Jongbloed-Unpacking Global Health Governance

8/14/2019 Jongbloed-Unpacking Global Health Governance

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UNPACKING GLOBAL HEALTH GOVERNANCE:

Understanding the relationship between the World Health Organization and

the Bill & Melinda Gates Foundation from a health equity perspective

In the face of rising infectious disease such as AIDS, TB, and malaria, and the

increasing marginalization of health problems that do not affect the developed

world, the importance of an international, independent organization that is brave,

aggressive and vocal in its defense of global public health has never been more

important (Ford and Piedagnel quoted in Lee, et al, 2009, p.419).

INTRODUCTION

The last twenty years has seen a shift from international health to global

health, where intergovernmental actors have been replaced by transnational institutions(Birn, et al, 2009; Brown, et al, 2006). Private foundations, non-governmental

organizations (NGOs), and global health partnerships have gained power and prestige as

United Nations (UN) organizations, such as the World Health Organization (WHO), have

seen their agency undermined. Changes in the governance structure of global health,

especially the entry of extremely powerful private institutions, have affected the quest for

global health equity in a number of ways. This paper looks at the implications of this

transition on health equity at a global level by looking specifically at the growth of the


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Bill & Melinda Gates Foundation and its relationship with the WHO. 1 First, it establishes

a framework within which to understand health equity. Then, it provides a historical

perspective of the diminished capacity of the WHO while examining the rise in

prominence of the Gates Foundation, and also their relationship to each other. Finally,

the paper discusses the impact of the rise and fall of these two institutions on health

equity at an international level.

A FRAMEWORK FOR HEALTH EQUITY

According to Braveman and Gruskin (2003), equity in health is the absence of

systematic disparities in health (or in the major social determinants of health) between

groups with different levels of underlying social advantage/disadvantagethat is, wealth,

power, or prestige. A look at indicators of health across the globe and within countries,

including life expectancy and maternal mortality, makes it clear that health equity

remains a goal rather than an achievement. Since the early 20 th Century, cooperation to

address health across national borders has occurred, but it was not until the Declaration of

Alma Ata in 1978 that the notion of health for all gained prominence in public discourses

around health (Birn, et al, 2009). In recent years, health has been viewed through a

human rights framework and in terms of the social determinants of health (Farmer, 2005;

WHO, 2008). The notion of health equity encompasses most of these perspectives andforms the basis of this papers argument.

1 In McCoy, et al (2009b)s recent article entitled The Gates Foundations grant making program for globalhealth, the authors suggest that one investigation that would bring greater clarity to the structure of globalhealth governance is the critical examination of the nature and effets of the relationship between the GatesFoundation and the World Bank, World Health Organization and key global health partnerships (p. 1651).This paper attempts to respond directly to this suggestion.


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Loewenson (2009) suggests that there are four elements that support the

achievement of health equity: health for all; health in all policies; health equity; and

social empowerment. First, health for all involves ensuring that every person has access

to health care. For example, that they do not face financial or geographical barriers to

accessing health care facilities. Second, health in all policies suggests that health issues

are considered in all policy development, from international financial regulations to

municipal level housing planning. Third, health equity requires a redistribution of

resources throughout the health system that cannot be left to the market. And finally, it

involves social empowerment where there is recognition that people make up the centralrole in health systems.

At an international level, there is a push for health equity from a number of

sources, one of which is the Global Health Watch (GHW). The WHO is often seen as the

actor best positioned to lead the quest for global health equity both because of its policy

setting mandate and its representation of 193 countries. The most recent Global Health

Watch (2008) argues for a centralized, accountable and effective multilateral global

health agency, driven by a desire to promote health with the understanding that the

distribution of health and health care is a core marker of social justice (p. 224). Since its

establishment on April 7, 1948, the World Health Organization has sought to fill this role

(Birn, et al, 2009).

