The Bill and Melinda Gates Foundation (The Gates Foundation) is the largest private foundation in the world. Although there is a long history of private philanthropic funding agencies, such as the Rockefeller Foundation and the Ford Foundation that contributed to global health, the Gates Foundation is in a league of its own and is a cut above the rest.
The Gates Foundation grants focuses on the following three programmes: -
• A programme, based in the USA, that concentrates on secondary and post-secondary education
• A global programme, that focuses on development hunger and poverty. This programme primarily caters to the poor especially small farmer
• A global health programme.
The Gates Foundation's Grant--Features
The total amount granted by the Grant foundation in 2007 was US $2·01 billion of which $1·22 billion was contributed towards global health. This matched closely to the WHO's annual budget (approximately $1·65 billion). In comparison, the grant money spent by the Rockefeller Foundation was a feeble $0·17 billion.
The profound effect that the Gates Foundation has on global health is evident in the money it invests in malaria research. In the late 1990s, $84 million was the yearly budget earmarked for malaria research; since the year 2000, the Gates Foundation has increased this amount three times over.
Some of the salient features of the grants provided by the foundation are listed below-
• The Gates Foundation granted 1094 grants valued at $8·95 billion between January '98, and December, 2007. The size of individual grants considerably varied. The smallest grant was $3500, whereas the biggest was $750 million
• 65% ($5·82 billion) of Gates Foundation global health funding was shared by 20 organizations
• The period of time the grant was given varied from less than 1 year to greater than 5 years. The majority of them were provided for a period between 2- 5 years.
However, a lot of dust has been raised over the lack of accountability of private foundations in general and the role of the Gates Foundation in particular. The Gates foundation's global health programme has not been properly assessed and it is this aspect that the report is hoping to discuss.
The recipients of the grant include supranational or intergovernmental organizations, USA, Europe, other high middle and low income countries, UN agency, World Bank, government and non governmental, profit and non profit organizations, public and private sector organizations and universities.
• The largest proportion of funding was received by non-governmental or non-profit organizations. Of the 659 grants awarded to these organizations, 560 primarily went to those in the USA and other high-income countries,
• A large group of 'think tanks' or policy research institutes, such asthe Center for Global Development in Washington DC, USA are being supported by the Gates foundation grants and form the second biggest category of recipients.
• The third biggest category of recipients was the universities in the USA and few in the UK. Of the 231 grants awarded to universities, a mere 12 were given to universities in low-income or middle-income countries.
• Intergovernmental organizations were identified as the fourth biggest category of recipients. They accounted for about 8% of all the funding. Most of this money went to WHO Public awareness and advocacy organizations were also major recipients
• Government agencies and for-profit companies received the Gates grants infrequently.
The activities that the grant supported primarily included the following: -
• Research and development. Basic science research, applied health research, vaccines, microbicides and diagnostic equipments, purchase and supply of drugs and health care delivery.
• Civil society development (carried out in low-income and middle-income countries),
• Programme, policy development, organizational support.
• Advocacy, Scientific meetings, conferences, awards,
• Formal training / education
• Food fortification/ nutrition enhancement,
Disease /Health conditions
The Gates foundation funds research, prevention, control and management of the following diseases /health conditions:-
• HIV/AIDS and associated diseases
• Non-HIV sexually transmitted infections
• Tuberculosis (does not include immunization with BCG)
• Vaccines (when target disease not specified)
• Vaccine-preventable illnesses
• GI diseases like diorrhoea
• Respiratory diseases
• Cervical cancer
• Family planning / Malnutrition/Child and maternal health
• Neglected / tropical infectious diseases (such as filariasis, leishmaniasis, dracunculiasis)
• Traditional medicine
• Humanitarian aid / emergency relief
• Sexual and reproductive health or women's health
• General health
The Gray Zone
A study was conducted by a group of researchers McCoy, Kembhavi, Patel and Luintel on the global health programme of the Gates foundation and they came up with the following discoveries-
a) Several grants could be potentially placed in more than one category. The researchers were unable to produce a set of discrete, non-overlapping grant categories.For example, there is an inevitable overlap between child health and vaccines or between sexual / reproductive health and HIV/AIDS.
b) The descriptions of several grants were vague and brief. For example, it was not clear if the grant to health programmes were focused on the clinical activities as opposed to public health activities.
c) It appears that there could be a disparity between the amount of the grant specified on the website and the actual money disbursed to the recipient.
d) The Gates Foundation funds a wide range of organizations that contribute to global health including the WHO and the World Bank. All of them are linked with the Gates Foundation because of certain funding arrangements. Gates Foundation is not a passive donor and these arrangements could provide the foundation with a leverage that would enable it to influence the structure and policy agenda of global health and the controlling bodies of civil society.
e) Another notable feature is that the majority of the recipients are US-based who accounted for 82% of the total grants awarded between 1998-2007.
f) A substantial portion of the funding went to a few universities and some non-profit or non-governmental organizations. The organization PATH, University of Washington, Johns Hopkins University, Harvard University, and Columbia University are some of these beneficiaries. What were the features of these universities/organizations that made them qualifiers for the grant?
g) Ambiguities regarding the categorization of the recipient organizations also abound-- for example, some organizations had both non-profit and for-profit components, and some were part government and part non-government organizations.
h) Grant making by the Foundation is carried out largely through an informal system of personal networks and is not executed transparently.
i) WHO is being funded by the Gates foundation through a series of separate Gates Foundation grants which may be conditional and donor-determined.
J) Funding was disproportionately allocated to promote new technologies rather than helping to overcome the barriers to the use of existing ones.
k) Certain diseases such as diarrhea, pneumonia, malaria, HIV/AIDS, and tuberculosis, as well as vaccine-preventable diseases were prioritized not necessarily based on the 'need of the hour'.
l) The foundation's over emphasis on technology has helped to take the focus away from the social determinants of health.
Gates foundation directly funds certain World Bank activities AND acts as a conduit to channel funds to other recipients as a result of which it is likely to have a major say in global health governance. It would therefore be necessary to monitor and evaluate the nature of the relationship between the Gates Foundation and the World Bank and its effects.
The Foundation funds the management, prevention and eradication of diseases not necessarily on the basis of priority. There are some indirect implications of the various reports that indicate that factors besides science, technology and opportunity play some role in decision making!
The active role played by the Gates foundation has promoted the formation of loose horizontal networks and has also helped to further increase the existing disparities between developed and developing countries.
Taking all this into account one wonders "Who is Bill Gates accountable to for influencing or promoting these policies?" As an organization that enjoys tax exemptions it must be subjected to some form of auditing by indepandant outside agencies to ensure it's credibility and in order for it not be marred by controversy.
Although no one doubts Bill Gates' genuine desire to help the poor and to do good, it is important to ensure that this desire is translated into genuine measures that effectively improve the health and well being of the poor and the needy.
David McCoy, Gayatri Kembhavi, Jinesh Patel, Akish Luintel
"The Bill & Melinda Gates Foundation's grant-making programme for global health"
The Lancet, Vol. 373 No. 9675 pp 1645-1653 (May 09, 2009)
Dr. Reeja Tharu/L