Please note! This essay has been submitted by a student.
It seems we are approaching a new age with an exploding trend of global health-related philanthropy amongst the most wealthy individuals, something that has been built upon the framework of key institutions such as the Ford Foundation, the Rockefeller Foundation, and the World Health Organization (WHO). Wealthy individuals such as Warren Buffet, George Soros, and Bill and Melinda Gates have established themselves as well-known philanthropists through super-donations in the name of welfare or education, making huge impacts in the global community. Some have even founded their own organizations, and their generosity has attracted immense praise and fame in recent years. However, the motives of these philanthropists are often heavily debated, as their widespread involvement in charities can bring a desire to control the size, timing, and distribution of their funds, furthering their influence over the conditions and institutional frameworks that we live in. The resulting philanthropic organizations are now the instigators and authoritative figures of such charities, instead of merely their supportive donors .
The largest private philanthropic organization in the world, and arguably the most influential, is the Bill and Melinda Gates Foundation. It was established in 2000 and has made profound contributions to international health policies, global health initiatives, and research. The foundation’s stated priority is improving global equity and diminishing health disparities with a view that all human lives are equally valuable . They focus their efforts on diseases that disproportionately affect the poor, for example contributing to a three-fold increase in funding for malaria research since the 1990s.
However, the acclaim that the Gates Foundation has received in the public eye demands scrutiny, as concerns of the role, effect, and lack of accountability of the Foundation surface . This paper will critique the Bill and Melinda Gates Foundation by assessing the relationship between its authority and legitimacy in the context of global health governance, and the effects this has on human rights.
The Gates Foundation is well positioned to leverage financial contributions to perpetuate their own legitimacy and authority in decisions on the content of policies, priorities, and initiatives in global health. Legitimacy is valuable as a means of justifying the exercise of power and others’ compliance with such power. The issue that arises with the Gates Foundation, however, is their practice of self-legitimation and how some actors are more influential than others, through its ability to involve private investments in the process . This allows them to use money as a form of power to influence international institutions and shape the knowledge and ideas at the core of global health policy . The foundation influences the content of global health initiatives by creating and disseminating knowledge, and selecting who conducts research and what it is about . However, a close look at the Foundation’s exercise of influence and choices in funding allocation calls its legitimacy into question.
Indeed, the Gates Foundation is not a passive donor – it engages actively in policy-making and is represented on the governing panels of many global health partnerships and initiatives . They carry massive influence over global health architecture and policy agendas, owing to their contributions totalling $41 billion since 2000 and their over $40 billion in assets as of 2017 . The grant process seems to be largely managed within an informal basis of personal networks rather than a transparent, systematic selection based on peer review. While they fund a variety of organizations ranging from the United Nations and World Bank, a considerable fraction of funding is concentrated in a small core of universities and non-profit/non-governmental organizations, 82% of which are US-based . For example, the organization PATH received nearly $1 billion, the University of Washington received grants worth nearly $280 million over the same period, and the Institute for OneWorld Health, Johns Hopkins University, Harvard University, and Columbia University together received grants totalling $559 million. This concentration of funding raises questions about the motives of the Gates Foundation in regards to its desire for a voice within these institutions.
The Gates Foundation’s choice of partnerships has raised concerns about conflicts of interest. Examples include its investment in companies which are thought to precipitate health problems, such as Coca-Cola and Royal Dutch Shell Large voluntary investments in organizations like the WHO, which have a history of problems with finance and voluntary contributions, can also lead to decisions set by a marketplace of health initiatives that can produce short-term preferences.
An example of short-term agenda-setting is the Foundation’s preference for funding vertical, disease-specific interventions such as malaria and HIV/AIDS. This has been shown to draw attention and funding away from horizontal health initiatives, such as clinician training and health centre management . Horizontal health systems are valuable in sustaining global health interventions and serve as a basis of health care, but the Gates Foundation is seen to exacerbate the lack of emphasis on the important role of these programmes . This could be seen as philanthropists pursuing marketable victory stories over practical healthcare delivery, and thus perpetuating healthcare inadequacies. Another example is the Gates Foundation’s over-emphasis on technology and novel vaccine development rather than tackling inefficiencies in healthcare delivery that prevent cost-effective technologies from reaching those most in need (McCoy et al., 2009). Most child mortality in low-income countries is a result of underlying determinants of health including educational/occupational disparity, family planning, and access to basic needs (Woldeamanuel et al., 2019). Rather than viewing these mortalities as a clinical dilemma that requires technology or drug intervention, a more effective strategy may lie in a public health approach that entails socioeconomic and political intervention to safeguard universal access to clean water and adequate sanitation. Thus, the long-term development goals and capabilities of horizontal health systems in low-income and middle-income countries may be undermined by the Gates Foundation’s massive support of disease-based programmes (McCoy et al., 2009). Consequently, this may contribute to the health disparity more than it diminishes it and can possibly intervene with the humans rights of individuals by disrupting the very systems that are trying to provide them.