THE WORLD HEALTH ORGANIZATION


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The World Health Organization is a membership based intergovernmental agency

created as part of the UN system to deal with health issues on an international level. The

WHOs mission is the attainment by all peoples of the highest possible level of health

(Birn et al, 2009, p. 73). This mission includes specific references to health equity and

reaching poor and underserved populations (WHOb). In particular, the WHO performs

the following functions: providing leadership on matters critical to health and engaging

in partnerships where joint action is needed; shaping the research agenda and stimulating

the generation, translation and dissemination of valuable knowledge; setting norms and

standards and promoting and monitoring their implementation; articulating ethical andevidence-based policy options; providing technical support, catalyzing change, and

building sustainable institutional capacity; and monitoring the health situation and

assessing health trends (WHOa). In essence, the WHO has a role in both policy and

practice, and is the closest thing we have to a Ministry of Health at the global level

(GHW, 2008a, p. 225).

Over the years, however, the WHOs ability to carry out its mission has changed,

primarily as a result of changing approaches of its funders. Traditionally, governments

fund UN organizations with the donations being determined by a calculation involving

both the countrys population and the size of its economy. Once the WHO receives the

money, it is up to its governing bodies the World Health Assembly and the Executive

Board to determine how the money will be spent (Birn, et al, 2009). These pre-determined contributions make up what is known as the regular budget funds (RBFs) and

have traditionally been supplemented by extra-budget funds (EBFs) (GHW, 2008a, p.

225). These extra-budgetary funds are donated on a voluntary basis by governments or


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private organizations and are subject to the conditions of those who donate them (Birn, et

al, 2009, p. 75). Since the 1970s when the majority of WHO spending utilized regular

budget funds (80 percent of spending), there has been a shift to the point where three-

quarters of the WHOs spending in 2008 came from extra-budgetary funds (GHW,

2008a, p. 226). The implication of this transition is that control over spending has moved

from the hands of the WHOs governing structure and into the hands of a multitude of

private and public donors. Lee, et al (2009) gives an example of the WHO

accommodating the pharmaceutical industry as a result of its dependence on extra-

budgetary support from private donors, though its perceived support of industry-discounted rather than generic drugs (p. 419; GHW, 2008a, p. 230).

According to the Global Health Watch (2008a), this change in investment from

regular budget funds to extra-budgetary funds came partly as a result of a broader change

in UN system financing. In 1980, UN members pushed for a policy that ensured that

their contributions would account for inflation, but not grow beyond the current level. In

1993, they decided further to stop even this adjustment for inflation and introduced a

policy of zero nominal growth, effectively freezing funding for all UN organizations

(GHW, 2008a, p. 227). They also explain that the problem of late and non-payment of

contributions (to the tune of US$35 million to the UN overall in 1999) played a role in

increasing the WHOs reliance on extra-budgetary funds (GHW, 2008a, p. 227). Birn, et

al (2009) suggests that regular budget funds for the WHO were also diminished as aresult of the World Banks entry into international health in the early 1980s which

redirected funds away from the WHO (p.75). As well, perceived politicization of UN

organizations, such as the WHOs campaign against irrational prescribing of medicines


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and breast milk substitutes, led to the decreased interest in providing regular budget

funds to the WHO (GHW, 2008a p. 227). Lee, et al (2009) notes that another reason

behind reduced support for the WHO could be because of the perceived threat to vested

economic interests (p.420). In general, however, a much greater reliance on EBFs

reflect[s] the preference of donors towards having greater control over their money

(GHW, 2008a, p.226).

THE BILL & MELINDA GATES FOUNDATION

One of the actors that has emerged as a major extra-budgetary supporter of the

WHO in the last ten years is the Bill & Melinda Gates Foundation. After amassing great

wealth as the founder of Microsoft, Bill Gates and his wife, Melinda, decided in 1994 to

establish the Gates Foundation (GFc). Currently, the Foundation works in three areas:

global development, education, and global health. It is the latter initiative that is the

focus of this paper. At the end of 2008, the Gates Foundation reported assets of just

under US$30 billion and distribution of grants totaling just under $5.5 billion (GF, 2008).

To put these figures into perspective, Piller, et al (2007) note that the Foundations

endowment is greater that the gross domestic product of 70 percent of the worlds

nations.

