[health-vn] Lancet: What has the Gates Foundation done for global health?

[Vern Weitzel]

Subject: 	PHA-Exch> Lancet: What has the Gates Foundation done for
global health?
Date: 	Mon, 11 May 2009 17:58:41 +0700
From: 	Claudio Schuftan <cschuftan at phmovement.org>
To: 	pha-exchange at phm.kabissa.org




From: *Brian Pazvakavambwa* PazvakavambwaB at zw.afro.who.int
<mailto:PazvakavambwaB at zw.afro.who.int>

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

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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
<http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(08)61485-3/abstract> 

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.