A paper in this week's Lancet raises questions about the transparency, accountability and governance of the Gates Foundation (GF). This Health Policy paper is written by Dr David McCoy, Centre for International Development, UCL (University College London), UK, and colleagues. An Editorial and Comment accompany the piece.
The Gates Foundation (GF) is the largest private grant-making foundation in the world. McCoy and colleagues analysed where and how its funds have been used. Between 1998 and 2007, the GF awarded 1094 grants worth almost US$ 9 billion. Individual grants varied from $3,500 to $750 million. Some 65% of all funds was shared by just 20 organisations, including The Global Alliance for Vaccines and Immunisation (GAVI), the Global Fund, an American NGO called PATH, and a small selection of universities in the US and UK. GAVI received two grants of $750 million, one to purchase new vaccines, and the other for general operating support. A total of 76 universities worldwide received $1.8 billion of funding, but nearly 60% of this went to just eight institutions in the US and UK. WHO received $336 million (4% of its total funding) — the GF is now one of the biggest donors to WHO, exceeding the contributions of most G20 governments. In terms of geographical location, 40% went to international or 'supranational' bodies, eg, GAVI and WHO. Of the remaining funds, 82% went to organisations based in the USA, 13% to Europe and other high income countries, and 5% to low- and middle-income countries.
The authors say: "All the key contributors to global health have an association with the Gates Foundation through some sort of funding arrangement. Coupled with the large amount of money involved, these relations give the foundation a great degree of influence over both the architecture and policy agenda of global health. Through its funding of non-governmental organisations and policy think tanks, the foundation also confers power and influence on a selected number of organisations and in doing so, establishes some leverage over the voice of civil society."
Regarding disproportionately high funding to certain US Universities, the authors add: "This large amount of funding concentrated within a small number of US-based institutions raises questions about their privileged status among organisations operating in global health."
On the subject of accountability, the authors say: "Grant making by the Gates Foundation seems to be largely managed through an informal system of personal networks and relationships rather than by a more transparent process based on independent and technical peer review...the process by which individual proposals for projects are solicited, adjudicated, and funded is unclear."
The authors also question the priority given to technological/research solutions over health system strengthening – since there are many existing cost-effective technologies that do not reach those in need. They say: "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."
In the accompanying Comment, Professor Robert Black, Johns Hopkins Bloomberg School of Public Health, Baltimore, USA, and colleagues say that the very limited direct funding from GF to low- and middle-income countries is 'arguably the most unfortunate imbalance in the research portfolio of the Foundation'. They conclude: "A modest shift of the balance of the Foundation's funding from the purchase of commodities to research, from heavily funded diseases to truly neglected diseases (such as pneumonia and diarrhoea), and from high-income-country institutions to those in settings where the problems exist would make enormous additional contributions to global health."
The Editorial praises the GF's contribution to GAVI, and other successful projects. However, it says there is serious anxiety about the transparency of the Foundation's operation. It adds: "Although [the Foundation] is driven by the belief that 'all lives have equal value', it seems that the Foundation does not believe all voices have equal value, especially voices from those it seeks most to assist."
The Lancet has five proposals for the GF. First, improve its governance. Second, be more transparent and accountable in its decision making. Third, devise a grant award plan that more accurately reflects the global burden of disease. Fourth, do more to invest in health systems and research capacity in low-income countries. And 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 Editorial concludes: "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."
Dr David McCoy, Centre for International Development, London, UK T) +44 (0)7952 597244 E) d.mccoy@ucl.ac.uk
Alternative contact Ruth Metcalfe, UCL Media Relations Manager on T) +44 (0)20 7679 9739, M) +44 (0)7990 675 947, out of hours +44 (0)7917 271 364, E) r.metcalfe@ucl.ac.uk
For Professor Robert Black, Johns Hopkins Bloomberg School of Public Health, Baltimore, USA, please contact Tim Parsons T) +1 410-955-7619 E) tmparson@jhsph.edu / rblack@jhsph.edu
Lancet Press Office T) +44 (0) 7424 4949 E) pressoffice@lancet.com
For full Health Policy, Comment, and Editorial see: http://press.thelancet.com/gates.pdf
Journal
The Lancet