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the Bill & Melinda Gates Foundation from a health equity perspective
“In the face of rising infectious disease such as AIDS, TB, and malaria, and the
aggressive and vocal in its defense of global public health has never been more
INTRODUCTION
The last twenty years has seen a shift from “international” health to “global”
organizations (NGOs), and global health partnerships have gained power and prestige as
United Nations (UN) organizations, such as the World Health Organization (WHO), have
seen their agency undermined. Changes in the governance structure of global health,
especially the entry of extremely powerful private institutions, have affected the quest for
global health equity in a number of ways. This paper looks at the implications of this
transition on health equity at a global level by looking specifically at the growth of the
1
Bill & Melinda Gates Foundation and its relationship with the WHO.1 First, it establishes
perspective of the diminished capacity of the WHO while examining the rise in
prominence of the Gates Foundation, and also their relationship to each other. Finally,
the paper discusses the impact of the rise and fall of these two institutions on health
systematic disparities in health (or in the major social determinants of health) between
power, or prestige.” A look at indicators of health across the globe and within countries,
including life expectancy and maternal mortality, makes it clear that health equity
remains a goal rather than an achievement. Since the early 20th Century, cooperation to
address health across national borders has occurred, but it was not until the Declaration of
Alma Ata in 1978 that the notion of health for all gained prominence in public discourses
around health (Birn, et al, 2009). In recent years, health has been viewed through a
human rights framework and in terms of the social determinants of health (Farmer, 2005;
WHO, 2008). The notion of health equity encompasses most of these perspectives and
1
In McCoy, et al (2009b)’s recent article entitled The Gates Foundation’s grant making program for global
health, the authors suggest that “one investigation that would bring greater clarity to the structure of global
health governance is the critical examination of the nature and effets of the relationship between the Gates
Foundation and the World Bank, World Health Organization and key global health partnerships” (p. 1651).
This paper attempts to respond directly to this suggestion.
2
Loewenson (2009) suggests that there are four elements that support the
achievement of health equity: health for all; health in all policies; health equity; and
social empowerment. First, health for all involves ensuring that every person has access
to health care. For example, that they do not face financial or geographical barriers to
accessing health care facilities. Second, health in all policies suggests that health issues
resources throughout the health system that cannot be left to the market. And finally, it
involves social empowerment where there is recognition that people make up the central
sources, one of which is the Global Health Watch (GHW). The WHO is often seen as the
actor best positioned to lead the quest for global health equity both because of its policy
setting mandate and its representation of 193 countries. The most recent Global Health
Watch (2008) argues for a centralized, “accountable and effective multilateral global
health agency, driven by a desire to promote health with the understanding that the
distribution of health and health care is a core marker of social justice” (p. 224). Since its
establishment on April 7, 1948, the World Health Organization has sought to fill this role
3
The World Health Organization is a membership based intergovernmental agency
created as part of the UN system to deal with health issues on an international level. The
WHO’s mission is “the attainment by all peoples of the highest possible level of health”
(Birn et al, 2009, p. 73). This mission includes specific references to health equity and
reaching poor and underserved populations (WHOb). In particular, the WHO performs
the following functions: “providing leadership on matters critical to health and engaging
in partnerships where joint action is needed; shaping the research agenda and stimulating
the generation, translation and dissemination of valuable knowledge; setting norms and
standards and promoting and monitoring their implementation; articulating ethical and
building sustainable institutional capacity; and monitoring the health situation and
assessing health trends” (WHOa). In essence, the WHO has a role in both policy and
practice, and is “the closest thing we have to a Ministry of Health at the global level”
Over the years, however, the WHO’s ability to carry out its mission has changed,
both the country’s population and the size of its economy. Once the WHO receives the
money, it is up to its governing bodies – the World Health Assembly and the Executive
Board – to determine how the money will be spent (Birn, et al, 2009). These pre-
determined contributions make up what is known as the regular budget funds (RBFs) and
4
private organizations and are subject to the conditions of those who donate them (Birn, et
al, 2009, p. 75). Since the 1970s when the majority of WHO spending utilized regular
budget funds (80 percent of spending), there has been a shift to the point where three-
quarters of the WHO’s spending in 2008 came from extra-budgetary funds (GHW,
2008a, p. 226). The implication of this transition is that control over spending has moved
from the hands of the WHO’s governing structure and into the hands of a multitude of
private and public donors. Lee, et al (2009) gives an example of the WHO
budgetary support from private donors, though its perceived support of industry-
discounted rather than generic drugs (p. 419; GHW, 2008a, p. 230).
