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Lancet article critical of Gates giving
 
 
  Low-key grumbling from critics for some time has suggested that the Bill & Melinda Gates Foundation lacks sufficient transparency and accountability and places too much emphasis on high-tech solutions. Now one of the world's premier medical journals is drawing some of the same conclusions after an analysis of the foundation's health spending over 10 years.
 
By Kristi Heim and Sandi Doughton
 
Seattle Times staff reporters
 
Low-key grumbling from critics for some time has suggested that the Bill & Melinda Gates Foundation lacks sufficient transparency and accountability and places too much emphasis on high-tech solutions.
 
Now one of the world's premier medical journals is drawing some of the same conclusions after an analysis of the foundation's health spending over 10 years.
 
"The foundation's emphasis on technology ... can detract attention" from the basic causes of health problems and can skew the health-spending priorities of poor countries, author David McCoy writes in one of a series of articles published Friday in the medical journal The Lancet. McCoy is senior clinical associate at University College London.
 
As the largest private foundation in the world, the Gates Foundation itself defies precedent in its ability to influence global health. The foundation's spending on global health was nearly equal to the World Health Organization's annual budget in 2007.
 
Yet the Gates Foundation is not held accountable, nor is it open about the way it sets priorities and awards grants, according to the Lancet analysis.
 
"What are the foundation's future plans?" asks an editorial. "It's hard to know for sure."
 
The world's biggest philanthropy is upfront about being "driven by the interests and passions of the Gates family," but that's a "whimsical" way to exert such enormous power on the world stage, says an editorial accompanying the analysis.
 
"We think it's important that he (Bill Gates) hears some of the perspectives from others," said Robert E. Black, chairman of the department of international health at the Johns Hopkins Bloomberg School of Public Health, and the lead author of a commentary published along with the Lancet analysis.
 
Gates Foundation spokeswoman Karen Lowry Miller said the foundation welcomed the article and its findings.
 
"We're totally open to this and will take all of this into consideration," she said.
 
Tadataka "Tachi" Yamada, president of the foundation's global-health program, plans to meet with McCoy in the future, she said. The foundation is also preparing to publish more information on its Web site about its approach to grants, decision-making process and strategy, Miller said.
 
The analysis finds that more than half of the philanthropy's $9 billion in spending went to just 20 organizations. Among universities, about 60 percent of the foundation's research funding went to eight institutions in the U.S. and the U.K.
 
As a result those organizations and universities now have "privileged status" and are able to exert huge influence over global-health policies worldwide, the articles say.
 
Over the past decade, more than a third of the funding went to research and development or basic sciences, "a technological bias that reflects the priorities of Bill Gates himself," McCoy writes. Yet most childhood deaths result from a lack of access to basic needs such as food, housing, water and safe employment.
 
"We think we have a strong global-health strategy that really gets to the problems of the developing world," Miller responded. "We're not trying to be everything. We're trying to be where we can have the most value."
 
Johns Hopkins' Black has received Gates funding. And, though he joked that he may not receive any more, he said he's convinced that Bill and Melinda Gates are committed to improving health around the world.
 
"I know their motivations are good, and I hope their responsiveness is, too," Black said.
 
In his commentary, he said the foundation's emphasis on future solutions, like new vaccines and drugs, ignores the fact that treatments and health strategies that are known to work are not being implemented.
 
The foundation could see a quicker payoff if it would instead focus on research on ways to improve delivery of health care and the best ways to get people to take simple steps that boost health, like breast feeding their babies, he said.
 
The journal was not without praise.
 
"The Gates Foundation has added renewed dynamism, credibility and attractiveness to global health," the Lancet said in an editorial.
 
But McCoy's analysis concludes that 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 article singles out Seattle-based PATH, which was awarded nearly $1 billion, saying the amount "raises the question as to whether some organizations might be better characterized as agents of the foundation rather than as independent grantees."
 

Gates' billions for global health not all well spent
 
PARIS (AFP) - 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.
 

Accelerating the health impact of the Gates Foundation COMMENT
 
The Lancet, Volume 373, Issue 9675, Pages 1584 - 1585, 9 May 2009
 
Robert E Black a, Maharaj K Bhan b, Mickey Chopra c, Igor Rudan d e, Cesar G Victora f
 
"The list of grantees is striking in the dominance of funding to international agencies and partnerships, as well as non-governmental organisations and universities in the USA and other high-income countries.1 The health problems being targeted are in low-income countries and little of the research and development funding is going to capable individuals and credible institutions in these countries. The very limited direct funding to these countries is arguably the most unfortunate imbalance in the research portfolio of the Foundation because it excludes scientists and programme managers who best understand the problems from contributing creative solutions"
 
In recent years the Bill & Melinda Gates Foundation has made enormous investments in global health. As a private foundation, it can decide its agenda, yet because of the huge influence it has, especially on research that addresses the major health problems of low-income countries, its decisions and priorities have become the subject of intense interest by the global health community. In The Lancet today,1 David McCoy and colleagues' description of the grant commitments by the Foundation provides an opportunity for analysis that may form part of a "natural feedback loop" that Bill Gates said in his first annual letter was currently missing.2 Such informal scrutiny could assist the Foundation to assess whether its investments are consistent with its mission and appropriately balanced to achieve optimum results.
 
The mission of the Foundation to improve maternal and child health with a philosophy that "every life has equal value" is an admirable commitment to global equity. We will use the Foundation's major focus on reducing child mortality and related research to illustrate points, although we believe that they apply generally to the Global Health Program of the Foundation. Gates has stated a goal of reducing the current 10 million annual child deaths by half in the next 20 years.2 This is less ambitious than the Millennium Development Goal 4 target of a two-thirds reduction in child deaths by 2015. For a Foundation that indicates that the current number of child deaths is unacceptable and needs to be addressed urgently, this point is surprising but consistent with the Foundation's focus on the development of new health technologies, which usually require decades.
 
