to institutionalize SMART (specific, measurable, achievable, relevant and time-bound) indicators and operations. The mechanized approach is also indicative in the foundation’s ‘Gender Equality Toolbox’, which partners and grantees are encouraged to use to develop, manage and measure ‘the results and impact of gender intentional and gender transformative investments’ (BMGF, n.d.-a, para. 1).

Hence, returning to the ‘Embrace, Extend, Extinguish’ analogy for the Gates Foundation’s influence and authority in global public health, the organization has embraced the potential impact of gender inequity on health. It extends influence by aligning operations and making alliances with international, national and subnational actors. It showcases commitment through substantial investment. As a technical innovation, gender equality and the empowerment of women can be instrumentalized within agendas of economic growth, population stabilization and climate change. Thirdly, the Foundation exercises significant influence over how social inequalities are addressed, and how gender inequality links with health outcomes in the present and future (smart women making the right reproductive choices). This can contribute to smothering arguments around the need for expanding education, attending to caste- and gender-based atrocities – issues that are incompatible with its endorsement of rational, individual choice and expanded markets. Positioning interventions as technical partnerships rather than socio-political struggle, the Foundation, the government and various partners can govern the scope of improvements in gender inequality and female reproductive health.

III. The female participant incorporated

RMNCH programmes proceed with the assumption of a self-evident neutral idea of a woman who is available as a needing, willing and obedient participant. In practice, this ‘woman’ is also created iteratively as a result of technical interventions. Engaging targeted beneficiaries as participants is correlated with better health outcomes (Beck et al., 2019; George et al., 2015). However, the extensive promotion of needs-based and participatory programming appears to have lost its meaning even as it becomes more common. A scoping review of community-based RMNCH interventions found that ‘community-engagement’, ‘community-mobilization’, ‘community-participation’ and ‘stakeholder engagement’ are used interchangeably, inconsistently and without formal descriptions (Dada et al., 2023). This raises scepticism over what is taking place under these initiatives.

The involvement of targeted beneficiaries has been part of the development enterprise at least since the mid-twentieth century but it gained greater currency in the 1990s (Cooke & Kothari, 2001; Cornwall, 2006). Through participatory rural appraisal (PRA), Chambers (1997) drew attention to the erroneous assumptions about the superiority of external expertise and large-scale investments to improve the knowledge and practices of rural populations. Chambers’ argument on epistemological privileges perpetuating structural inequities demanded a two-part commitment. Firstly, it necessitated greater engagement with the knowledge, needs and experiences of those under intervention, and secondly, it required large, powerful entities to acknowledge and address the ways in which they were complicit in creating and perpetuating inequality. The former has been adopted more readily than the latter. In practice, the posture of epistemic humility and willingness to learn from rural communities is offset by the predetermined and ritualistic format of participation (Cornwall, 2003; Wilson, 2015). Also, in practice, it is difficult to surmise whether participation is empowering or disempowering, imposed or desired. Therefore, it is less important to assess the intent or format of participation, especially because this approach works alongside overly disciplinary and coercive modes of governance (Green, 2010). What matters is how the differently positioned actors confront, employ and interpret participation and to what ends.

The increased attention on the Gates Foundation’s protracted authority compelled CEO Mark Suzman to emphasize that the organization channels its money and influence to make up for the lack of political will and resources in countries where it is present. It uses the privilege and reputation of the co-founders ‘to elevate the voices of those who don’t have a global platform’ (Suzman, 2023, para. 9).

RMNCH requires an ideal-type community of female beneficiaries, participating as free and willing agents. When this female participant is produced, she can validate the need, purpose and practices of intervention. In this section, I argue that this female participant is made to perform a distinct and crucial function of reinforcing the social authority, technical soundness and moral legitimacy of RMNCH interventions. In governing participation as such, RMNCH delimits the scope of what counts as women’s health interventions.

The participation of the female beneficiary is a boundary object.⁸ Boundary objects are concepts, theories, people, or actual objects that hold different meanings and uses across social groups. They serve as means for communicating coherently across disciplines, sectors, contexts and geographies. The materiality of boundary objects refers less to its physical ‘thing-ness’ and more to the quality of being used, applied, shared and acted upon (Star & Griesemer, 1989). Boundary objects inhabit the space between different social worlds that may not fully agree on its meaning and scope, but manage to cooperate because these objects can be employed with low or high specificity depending on context.

In 2010, Susan Leigh Star revisited her coinage of boundary objects and revealed that she originally planned to call the concept ‘marginal object’. Marginality, she notes, traditionally denoted ‘membership in more than one social world’, critically valuable to understanding how boundaries between different social worlds are created and maintained (Star, 1989, p. 411). Marginal people, in her example, are people of mixed racial heritage tasked with authenticating and managing their identities through shapeshifting between two worlds; oscillating to be seen and to fit in (Star, 2010; Star & Griesemer, 1989).