According to the Global Health Watch (2008a), this change in investment from
regular budget funds to extra-budgetary funds came partly as a result of a broader change
in UN system financing. In 1980, UN members pushed for a policy that ensured that
their contributions would account for inflation, but not grow beyond the current level. In
1993, they decided further to stop even this adjustment for inflation and introduced a
policy of zero nominal growth, effectively freezing funding for all UN organizations
(GHW, 2008a, p. 227). They also explain that the problem of late and non-payment of
contributions (to the tune of US$35 million to the UN overall in 1999) played a role in
increasing the WHO’s reliance on extra-budgetary funds (GHW, 2008a, p. 227). Birn, et
al (2009) suggests that regular budget funds for the WHO were also diminished as a
result of the World Bank’s entry into international health in the early 1980s which
redirected funds away from the WHO (p.75). As well, “perceived politicization of UN
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and breast milk substitutes,” led to the decreased interest in providing regular budget
funds to the WHO (GHW, 2008a p. 227). Lee, et al (2009) notes that another reason
behind reduced support for the WHO “could be because of the perceived threat to vested
reflect[s] the preference of donors towards having greater control over their money”
One of the actors that has emerged as a major extra-budgetary supporter of the
WHO in the last ten years is the Bill & Melinda Gates Foundation. After amassing great
wealth as the founder of Microsoft, Bill Gates and his wife, Melinda, decided in 1994 to
establish the Gates Foundation (GFc). Currently, the Foundation works in three areas:
global development, education, and global health. It is the latter initiative that is the
focus of this paper. At the end of 2008, the Gates Foundation reported assets of just
under US$30 billion and distribution of grants totaling just under $5.5 billion (GF, 2008).
To put these figures into perspective, Piller, et al (2007) note that the Foundation’s
endowment is greater that the gross domestic product of 70 percent of the world’s
nations.
The Gates Foundation mission is to “target diseases and health conditions that
cause the greatest illness and death in developing countries, yet receive little attention and
resources” (GFa). It does this by discovering, developing and delivering new disease-
6
issues. At present, the Gates Foundation invests heavily in research and delivery of
vaccines and medicines, putting the GAVI Alliance, PATH, Aeras Global TB Vaccine
Development, Medicines for Malaria Venture and the Global Fund to Fight AIDS, TB
and Malaria among the top recipients of its funds (McCoy, et al, 2009b, p.1648).
Through its extensive grant-making capabilities, the Gates Foundation has seen its
influence on global health policy and priorities strengthen over time, resulting in
(GHW, 2008b, p. 251). At present, the Foundation is a funder and board member of
various massive global health initiatives, including the Global Fund to Fight AIDS,
Tuberculosis and Malaria, the Global Alliance for Vaccines and Immunizations, and the
Stop TB Partnership, to name a few (GHW, 2008b, p. 249). In 2007, the Gates
Foundation joined with the WHO, UNICEF, UNFPA, UNAIDS, GFATM, GAVI, and
the World Bank to form an informal group of eight health-related organizations, known
as the “H8”(IHP, 2007). Like its namesake, the G8, this group of health actors represents
significant power over the global health agenda and at present, the Gates Foundation is
success in several areas, especially in the area of vaccines and immunizations. However,
7
there are some that question the Foundation’s approach to global health, particularly in
ACCOUNTABILITY
philanthropy’ is the transfer of social wealth and social power from the public
Damon refers. Unlike public organizations like the WHO, the Gates Foundation lacks
accountability similar to those found in the public sector, the Gates Foundation is
essentially subsidized by public coffers: foundation endowments are tax free (Birn, et al,
2009, p.99; McCoy, et al, 2009a, p.4). McCoy, et al (2009a) estimate that US$225
sense that it is money foregone by the state through tax exemptions” (p.4).
