PHA-Exchange> Gates Foundation 'could do more'

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from Vern Weitzel <vern at coombs.anu.edu.au> -----

BMJ  2007;334:874-876 (28 April), doi:10.1136/bmj.39183.534919.94
Feature
Global health
Great expectations

Hannah Brown, freelance journalist

Cambridge

hannah at two-cultures.com

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; {euro}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 
David Sanders, director of the School of Public Health at the University of 
the Western Cape, South 
Africa.

These vertical programmes, which are a long standing 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 Sanders 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 Sanders.

Technology versus delivery

Whereas the Gates Foundation contests claims that it is neglecting the 
strengthening of health 
systems, co-chairs Bill and Melinda Gates 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, according to Anne 
Mills, of the London 
School of Hygiene and Tropical Medicine, London, unless the foundation starts 
bridging the existing 
knowledge gap between proved technologies and how best to deliver them to 
communities, the problem 
is just going to 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 Sanders 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 
Sanders. GAVI had the primary 
aim of enticing the drug industry to produce more and new vaccines. But, says 
Professor Sanders, "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, 
according to Lincoln Chen, president of the New York based China Medical Board 
and an associate at 
Harvard University's Global Equity Initiative, 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

David 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 Gates 
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 
Sanders 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."





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