Great expectations: (From The Bill and Melinda Gates Foundation)

[Guest guest]

Great expectations

Hannah Brown

BMJ 2007;334(7599):874 (28 April), doi:10.1136/bmj.39183.534919.94

874 BMJ, 28 APRIL 2007,Volume,334

The Bill and Melinda Gates Foundation is the world's biggest grant

giving charity and has done much to raise the profile of global

health. But critics claim its special brand of philanthropy is

damaging health systems in developing countries and distorting aid

priorities. Hannah Brown reports

Ask anyone with a passing interest in global health what the Gates

Foundation means to them and you'll likely get just one answer:

money. In a field long fatigued by the perpetual struggle for cash,

the foundation's eagerness to finance projects neglected by many

other donors raised high hopes among campaigners that its impact on

health would be swift and great. And with the

commitment last June by America's second richest man, Warren Buffet,

to effectively double the foundation's $30bn (£15bn; €22bn)

endowment,1 hopes of substantial health achievements grew higher

still.

But despite Bill Gates's prediction at a press conference to mark

Buffet's pledge that there was now " No reason why we can't cure the

top 20 diseases " 2 observers are starting to question whether all this

money is reaping sufficient rewards. For although the foundation has

given a huge boost to research and development into technologies

against some of the world's most devastating and neglected diseases,

critics suggest that its reluctance to embrace research,

demonstration, and capacity building in health delivery systems is

worsening the gap between what technology can do and what is actually

happening to health in poor communities. This situation, critics

charge, is preventing the Gates's grants from achieving their full

potential.

As one of the Gates Foundation's three main focuses, along with

global development and its US programme, global health projects

receive a substantial amount of the charity's annual spending. To

date, almost half of all awards have been in this area, a total of

$6bn.

When the Gates Foundation first started this generous spending in

2000, it was greeted with enthusiasm as a refreshing alternative to

the staid, sluggish agencies that had until that time dominated

global health. More nimble than the bureaucratic intergovernmental

organisations of the UN system, including the World Health

Organization, the Gates Foundation won respect for prioritising

research gaps, promoting new financing mechanisms, and embracing

partnerships with key global health actors.

However, the foundation's business-like approach has also gained its

fair share of detractors. A commitment to results oriented spending

ensures that money is linked to measurable and demonstrable

outcomes. But although this strategy makes accounting easier to

handle, it has perpetuated vertical, disease specific funding

strategies that damage health systems in developing countries,

according to , director of the School of Public Health

at the University of the Western Cape, South Africa.

These vertical programmes, which are a longstanding feature of many

global health initiatives, lead to fragmentation of health systems

because they require separate planning, staffing, and management from

other health services.3 Although the programmes can efficiently meet

short term targets, Professor says such successes come at the

expense of sustainable improvements in health. " Unless there has

been a very concerted effort at preserving local capacity and

ensuring retention of staff then it is not a sustainable approach, "

he says. What is more, he adds, vertical programmes tend to distort

government priorities in developing countries, even if local

ministers are committed to broad health system improvements. " Even

if governments develop coherent policies and integrated plans it is

quite difficult to hold that line when your big funders. with more

money than those countries' overall health budgets want to focus on

single diseases, often using a single technology rather than a more

comprehensive approach, " explains Professor .

Technology versus delivery

Whereas the foundation contests claims that it is neglecting the

strengthening of health systems, co-chairs Bill and Melinda Gates

Are the Gates's grants achieving their full potential?

Where the gates money goes

Malaria $642m

Vaccine preventable diseases $1.9bn

HIV and AIDS $1.1bn

Child health $164m

Tuberculosis $321m

Nutrition $191m

Acute diarrhoeal illness $89m

Acute lower respiratory infections $239m

Reproductive and maternal health $522m

Other infectious diseases $596m

Breakthrough science $448m

Advocacy $532m

Emergency relief $61m

Grants from 1995-2005 listed in Gates Foundation Global

Health Program Fact Sheet (March 2006)

www.gatesfoundation.org/nr/downloads/globalhealth/GH_fact_sheet.pdf

have made no secret of the fact that they see breakthrough

technologies as key instruments in global health. The foundation

described its policy to the BMJ: " Effective and affordable health

tools aren't available for many diseases. For this reason, we have

focused a significant portion of our grant-making on discovering and

developing new vaccines, drugs, and other tools that could save

millions of lives. " However, Anne Mills, of the London School of

Hygiene and Tropical Medicine, London, says that unless the

foundation starts bridging the existing knowledge gap between proved

technologies and how best to deliver them to communities, the problem

will just get worse. " When money goes into new technologies you are

just going to see more need for evidence on delivery systems to get

them into practice, " she explains.