The Gates Foundation has also been accused of failing to fairly tender its grant
8
(2009b) notes that “grant making by the Gates Foundation seems to be largely managed
process based on independent technical and peer review” (p.1650). The Global Health
Watch (2008b) notes that “the absence of robust systems of accountability becomes
particularly pertinent in light of the foundation’s extensive influence” (p. 250). Despite
this lack of accountability, the Foundation still manages to have significant influence
VERTICAL PROGRAMS
A survey of the Gates Foundation’s programs on its website indicates that its
focus is often disease-based. For example, large portions of Gates Foundation funding go
which works to build capacity to provide health care for a multitude of different ailments.
It has further been argued that health care on its own is insufficient: the structural
determinants of health must be addressed through a health equity approach (like the one
Birn (2005) notes that the Gates Foundation approach is often technology based.
She suggests that their approach arises from an assumption “that the problems of global
health stem from a shortage of scientific knowledge, translated into technical solutions”
(Birn, 2005, p. 4). The Global Health Watch (2008b) uses the example of the Gates
9
focuses disproportionately on development of new technology rather than overcoming
2009b, p1649). It is possible to question whether the answers to the world’s health
problems can be found outside of the areas that carry the largest burden of infectious
FUNDING SOURCES
sustainability of their programming over time. However, it has become clear that there
has been no effort to coordinate this investment with the charitable mission of the
organization. In fact, it seems that in several cases, the investment of the Gates
Foundation’s endowment directly “contravene its good works” (Piller, et al, 2007). More
Foundation negates their efforts at disease control and eradication. For example, in
Nigeria, a community receiving vaccines from the Gates Foundation against polio and
through contributions from the Gates Foundation endowment (Piller, et al, 2007). After
the discovery of this hypocrisy in 2007, the Gates Foundation has, instead of becoming
10
more responsible investors, worked to try to better separate their endowment from their
charity on paper.
PRO-BUSINESS APPROACH
Bill Gates’ business background has had a considerable influence on the Gates
Foundation approach to global health. Global health has been impacted by Microsoft’s
actions prior to the Gates’ Foundation involvement, especially around the issue of
intellectual property rights and pharmaceuticals. For example, Microsoft was a strong
advocate for strict regulations in the agreement on Trade Related Aspects of Intellectual
Property Rights (TRIPS), which continues to affect access to essential medicines around
the world. The Gates Foundation maintains strong ties with the pharmaceutical industry,
as the president of their Global Health Program. McCoy, et al (2009a) argue that
“pharma companies benefit considerably from global health programs that emphasize
delivery of medical commodities and treatment,” as the Gates Foundation approach does
(p. 9).
To this day, the Gates Foundation remains strongly confident in the private
sector’s ability to solve global public health problems. In fact, the Global Health Watch
(2008b) goes so far as to accuse the Gates Foundation of converting global health
problems into business opportunities (p. 255). This is further illustrated by McCoy, et al
(2009b)’s point that only five percent of Gates Foundation funding is directed towards
lower or middle income countries (p.1649). In other words, most of the Gates
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Foundation funding remains in North America, sustaining think tanks, universities,
One of the ways that Gates pro business approach manifests itself is through the
partnerships bring together public and private sector actors to tackle a particular health
immunization. The public-private partnership model for global health, such as the Stop
TB Partnership, Roll Back Malaria, the Global Fund to Fight AIDS, Tuberculosis and
Malaria, and the Global Alliance for Vaccines and Immunization, almost by definition
partnership] for primary health care!” (p. 106). They go on to suggest that “most [public-
private partnerships] channel public money into the private sector, not the other way
controversy surrounding the Gates Foundation’s approach to global health policy making
and practice, it hints at the serious issues of the rise of an unaccountable, market-oriented,
private institution in setting the agenda for global health. It is impossible to separate the
factors that have weakened the international administrative body for health (the WHO)
and allowed for the growth in power and reach of private philanthropy for health (in
particular, the Gates Foundation). Next, we look at the specific ways in which these two
institutions interact, with a specific focus on how the Gates Foundation’s role as a donor
to practically every global health actor gives it power to set policy and even co-opt the
12
THE RELATIONSHIP BETWEEN THE WHO AND THE GATES
FOUNDATION
partnerships and research institutes, the Gates Foundation is a major funder of the WHO
(McCoy, et al, 2009b). Since 1998, the Foundation has contributed over US$505 million
This total makes the WHO the fourth largest recipient of Gates Foundation funding and
the largest intergovernmental organization grant recipient (McCoy, 2009b, p. 1649). The
governments, the only exceptions being the United States and Britain. Currently, the
Foundation ties for third largest funder of the WHO with Japan (GHW, 2008a, p. 227).
