Count me as a fervent admirer of Bill Gates’ enlightened philanthropy, especially in global health.
I join many who have welcomed a recent announcement by Bill Gates that he plans to give away virtually all his financial fortune to philanthropic activities in the next 20 years – most of it for health, education and agriculture in Africa.
What a noble contrast with the world’s richest man, Elon Musk, who with his billionaire buddies at the White House, engineered the brutal dismantling of USAID and drastic cuts in funding for CDC, NIH, WHO, UNICEF and other UN agencies, NGOs and universities doing pioneering health research and service delivery to save the lives and protect the health of millions of vulnerable people around the world, especially women and children in developing countries.
Predictably, there have also been some critics and skeptics of Bill Gates personally and the work of the Bill and Melinda Gates Foundation (BMGF). Among them, there are some cynics who instinctively suspect ulterior motives of all rich capitalists. And then there is a cottage industry of some crackpot conspiracy theorists who insinuate even more sinister motives – of Gates trying to use Africans as guinea pigs in testing experimental vaccines, introducing genetically modified crops to thwart traditional organic agriculture, controlling people through human microchipping, sterilizing women in India and Africa with a hidden agenda of depopulating non-white people from the world, and the list goes on.
At a more serious level, there are some thoughtful, professional critics of Gates’ approach to global health who admire his intentions and recognize his humanitarian credentials but question the wisdom or the sustainability of his approach.
One such critic is Dr. Mukesh Kapila, a respected expert in global health, international development, and humanitarian affairs. He recently wrote a thoughtful critique entitled, “The philanthropy of Bill Gates must be approached with caution”.
“Technocratic Prescriptions and Vertical Campaigns”
As a development professional, I tend to agree – in principle – with many of Kapila’s cautionary concerns that lavishing vast sums of money with a laser-like focus on a set of narrowly selected goals with highly technocratic prescriptions can produce some spectacular achievements in the short-run but may not be sustainable over the long haul. There is some merit to his critique of such “technocratic” solutions not being holistic, distorting the priorities and budgetary allocation of developing countries in support of “vertical” interventions and possibly de-prioritizing other equally or more pressing development challenges.
However, in practice, I differ with Kapila’s reservations, based on my experience at UNICEF and my observation of how well thought-through investment in selected, ambitious but achievable goals can help generate the political will to effect meaningful progress on a broader front of human development priorities.
Kapila’s critique of Gates reminds me of a similar debate in the 1980s and 90s when UNICEF Executive Director James Grant launched a “Child Survival and Development Revolution” (CSDR). It was unconscionable, he argued, that 40,000 children a day, or 15 million annually, were dying at that time, when there were many low-cost, readily available interventions to prevent such deaths.
Like the Green Revolution that multiplied agricultural production and prevented famine in Asia, Grant argued that a child survival revolution could drastically cut down child deaths and unleash a virtuous cycle of child well-being and human development.
Growth monitoring, Oral rehydration therapy, Breastfeeding, and Immunization, were proposed as the cutting-edge interventions, in tandem with female education, family planning, and food supplements – known as GOBI-FFF.
Vindication of the ‘Mad American’
Initially, some of Jim Grant’s ideas were considered as heretical, idealistic and even naïve. Some Europeans even accused him of being a ‘Mad American’ with a missionary zeal and over-blown ambition.
The World Health Organization criticized these selective child-focused interventions fearing they would detract from its pursuit of a more holistic primary health care (PHC) approach approved at the historic Alma Ata Conference in 1978.
The Alma Ata Declaration had defined health as a fundamental human right and endorsed a strategy for guaranteeing “Health for All’’ by the year 2000. In principle, PHC was a brilliant idea, but in practice not much changed in the early years after Alma Ata, as the decade of the 1980s saw developing countries mired in the debt crisis, and the onset of structural adjustment programmes that sapped away the vitality of health systems and social development.