Professor also believes the Gates Foundation's penchant for

technological solutions limits the public health impact of its

programmes because it ignores the realities of life in developing

countries. " It is pretty clear that in the countries that I am

acquainted with in southern and eastern Africa, the biggest problem

is not lack of technology but systems to implement it; health systems

have been seriously weakened by years of underfunding as a result of

economic crises and structural adjustment, " he says.

One of the starkest examples of the technology-delivery divide is the

GAVI Alliance (formerly known as the Global Alliance for Vaccines

and Immunisation), a partnership established with a grant from the

Gates Foundation in 2001. The alliance was set up at a time when

worldwide immunisation rates were poor after steep rises in the

1980s.led mainly by Unicef .had waned. " Vaccination coverage had

stagnated and in Africa it was at a miserable 50%, " explains

Professor .

GAVI had the primary aim of enticing the drug industry to produce

more and new vaccines. But, says Professor , " We can't even

administer the old vaccines to children in Africa. "

GAVI has since begun investing directly into health system support

for vaccine delivery, but Lincoln Chen, president of the New York

based China Medical Board and an associate at Harvard University's

Global Equity Initiative, says that the foundation has not yet

achieved an ultimately effective balance. " I don't think Gates'

investments are yet adequately balanced in closing the gap between

what we know and what we can deliver, " he says. " I can understand

Gates saying `That's not what a foundation can solve; it is too

messy' but I look at the Rockefeller 100 years ago. It worked the

whole system: the human resources in medical education and research,

the necessary technologies, and the requisite social institutions

for global health. Arguably, Rockefeller's huge investments in modern

scientific medical education4 and establishing the field of public

health5 were even more important than [its funding of] the discovery

of penicillin and yellow fever vaccine. Gates has the opportunity to

better balance its catalytic investments for the 21st century, " he

says.

Growing criticism

The foundation is also attracting negative comments from other

quarters. Grant recipients note that it is getting slower at

processing applications and often seems to be giving mixed signals on

funding priorities. " [The foundation] is at an uncomfortable stage " ,

says Professor Mills. " It's not as quick and fast as it used to be

and not as predictable as more established research funders. " While

the increasing tiresome administrative processes can be explained by

increased interest following Warren Buffett's donation, the Gates

Foundation admits it might need to grow.

" We are expanding our internal capacity to keep pace with the growing

endowment and interest, " a spokesperson said.

Critics also frequently chide the organisation for its choice of

predominantly northern institutions when awarding grants, citing

substantial funding commitments for the Seattle based Programme for

Appropriate Technologies in Health and several academic institutions,

including the London School of Hygiene and Tropical Medicine and

Harvard University. But the most recent bout of negative publicity

emerged after a minor scandal about the foundation's endowment

investments.

An investigation by the LA Times published in January this year

revealed that, although the foundation refuses to put money into

tobacco companies, it is not averse to buying stock in firms

responsible for releasing harmful pollutants or keeping prices of HIV

drugs unaffordably high.6 7 The foundation caused further

consternation among health campaigners in its response to the

investigation: after initially announcing a review of its investment

policies in the wake of the LA Times' reports, it later issued a

detailed statement explaining that no changes would be made.8

McCoy, editor of Global Health Watch, sees this move

as " Exposing the hypocrisy of the Gates Foundation and the double

standards that it employs. " He says that the foundation's decision

exemplifies the fact that it is prepared to confront only obvious

health problems while continuing to ignore the wider political and

social issues. Dr McCoy notes the irony behind the fact that the

foundation's enormous wealth is derived from the very distortions and

injustices in the global political economy that keeps billions of

people impoverished and unable to access health care. " The mere fact

that we have one individual able to concentrate and accumulate so

much wealth points to more fundamental questions about the way that

the global political economy is organised, and we need a bigger

discussion about how to shift the proceeds of economic growth to more

people, " he says. He adds that while even grand-scale grant giving

may seem to be a beneficial action, philanthropy can actually make

underlying social and economic problems. the true determinants of

health. more difficult to resolve because it can hinder health system

development.

