Bill Gates’ double-edged influence on global health

Bill Gates' double-edged influence on global health

The American billionaire has just published a book, How to Prevent the Next Pandemic [Ndlr – paru en français le 4 mai dernier chez Flammarion sous le titre Comment éviter la prochaine pandémie] in which he outlines his plan to “avoid another pandemic killing millions and wiping out the global economy”. This isn’t the first time the former Microsoft CEO has offered advice on outbreaks.

He had already shared his thoughts on Ebola or the Covid crisis, but the situation is nonetheless surprising and reveals the place occupied by the Bill-and-Melinda-Gates Foundation in the landscape of global health in today. What exactly is this place and what influence does the Gates Foundation have on the governance of global health? Should we applaud it or fear it? How did we get here ?


From Rockefeller to Bill Gates, or the advent of philanthropic capitalism

The involvement of foundations in the field of health began with the Rockefeller Foundation, named after the first American billionaire who built his fortune on oil, and emblematic of the very first philanthropic organizations linked to the industrial revolution.

The number of foundations has continued to increase since then, particularly over the past twenty years, with particular investment in the health sector. Beyond, of course, those linked to pharmaceutical laboratories, several of them (such as the EGPAF Foundation, KFF, the Wellcome Trust in Great Britain, or the Clinton Foundation) are involved in the issues international

Emblematic of what is now called “philanthrocapitalism” which considers that the search for maximum profit can perfectly go in the direction of the common good, the Gates Foundation occupies a central place in this environment, carrying the idea that it it is not only about redirecting the accumulated profits towards projects to fight against inequalities, it is also about applying the methods of the private sector to the fight against poverty and making the profit motive an engine of benefit of all, what Bill Gates himself calls “creative capitalism”.

The Pervasiveness of the Bill-and-Melinda-Gates Foundation in Global Health

Since its creation in 2000, the role of the Gates Foundation has grown considerably to become a key player in global health.

An important place in health financing

The $4.6 billion devoted to health issues in 2020 by the Gates Foundation represents more than 8% of global health aid, exceeding funding from countries that are considered to be particularly involved in global health such as Germany, the United Kingdom, Japan or even France.

Beyond the amounts, it is above all the diversity of the actors supported by the Gates Foundation that challenges. The Gates Foundation financially supports all United Nations agencies involved in health – including the first of all, the World Health Organization. Recall that the Gates Foundation is the third largest donor to the WHO, after the United States government and the United Kingdom.

It also finances ministries of health (Chinese or Brazilian for example), development banks (such as the International Bank for Reconstruction and Development), partner foundations (such as the Clinton Foundation), the media (such as PBS NewsHour, ABC, The Guardian where the World Africa), many NGOs and even companies, whether pharmaceutical laboratories (such as Abbott, Bayer, Pfizer, Sanofi) or companies such as Vodafone or Mastercard.

A central role in the production of data and new knowledge

Bill Gates’ deep belief in the importance of technology and innovation leads him not only to largely finance the world of businesses and start-ups, but also to dedicate part of his fortune to academic research. Not content to fund the largest universities in the world (such as Harvard, Columbia, Imperial College, or even Johns-Hopkins), the Gates Foundation has even created its own research institutes, such as The Institute for Disease Modeling and especially The Institute of Health Metrics and Evaluation, which competes with the WHO in its role as an observatory of global health issues.

Part of the decisions taken at the global level are therefore based on data from an organization funded by a private foundation – whose estimates are based on particularly complex calculation methods that are difficult to “break down”.

Support for the emergence of public-private partnerships on the international scene

The Gates Foundation has also played an important role in the emergence of a new type of international organization: public-private partnerships. Unlike United Nations agencies, which by definition only bring together States (according to the logic “one country = one vote”), these new initiatives, presented as a response to the cumbersomeness of the UN administration, are open to representatives of the private sector in the broadest sense, be they representatives of companies or associations.