The Gates Foundation supports the WHO’s through vertical programming with
some operational support. According to the Foundation website, its grants to the WHO
fall into 14 categories (see Table 1). Most of these grants are focused on specific
diseases, including HIV/AIDS and malaria, with vaccines and maternal, newborn and
child health also receiving significant attention. Most interestingly, the category that
received the most amount of grant money between 1999 and 2009 was left uncategorized.
A closer look at the details of these grants suggests that they are more geared to WHO
operations than the other grants. Since 1998, the Gates Foundation has contributed
almost US$100 million towards often ambiguous projects like “[engaging] the global
health community in a creative and robust process to guide the future of health.” Though
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these types of projects have been granted less frequently in the last few years, as recently
as 2006, the Gates Foundation contributed US$5 million “to support the transition of the
politicized role in the WHO than the Gates Foundation would usually admit to.
It is important to note explicitly here that although the WHO has a mandate and
mission that supports the development of health systems and supports work to improve
the social determinants of health, it is no doubt constrained by the fact that its third
leadership initiatives. Clearly, the power of the Gates Foundation through its grants to
the WHO affects the organization’s ability to work towards health equity or a human
14
The Gates Foundation effects the WHO’s agency both directly through grant
making and also by its involvement with other global health stakeholders in policy
making. Competition for Gates Foundation funds has caused a trend towards aligning
with its priorities among several global health institutions. As well, the Gates Foundation
has created a number of new institutions, such as the GAVI Alliance and the Institute for
Health Metrics and Evaluation that have an affect on the global health landscape.
Because it is often not represented in these new institutions, WHO priorities are often
sidelined.
One of the big ways that the WHO has been affected by the Gates Foundation’s
rise in power both directly and indirectly, is the change towards a market-oriented global
health sector. While the Gates Foundation is not the only catalyst in this direction, it is
certainly acting on this interest at a very high level, for example through its participation
in the H8. In the policy statements of the Meeting of Global Health Leaders (H8) in
2007, five objectives were laid out that are particularly market-oriented, and make
explicit reference to the private sector’s role “in delivering health services, in financing
health care, and in bringing new technologies to market” (UNICEF, 2007). The fact that
the Gates Foundation is a funder of all of the other members of the H8 likely puts it in a
This pro-market approach to health has led to the rise of the public-private
partnerships for health discussed above. Through their support of these programs, the
Gates Foundation affects the agency of the WHO to determine global health policy. Birn,
et al (2009) states that “the WHO’s ability to tackle major international health problems
15
providing insufficient accountability and low cost-effectiveness (p. 107). “Public-private
impeding integrated approaches” (Birn, et al, 2009, p. 106). However, as public private
partnerships have become a donor priority they have thus have gained resources and
support from the WHO. Even by providing support, the WHO remains marginal in the
CONCLUSION
Overall we have looked at how the Gates Foundation, through its considerable
grant making capabilities, has affected the ability of the World Health Organization to
fulfill its mission of “the attainment by all peoples of the highest possible level of health”
equity, it is possible to see how the changing governance structures of global health have
programming above health system strengthening, “health for all” has become “treatment
of certain diseases”. The voices, such as the World Health Organization, that should
promote “health in all policies” have been co-opted and now toe the donor line. The
health commodities from industrialized countries. And finally, increased competition for
16
donor funds, a pro-business approach, and emphasis on technology-based solutions have
precluded the social empowerment necessary to put people first in health systems.