In development parlance, marginality indicates a peripheral and neglected entity. Here, the idea of multiple memberships is pertinent. Female beneficiaries in rural Uttar Pradesh are targeted in recognition of their marginalized status in terms of caste, gender, location, educational status and experiences of reproductive morbidity. Including this marginalized individual is a crucial representational artefact to give the impression of voluntary, equitable interventions (Green, 2010). The female participant reconciles the various stakeholders who, in different ways, lay methodological and substantive claims upon her. It is the needs of women and girls that the Gates Foundation invokes as justification for its RMNCH funding (Suzman, 2023, para. 9). However, there are myriad instances in which this is detrimental to an expansive, equitable and politically progressive research, and policymaking for women.⁹

Anjali, an associate at Population Council has worked on RMNCH for over 20 years. In this period, she has found it difficult to expand the discourse beyond family planning and maternal mortality (personal communication, 28 July 2022). Anjali recalls that infertility was included for the first and last time in the third iteration of the District Level Household and Facility Survey (DLHS).¹⁰ The survey revealed that densely populated states such as Uttar Pradesh and Bihar have the highest levels of female infertility (over 10 per cent) (IIPS, 2010). The DLHS also had questions on obstetric fistula, unmarried women and sex education. These questions were abandoned in the fourth round of the DLHS, and the survey was not conducted in Uttar Pradesh and eight other states that continue to perform poorly on RMNCH indicators (Accountability Initiative, 2013). By dropping gynaecological issues from the DLHS, and by abandoning the survey in states with high rates of gendered morbidity and mortality, policymakers can add and subtract from women’s health as needed. There is also less impetus to expand focus when the SDGs are primarily concerned about improvements in total fertility rate, maternal mortality rate, and infant mortality rate.

It is not as if evidence on other aspects of female well-being does not exist. But one finds that these instances are not recognized as women’s health because they fall outside the category of RMNCH/SRHR one way or another. A colleague of Anjali’s worked with Self Employed Women’s Association (SEWA), an organization of women across the trade and informal sector.

[At SEWA] one heard a history of the complete ignorance of gynaecological morbidity, by providers, by policy, by women, by their families, by society where we just didn’t understand that excessive menstrual bleeding is a gynaecological morbidity that can be treated. (Personal communication, 3 August 2022)

Similarly, some key-informants felt compelled to clarify that they did not work on ‘women’s health’ even when they evidently had experience catering to women’s mental or physical well-being. For instance, Shikha worked with UNHCR in the late 1980s, as a counsellor on health and gender needs with adolescent girls and women, Afghan refugees, Iranian and Sudanese migrants who had endured various forms of gendered violence. Despite this experience, she felt that her work did not qualify as women’s health (personal communication, 7 July 2022).

In her 14 years as a public health researcher in Uttar Pradesh, Hema witnessed several improvements in institutional deliveries and antenatal care. However, this focus on RMNCH has overwhelmed other women’s health issues (personal communication, 22 January 2022). For gynaecological concerns such as uterine prolapse, urinary incontinence, or leucorrhoea, biomedical care is sought only when a surgical intervention or urgent care becomes unavoidable. Hema pointed to the dearth of interventions to address the intersecting vulnerabilities of gender, class and caste that shape trust in public healthcare facilities. At primary health centres, nurses are more likely to pressurize lower caste women for post-partum IUCD insertion. Hema also mentioned the difference between how projects and targeted beneficiaries assess the success and failure of the intervention. In a quantitative assessment, one in 2,000 women experiencing contraceptive failure might count as a negligible failure rate (0.05 per cent), but ‘in rural areas, one story is enough’ to create scepticism.

In the absence of a structural intervention, gender norms create significant stigma about problems concerning domestic abuse, depression, suicidal ideation, white discharge, or unwanted pregnancies. For instance, Preeti works at a Delhi-based advocacy organization that focuses on destigmatizing sexual healthcare. During the COVID-19 lockdown, young and unmarried women reached out to Preeti’s organization from across the country, desperately seeking help for stress, depression, urinary tract infections, sexually transmitted infections and unintended pregnancies. Her team collated a list of doctors and counsellors who were willing to provide respectful, remote consultations. The list was made available on social media. However, the organization lost out on data since the focus was on facilitating anonymized access.

The people being intervened upon serve as distinct evidence in the accounting for change. There is, in effect, habeas corpus summons for all development interventions to ‘produce the body’ of beneficiaries participating as free and willing agents with a self-avowed need. Priti’s organization was prioritizing people’s privacy versus showcasing reach and impact on important issues of female health. This resulted in a failure to produce the female participant.

In contrast, the orchestrated participation of women under RMNCH initiatives serves as evidence for minimizing the need for challenging stigmatized gynaecological issues, patriarchal norms and reinforces the efficacy of standardized projects and methodologies. As a result, RMNCH becomes a Goldilocks zone in which the women's health agenda is legible. It also has a normative dimension – ‘Women’s health’ in terms of reproductive functions but not sexual needs; women’s sexuality as primarily within marriage and unescapably heteronormative; as necessarily maternal but not too often. These parameters strengthen the biosocial dogma of reducing women’s health to reproductive functions. They reinforce the boundary of what counts as urgent and relevant healthcare needs for female populations in low-resource settings.

