EXTREME CLOSE-UP. Ashok Alexander: Aiming for charity on a grand scale

Management consultant turned public health advocate Ashok Alexander has the classic business grounding of a top-flight McKinsey consultant that he brings to the traditionally laidback world of NGOs.

When remedying ills, he likes the benefits to be scaled up to reach the largest number of people in the shortest timeframe.

Alexander did just that at the Bill & Melinda Gates Foundation, which threw hundreds of millions of dollars into the fight against HIV in India.

Now, armed with experience picked up over a decade at the foundation, he’s launched a new organisation, Antara, and is looking for an all-India solution to resolve the chronic problems of maternal health and childcare.

“At Avahan (the Gates project), we scaled up very quickly, and the single biggest takeaway was capital S for scale,” says Alexander. “My grounding is business, not public health. That’s relevant for everything I’ve done in Antara and Avahan.”

A report in medical journal Lancet estimated that Avahan’s work in half-a-dozen States hardest-hit by HIV prevented 600,000 infections. At the same time, critics say the big-spending programme failed to make a lasting contribution to combating the virus precisely because it tried to do too much, too fast.

Today, Alexander’s attempting to replicate the successes of the anti-HIV campaign, but this time it’s on a shoestring. For starters, the Antara programme is being rolled out in just one State, Rajasthan, where it’s backed by Chief Minister Vasundhara Raje Scindia.

But Alexander still yearns for scale. “My job is visualising where things can go: Can this go all-India? Should we be trying to work in another State or just stick with Rajasthan?”

Alexander, whose father was PC Alexander, former Maharashtra Governor, was a national-level chess player in his teens. He now plays “speed games” on the internet. And went on to spend 17 years at McKinsey.

His chess playing and McKinsey roots are leitmotifs in his conversation. “When we started Avahan, we needed data to get a grip on the market,” he says. “Not macro-level data on how many infections in India, but micro-level, like how many types of sex workers are there, what’s the transaction frequency...”

Then, almost in the same breath, he segues from a business approach to a chessboard analogy, saying: “When you play chess, the reason you can play is because of pattern recognition. This was played in 1936 in Nottingham or last week by Vishy Anand.”

For Alexander, life’s traced an unexpected pattern from St Stephens, the Delhi School of Economics and IIM-Ahmedabad to the rural hinterlands.

He joined McKinsey in New York and the first great upheaval happened when he came to India as part of a team to launch the firm’s business here.

“It was a crazy concept to start a McKinsey office in India and charge international fees. Luckily, we were on the cusp of liberalisation and it was the right time,” he says.

But the real life-changing event came when a McKinsey partner called from the US and asked Alexander to make arrangements for Bill Gates and his team, who were visiting India and planning to spend megabucks on HIV prevention.

Alexander didn’t have anyone to put on the job, so he stepped in. “Over three intense weeks, I realised this was something huge. The plans may be crazy-sounding, but the aspirations were genuine — to stop HIV in India.” When asked if he’d lead the India team, he replied, “I’m on.” Initially, Alexander’s phone rang off the hook when word went out he had $100 million to spend (Gates’ investment eventually climbed to over $250 million).

But his efforts quickly turned into a walk along a road to despair. He hit a brick wall in encounters with the government.

He says: “The attitude basically was — who do you guys think you are, coming here and waving a $100-million cheque? We’re not a banana republic.” Worse was to follow, when he went out in the field and got a brutal education in the ground realities of the sex trade.

The sex workers were dismissive when he attempted to lecture them. Says Alexander: “As one woman said: ‘Are you telling us about condoms? I’ll tell you things about condoms you’ll never know. You’re telling me about sexually transmitted infections and that I’ll die in 10 years. For me, that’s a lifetime. It’ll be God’s blessing if I live 10 years’.”

Adding to the complexity of reaching out to sex workers was the fact that, unlike in other countries, only a small portion of the trade takes place in brothels. But Alexander and his team realised one common factor in sex workers’ lives was they faced almost constant violence — from clients to police and boyfriends.

A turning point for the HIV campaign was the creation of “safe” drop-in centres where sex workers could retreat, bathe and rest.

“People were coming because they wanted to join the violence-reduction programme, not the HIV-prevention programme. And when they came we started creating links...”

“The (HIV) programme started mushrooming” and “the sales force were the practising sex workers,” he recounts. “I used to tell my McKinsey colleagues: I challenge you to find a corporate sales force more sophisticated than mine.”

As the Gates Foundation’s HIV work wound down, Alexander says he became increasingly focused on the “enormous tragedy” of maternal and child deaths. India has a maternal mortality rate of 174 per 100,000 live births while under-five mortality is 47.4 per 1,000 births, some of the worst rates in the world.

This time, there are no big Gates Foundation bucks supporting him, but Scindia has put her clout behind his Antara project, which operates in Rajasthan’s Jhalawar and Baran districts. Alexander has some donors but more would be welcome, he says.

He regularly hops on a night train from Delhi and makes his rounds of villages, meeting with district magistrates, health workers and women. Again, mapping the problem has been crucial — mainly because there are no accurate maps of each village.

“You really don’t know how many malnourished children are there or how many high-risk pregnancies.” He has also enlisted teenage schoolgirls in villages to help expectant mothers and see they’re getting enough nutrition and make reports for follow-up by anganwadi workers.

At Antara, Alexander is turning to technology and working on a tablet that can be used by village workers to replace the cumbersome 17 registers in which they record health details. He expects the tablets to be a transformative tool in relaying information about problems to officials at the block, district and State level.

“The solutions here need a little twisting from the solutions there…I’m learning furiously. I’m also smarter because I don’t have money,” he says. But “it’s given me an extreme sense of satisfaction that two or three of the things we’re doing are already catching fire.”

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