The Gates Foundation mission is to target diseases and health conditions thatcause the greatest illness and death in developing countries, yet receive little attention and

resources (GFa). It does this by discovering, developing and delivering new disease-

fighting technology, as well as engaging in advocacy to build awareness of global health


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issues. At present, the Gates Foundation invests heavily in research and delivery of

vaccines and medicines, putting the GAVI Alliance, PATH, Aeras Global TB Vaccine

Foundation, International AIDS Vaccine Initiative, Global Alliance for TB Drug

Development, Medicines for Malaria Venture and the Global Fund to Fight AIDS, TB

and Malaria among the top recipients of its funds (McCoy, et al, 2009b, p.1648).

Through its extensive grant-making capabilities, the Gates Foundation has seen its

influence on global health policy and priorities strengthen over time, resulting in

extensive financial influence across a wide spectrum of global health stakeholders

(GHW, 2008b, p. 251). At present, the Foundation is a funder and board member of various massive global health initiatives, including the Global Fund to Fight AIDS,

Tuberculosis and Malaria, the Global Alliance for Vaccines and Immunizations, and the

Stop TB Partnership, to name a few (GHW, 2008b, p. 249). In 2007, the Gates

Foundation joined with the WHO, UNICEF, UNFPA, UNAIDS, GFATM, GAVI, and

the World Bank to form an informal group of eight health-related organizations, known

as the H8(IHP, 2007). Like its namesake, the G8, this group of health actors represents

significant power over the global health agenda and at present, the Gates Foundation is

the only private organization represented within this group.

A CRITIQUE OF THE GATES FOUNDATION APPROACH

The position of the Gates Foundation has enabled it to achieve recognizable

success in several areas, especially in the area of vaccines and immunizations. However,


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there are some that question the Foundations approach to global health, particularly in

terms of accountability, funding sources, programmatic method, and pro-business focus.

ACCOUNTABILITY

As poignantly articulated by Andre Damon (2007) in an article for the World

Socialist Web Site,

what is inherent but unstated in the much vaunted rise of venturephilanthropy is the transfer of social wealth and social power from the public

sector where at least, theoretically, some form of democratic control or

influence is possible to a wealthy elite accountable to no one but themselves.

The Gates Foundation is one of the practitioners of venture philanthropy to which

Damon refers. Unlike public organizations like the WHO, the Gates Foundation lacks

accountability to any type of board or governing council. Even without mechanisms of

accountability similar to those found in the public sector, the Gates Foundation is

essentially subsidized by public coffers: foundation endowments are tax free (Birn, et al,

2009, p.99; McCoy, et al, 2009a, p.4). McCoy, et al (2009a) estimate that US$225

billion in holdings by US foundations actually belongs to the American public in thesense that it is money foregone by the state through tax exemptions (p.4).

The Gates Foundation has also been accused of failing to fairly tender its grant

monies. In his detailed investigation of Gates Foundation grant making, McCoy, et al


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(2009b) notes that grant making by the Gates Foundation seems to be largely managed

through an informal system of personal networks rather than by a more transparent

process based on independent technical and peer review (p.1650). The Global Health

Watch (2008b) notes that the absence of robust systems of accountability becomes

particularly pertinent in light of the foundations extensive influence (p. 250). Despite

this lack of accountability, the Foundation still manages to have significant influence

within the global health industry.

VERTICAL PROGRAMS

A survey of the Gates Foundations programs on its website indicates that its

focus is often disease-based. For example, large portions of Gates Foundation funding go

towards HIV/AIDS, tuberculosis, malaria, polio and measles. Known as vertical

programming this approach to health operates in contrast to a health systems approach

which works to build capacity to provide health care for a multitude of different ailments.

It has further been argued that health care on its own is insufficient: the structural

determinants of health must be addressed through a health equity approach (like the one

outlined at the start of this paper), if health for all is to be achieved.

Birn (2005) notes that the Gates Foundation approach is often technology based.

She suggests that their approach arises from an assumption that the problems of globalhealth stem from a shortage of scientific knowledge, translated into technical solutions

(Birn, 2005, p. 4). The Global Health Watch (2008b) uses the example of the Gates

Foundations approach to child mortality. It suggests that the Foundations research


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focuses disproportionately on development of new technology rather than overcoming

barriers to delivery or utilization of existing technology (p. 253).