Finally, as with all private philanthropic organisations, the Gates

Foundation attracts criticism for the simple reason that its money is

private and therefore not really open to public accountability.

According to Dr McCoy, the large degree to which the foundation has

become a funder of independent academic institutions, non-

governmental organisations, global health agencies, and even

journalists raises concerns about self censorship and a reluctance to

subject itself to proper scrutiny. The foundation counters that it

is continuously striving for openness through providing detailed

information about grants on its website and seeking external opinions

on some funding requests.

For some, however, having to rely on the foundation's commitment to

accountability is not sufficient, given the influence it enjoys.

Anne-Emanuelle Birn, Canada chair in international health at the

University of Toronto, thinks that because the foundation only part-

funds most initiatives, and selectively picks good performers, that

its decisions influence other donors' choices about where to put

their money. This means, according to Dr Birn, that although the

Gates Foundation's grants may not be making a huge impact on the

ground, it is substantially affecting global health priorities.

" When the Gates Foundation invests there are a whole range of

bilateral agencies and governments that are interested in joining

on, " says Dr Birn. " Organisations want to be associated with what are

perceived to be successful initiatives. " And this influence on how

taxpayers' money is spent should, she argues, confer greater

responsibility. Dr Birn, Dr McCoy, and Professor all share

the belief that the Gates Foundation. And Bill Gates himself should

use its profile and clout in financial circles to lobby for changes

to improve the economic condition of developing countries as well as

funding health programmes.

Positive effect

One thing observers do not contest is that in the seven years since

the foundation was set up, it has been a key advocate for global

health as an issue of international concern.

" The field is not treated any more like a charity side show in part

because Gates entered with money and has given the field visibility, "

says Professor Chen. And, importantly, the foundation's existence has

prompted the traditional global health actors to take a much-needed

look at what niche they can occupy now. For example, says Professor

Mills, " because Gates is coming with an awful lot of money it has

stimulated the [unicef, UN Development Programme, World Bank, and WHO

sponsored] Special Programme for Research and Training in Tropical

Diseases to rethink its core business to focus on southern

partnerships and developing capacity because it can't compete in

terms of the volume of money for scientific investments. "

The foundation has also created a more stable environment for

research. Professor Mills says the scale of the funding available

through the foundation has enabled a different approach to research

from that allowed by the necessarily restricted traditional sources

of global health funding. " The research agenda surrounding potential

new tools, such as intermittent presumptive treatment of malaria in

infants, can now be addressed in a set of coordinated studies, rather

than piecemeal as funding permits, " she explains.

However, to make the organisation more successful in terms of global

health outcomes, she agrees that it must extend its funding to aid

countries with policy choices and decision making. " My hope is that

Gates will come to realise they do have to engage with health systems

research. If they don't we will have many new technologies but they

won't get used, " says Professor Mills.

While conceding that " the initial funding hasn't yet translated into

anything dramatic in the field, " Professor Chen believes that Bill

and Melinda Gates at least seem to have the right motivation for the

task of co-chairing the world's biggest grant-giving charity. " I

think they are honestly trying to do a good job, " he says. " Much of

the innovation and creativity of philanthropy is about taking some

risks to achieve breakthrough results. "

Praise and criticism for the Gates Foundation

Pros

Raised profile of global health

Forced UN and other agencies to rethink role

Created a more stable environment for research

Brought in much needed funds

Cons

Focus on technology rather than delivery

Perpetuated vertical programmes; not strengthening existing health

systems

Funding mainly goes to northern organisations

Too slow to make decisions

Not sufficiently accountable

____________________

Hannah Brown is a freelance journalist

hannah@...

Competing interests: None declared.

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