The Gates Foundation has expanded the power of private philanthropic organisations, say Marlee Tichenor and Devi Sridhar
The Bill and Melinda Gates Foundation was established in 1997 with the goal of tackling diseases in the global South through data and technology driven approaches. As a private philanthropic institution without the same limitations on its investments as governments, the foundation has had the freedom to make its own decisions about where it chooses to invest its funding portfolio.  Over the past 20 years, the foundation has grown into one of the leading voices in global health, often sitting at the table with heads of state and heads of multilateral organisations as decisions are made about investment priorities. This has disrupted the nature of global health governance through changing the nature of what it means to be “public.”
In 2017, the Gates Foundation provided $3.3bn (£2.5bn; €2.9bn) of the world’s global health funding, tying the private philanthropic organisation in second with the United Kingdom for development assistance for health. The Gates Foundation’s major investment in the World Health Organization, the Global Fund to Fight AIDS, Tuberculosis, and Malaria, and GAVI, the Vaccine Alliance—along with the global health partnerships it helped found, such as the Primary Health Care Performance Initiative and the Global Financing Facility—make clear in budgetary terms how influential the Gates Foundation is in setting the agenda and in managing the world’s health. 
In the process, the Gates Foundation has simultaneously expanded its reach into the production of global health data, the dissemination of these data, and their uptake by global health institutions such as WHO and the World Bank. The expansion of private, albeit philanthropic, interests into domains that are perceived as public and independent raises major questions about the influence of private actors, the effects of the monopolisation of data, and the nature of accountability in global health governance. The present governance system provides no mechanisms to tackle these issues.
The Gates Foundation financially backs the Institute for Health Metrics and Evaluation (IHME), part of the University of Washington, through an initial grant of $105m and a follow-up grant of $279m to produce global health data. IHME produces global burden of disease data, national estimates of health spending, and development assistance for health data. The IHME is required by the Gates Foundation to produce new estimates every year on the world’s health problems through the Global Burden of Disease study. The Gates Foundation uses these data to inform its funding portfolio. Never before has one institute had such a defining power through analytics.
These data are then published in the global burden of disease studies, with the flagship studies published exclusively in the Lancet, a highly esteemed, open space for global health debate.  As is common practice in the publishing industry, the Gates Foundation pays for these studies to be open access. The Gates Foundation helps increase the influence of these data and shapes how global health problems are discussed, as is evident in the high number of citations of these studies.
Furthermore, in May 2018, the IHME and WHO signed a memorandum of understanding, which noted that from 2019 there will be a single global burden of disease study published in the Lancet, rather than one produced by WHO and one by IHME. WHO has agreed to use IHME data in their own 2019-23 general programme of work and for their own estimates for burden of disease, and WHO data specialists will be seconded to the IHME. There are advantages to taking the global burden of disease analysis out of WHO. For example, the Gates Foundation and IHME have more available resources, and the partnership will require IHME and WHO to deal with tensions at the heart of their methodologies.
However, there are also downsides. The methods used are increasingly complex and incomprehensible even to global health experts, and it leaves us dependent on a single partnership for global data production. The agreement is also an indication of how the Gates Foundation has expanded its ownership of the measurement of global health problems into the heart of the foremost global health institution and ensured that only these data will be accepted globally. The Gates Foundation has guaranteed that its own preferred methodologies for measuring global health data take precedence. It is too early to know how this partnership will affect country involvement in the production of estimates.
This disruption has not been sufficiently discussed in global health. What does it mean for public and impartial global health spaces to be influenced by private philanthropic interests in this way? What does it mean for public organisations to be tied, even indirectly, to a private foundation with particular investment interests to shape the discussion about which global health problems count the most and how we should tackle them? By occupying and changing the nature of public spaces in global health, the Gates Foundation has expanded the power of private philanthropic organizations while not opening new means of holding such actors accountable. This global health governance challenge must be tackled, as data and algorithms will play an ever expanding role in defining approaches and setting priorities.
Competing interests: None declared.
1 Gates B. JP Morgan Healthcare Conference speech. 8 Jan 2018. https://www.gatesfoundation.org/Media-Center/Speeches/2018/01/JP-Morgan-Healthcare-Conference?mod=article_inline
2 Clinton C, Sridhar D. Governing global health: who runs the world and why? Oxford University Press, 2017.