David McCoy, Gayatri Kembhavi, Jinesh Patel, and Akish Luintel
The Bill & Melinda Gates Foundation (henceforth referred to as the Gates Foundation) is the largest private grant‐making foundation in the world. It has three main programmes: a US programme that focuses on secondary and post‐secondary education; a global development programme that focuses on hunger and poverty (with an emphasis on small farmers and financial services for the poor); and a global health programme. The total amount paid out by the foundation for all grants in 2007 was US$2.01 billion, of which $1.22 billion (61%) was for global health.
Although there is a long history of private philanthropic funding in global health – notably by the Rockefeller Foundation and the Ford Foundation – the influence of the Gates Foundation is of a different order. In 2007, the amount spent by the Gates Foundation on global health was almost as much as WHO’s [World Health Organization’s] annual budget (approximately $1.65 billion), and was substantially more than the total grant spending of the Rockefeller Foundation across all programmatic areas in the same year ($0.17 billion). The Gates Foundation’s effect on global health is evident in malaria research. In the late 1990s, only $84 million was spent on malaria research yearly; since 2000, the Gates Foundation has helped to roughly treble this amount. However, there have been concerns about the role, effect, and lack of accountability of the Gates Foundation (and of private foundations in general). So far, the foundation’s global health programme has not been properly assessed. In this report, therefore, we describe and discuss the foundation’s grant‐making programme for global health. Although we do not assess the impact or cost‐effectiveness of the programme, this analysis provides a useful starting point. […]
Between January, 1998, and December, 2007, 1,094 grants were awarded for global health by the Gates Foundation; the total value of these grants was $8.95 billion. Table 36.1 shows the number and total value of new global health grants awarded every year, and the actual expenditure on grants per year. The amount of funding committed to new global health grants fell from 1999 to 2002, before rising until 2006 and then falling again in 2007. Although the number and value of new grants awarded in 2007 was lower than in 2005 and 2006, actual expenditure grew.
The size of individual grants varied substantially. The smallest grant was for $3,500, whereas the largest was for $750 million. The length of grants varied from less than 1 year to more than 5 years, but most (777 [71%]) were awarded for periods of between 2 years and 5 years. […]
65% ($5.82 billion) of all Gates Foundation global health funding was shared by 20 organisations, including five global health partnerships – such as the Global Fund to Fight AIDS, Tuberculosis and Malaria and GAVI Alliance, which together received a quarter of all funding through ten grants. Global health partnerships were the second largest category of recipient. Other global health partnerships that received funding between 1998 and 2007 were the Global Alliance for Improved Nutrition (which directly received about $58 million but also benefited from a grant of $50 million that was channelled through the World Bank), the International Partnership for Microbicides (about $60 million), the International Trachoma Initiative (about $31 million), and the Global Alliance to Eliminate Lymphatic Filariasis (about $20 million, but channelled through the World Bank).
Table 36.1 Number and total value of new global health grants between 1998 and 2007 (and total disbursements per year) made by the Bill & Melinda Gates Foundation.
| 1998 | 1999 | 2000 | 2001 | 2003 | 2004 | 2005 | 2006 | 2007 | Total | |
| Number of new grants | 34 | 68 | 81 | 68 | 108 | 137 | 200 | 197 | 129 | 1094 |
| Total value of grants awarded (US$, millions) | 151 | 1132 | 632 | 388 | 477 | 780 | 1981 | 1991 | 1079 | 8949 |
| Amount disbursed (US$, millions)* | – | 686 | 554 | 856 | 577 | 442 | 844 | 916 | 1220 | 6602 |
Data for annual disbursements were obtained from annual reports or financial statements on the Gates Foundation website. The Gates Foundation’s operational and administrative costs are excluded.
* The amount disbursed in 1998 was unavailable on the Gates Foundation website
The category of organisation that received the largest proportion of funding was non‐governmental or non‐profit organisations. Between 1998 and 2007, the Gates Foundation awarded grants worth $3.30 billion to a wide range of over 100 such organisations, including those that are mainly research‐based, those that are mainly involved in health‐care delivery, and those with a focus on public awareness or advocacy. The non‐governmental or non‐profit organisation that received the most amount of funding was the Program for Appropriate Technology in Health (PATH; Seattle, WA, USA), which was awarded 47 grants worth a total of $949 million, mostly for medical research and development. The Gates Foundation has helped to increase PATH’s annual expenditure from less than $20 million to over $150 million during the past decade. The next three largest recipients in this category were the Institute for OneWorld Health (a non‐profit pharmaceutical company set up in San Francisco, CA, USA, to discover and develop new drugs for neglected diseases), the Save the Children Federation, and the Aeras Global TB Vaccine Foundation (a non‐profit product development partnership focused on tuberculosis). Other non‐governmental organisations that received large amounts of funding were Family Health International, Care International, and World Vision, which received grants worth $56 million, $41 million, and $8 million, respectively.
Public awareness and advocacy organisations were also major recipients. The US‐based ONE Campaign, which focuses on poverty and preventable global disease, received a grant worth $22 million in 2007; and DATA, an advocacy organisation for Africa, received two grants (in 2003 and 2006) worth a total of $26 million. In 2008, the ONE Campaign and DATA merged to become a single organisation known as ONE, which is now led by a former executive of the Gates Foundation. The International HIV/AIDS Alliance, which supports community action within developing countries as well as international research, policy analysis, and advocacy, received grants worth about $42 million. ActionAid International received a grant of just under $11 million to develop a network of non‐governmental organisations to monitor and lobby European governments and the European Commission to support the right to health. […]
Recent changes to collaboration in global health have been characterised by the emergence of loose horizontal networks, where it is unclear who is making decisions and who is accountable to whom. Indeed, the Gates Foundation has helped to promote the emergence of these networks. One investigation that would bring greater clarity to the structure of global health governance is the critical examination of the nature and effects of the relationship between the Gates Foundation and the World Bank, WHO, and key global health partnerships.
