The Lancet medical journal has published an attack on The Bill and Melinda Gates Foundation, saying that its influence distorts the global health agenda.
The foundation doesn't invest enough in implementing proven interventions; spends too much on high-risk research at the expense of options that are more likely to deliver; and sends very little of its money directly to capable research institutions in the developing world, according to a research paper, commentary and editorial article in the latest edition of The Lancet (8 May).
The foundation is the largest private grant-giving organisation in the world and has "a great degree of influence over both the architecture and policy agenda of global health", said David McCoy, a senior research fellow at the Centre for International Health and Development at University College London, United Kingdom, and colleagues.
McCoy's team analysed global health grants awarded by the foundation between January 1998 and December 2007, finding the foundation donated almost US$9 billion spread across 1,094 grants ranging from US$3,500 to US$750 million.
Some 65 per cent of grants were awarded to just 20 organisations, with low-income countries directly receiving just five per cent of funds.
An editorial in the journal calls the foundation's boost to global health funding "astonishing", saying it has "challenged the world to think big and to be more ambitious about what can be done".
But it expresses concern at its priorities. "For example, a focus on malaria in areas where other diseases cause more human harm creates damaging perverse incentives for politicians, policymakers, and health workers."
The foundation's grant-making system is also scrutinised — it "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", says the team.
The supporting editorial goes a step further, describing the foundation's self-professed guidance by "the interests and passions of the Gates family" as "a whimsical governance principle".
In an accompanying comment article Robert E. Black of the John Hopkins School of Public Health and colleagues write that the best role for the Gates Foundation is in pursuing low-risk, high-reward research such as oral rehydration therapy or zinc tablets for diarrhoea, rather than its high-risk, high-reward approach.
Black and colleagues also criticise the lack of direct funding to low- and middle-income countries.
Tadataka Yamada, executive director of the Global Health Programme at the Gates Foundation reaffirmed the foundation's pro-technology stance at a media briefing in London, United Kingdom, last month (30 April).
"Fundamentally we believe that technology-based solutions are the most cost-effective approaches for the poorest people," he told SciDev.Net. "We invest a lot in ensuring that existing health solutions are adequately provided … but where there are no solutions we work hard to try and create new solutions and make sure they're available."
The foundation declined to submit a response for publication in The Lancet but told the Associated Press: "We welcome this article and its findings. We try to be very thoughtful about how to target our resources, and we constantly seek out feedback from outside experts and stakeholders."
"In the end, we use our best judgement to determine where our funding can achieve the greatest reductions in health inequity around the world.
A full Q&A with Tadataka Yamada will be published soon on SciDev.Net.
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