The balance of power between public and private actors in global health must be
restored, in particular between the World Health Organization and the Gates Foundation.
agency, driven by a desire to promote health with the understanding that the
distribution of health and health care is a core marker of social justice” (p. 224).
To restore the policymaking power of the WHO, the Gates Foundation must
for health. This recognition should lead to direct budgetary support to the WHO without
donor conditionalities and active representation of the WHO in all institutions related to
global health including public-private partnerships and the Gates Foundation itself. As
well, the Gates Foundation should acknowledge that the achievement of health for all will
only occur through changes to structural factors that undermine health, as well as
considerable inputs to promote health. Perhaps it is idealistic, but with this recognition
could come responsible investing, greater support for health systems strengthening, and
more involvement of stakeholders from the developing world. Otherwise, we risk the
complete takeover of global public institutions for health by private organizations that fial
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Birn, A., (2005). Gates’s grandest challenge: transcending technology as public health
ideology. The Lancet, p. 1-6.
Birn, A., Holtz, T., & Pillay, Y. (2009). Chapter 3: International Health Agencies,
Activities and Other Actors. Textbook of International Health: Global Health in a
Dynamic World. New York: Oxford University Press, p. 61-131.
Braveman, P., & Gruskin, S. (2003). Defining equity in health. Journal of Epidemiology
and Community Health, 57, p. 254-258.
Brown, T., Cueto, M., & Fee, E. (2006). The World Health Organization and the
transition from “international” to “global” public health. American Journal of Public
Health, 96, 1, p. 62-72.
Damon, A. (2007). The Gates Foundation and the rise of “free market” philanthropy.
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http://www.wsws.org/articles/2007/jan2007/gate-j22.shtml
Gates Foundation. (2008). Annual Report. Retrieved July 29, 2009 from
http://www.gatesfoundation.org/annualreport/2008/Pages/combined-statements-financial-
position.aspx
Gates Foundation. Global Health Program. Retrieved July 29, 2009 from
http://www.gatesfoundation.org/global-health/Pages/overview.aspx
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Commission on the Social Determinants of Health. Global Health Watch 2: An
Alternative World Health Report. London: Zed Books, p. 224-239.
Global Health Watch. (2008). Chapter D1.3: The Gates Foundation. Global Health
Watch 2: An Alternative World Health Report. London: Zed Books, p. 240-259.
International Health Partnership. (2007). About: Health 8 Agencies. Retrieved July 29,
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and health. The Lancet, 373, p. 416-422.
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Loewenson, R. (2009). Dimensions and drivers of equity oriented health systems in
Africa. Lecture, June 24.
McCoy, D., Chand, S., & Sridhar, D. (2009). Global health funding: how much, where it
comes from and where it goes. Health Policy and Planning, 1-11.
McCoy, D., Kembhavi, G., Patel, J., & Luintel, A. (2009). The Bill & Melinda Gates
Foundation’s grant-making programme for global health. Lancet, 373, p. 1645–53.
Piller, C., Sanders, E., & Dixon, R. (2007). Dark clouds over the good works of the
Gates Foundation. Los Angeles Times, January 7.
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www.unicef.org/health/.../Meeting_of_Global_Health_Leaders_-_Final_Summary.pdf
World Health Organization. The role of the WHO in public health. Retrieved July 29,
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ANNEX 1
Grants made by the Gates Foundation to the World Health Organization between 1998
and 2009. From the Gates Foundation Website.