HIV/AIDS, a disease unknown at the time of Alma Ata came to dominate the world’s health agenda, even as the struggle against older diseases, such as malaria and tuberculosis, defied efforts to tame them. The less glamourous, neglected diseases of the poor, malnutrition, poor sanitation, and the slow pace of progress in basic education and women’s empowerment, so vital for improved health, limped along listlessly. Thus, PHC became a dream deferred.
Boosting PHC through Child Survival and Development
Though meant to be multi-sectoral, in the early years after Alma Ata, PHC was still generally seen as a health sector concern. It took the UNICEF-led Child Survival and Development Revolution (CSDR) that gave a new boost to PHC. CSDR put health issues firmly onto the world’s political and development agenda going well beyond ministries of health and garnering the support of presidents, prime ministers, governors, mayors, parliamentarians, civic leaders and celebrities, the media and the academia.
Inverting the “Health for All” motto to “ALL for Health”, the CSDR saw everyone, from film stars to schoolteachers, heads of religious organizations to heads of states, actively involved in promoting immunization, oral rehydration therapy and other health and nutrition interventions on a large scale.
Like Gates today, in the 1980s and 90s, Jim Grant and UNICEF were accused of pursuing a “vertical” campaign approach that would detract from health systems strengthening and would, therefore, be unsustainable.
Some critics argued that Grant over-simplified the world’s development challenges by boiling them down to just a few “technical” interventions aimed at reducing child mortality. After all, development is much more than reducing the quantity of deaths. How about the quality of life, social justice, gender equality, economic development, human rights, protection of the environment, and building of systems and infrastructure to sustain development gains?
For those who knew Jim Grant, this was a false and superficial critique. Far from being simplistic and narrowly focused, Grant had a broad and holistic vision of development. He was very aware of the multi-faceted nature and complexities of development. He spoke forcefully on issues ranging from the need to end the “apartheid of gender”, to reducing military expenditures, providing debt relief and fair terms of trade for developing countries.
He argued for restructuring foreign aid and national development budgets in favour of basic social services. He challenged the prevailing orthodoxy of powerful international financial institutions and called for “adjustment with a human face” (AWHF).
Initially, many established economists, including those from the World Bank and IMF dismissed AWHF as UNICEF’s infantile tantrum. But over time, evidence-based case studies calling for protecting the poor and vulnerable in designing structural adjustment programmes gathered strong support from many development economists and civil society activists and eventually forced the World Bank and IMF to change their policies.
Child Survival as a ‘Trojan Horse’ for Human Development
UNICEF advocated for the child survival revolution with a small number of
highly “doable” interventions, not as a simplistic formula for just reducing
mortality, but as a “Trojan Horse” for combating poverty, promoting democracy,
slowing down population growth and accelerating economic development.
Nothing is more disempowering to parents than to see their children die. Inability to save their children makes parents feel powerless and fatalistic. On the other hand, when parents feel that they can take action to save their children’s lives, they feel a sense of empowerment rather than helplessness.
When parents know that simple, low-cost actions can help their children survive and thrive, they begin to demand more such services, and politicians are forced to respond. Thus, starts a virtuous cycle of empowerment and upward mobility.
Ministries of health in most developing countries were among the weakest departments of the government. They did not have adequate human or financial resources, organizational outreach or political clout to make a quantum jump in immunization and other life-saving services. Recognizing this, UNICEF developed a two-pronged strategy to overcome these constraints.
At the governmental level, going beyond ministers of health, UNICEF persuaded presidents, prime ministers, governors and mayors to adopt immunization (and other child survival interventions) as their own priority programmes. Leaders were persuaded that provision of such life-saving services would give them great political dividends and electoral votes at minimal financial cost.
Reaching beyond governments, UNICEF cultivated the support of religious leaders, the mass media, academia, film stars and sports personalities, and non-governmental organizations to take child survival interventions to nationwide scale. In an era before the advent of mobile phones, internet and today’s social media, such outreach and social mobilization greatly reinforced and energized the usually weak and lethargic health ministries.
As a result, the actions or inaction of health services came under national spotlight. This helped to revitalize health services by giving them unprecedented political visibility and subjecting their performance to public accountability.
