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What has the Gates Foundation done for global health?

11 May 2009 (The Lancet)

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What has the Gates Foundation done for global health?

The answer to this question is: a great deal, but…

The massive boost to global health funding that the Bill & Melinda Gates Foundation has given since its inception in 1994 is astonishing. The Foundation’s current expenditure of around US$3 billion annually has challenged the world to think big and to be more ambitious about what can be done to save lives in low-income settings. The Gates Foundation has added renewed dynamism, credibility, and attractiveness to global health. In particular, the Foundation inaugurated an important new era of scientific commitment to global health predicaments. For example, other more well-established funding organisations—such as the US National Institutes of Health—now take their international health responsibilities far more seriously thanks to the Foundation’s energetic advocacy. Perhaps even more important is the fresh and deep political commitment to health that the Foundation has fostered.

There are several big successes the Foundation can take credit for. The Global Alliance for Vaccines and Immunisation, which received an initial gift from the Foundation of $750 million in 1999, has been its single most important contribution to global health so far. To that we would add the Foundation’s investment in the Seattle-based Institute for Health Metrics and Evaluation, which, in its short life, has made a critical impact on international policy and thinking, acting as a valuable independent scientific monitor of global programmes in health.

But apart from questions over its investments, the Gates Foundation has received little external scrutiny. Last year, Devi Sridhar and Rajaie Batniji reported that the Foundation gave most of its grants to organisations in high-income countries. There was a heavy bias in its funding towards malaria and HIV/AIDS, with relatively little investment into tuberculosis, maternal and child health, and nutrition—with chronic diseases being entirely absent from its spending portfolio. In The Lancet today, David McCoy and colleagues extend these findings by evaluating the grants allocated by the Gates Foundation from 1998—2007. Their study shows even more robustly that the grants made by the Foundation do not reflect the burden of disease endured by those in deepest poverty. In an accompanying Comment, Robert Black and colleagues discuss the alarmingly poor correlation between the Foundation’s funding! and childhood disease priorities.

The concern expressed to us by many scientists who have long worked in low-income settings is that important health programmes are being distorted by large grants from the Gates Foundation. For example, a focus on malaria in areas where other diseases cause more human harm creates damaging perverse incentives for politicians, policy makers, and health workers. In some countries, the valuable resources of the Foundation are being wasted and diverted from more urgent needs.

There is also a serious anxiety about the transparency of the Foundation’s operation. What are the Foundation’s future plans? It is hard to know for sure. The first guiding principle of the Foundation is that it is “driven by the interests and passions of the Gates family”. An annual letter from Bill Gates summarises those passions, referring to newspaper articles, books, and chance events that have shaped the Foundation’s strategy. For such a large and influential investor in global health, is such a whimsical governance principle good enough? Whose advice has the Foundation taken in devising its strategy? Sadly, the Foundation has acquired a reputation for not always listening to its friends. Although it is driven by the belief that “all lives have equal value”, it seems that the Foundation does not believe that every voice has equal value, especially voices from those it seeks most to assist.

We have five modest proposals for the Gates Foundation. First, improve your governance. Visibly involve diverse leaders with experience in global health in your strategic and operational stewardship. Second, be more transparent and accountable in your decision making. Explain your strategy openly and change it in the light of advice and evidence. Third, devise a grant award plan that more accurately reflects the global burden of disease, aligning yourself more with the needs of those in greatest suffering. Fourth, do more to invest in health systems and research capacity in low-income countries, leaving a sustainable footprint of your commitment. Finally, listen and be prepared to engage with your friends. The Lancet was sorry that the Foundation declined our invitation to respond to the paper by McCoy and colleagues, and to set out its vision for their role in global health.

The Gates Foundation says that it is “open to amending” its principles as it grows and learns more about its work. Now is an inflection point in the Foundation’s history, a moment when change is necessary.