Grant Number of
Year Recipient Category Program Grant Amount (US$) Grants
20
2008 WHO Malaria Global Health $13,839,336
2008 WHO Malaria Global Health $6,620,000
2008 WHO Malaria Global Health $2,977,349
2007 WHO Malaria Global Health $3,226,472
2007 WHO Malaria Global Health $4,943,750
2007 WHO Malaria Global Health $165,000
2007 WHO Malaria Global Health $4,540,340
2006 WHO Malaria Global Health $2,000,000
2006 WHO Malaria Global Health $2,157,830
2006 WHO Malaria Global Health $5,056,468
2004 WHO Malaria Global Health $1,454,076
2006 WHO Malaria, Vaccines Global Health $378,000
Malaria Total $77,672,587 14 grants
2006 WHO Maternal, Newborn & Child Health Global Health $35,096,912
2006 WHO Maternal, Newborn & Child Health Global Health $3,490,000
2005 WHO Maternal, Newborn & Child Health Global Health $999,500
2005 WHO Maternal, Newborn & Child Health Global Health $401,629
2005 WHO Maternal, Newborn & Child Health Global Health $198,351
2004 WHO Maternal, Newborn & Child Health Global Health $710,000
2002 WHO Maternal, Newborn & Child Health Global Health $990,000
2000 WHO Maternal, Newborn & Child Health Global Health $10,000,000
1999 WHO Maternal, Newborn & Child Health Global Health $10,000,000
Maternal, Newborn & Child Health Total $61,886,392 9 grants
21
2005 WHO Polio Global Health $25,000,000
2005 WHO Polio Global Health $3,937,500
Polio Total $68,711,412 3 grants
2008 WHO Tuberculosis Global Health $1,869,359
2006 WHO Tuberculosis Global Health $5,632,150
2005 WHO Tuberculosis Global Health $850,000
2000 WHO Tuberculosis Global Health $10,000,000
Tuberculosis Total $18,351,509 4 grants
2008 WHO Vaccines Global Health $647,139
2008 WHO Vaccines Global Health $1,047,177
2007 WHO Vaccines Global Health $28,507,852
2007 WHO Vaccines Global Health $999,532
2007 WHO Vaccines Global Health $150,177
2006 WHO Vaccines Global Health $52,382
2006 WHO Vaccines Global Health $6,842,314
2006 WHO Vaccines Global Health $65,707
2004 WHO Vaccines Global Health $543,393
1998 WHO Vaccines Global Health $250,000
Vaccines Total $39,105,673 10 grants
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ANNEX 2
Details of Uncategorized Grants made by the Gates Foundation to the World Health
Organization. From the Gates Foundation Website.
Grant Duration of
Date Purpose Amount Grant Location
Purpose: to support the Global Health Workforce Alliance in
Dec-07 addressing the global crisis in human resources for health $5,000,000 2 years Global
Purpose: to support the transition of the WHO Director- 2 years and
Nov-06 General Elect $5,000,000 1 month Global
Purpose: to support a conference on strengthening health
Oct-06 leadership and management in low income countries $303,848 7 months Global
Purpose: to engage the global health community in a creative
Jul-05 and robust process to guide the future of health $917,560 5 years Global
Purpose: to accelerate the development and introduction of
Jun-05 prophylactic HPV vaccines in developing countries $7,053,035 5 years Global
Dec-04 Purpose: to support the Health Metrics Network (HMN) $49,605,966 7 years Global
Purpose: to provide general operating support for the
Sep-04 Ministerial Summit on Health Research $198,263 6 months Global
Purpose: to train young professionals from developing
Jun-04 countries to become future leaders in public health $4,740,801 4 years Global
Purpose: to define the structure and range of activities for the
Health Metrics Network through a collaborative process with
Jun-04 partners and stakeholders across the globe $937,900 1 year Global
Jun-03 Purpose: for general operating support $5,000,000 1 year Europe
Purpose: to support activities for the surveillance and
May-03 containment of drug resistance in malaria, HIV and TB $350,000 1 year Global
Purpose: to support follow-up on the Commission of
Macroeconomics and Health (CMH) report at the country, 3 years and
Oct-02 regional, and global levels $10,121,473 2 months Global
Purpose: to build mapping tools for rapid analysis of
Aug-02 infectious disease incidence and prevalence $4,951,953 5 years Global
Purpose: to support an alliance of five agencies to work
collaboratively on preventing cervical cancer in developing Africa,
Sep-99 countries $3,952,458 2 years Asia
23