In May, The Lancet asked, 'êWhat has the Gates Foundation done for global health?'ê This Friday, the leading medical journal provides one answer: It helped quadruple funding for global health to $21.8 billion in 2007, up from $5.6 billion in 1990. The study, conducted by the Institute for Health Metrics and Evaluation in Seattle, looked at all health assistance from public and private institutions to low-income and middle-income countries, 1990-2007.
The Bill & Melinda Gates Foundation became a major funder — and advocate for expanded government and philanthropic spending — in 1999. At that time, health assistance was already rising, but it took 11 years, beginning in 1990, to double in size. Starting in 2001, however, the next doubling took only 6 years.
Money from private sources has been rising fast, from 19% in 1998 to a recent peak of 26.7%. Explaining the causes of this the increase is difficult, but the study notes that this period 'êcorresponded with the entry of the Bill & Melinda Gates Foundation into the development arena.'ê By itself, the foundation'ês piece of the funding pie has steadily expanded to a peak of about $1.25 billion in 2007.
The funding deluge has washed away the old order that once reached from the United Nations to the developing nations. This has created some sticky accountability problems. For example, two major new institutions have sprung to multi-billion dollar heights almost overnight: the Global Vaccine Access Initiative (GAVI) and the Global Fund to Fight AIDS, Tuberculosis and Malaria. From less than 1% of total global funding each in 2002, their funding flows grew to 4.2% and 8.3% respectively in 2007.
Both are public-private partnerships in which the influence of WHO, UNICEF, and the World Bank is diluted. These three are permanent board members of GAVI, along with the Gates Foundation. But they are non-voting board members of the much larger Global Fund, which formally cut administrative ties to WHO earlier this year. Fully non-government organizations (NGOs) are also increasing their influence. NGO spending of funds from both the public and private sectors has, the study says, 'êexpanded tremendously.'ê
The revolution might have gone too far, not only by scaling back the part played by the UN system and the World Bank but also by bringing about a qualitative shift: 'êthe changed status of these organizations.'ê The former aristocrats, especially WHO and UNICEF, now must compete with recipient countries, NGOs, and other organizations for funding. Under the ancien regime, they were sustained by the taxing power of governments.
Why mind the decline of that sclerotic bureaucracy, particularly in its most acute, international form? The worry is a crisis of legitimacy, according to the study. Requiring WHO and UNICEF to chase dollars is more than just ignominious. It 'êruns the risks of undermining their crucial role as trusted neutral brokers between the scientific and technical communities on the one hand, and governments of developing countries on the other.'ê A large and growing array of organizations are scrambling to save the world based on often diverging or conflicting views. How should the process be governed?
The Lancet raised the question of governance more radically back in May. One of several articles concerning the role of the Gates Foundation depicted its pervasive, financially-based influence. Among the foundation'ês few acts then earning praise was funding the creation of the Institute for Health Metrics and Evaluation (IHME). Ironically, however, creating IHME at first raised cries of protest in the scientific community, fearful that the Gates Foundation was 'êcreating its own WHO.'ê
Finding, engineering, or just approximating neutrality presents serious challenges. The senior author of this week'ês Lancet study on health assistance is Chris Murray, director of the Gates-funded IHME. Murray'ês work in devising quantitative approaches to public health has done much to enable rational health policymaking. The current study, for example, observes that Nicaragua received more than 30 times the amount of health assistance as Turkmenistan although the countries have nearly identical disease burdens. The policy implications are inarguable — unless you'êre the Nicaraguan minister of health.
Or take the example of the former health minister of Brazil, JosÃ© Serra, who didn'êt like a study published when Murray was working for WHO. In a ranking of national health system performance, Murray'ês analysis landed France in first place and Brazil much, much further down: 152nd. Headlines read 'êNational disgrace'ê and Serra lost the presidential election in 2002. However Serra's next campaign, to bar WHO from ranking member nations, succeeded. Murray and the IHME are at least free of that constraint.
All the new money in global health refreshes the evergreen dilemmas about accountability. The funding boom gives added zing to another old question: What does the money do? Does health assistance actually increase spending on the ground? At least for a time, the Mexican treasury cut the Health Ministry budget by one dollar for every dollar of health aid received. Another urgent question: When aid actually does increase spending on health, does it make people healthier? Or is it "dead aid,'ê as Zambia native and Goldman Sachs veteran Dambisa Moyo puts it in a book of that title?
These, oddly, are good problems to have, the kind that having funding creates. But will the momentum be sustained? The financial crisis certainly threatens the funding gains. Preemptively, the Gates Foundation increased its own spending level, even though it will cost them later. In doing so, the foundation might avert not only immediate suffering and death but a loss of funding momentum — a surge they worked rather successfully to create.