Bill Gates is ready to spend more on global health - governments should too, says foundation official

In the last two decades philanthropic donors, namely Bill and Melinda Gates, have grown to become some of the most powerful voices in global health, raising questions over their influence and where the division of responsibility with public actors should lie.

In Geneva, the presence of the Microsoft mogul-turned philanthropist's foundation is palpable - from its role in Gavi, the Vaccine Alliance and The Global Fund to its donations to the World Health Organization.

In a frank conversation with Suerie Moon, co-director, Global Health Centre at The Graduate Institute, Chris Elias, president of the Bill & Melinda Gates Foundation’s global development division, addressed criticism over its influence at the WHO and what the “appropriate” roles of private and public actors should be.

“The fact that the World Health Organisation receives about 23 per cent of its support from its member states, and therefore has to receive over three-quarters of its support from voluntary contributions, is a huge vulnerability,” he said at the webinar held earlier this month.

“I attend the World Health Assembly most years, and each year, the member states give the WHO more mandate, more to do, and yet they've had effectively a flat budget for the last 20 years. That’s not how we should run the global health architecture.”

For Elias, he asks governments who criticise the way they fund WHO to put their money where their mouth is. “If ideally, member states would finance the WHO, then they wouldn’t need the Bill and Melinda Gates’ resources”.

When the Foundation first started out in 1997 it set itself the task of tackling “poverty, disease and inequity” around the world.

“A little over 20 years ago, Bill and Melinda realised that many of the diseases that were a nuisance here in the United States but could be treated and rarely caused death, were actually significant causes of morbidity and mortality in developing countries and that health inequity, really helped to motivate them in putting together the foundation,” said Elias.

As a private philanthropic institution without similar limitations on investments as governments, this allows the foundation to be “catalytic and nimble” in responding to emergencies such as the Covid-19 pandemic, where the organisation has the freedom to fund projects it deems fit.

Over the last 16 months, the Bill & Melinda Gates Foundation has committed at least $1.75bn to the global response to the coronavirus pandemic. That includes support for vaccines via funds for the Covax vaccine sharing initiative, co-led by the WHO, and via direct support for some vaccine manufacturers such as the Serum Institute of India.

The Foundation is the second-largest funder of the World Health Organization just behind the United States, providing 9.8 per cent of the health agency’s funds. At the same time, contributions from member states have dropped from 46 per cent of the total budget in 1999 to 17 per cent last year, according to a recent report.

Last year, then US president Donald Trump said he would cut back the funding to WHO, which would have left about a 17 per cent hole in the agency’s funding. If they had, the Gates Foundation would have been the single largest funder.

Over the years, the foundation has invested in areas where the WHO’s programme of work decided on by member states aligned with its own strategies - from polio eradication to nutrition - which Elias said now adds up to over 100 active grants.

“That does mean that some parts of the WHO are better supported than others because we don’t have a strategy for everything in global health. Again, this is a vulnerability that the governing body needs to assess,” Elias said.

Ironically, as the Foundation is criticised on the one hand for having too much influence, yet on the other hand it is expected to lobby governments in other multilateral endeavours.

With the current debate on the Trade-Related Aspects of Intellectual Property Rights (TRIPS) at the World Trade Organization, Elias was asked what the foundation could do to sway governments in the way they position themselves on vaccine waivers.

“Those are discussions that happened at the governing body of WTO, which we're not a member of, therefore as far as I am aware we do not use our voice to try and influence. Our focus however goes back to the discussion on intellectual property. We have been trying to influence how we get more vaccines supplies and leveraging the capabilities that are currently out there. If there was a strong case for waiving trips we can have that debate but right now the focus is on how can we help Covax, ” said Elias.

Technology transfer plays a more important role than patents, pointing to the instrumental role in mediating the successful licensing deal in the case of the India Serum Institute, for the AstraZeneca dose, which makes up the biggest donation to the Covax vaccine equitable sharing programme.

With the vaccine alliance, Gavi “we were able to move with Serum Institute of India because it is such a large scale and well established partner of Covax, but it’s not exclusive in any regard,” Elias said.

Sharing knowledge on mechanisms like the WHO’s proposed  Covid-19 Technology Access Pool (C-TAP), which will share intellectual property on Covid health technologies could prove useful but he stressed it is not needed now.

“The real issue is to build more manufacturing capacity, that’s a different kind of problem which will not be solved by C-TAP, so we’re not opposed to C-TAP, it’s just not in our experience the solution we need at this moment.”

Beyond health, the foundation is also wading into other challenges of broad public concern. Recently, the Foundation’s co-chair Bill Gates released a new book How to Avoid a Climate Disaster,  spelling out what he believes the world should focus on to speed efforts to reach net-zero greenhouse gas emissions.

This has established a new trajectory in which the Gates hope will help tackle “poverty, disease and inequity” around the world.

“Climate change is one of the most difficult challenges the world has ever taken on,” Bill Gates wrote in his annual letter. “But I believe we can avoid a climate catastrophe if we take steps now to reduce emissions and find ways to adapt to a warmer world."

In a similar vein to global health, questions about the Foundations’ role in climate change are beginning to surface.