It would be simplistic to argue that the relentless frame of ‘maternal and child health’ creates normative pressures for all women to be mothers or that their health is only evaluated in terms of reproductive potential. Rather, RMNCH is a sundial that casts a shadow on all female lives such that their health is determined in relation to reproductive function, regardless of where they stand.

The ‘female participant’ thus incorporated validates the need and impact of RMNCH programming across different settings. She also sustains the boundary between serious and innocuous health issues, evidence and non-evidence. This makes RMNCH a more manageable and feasible technical enterprise but much less capable of securing meaningful improvements.

Conclusion

Examining projects in Uttar Pradesh, I elaborated on the political comportment of technical interventions – a set of relationships, strategies and processes that stand to inhibit the conceptualization of women’s health. It is an argument to study technical interventions as a form of politics to fully grasp the impact of this era of global health operations. The ‘technical’ carves out a path of least resistance, and results in sustaining rather than reforming gender inequity as a determinant of health. Intervention serves the rationality and circumstances of the structures that produce inequality and disempowerment. Drawing upon intersecting networks of power and privilege, technical enterprise creates disempowering and harmful effects in the lives of targeted communities. In reinforcing rather than challenging social norms and political regimes, it casts a long shadow on the health of people outside its periphery.

The myth of the technical obfuscates the multi-scalar coalitions of caste, class, ethnic, racial and gendered power that retain a majority stake in deciding who and what counts as a priority for intervention. The decisions, processes and relationships borne out of these coalitions engender dominant modes of thinking about the causes and circumstances in which preventable morbidity and mortality exist, pushing alternative conceptualizations to the margins.

It is imperative that this critical scrutiny not be interpreted as a condemnation of the resources made possible by the Gates Foundation, or an antagonism of participatory approaches. The question at hand is whether investments in preventable morbidities and mortalities need to be through the current arrangement; it is about parsing through the assumptions undergirding the myth of philanthrocapitalism and understanding the fuller account of the impact.

Ethical approval statement

The study received ethics approval from the University of Oxford Central University Research Ethics Committee (Reference number: CUREC 1A/ODID C1A 20-033). Informed verbal consent was secured for data collection and for audio recording.

Acknowledgements

A special thanks to Simukai Chigudu for his supervision of this research. I am grateful for feedback from Rishita Nandagiri and Tom Scott Smith that strengthened this paper. I also thank the anonymous referees at Economy and Society.

Disclosure statement

In 2013–2014, I worked as a research assistant for a UP-based public health expert mentioned in this paper. However, the analysis is devoid of any information I may have gained during my time as an employee. No conflict of interest to disclose.

Additional information

Funding

This research and writing were made possible through small grants from the Oxford Department of International Development (ODID), Wolfson College, Oxford Faculty of Asian and Middle Eastern Studies, the Global Challenges Research Fund, and the Global Social Medicine Network at King’s College London.

Notes on contributors

Vyoma Dhar Sharma

Vyoma Dhar Sharma is a postdoctoral fellow working on the O’Neill-Lancet Commission on Racism, Structural Discrimination and Global Health in Washington D.C. Her doctoral work examined the endurance of ‘Reproductive & Child Health’ as a predominant understanding of women’s health in India with an in-depth focus on Gates Foundation funded projects in Uttar Pradesh.

Notes

1 ‘Woman’ is a historically contingent, relational, and situated position rather than a self-evident, natural fact. RMNCH interventions are biosocial, i.e., focusing on female reproductive functions while also gaining meaning through the normative segmentation of a woman’s lifecycle. Consequently, the paper focuses on persons assigned female at birth while intrinsically contesting the essentially reproductive framing of ‘woman’.

2 $2,977,183,864. This is a conservative estimate based on a summation of Gates Foundation grants listed under the category of either ‘Family Planning’ or ‘MNCH’ (Maternal, Newborn, Child Health) only. A range of other grants also mention ‘Family Planning’ and ‘MNCH’, combined with categories such as ‘Empower women and girls’ or ‘MNCH discovery and tools’.

3 This research is enriched by forgoing scholarship on participatory approaches, namely, Chambers (1997), Cleaver (2001), Cooke and Kothari (2001), Cornwall (2003, 2006), Green (2010), Hickey and du Toit (2007) and Wilson (2015).

4 Harvard School of Public Health (HSPH) reports the grant figure as $14.1 million. https://www.hsph.harvard.edu/news/press-releases/gates-grant-maternal-infant-deaths-india/.

5 Intervention details presented in a web-based panel.

6 Grants to ‘University of Manitoba’ where the purpose explicitly mentions Uttar Pradesh.

7 I adapt this strategy by drawing upon the technical elaboration by Ravindran (2022), https://web.archive.org/web/20220904152256/http://theurbanengine.com/blog//embrace-extend-extinguish-by-microsoft.

8 See Green (2010) for a discussion of participation as a ‘boundary object’ in development programmes.

9 I explore this in https://somatosphere.net/family-planning-projects-unpacking-the-spectacle-of-womens-empowerment-in-uttar-pradesh-india/.

10 The DLHS was the first district level health survey in India, initiated to assess people’s utilization of public health facilities for RMNCH services. There has been a total of four rounds of the DLHS survey (1998–1999), (2002–2004), (2007–2008) and (2012–2013).