Finally, as will be more closely examined in the section on the Gates

Foundations pro-business approach, it is important to note that 95 percent of Gates

Foundation funding is given to recipients based in industrialized countries (McCoy et al,

2009b, p1649). It is possible to question whether the answers to the worlds health

problems can be found outside of the areas that carry the largest burden of infectious

disease and the lowest capacity to care for their sick.

FUNDING SOURCES

The Gates Foundation endowment is invested each year to ensure the

sustainability of their programming over time. However, it has become clear that there

has been no effort to coordinate this investment with the charitable mission of the

organization. In fact, it seems that in several cases, the investment of the Gates

Foundations endowment directly contravene its good works (Piller, et al, 2007). More

specifically, the negative health outcomes caused by industry invested in by the

Foundation negates their efforts at disease control and eradication. For example, in

Nigeria, a community receiving vaccines from the Gates Foundation against polio and

measles has simultaneously been suffering from a disproportionately high incidence of debilitating respiratory problems from a neighbouring petroleum refinery that is financed

through contributions from the Gates Foundation endowment (Piller, et al, 2007). After

the discovery of this hypocrisy in 2007, the Gates Foundation has, instead of becoming


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more responsible investors, worked to try to better separate their endowment from their

charity on paper.

PRO-BUSINESS APPROACH

Bill Gates business background has had a considerable influence on the Gates

Foundation approach to global health. Global health has been impacted by Microsofts

actions prior to the Gates Foundation involvement, especially around the issue of

intellectual property rights and pharmaceuticals. For example, Microsoft was a strongadvocate for strict regulations in the agreement on Trade Related Aspects of Intellectual

Property Rights (TRIPS), which continues to affect access to essential medicines around

the world. The Gates Foundation maintains strong ties with the pharmaceutical industry,

including the appointment of a former GlaxoSmithKline executive Dr. Tadataka Yamada

as the president of their Global Health Program. McCoy, et al (2009a) argue that

pharma companies benefit considerably from global health programs that emphasize

delivery of medical commodities and treatment, as the Gates Foundation approach does

(p. 9).

To this day, the Gates Foundation remains strongly confident in the private

sectors ability to solve global public health problems. In fact, the Global Health Watch

(2008b) goes so far as to accuse the Gates Foundation of converting global healthproblems into business opportunities (p. 255). This is further illustrated by McCoy, et al

(2009b)s point that only five percent of Gates Foundation funding is directed towards

lower or middle income countries (p.1649). In other words, most of the Gates


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Foundation funding remains in North America, sustaining think tanks, universities,

NGOs, research facilities, and, surprisingly, private business. .

One of the ways that Gates pro business approach manifests itself is through the

promotion of what are known as public-private partnerships for health. These

partnerships bring together public and private sector actors to tackle a particular health

issue, such as HIV/AIDS or malaria, usually with a focus on delivery of treatment or

immunization. The public-private partnership model for global health, such as the Stop

TB Partnership, Roll Back Malaria, the Global Fund to Fight AIDS, Tuberculosis and

Malaria, and the Global Alliance for Vaccines and Immunization, almost by definitionsupport vertical programming. As Birn, et al (2009) notes, there is no [public-private

partnership] for primary health care! (p. 106). They go on to suggest that most [public-

private partnerships] channel public money into the private sector, not the other way

around (Birn, et al, 2009, p.106).

Though this section has not included an exhaustive examination of the

controversy surrounding the Gates Foundations approach to global health policy making

and practice, it hints at the serious issues of the rise of an unaccountable, market-oriented,

private institution in setting the agenda for global health. It is impossible to separate the

factors that have weakened the international administrative body for health (the WHO)

and allowed for the growth in power and reach of private philanthropy for health (in

particular, the Gates Foundation). Next, we look at the specific ways in which these twoinstitutions interact, with a specific focus on how the Gates Foundations role as a donor

to practically every global health actor gives it power to set policy and even co-opt the

WHO into policies that undermine its mandate.


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THE RELATIONSHIP BETWEEN THE WHO AND THE GATES

FOUNDATION

As well as providing funding to numerous NGOs, universities, global health

partnerships and research institutes, the Gates Foundation is a major funder of the WHO

(McCoy, et al, 2009b). Since 1998, the Foundation has contributed over US$505 million

in extra-budgetary support to the WHO through a total of 87 different grants, (GFb).

