Attachment

equipment fails due to lack of maintenance. According to Gates, problems like these are too low-tech to attract the world's best brains. "Unfortunately, it's a very mundane, practical thing," he says. "It's not sexy from a scientific point of view." A businessman's understanding of incentives helps. The number of fridges needed is not large enough to provide a profitable market for manufacturers so the foundation has had to make financial commitments in advance. The business model of the vaccine makers gives them little reason to lower their manufacturing costs to make their products more affordable, he adds. Their high costs are more than covered by prices they can charge in the developed world and any mistakes they might make as a result of tampering with their carefully regulated production processes would jeopardise that existing business. ""That's not science -- that's, how the hell do you make 50 cent vaccines?" Gates Foundation project Needle-free immunisation The disposable-syringe jet injector (DSJI) is a needle-free immunisation system developed by Path, a non-profit organisation, with funding from the foundation. Using a pressurised liquid stream to push through the skin, it prevents cross-contamination and injuries to medical staff. Management methods that would be immediately familiar to anyone involved in the fast-moving technology world are also being brought to bear. These include employing the rapid cycle of trial and error that new tech companies engage in before pouring money into a formula that works -- a process known as "scaling", which takes place as they race to capitalise on a new market before rivals emerge. Apoorva Mallya, a senior program officer who works on country implementation, puts the success in stamping out the disease in India partly down to pouring money into local initiatives that had the potential to be effective across the country, but which were being conducted on too small a scale to make a difference. These included assigning community mobilisers to individual districts and neighbourhoods before vaccination drives began in order to organise meetings of women and overcome distrust or resistance. "We went in and funded them for a massive expansion across India," he says. Another method familiar from the tech world involves more effective data collection and analysis. Vaccination drives fail if too many children fall through the net. To get a better understanding of effectiveness, the foundation has paid for teams of researchers to use statistical sampling to see if adequate coverage levels have been reached. Measurement is also being brought to bear to build a more detailed understanding of how costs are incurred in vaccination drives. Without that data, it's hard to know where to focus attention to make global health programmes more effective, says Orin Levine, who runs the foundation's vaccination efforts. "We don't necessarily differentiate where the costs are in the system yet, so it makes it harder to say an innovation in [a particular area] will be something we really want," he explains. This kind of rigour would be familiar inside an engineering-centric company such as Microsoft, where rationality reigns. But in the more chaotic world of global aid, with its loose alliance of government agencies, NGOs and charities -- many of them operating with only partial information -- it does not pay to assume such disciplines. Learning to work in that world is one of the greatest adjustments. "The fact that people don't understand numbers and systems thinking and science and logic, that's OK," Gates says -- though his famous impatience might belie such a claim. "I only need a half of the people who contribute to really think in a way where I can say, hey, come on, there's a theory of change here, do you get it, do you get if that piece doesn't happen, it completely messes up that piece?" Like many self-made business people, Gates is wary about the ability of governments to deal with some of society's most pressing problems. Personal experience might have something to do with it. More than a decade ago, his fight with the US Department of Justice over whether Microsoft had acted illegally to defend its PC software monopoly ended in defeat, though a settlement with the George W Bush White House saved the company from the forced break-up that a judge had ordered. Gates describes himself as a natural optimist. But he admits that the fight with the US government seriously challenged his belief that the best outcome would always prevail. With a typically generalising sweep across history, he declares that governments have "worked pretty well on balance in playing their role to improve the human condition" and that in the US since 1776, "the government's played an absolutely central role and something wonderful has happened". But that doesn't settle his unease. "The closer you get to it and see how the sausage is made, the more you go, oh my God! These guys don't even actually know the budget. It makes you think: can complex, technocratically deep things -- like running a healthcare system properly in the US in terms of impact and cost -- can that get done? It hangs in the balance."