A notable finding was that 42% of all funding was spent on either health‐care delivery (including humanitarian relief) or increasing access to drugs, vaccines, and other medical commodities. However, the foundation’s reputation for focusing on biotechnological developments was also confirmed. More than a third (37%) of funding was for research and development, or basic sciences research. Furthermore, the size of grants for research and development seems to have increased in recent years compared with those for health‐care delivery. Similar findings were reported in a previous analysis of the foundation’s support for child health research, which concluded that funding was disproportionately allocated to the development of new technologies rather than towards overcoming the barriers to the use of existing technologies. This technological bias reflects the priorities of Bill Gates himself. In his recent annual letter, he stated that “optimism about technology is a fundamental part of the foundation’s approach” and he described the key approach to eliminating the main causes of early childhood mortality as “the invention of a handful of new vaccines and getting them into widespread usage”. Although we did not calculate a composite figure for all vaccine‐related funding (i.e., for research and development, basic science research, health‐care delivery, purchase and supply, advocacy or policy development), we estimate that at least half of all funding was linked to vaccination.
The allocation of funding by disease or health issue reflects the explicit strategy of the Gates Foundation to focus on several priority diseases – namely, diarrhoeal disease, pneumonia, malaria, HIV/AIDS, and tuberculosis, as well as vaccine‐preventable diseases in general. A key question that emerges from these data is whether the foundation allocates its funding according to need, both in selection of diseases and health issues, and in the focus on vaccines and technology.
A cursory look at the data suggests a prioritisation of HIV/AIDS and malaria over maternal health or mental illness, even though these conditions together make up five of the ten leading causes of disease burden in women aged 15–44 years in low‐income and middle‐income countries, whereas prematurity, low birthweight, birth trauma, and birth asphyxia together contribute 8% of the total burden of disease in low‐income countries. However, the issue of priority setting cannot be answered by looking at the Gates Foundation in isolation. The foundation might after all be choosing to fill a gap that has been neglected by the market or other funders. Additionally, the foundation’s allocation of funding for research and development will be determined by factors other than measures of the burden of disease, such as the state and cost of science and the type of research and development needed. Nevertheless, other analyses of global health funding suggest a need to examine the priorities of the Gates Foundation. One study that assessed spending on global health by the World Bank, the Gates Foundation, the US Government, and the Global Fund in 2005 found that funding per death varied substantially across types of disease – for example, $1,029.10 for HIV/AIDS compared with $3.21 for non‐communicable diseases. Another study that analysed global spending on neglected diseases (including private sector investment) found that only three diseases (HIV/AIDS, malaria, and tuberculosis) accounted for 80% of the total expenditure. The investigators also found that much more was spent on drugs and vaccines than on diagnostics and calculated that the Gates Foundation contributed about a fifth of all funding for research and development for neglected diseases. They concluded that factors beyond science, technology, and opportunity were clearly playing a part in decisions about funding.
One argument used to make the case that the Gates Foundation over‐emphasises technology and new vaccine development is that many existing cost‐effective technologies do not reach the people who need them because of poverty or health system failings. Additionally, most of the high child mortality in poor countries results from an underlying lack of access to basic needs such as food, housing, water, and safe employment. Thus, rather than viewing the hundreds of thousands of child deaths from rotavirus infection as a clinical problem that needs a vaccine solution, a better approach might be to view it as a public health problem that needs a social, economic, or political intervention to ensure universal access to clean water and sanitation. However, these concerns about the foundation’s technology‐based approach need to be considered alongside three counter‐arguments. First, as previously mentioned, a substantial amount of funding is spent on service delivery (albeit largely through vertical programmes) or increasing access to existing technologies. Second, the responsibility for funding and developing delivery systems belongs to governments and other types of donors. Third, the Gates Foundation has a separate programme of funding aimed at addressing malnutrition and chronic hunger through various agricultural interventions. Nonetheless, there should be more data‐driven discussion about the overall effect of the Gates Foundation’s approach to global health improvement. In view of its receipt of public subsidies in the form of tax exemptions, there should also be an expectation that the foundation is subject to some public scrutiny.
The Gates Foundation is a major contributor to global health with enormous financial power and policy leverage. Its decisions can have a substantial influence on other organisations. The foundation’s emphasis on technology, however, can detract attention from the social determinants of health while promoting an approach to health improvement that is heavily dependent on clinical technologies. The support of vertical, disease‐based programmes can undermine coherent and long‐term development of health systems, and its sponsorship of global health policy networks and think tanks can diminish the capabilities of Ministries of Health in low‐income and middle‐income countries. Additionally, the foundation’s generous funding of organisations in the UK and USA accentuates existing disparities between developed and developing countries while neglecting support for the civic and public institutional capacities of low‐income and middle‐income countries. Although Bill Gates’ annual letter indicates a genuine desire of the foundation to help the poor and to do good, further independent research and assessment are needed to ensure that this desire is translated into the right and most cost‐effective set of approaches, strategies, and investments for improving the health of the poor.