What has the Gates Foundation done for global health?

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What has the Gates Foundation done for global health?

Editorial. The Lancet, Volume 373, Issue 9675, Page 1577, 9 May 2009

doi:10.1016/S0140-6736(09)60885-0 Cite or Link Using DOI

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, 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, 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.

http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(09)60885-0/fullte\

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