This total makes the WHO the fourth largest recipient of Gates Foundation funding andthe largest intergovernmental organization grant recipient (McCoy, 2009b, p. 1649). The

Gates Foundations contributions to the WHO exceed the contributions of most

governments, the only exceptions being the United States and Britain. Currently, the

Foundation ties for third largest funder of the WHO with Japan (GHW, 2008a, p. 227).

The Gates Foundation supports the WHOs through vertical programming with

some operational support. According to the Foundation website, its grants to the WHO

fall into 14 categories (see Table 1). Most of these grants are focused on specific

diseases, including HIV/AIDS and malaria, with vaccines and maternal, newborn and

child health also receiving significant attention. Most interestingly, the category that

received the most amount of grant money between 1999 and 2009 was left uncategorized.

A closer look at the details of these grants suggests that they are more geared to WHOoperations than the other grants. Since 1998, the Gates Foundation has contributed

almost US$100 million towards often ambiguous projects like [engaging] the global

health community in a creative and robust process to guide the future of health. Though


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these types of projects have been granted less frequently in the last few years, as recently

as 2006, the Gates Foundation contributed US$5 million to support the transition of the

WHO Director-General Elect (GFb). This type of involvement suggests a more

politicized role in the WHO than the Gates Foundation would usually admit to.

Grant CategoryTotal Amount

(US$)Number of

GrantsHIV/AIDS $48,829,284 16Malaria $77,672,587 14Uncategorized $98,133,259 14Vaccines $39,105,673 10Maternal, Newborn & Child Health $61,886,392 9Advocacy & Public Policy $51,950,517 6Neglected Diseases $11,494,448 4Tuberculosis $18,351,509 4Polio $68,711,412 3Diarrhea $5,550,684 2Pneumonia & Flu, Vaccines $15,676,537 2Emergency Relief $625,000 1Nutrition $6,477,697 1Water, Sanitation & Hygiene $293,800 1

Table 1: Grants made to WHO by Gates Foundation between 1998 and 2009(accessed from the Gates Foundation website, July 2009)

It is important to note explicitly here that although the WHO has a mandate and

mission that supports the development of health systems and supports work to improve

the social determinants of health, it is no doubt constrained by the fact that its third

biggest donor is determined to fund vertical programs and politically-motivated

leadership initiatives. Clearly, the power of the Gates Foundation through its grants to

the WHO affects the organizations ability to work towards health equity or a human

rights approach to health.


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The Gates Foundation effects the WHOs agency both directly through grant

making and also by its involvement with other global health stakeholders in policy

making. Competition for Gates Foundation funds has caused a trend towards aligning

with its priorities among several global health institutions. As well, the Gates Foundation

has created a number of new institutions, such as the GAVI Alliance and the Institute for

Health Metrics and Evaluation that have an affect on the global health landscape.

Because it is often not represented in these new institutions, WHO priorities are often

sidelined.

One of the big ways that the WHO has been affected by the Gates Foundationsrise in power both directly and indirectly, is the change towards a market-oriented global

health sector. While the Gates Foundation is not the only catalyst in this direction, it is

certainly acting on this interest at a very high level, for example through its participation

in the H8. In the policy statements of the Meeting of Global Health Leaders (H8) in

2007, five objectives were laid out that are particularly market-oriented, and make

explicit reference to the private sectors role in delivering health services, in financing

health care, and in bringing new technologies to market (UNICEF, 2007). The fact that

the Gates Foundation is a funder of all of the other members of the H8 likely puts it in a

unique position of power within this group.

This pro-market approach to health has led to the rise of the public-private

partnerships for health discussed above. Through their support of these programs, theGates Foundation affects the agency of the WHO to determine global health policy. Birn,

et al (2009) states that the WHOs ability to tackle major international health problems

is inhibited by the public-private partnership model by fragmenting health care, and


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providing insufficient accountability and low cost-effectiveness (p. 107). Public-private

partnerships entrench vertical programs, jeopardizing health systems development and

impeding integrated approaches (Birn, et al, 2009, p. 106). However, as public private

partnerships have become a donor priority they have thus have gained resources and

support from the WHO. Even by providing support, the WHO remains marginal in the

decision-making processes of these public-private partnerships; it does not have a vote on

several of the partnerships boards (Birn, et al 2009, p. 107).