The Foundation’s choice of disease focus has also elicited concern. In 2008, it was reported that the Foundation gave most of its grants to organizations in high-income countries with an emphasis on infectious disease (Sridhar and Batniji, 2008). However, little funding went towards respiratory diseases, maternal and reproductive health, and nutrition, and chronic diseases were completely absent (Sridhar and Batniji, 2008). It can thus be argued that grants made by the Gates Foundation do not represent the burden of disease amongst those who suffer most from poverty (McCoy et al., 2009). It might be argued that funding priorities reflect issues neglected by other funders, and allocation of funding is not solely based on the burden of disease but other factors, such as the costs and type of research needed (McCoy et al., 2009). Moran et al. (2009) also found that vaccines and drugs were significantly more funded compared to diagnostics and that the Gates Foundation provided about a fifth of all research for neglected diseases (Moran et al., 2009). However, they also found that 80% of global expenditure (including public and private sectors) was spent on HIV/AIDS, malaria, and tuberculosis, which together also received over 42% of Gates Foundation funding between 1998 and 2007 (Sridhar and Batniji, 2008).
These concerns of funding allocation call into question the legitimacy of the Gates Foundation, especially in regards to their authoritative role in global health and its associated policies and production of knowledge. It can be argued that much of the Foundation’s legitimacy stems from the personal success and wealth of Bill Gates and the influence of the trustees (Bill Gates, Melinda Gates, Bill Gates Sr., and Warren Buffet) (Harman, 2016). This is one of the major limitations of the Foundation that make it undemocratic and unaccountable to many and does not justify the legitimacy that the Gates Foundation enjoys in its current role within global health governance (Harman, 2016).
The nature of the Bill and Melinda’s heroic character is questionable when the effectiveness of their efforts is put into context. If it is assumed that these philanthropists view their charitable contributions no different than their investment portfolios (Hay and Muller, 2013), then it is understandable why they would prefer to invest in vertical interventions. In the public eye, it is much more attractive for an organization to cure a large population infected with a viral disease than to provide counselling or clinician training on a smaller scale, and the results are seen much more quickly. This is not to undermine the work done by the Gates Foundation or to scrutinize their intentions or motives as selfish or cruel, but to underscore the extent to which the Foundation controls their image in the media. When Bill Gates left Microsoft to pursue work in the Foundation full-time, the press was met with a range of articles praising Bill and Melinda, being named “The Good Samaritans” of Time’s persons of the year, “Business Heroes of 2010” in The Guardian, and “one of the world’s great philanthropists” in Forbes (Harman, 2016). With this extent of media exposure and praise, it is unreasonable to expect the public to have a negative perspective on the Gates’ character, which only further enhances the legitimacy and prestige of the Foundation.
One possible limitation in this argument arises from the need for organizations to attract interest and attention in order to thrive. This counterargument is that the establishment of influence and prestige is necessary to the Gates Foundation’s success and ability to effect positive change. Investment in influential institutions, marketing, and self-promotion may amplify and feed back into future funding and success. While the aforementioned issues with the Foundation’s legitimacy do not preclude it from having a place in global health initiatives, they should prompt us to question whether such organizations are fit to influence decisions about policy and investment priorities. We should consider whether the presence of large philanthropic organizations on key governing bodies introduces a conflict of interest that could undermine the interests of the very people such organizations aim to serve.
Based on these findings, some humble suggestions for the Gates Foundation can be made. First, improve the transparency of their decision-making process for funding allocation and grants. The process behind their decision-making strategies should be discussed openly and feedback and evidence should play a role. Second, increase funding and partnerships with international institutions and institutions with global health experience, introducing more diversity and expertise to their operation. Third, redistribute focus from vertical interventions to horizontal systems that build a sustainable foundation for addressing systemic socioeconomic health determinants. This would align the foundation’s stated interest of health equity and human rights by serving those who are most in poverty. Lastly, allocate more investment in research and healthcare systems outside of the US, in low-income countries, where the Foundation’s commitment to welfare and health equity would be the most sustainable and effective. These solutions would contribute to their issues of legitimacy, most notably self-legitimacy, as a means of justifying their Foundation and the work they do.
While the Gates Foundation is a major contributor to global health endeavours, its legitimacy as an authority in global health research should be viewed critically and its motives deserve questioning. Much of the foundation’s success and perceived legitimacy is self-originating, stemming from Bill Gates’ previous fame as the CEO of Microsoft and the prestige of its trustees and partner organizations. A closer look at the organization’s activities reveals a focus on vertical, technologically-focussed endeavours, which may serve short-term interests rather than building the foundation for sustainable interventions. This garners praise for the organization while quietly undermining innovation in horizontal infrastructure and leaving the most vulnerable populations underserved. Some may argue that this work is “better than nothing,” but eradicating a disease while failing to address its underlying socioeconomic causes leaves populations vulnerable to recurrence.
The Foundation’s guiding principle that all lives are equally valuable speaks to a fundamental belief in human rights. Within this is the right to access healthcare services. It is evident that the Gates Foundation’s efforts often fail to promote this right, and may at times draw support or attention away from competing initiatives focussed on healthcare delivery to those most in poverty. Arata Kochi, the former head of the WHO’s malaria programme, once commented that the Gates Foundation’s dominance has created a “cartel of malaria research,” which potentially restricts the diversity and views of scientists and could have “far-reaching, largely unintended consequences” (McNeil Jr., 2008). These unintended consequences serve as a cautionary tale about ascribing authority, legitimacy, and prestige on philanthropic organizations founded by independently wealthy individuals.