Not all of the billions of dollars given by the Bill and Melinda Gates Foundation to boost global health have been wisely spent, one of Britain's top medical journals said on Friday.
While praising the outsized philanthropy of the Microsoft founder and his wife, The Lancet said grant-giving was flawed by "whimsical governance" and failed to "reflect the burden of disease endured by those in deepest poverty."
The editorial accompanies an in-depth analysis of Gates Foundation donations from 1998 through 2007 showing what it describes as "imbalances" in how nearly nine billion dollars of health-related funds were distributed over that period.
University College London professor David McCoy and colleagues point to huge spending on new vaccines and drugs that may or may not work and often take decades to develop.
Helping health care systems in poor countries deliver proven treatments may be a better path to fulfilling the Foundation's goal of reducing the current 10 million annual child deaths by half within two decades, they suggest.
The study also notes that the lion's share of funding has gone to fight AIDS, malaria and tuberculosis, with relatively little spent on "neglected diseases" linked to poverty that are also major killers.
Pneumonia and diarrhoea, for example, together cause 40 percent of all child deaths.
In 2005, the distribution of aid grants from multiple sources -- including the Gates Foundation -- per death was more than 1,000 dollars for HIV/AIDS compared with just over three dollars for non-communicable diseases, they note.
The Lancet also questions the thin slice going directly to research institutions in the poor nations that stand to benefit from the Foundation's largesse.
"The very limited direct funding to these countries is arguably the most unfortunate imbalance in the research portfolio of the Foundation," noted Robert Black of Johns Hopkins University in a commentary, also in The Lancet.
The journal calls on the Gates's to make several "modest shifts": from the purchase of commodities to research, from heavily funded diseases to neglected ones, and from institutions in high-income countries to those in settings where the problems exist.
It also pointed to the Foundation's enormous influence, and their ability to help set the agenda for other major international organisations focused on global health.
In a reaction provided to AFP by email, the Foundation welcomed the outside scrutiny and said it "will consider the recommendations."
But at the same time it vigorously defended its choices.
"We have always devoted a major share of funding to the delivery of proven interventions, and we will continue to increase these investments," said Joe Cerrell, director of global health policy and advocacy.
Cerrell also pointed out that many of the diseases targeted by their funding, especially AIDS and tuberculosis, also have a major impact on children and families.