CONCLUSION

Overall we have looked at how the Gates Foundation, through its considerable

grant making capabilities, has affected the ability of the World Health Organization to

fulfill its mission of the attainment by all peoples of the highest possible level of health

(Birn et al, 2009). Returning to Loewensons (2009) conceptualization of global health

equity, it is possible to see how the changing governance structures of global health have

negatively effected the achievement of health equity. By prioritizing vertical

programming above health system strengthening, health for all has become treatment

of certain diseases. The voices, such as the World Health Organization, that should

promote health in all policies have been co-opted and now toe the donor line. The

redistribution of resources necessary to achieve health equity has been derailed byincreasing reliance on public-private partnerships to deliver treatment that prioritize

health commodities from industrialized countries. And finally, increased competition for


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donor funds, a pro-business approach, and emphasis on technology-based solutions have

precluded the social empowerment necessary to put people first in health systems.

The balance of power between public and private actors in global health must be

restored, in particular between the World Health Organization and the Gates Foundation.

Like the Global Health Watch (2008a) asserts,

It is worth aspiring to an accountable and effective multilateral global health

agency, driven by a desire to promote health with the understanding that the

distribution of health and health care is a core marker of social justice (p. 224).

To restore the policymaking power of the WHO, the Gates Foundation must

recognize the value of an independent, publicly accountable international governing body

for health. This recognition should lead to direct budgetary support to the WHO without

donor conditionalities and active representation of the WHO in all institutions related to

global health including public-private partnerships and the Gates Foundation itself. As

well, the Gates Foundation should acknowledge that the achievement of health for all will

only occur through changes to structural factors that undermine health, as well as

considerable inputs to promote health. Perhaps it is idealistic, but with this recognition

could come responsible investing, greater support for health systems strengthening, and

more involvement of stakeholders from the developing world. Otherwise, we risk thecomplete takeover of global public institutions for health by private organizations that fial

to prioritize health equity.


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REFERENCES

Birn, A., (2005). Gatess grandest challenge: transcending technology as public healthideology. The Lancet , p. 1-6.

Birn, A., Holtz, T., & Pillay, Y. (2009). Chapter 3: International Health Agencies,Activities and Other Actors. Textbook of International Health: Global Health in aDynamic World. New York: Oxford University Press, p. 61-131.

Braveman, P., & Gruskin, S. (2003). Defining equity in health. Journal of Epidemiologyand Community Health , 57, p. 254-258.

Brown, T., Cueto, M., & Fee, E. (2006). The World Health Organization and thetransition from international to global public health. American Journal of Public

Health , 96, 1, p. 62-72.

Damon, A. (2007). The Gates Foundation and the rise of free market philanthropy.World Socialist Web Site , January 22. Retrieved July 31, 2009, fromhttp://www.wsws.org/articles/2007/jan2007/gate-j22.shtml

Gates Foundation. (2008). Annual Report. Retrieved July 29, 2009 fromhttp://www.gatesfoundation.org/annualreport/2008/Pages/combined-statements-financial-position.aspx

Gates Foundation. Global Health Program. Retrieved July 29, 2009 fromhttp://www.gatesfoundation.org/global-health/Pages/overview.aspx

Gates Foundation. Grants. Retrieved July 29, 2009 fromhttp://www.gatesfoundation.org/grants/Pages/search.aspx

Gates Foundation. Timeline. Retrieved July 29, 2009 fromhttp://www.gatesfoundation.org/about/Pages/foundation-timeline.aspx

Global Health Watch. (2008). Chapter D1.2: The World Health Organization and theCommission on the Social Determinants of Health. Global Health Watch 2: An

Alternative World Health Report . London: Zed Books, p. 224-239.

Global Health Watch. (2008). Chapter D1.3: The Gates Foundation. Global Health

Watch 2: An Alternative World Health Report . London: Zed Books, p. 240-259.International Health Partnership. (2007). About: Health 8 Agencies. Retrieved July 29,2009 from http://www.internationalhealthpartnership.net/ihp_plus_about_agencies.html

Lee, K., Sridhar, D., & Patel, M. (2009) Bridging the divide: global governance of tradeand health. The Lancet , 373, p. 416-422.