The Foundation has provided substantial funds for service delivery, mainly through support for the supply of vaccines and medicines.1 While commendable, these funds might be better provided by national governments and international donors or agencies. We believe that the role best served by the Foundation is in research to advance global health, particularly research that is "high-reward", in their terminology.2 In the Foundation's statements, this term is usually preceded by "high-risk", but even more appealing would be research that is "low-risk and high-reward".2 The funding of the Foundation in research to improve child health should be examined for balance in the expected time frame for results, avenues of research (ranging from the development of new technologies to improving delivery of proven interventions), disease focus, and scientific leadership.
 
The research funding of the Foundation is heavily weighted toward the development of new vaccines and drugs,1 much of it high risk and even if successful likely to take at least the 20 years that Gates has targeted for halving child mortality. Vaccines for rotavirus diarrhoea have been in clinical trials for more than 25 years and the current generation of these vaccines, now in field trials in low-income countries of Asia and Africa, still might not have high efficacy in these settings. Additional funding might accelerate the development of new technologies, but as with the massive efforts to develop a vaccine to prevent HIV infection, will not guarantee success. Research to improve the delivery of proven interventions could be considered "low-risk and high-reward". Two-thirds of global child deaths could be prevented if existing interventions were fully implemented,3 yet population coverage of these interventions remains low and inequitable.4 Research on delivery of interventions, whether old or new technologies, and on health systems is essential to improve the quality and use of services, but only 3% of the funding from the US National Institutes of Health and 23% of that from the Gates Foundation were for research on delivery and use.5 The promise of this avenue of research has been noted;6, 7 however, the need has not been met by the Gates Foundation or other funders of international research.
 
Another imbalance is the poor correlation between funding and childhood disease burden. In particular, funding for research on pneumonia and diarrhoea, which cause about 40% of global child deaths,8 and maternal and child undernutrition, which is the underlying cause of 35% of child deaths,9 are relatively underfunded by the Foundation. For global research into the development of new products, funding for pneumonia and diarrhoea is much lower than justified by their high disease burden.10, 11 For these diseases, selective new vaccines and drugs would be useful, but there are effective preventive measures, such as breastfeeding and treatments, including antibiotics for pneumonia and oral rehydration therapy and zinc for diarrhoea. These crucial interventions have inadequate coverage in low-income countries and research can help identify and overcome barriers to correct practices.12, 13 Inexplicably such research that could lead to rapid improvements in child survival programmes and mortality reduction within 6 years rather than 20 years, has received only a few percent of the grant funding from the Gates Foundation.1
 
The list of grantees is striking in the dominance of funding to international agencies and partnerships, as well as non-governmental organisations and universities in the USA and other high-income countries.1 The health problems being targeted are in low-income countries and little of the research and development funding is going to capable individuals and credible institutions in these countries. The very limited direct funding to these countries is arguably the most unfortunate imbalance in the research portfolio of the Foundation because it excludes scientists and programme managers who best understand the problems from contributing creative solutions. More funding to institutions in low-income and middle-income countries would further develop their capacity for research, enable them to make national and regional contributions, and add to global knowledge.
 
The Bill & Melinda Gates Foundation is setting a new standard for financial investment and influence on global health. We applaud its commitment, which has changed the landscape for the better, but suggest that the Foundation examine and seek feedback on the urgency and means of attainment of its mission. A modest shift of the balance of the Foundation's funding from purchase of commodities to research, from discovery and development to delivery research, from heavily funded diseases to truly neglected diseases (such as pneumonia and diarrhoea), and from the high-income-country institutions to those in settings where the problems exist, would make enormous additional contributions to global health.
 
REB, MC, IR, and CV have received research funding from the Bill & Melinda Gates Foundation. MKB declares that he has no conflicts of interest.
 
References
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2 Gates B. 2009 annual letter from Bill Gates. http://www.gatesfoundation.org/annual-letter/Pages/2009-bill-gates-annual-letter.aspx. (accessed April 15, 2009).
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8 Bryce J, Boschi-Pinto C, Shibuya K, Black RWHO Child Health Epidemiology Reference Group. WHO estimates of the causes of death in children. Lancet 2006; 365: 1147-1152. Summary | Full Text | PDF(611KB) | CrossRef | PubMed
9 Black RE, Allen LH, Bhutta ZA, et al. Maternal and child undernutrition: global and regional exposures and health consequences. Lancet 2008; 371: 243-260. Summary | Full Text | PDF(1191KB) | CrossRef | PubMed
10 Moran M, Guzman J, Ropars AL, et al. Neglected disease research and development: how much are we really spending?. PLoS Med 2009; 6: e30. CrossRef | PubMed
11 Enserink M. Some neglected diseases are more neglected than others. Science 2009; 324: 37. PubMed 12 Rudan I, Arifeen SE, Black RE, Campbell H. Childhood pneumonia and diarrhoea: setting our priorities right. Lancet Infect Dis 2007; 7: 56-61. Summary | Full Text | PDF(91KB) | CrossRef | PubMed
13 Fontaine O, Kosek M, Bhatnager S, et al. Setting research priorities to reduce global mortality from childhood diarrhoea by 2015. PLoS Med 2009; 6: e41. CrossRef | PubMed
 
a Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD 21205, USA
b All India Institute of Medical Sciences, New Delhi, India
c Health Systems Research Unit, Medical Research Council, Cape Town, South Africa
d Croatian Centre for Global Health, University of Split Medical School, Split, Croatia
e Department of Public Health Sciences, University of Edinburgh Medical School, Edinburgh, UK
f Universidad Federal de Pelotas, Pelotas, Brazil
 
 
 
 
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