By pursuing time-bound and measurable goals, political leaders were held accountable for results, not just platitudes. They were praised for success and shamed by comparison. Pursuit of low-cost and high-impact child survival interventions made it good politics to invest in health.
In the process, the spirit of primary health care was revived not just as an immaculate concept but as a practical movement to create demand and deliver services that people cherished and leaders found popular.
Inspired by this, UNICEF was able to convene the largest gathering of world leaders in history until that time at the World Summit for Children (WSC) in 1990. WSC formulated ambitious goals related to children’s and women’s health as central to human development. This goal-oriented approach, convincing and committing national leaders and international organizations to a common development agenda served as the genesis of the Millennium Development Goals, and today’s Sustainable Development Goals.
Thanks to the political will harnessed initially by WSC and later by the MDGs and SDGs, great achievements have been made in people’s health. Childhood immunization increased dramatically; both mortality and fertility rates declined sharply; life expectancy and literacy improved impressively; health systems became more robust; and global partnerships for health became the most popular areas of public-private partnerships and philanthropy.
======
A Different Era, a Similar Opportunity
Today’s context is, of course, different from the 1980s or 90s. Bill Gates is not Jim Grant and BMGF is not UNICEF. It is also true that a private philanthropy cannot have the mandate and legitimacy of an inter-governmental UN agency. However, some of the lessons learned and strategies adopted are of continuing relevance.
As a technological genius with enormous wealth, applying his business acumen for producing results at scale, Gates can help harness the enormous power and potential of artificial intelligence which Grant could not have imagined just a few decades earlier.
One of Kapila’s critique of Bill Gates and BMGF’s approach is that “vertical” interventions can produce short term miracles but cannot be sustained over the long haul. UNICEF’s experience in this regard is very instructive. Indeed, after pushing childhood immunization rates to nearly 70% in Africa and 80% India by 1990 through vigorous advocacy, we saw immunization rates decline by 10 to 20 % points in the subsequent decade. This led some to argue: “you see, such vertical approach is not sustainable”.
But it is worth recalling that had there not been a concerted, even “heavy-handed” push, an incremental approach would probably have raised vaccination rates from 10-20% to possibly 40-50% as per the historically “sustainable” trajectory in those countries over the course of a decade or two. One can argue that even the countries that reached a spike of 70-80% and later stabilized around 60-70% are better off than if they had increased their vaccination coverage at a “sustainable” 40-50%.
=========
Kapila is right that unlike governments that have a responsibility to respond to the needs and demands of their citizens across a broad spectrum of health and development issues, private philanthropists like Gates do not necessarily have such responsibility. Hence injection of huge amount of money by such philanthropists could distort rightful national priorities.
But this is not a fair criticism. It is perfectly appropriate for any well-meaning donor to be selective and pick and choose those issues that they feel passionate about, provided they are consistent with national and global priorities agreed by governments. Indeed, it would be unreasonable to criticize private philanthropies for failing to do what we expect governments to do. It is for the governments to utilize the support they get from philanthropies to complement their efforts, not to expect them to substitute for the government’s responsibility or obligations.
Indeed, there is a perfectly defensible logic for Gates and private philanthropists like BMGF to be highly selective in investing in those areas that they feel give the biggest bang for their bucks. Some of the world’s top economists under the banner of “The Copenhagen Consensus” have long argued that there are some “Best Buys” for prioritizing investments that produce the greatest benefit for the most (or most deprived) people. If Gates proposes to allocate his resources on such “Best Buys”, as well as on some global public goods for humanity, like polio eradication, who are we to blame him for his judgment call?
Kapila offers a gratuitous advice that “Perhaps the Gates legacy would be more likely to endure if his Foundation listened more, preached less, and was open-minded to extend beyond its narrow silos”. That sounds good in principle, but I am not sure that it is a very practical advice for a 70-year-old philanthropist who feels a sense of urgency to spend his fortune to do some good for humanity in the next 20 years or so of his remaining lifetime.