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Loewenson, R. (2009). Dimensions and drivers of equity oriented health systems inAfrica. Lecture, June 24.

McCoy, D., Chand, S., & Sridhar, D. (2009). Global health funding: how much, where itcomes from and where it goes. Health Policy and Planning , 1-11.

McCoy, D., Kembhavi, G., Patel, J., & Luintel, A. (2009). The Bill & Melinda GatesFoundations grant-making programme for global health. Lancet, 373, p. 164553.

Piller, C., Sanders, E., & Dixon, R. (2007). Dark clouds over the good works of theGates Foundation. Los Angeles Times , January 7.

UNICEF (2007). Informal Meeting of Global Health Leaders. New York: 19 July.Retrieved August 2, 2009 fromwww.unicef.org/health/.../Meeting_of_Global_Health_Leaders_-_Final_Summary.pdf

World Health Organization (2008). Commission on the Social Determinants of Health.Retrieved July 25, 2008, from http://www.who.int/social_determinants/en/

World Health Organization. The role of the WHO in public health. Retrieved July 29,2009 from http://www.who.int/about/role/en/index.html

World Health Organization. The WHO Agenda. Retrieved July 29, 2009 fromhttp://www.who.int/about/agenda/en/index.html


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ANNEX 1Grants made by the Gates Foundation to the World Health Organization between 1998

and 2009. From the Gates Foundation Website.

YearGrantRecipient Category Program Grant Amount (US$)

Number of Grants

2008 WHO Advocacy & Public Policy Global Health $999,263

2007 WHO Advocacy & Public Policy Global Health $50,000,000





Advocacy & Public Policy Total $51,950,517 6 grants2006 WHO Diarrhea Global Health $5,504,8892005 WHO Diarrhea Global Health $45,795

Diarrhea Total $5,550,684 2 grants

2002 WHO Emergency Relief GlobalDevelopment $625,000

Emergency Relief Total $625,000 1 grant2008 WHO HIV/AIDS Global Health $43,767

2008 WHO HIV/AIDS Global Health $500,1382007 WHO HIV/AIDS Global Health $70,0002007 WHO HIV/AIDS Global Health $9,210,6302006 WHO HIV/AIDS Global Health $15,214,3202006 WHO HIV/AIDS Global Health $19,885,1762006 WHO HIV/AIDS Global Health $183,5492005 WHO HIV/AIDS Global Health $44,0782005 WHO HIV/AIDS Global Health $99,5982005 WHO HIV/AIDS Global Health $273,4902005 WHO HIV/AIDS Global Health $952,3622004 WHO HIV/AIDS Global Health $287,811

2004 WHO HIV/AIDS Global Health $994,4002003 WHO HIV/AIDS Global Health $25,0002002 WHO HIV/AIDS Global Health $50,0002001 WHO HIV/AIDS Global Health $994,965

HIV/AIDS Total $48,829,284 16 grants2009 WHO Malaria Global Health $7,828,4702008 WHO Malaria Global Health $22,485,496


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2008 WHO Malaria Global Health $13,839,3362008 WHO Malaria Global Health $6,620,0002008 WHO Malaria Global Health $2,977,3492007 WHO Malaria Global Health $3,226,4722007 WHO Malaria Global Health $4,943,750

2007 WHO Malaria Global Health $165,0002007 WHO Malaria Global Health $4,540,3402006 WHO Malaria Global Health $2,000,0002006 WHO Malaria Global Health $2,157,8302006 WHO Malaria Global Health $5,056,4682004 WHO Malaria Global Health $1,454,0762006 WHO Malaria, Vaccines Global Health $378,000

Malaria Total $77,672,587 14 grants

2006 WHO Maternal, Newborn & Child Health Global Health $35,096,912


2005 WHO Maternal, Newborn & Child Health Global Health $999,500






1999 WHO Maternal, Newborn & Child Health Global Health $10,000,000Maternal, Newborn & Child Health Total $61,886,392 9 grants

2006 WHO Neglected Diseases Global Health $5,030,092




Neglected Diseases Total $11,494,448 4 grants2004 WHO Nutrition Global Health $6,477,697