Gavi, the Vaccine Alliance, for example, was created on the basis of funding of 750 million dollars from the Gates Foundation in 1999. Many others will follow, all supported by the Gates Foundation such as the Global Fund to Fight AIDS, tuberculosis and malaria, GFF (Global Financing Facility) for the health of women, children and adolescents in 2015 or more recently the Coalition for innovations in epidemic preparedness.

An obvious weight in the definition of global strategies

The influence of the Gates Foundation on the development of international health policies goes through several routes: omnipresence in the places of governance of global health, seats on the boards of directors of public-private partnerships, participation in the informal group “H8”, earmarking of his entire financial contribution to the WHO on specific health issues, regular forums and speeches at international conferences, and in particular at the World Health Assembly, since his first speech in 2005 on smallpox. Some consider that its influence is such that the Gates Foundation endorses all decisions made within the WHO.

An opportunity or a risk for global health?

We could of course be content to rejoice that one of the richest men on the planet devotes a large part of his fortune, his energy and his intelligence to the fight against health inequalities, and give in to the “Bill Chill”. Effect” (beware of any criticism so as not to compromise the investments of tomorrow). In fact, his financial and personal involvement is impressive, and he has succeeded in injecting an obvious dynamic to put global health at the top of the international agenda, but is he therefore the best placed to define public health priorities? Several aspects are widely questioned.

The Foundation’s governance was initially the subject of criticism. If the list of funding is available on the Foundation’s website, it is rather the way in which decisions are made that challenges. In his book, Bill Gates describes the decision-making system he set up with Melinda about urgent requests: looks good, do you want us to do it and give your okay?” Then the other sends an email to approve the funding”. Decisions, including the most financially burdensome, have so far been taken by a particularly closed circle, made up of a maximum of 4 people: Bill, Melinda, Bill’s father (deceased in 2020) and American billionaire Warren Buffet (from 2006 to 2021).

It took until January 2022 for a board of directors including four outside personalities, in addition to Bill and Melinda Gates, to be set up. In fact, the organization was accountable to no one and was not subject to any independent evaluation, which is particularly questionable, when one realizes that the money of the Gates Foundation can be considered as that of American taxpayers. – the donations that supply the Foundation’s funding are subject to tax deductions and represent, in a way, a “loss of earnings” for the American budget.

It is then on the way of apprehending global health issues that the Foundation can be questioned. The Gates Foundation’s approach is deeply “technocentric” in the sense that it considers innovation and technology to be the main keys to solving problems (to the detriment of more structural approaches to strengthening health systems, or a work on the social, educational, economic or political determinants of health).

It is highly globalized (to the detriment of more localized approaches) and its constant search for efficiency leads it to systematically prioritize vertical approaches, centered on specific diseases, whose progress is easier to document.

The Foundation, which is backed by an investment fund linked to companies such as Coca-Cola, Caterpillar and Abbott, then clearly positions itself in defense of the interests of the for-profit private sector, systematically defending the intellectual property rights of laboratories ( against compulsory licenses and access to generics), participating in giving increasing importance to consulting firms, and in the dissemination of New Public Management standards in international organizations such as the Global Fund to Fight AIDS, Tuberculosis and malaria.

Finally, and perhaps most importantly, the risk of financial dependence of actors, and more specifically of global health researchers, is today a legitimate fear. The entire ecosystem held its breath when news broke of Bill and Melinda’s divorce. What would happen if tomorrow, the American billionaire became passionate about other causes or decided to shut down?

The question that arises here is not only that of the place taken by the Gates Foundation, it is also that of the place that the States have left to it over the past twenty years. Foundations are part of the global health landscape. In fact, they play an important role in the international public space and it is not a question here of calling this principle into question, but their influence on the definition of public policies requires safeguards which remain to be put in place in the global health governance.

Stephanie Tchiombiano

Political scientist, associate lecturer at the University of Paris 1 Panthéon-Sorbonne