Comment
8 Staedke SG, Mwebaza N, Kamya MR, et al. Home management of 10 Robert V, Macintyre K, Keating J, et al. Malaria transmission in urban
malaria with artemether-lumefantrine compared with standard
care in urban Ugandan children: a randomised controlled trial.
Lancet 2009; published online April 14. DOI:10.1016/S0140-6736(09)
60328-7.
9 Keiser J, Utzinger J, Caldas de Castro M, Smith TA, Tanner M, Singer BH.
Urbanization in sub-saharan Africa and implication for malaria control.
Am J Trop Med Hyg 2004; 71 (suppl 2): 118–27.
Accelerating the health impact of the Gates Foundation
See Editorial page 1577 In recent years the Bill & Melinda Gates Foundation
See Health Policy page 1645 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
The printed journal
includes an image merely
for illustration
AP
1584
sub-Saharan Africa. Am J Trop Med Hyg 2003; 68: 169–76.
11 Knudsen AB, Slooff R. Vector-borne disease problems in rapid urbanization:
new approaches to vector control. Bull World Health Organ 1992; 70: 1–6.
12 Medicines for Malaria Venture. Understanding the antimalarials market:
Uganda 2007. An overview of the supply side. 2008. http://www.mmv.org/
IMG/pdf/Uganda_Antimalarials_Market_report_MMV_2007_FINAL_.pdf
(accessed April 2, 2009).
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 interven-
tions could be considered “low-risk and high-reward”.
www.thelancet.com Vol 373 May 9, 2009

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
www.thelancet.com Vol 373 May 9, 2009
Comment
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 institu-
tions to those in settings where the problems exist, would
make enormous additional contributions to global health.
*Robert E Black, Maharaj K Bhan, Mickey Chopra,
Igor Rudan, Cesar G Victora
Department of International Health, Johns Hopkins Bloomberg
School of Public Health, Baltimore, MD 21205, USA (REB); All India
Institute of Medical Sciences, New Delhi, India (MKB); Health
Systems Research Unit, Medical Research Council, Cape Town,
South Africa (MC); Croatian Centre for Global Health, University of
Split Medical School, Split, Croatia (IR); Department of Public Health
Sciences, University of Edinburgh Medical School, Edinburgh, UK
(IR); and Universidad Federal de Pelotas, Pelotas, Brazil (CGV)
rblack@jhsph.edu
REB, MC, IR, and CV have received research funding from the Bill & Melinda
Gates Foundation. MKB declares that he has no conflicts of interest.
1 McCoy D, Kembhavi G, Patel J, Luintel A. The Bill & Melinda Gates Foundation’s
grant-making programme for global health. Lancet 2009; 373: 1645–53.
2 Gates B. 2009 annual letter from Bill Gates. January, 2009. http://www.
gatesfoundation.org/annual-letter/Pages/2009-bill-gates-annual-letter.aspx
(accessed April 15, 2009).
3 Jones G, Steketee RW, Black RE, Bhutta ZA, Morris SS. How many child deaths
can we prevent this year? Lancet 2003; 362: 65–71.
4 Bryce J, Daelmans B, Dwivedi A, et al. Countdown to 2015 for maternal,
newborn and child survival: the 2008 report on tracking coverage of
interventions. Lancet 2009; 371: 1247–58.
5 Leroy JL, Habicht J, Pelto G, Bertozzi SM. Currrent priorities in health
research funding and lack of impact on the number of child deaths per year.
Am J Public Health 2007; 97: 219–23.
6 Madon T, Hofman K, Kupfer L, Glass RI. Implementation science. Science 2007;
318: 1728–29.
7 Bennett S, Adam T, Zarowsky C, et al, Alliance STAC. From Mexico to Mali:
progress in health policy and systems research. Lancet 2008; 372: 1571–78.
8 Bryce J, Boschi-Pinto C, Shibuya K, Black R, and WHO Child Health
Epidemiology Reference Group. WHO estimates of the causes of death in
children. Lancet 2006; 365: 1147–52.
9 Black RE, Allen LH, Bhutta ZA, et al. Maternal and child undernutrition: global
and regional exposures and health consequences. Lancet 2008; 371: 243–60.
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.
11 Enserink M. Some neglected diseases are more neglected than others.
Science 2009; 324: 37.
12 Rudan I, Arifeen SE, Black RE, Campbell H. Childhood pneumonia and
diarrhoea: setting our priorities right. Lancet Infect Dis 2007; 7: 56–61.
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.
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