Nutrition Total $6,477,697 1 grant

2003 WHO Pneumonia & Flu, Vaccines Global Health $4,218,402

2002 WHO Pneumonia & Flu, Vaccines Global Health $11,458,135

Pneumonia & Flu, Vaccines Total $15,676,537 2 grants2006 WHO Polio Global Health $39,773,912


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22

2005 WHO Polio Global Health $25,000,0002005 WHO Polio Global Health $3,937,500

Polio Total $68,711,412 3 grants2008 WHO Tuberculosis Global Health $1,869,3592006 WHO Tuberculosis Global Health $5,632,150

2005 WHO Tuberculosis Global Health $850,0002000 WHO Tuberculosis Global Health $10,000,000

Tuberculosis Total $18,351,509 4 grants2008 WHO Vaccines Global Health $647,1392008 WHO Vaccines Global Health $1,047,1772007 WHO Vaccines Global Health $28,507,8522007 WHO Vaccines Global Health $999,5322007 WHO Vaccines Global Health $150,1772006 WHO Vaccines Global Health $52,3822006 WHO Vaccines Global Health $6,842,3142006 WHO Vaccines Global Health $65,7072004 WHO Vaccines Global Health $543,3931998 WHO Vaccines Global Health $250,000

Vaccines Total $39,105,673 10 grants

2007 WHO Water, Sanitation & Hygiene Global Health $293,800

Water, Sanitation & Hygiene Total $293,800 1 grant2007 WHO Uncategorized Global Health $5,000,0002006 WHO Uncategorized Global Health $5,000,0002006 WHO Uncategorized Global Health $303,8482005 WHO Uncategorized Global Health $917,5602005 WHO Uncategorized Global Health $7,053,0352004 WHO Uncategorized Global Health $49,605,9682004 WHO Uncategorized Global Health $198,2632004 WHO Uncategorized Global Health $4,740,8012004 WHO Uncategorized Global Health $937,9002003 WHO Uncategorized Global Health $5,000,0002003 WHO Uncategorized Global Health $350,0002002 WHO Uncategorized Global Health $10,121,4732002 WHO Uncategorized Global Health $4,951,953

1999 WHO Uncategorized Global Health $3,952,458Uncategorized Total $98,133,259 14 grants


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ANNEX 2Details of Uncategorized Grants made by the Gates Foundation to the World Health

Organization. From the Gates Foundation Website.

Date PurposeGrantAmount

Duration of Grant Location

Dec-07Purpose: to support the Global Health Workforce Alliance inaddressing the global crisis in human resources for health $5,000,0002 years Global

Nov-06Purpose: to support the transition of the WHO Director-General Elect $5,000,000

2 years and1 month Global

Oct-06Purpose: to support a conference on strengthening healthleadership and management in low income countries $303,8487 months Global

Jul-05Purpose: to engage the global health community in a creativeand robust process to guide the future of health $917,560 5 years Global

Jun-05Purpose: to accelerate the development and introduction of prophylactic HPV vaccines in developing countries $7,053,035 5 years Global

Dec-04Purpose: to support the Health Metrics Network (HMN) $49,605,9667 years Global

Sep-04Purpose: to provide general operating support for theMinisterial Summit on Health Research $198,263 6 months Global

Jun-04Purpose: to train young professionals from developingcountries to become future leaders in public health $4,740,801 4 years Global

Jun-04

Purpose: to define the structure and range of activities for theHealth Metrics Network through a collaborative process withpartners and stakeholders across the globe $937,900 1 year Global

Jun-03 Purpose: for general operating support $5,000,000 1 year Europe

May-03Purpose: to support activities for the surveillance andcontainment of drug resistance in malaria, HIV and TB $350,000 1 year Global

Oct-02

Purpose: to support follow-up on the Commission of Macroeconomics and Health (CMH) report at the country,regional, and global levels $10,121,473

3 years and2 months Global

Aug-02 Purpose: to build mapping tools for rapid analysis of infectious disease incidence and prevalence $4,951,953 5 years Global

Sep-99

Purpose: to support an alliance of five agencies to workcollaboratively on preventing cervical cancer in developingcountries $3,952,4582 years

Africa,Asia

Documents

Jongbloed-Unpacking Global Health Governance