Yes, there is a theoretical possibility, as Kapila argues, that Gates’ largesse supporting his passion projects runs some “risk of countries left high and dry in two decades, as is happening now with donors walking away from previous commitments”. But it is unfair to put the burden of future uncertainty on a generous and well-meaning philanthropist. As they say, “perfection can be the enemy of the good”.
Moreover, to assume that Gates will only support technical interventions implemented in a vertical manner rather than helping to strengthen health systems for sustainable progress is also unfounded based on actual experience.
Representing UNICEF, I served on the Board of GAVI, the Global Vaccine Alliance, one of Bill Gates’ brainchild initiatives during 2000-2007. GAVI is sometimes criticized for focusing exclusively on immunization, ostensibly following a “vertical” health delivery approach. But mindful of the need to build properly functioning health systems to ensure sustainability of the vaccination programmes, Board members of GAVI established and generously allocate significant funds to broader “Health Systems Support” with full backing of the Gates Foundation.
I have no doubt that going beyond any vertical or technocratic interventions, Gates would be responsive to any essential health systems support initiatives if recipient governments and communities request such help with good justification.
Undermining governments and core UN agencies?
I agree with Kapila that generous support from philanthropists like Bill Gates, other private donors, foundations and some governments has led to the creation of relatively well-funded global funds and partnerships that parallel, duplicate and might even undermine existing UN agencies such as WHO, UNICEF, UNFPA, etc. Today, various global health funds, partnerships, private foundations and philanthropies have bigger budgets for health than the H-6 group of UN agencies. Money talks, and many donors seem to prefer to channel their funding support through these partnerships than through the core UN agencies.
Some have argued that the rising trend of government donors and private philanthropists preferring to channel their support for health through global funds and PPPs is indicative of a subtle vote of no confidence in the efficacy of the core UN agencies. There is some merit in this argument.
After Jim Grant died in 1995, there was a perception in some quarters that the new leadership of UNICEF no longer gave top priority to child survival and began to give higher priority to other elements of child rights, including girls’ education, HIV/AIDS, protection of children in humanitarian emergencies, etc. This was a wrong perception. In reality, child health continued to command the lion’s share of UNICEF funding, but its advocacy for child survival was no longer as loud and eloquent as during the Grant era.
Bill Gates got interested in investing in global health around this time having learned from folks like New York Times columnist Nick Kristoff about the massive death toll of children in developing countries from readily preventable ailments, and from Dr. Bill Foege (a former Director of CDC and Chair of the Task Force for Child Survival) about how dramatic progress could be made with some targeted investment in massive expansion of childhood vaccination coverage. This information led Gates to commit to investing heavily in immunization and he came up with a novel modality to fund it. Thus, was born GAVI.
Had UNICEF, and for that matter, WHO, been seen as highly effective promoters of immunization, and open to new and innovative ways of mobilizing resources, it is conceivable that Gates might have funded those organizations instead of establishing GAVI. The same could be said of The Global Fund to Fight AIDS, Malaria and TB. In that sense, the creation of these alternative funding modalities was a vote of no-confidence in these existing UN modalities.
WHO and UNICEF, in particular, need to self-critically introspect why their well-established field network, close partnership with governments, and their governance and operational modalities are considered less effective than those of some of the new global funds and PPPs.
UNICEF, after all, was originally established as a “Global Fund” for children. And member states look to WHO to guide and assist them in tackling public health challenges of all kinds. Where and how did they fall short in the eyes of donors and others, prodding them to look for alternative funding and partnership modalities rather than strengthening these long-established UN agencies?
Without contesting the added value of innovative financing mechanisms through global funds and public-private partnerships, it is time for WHO and UNICEF to find ways to re-capture their leadership role in global health. This should be done not through any statutory re-assertion of their legitimacy as inter-governmental organizations, but by demonstrating that they too can match the new players in operational efficiency and more adaptable and effective governance including a suitable role for private sector donors as is the case with the new global funds.
As part of a massive restructuring of the whole UN system and the architecture of global development financing, perhaps the time has come to revisit the mandates and working modalities of various UN agencies and multilateral institutions. However, in the context of the role of philanthropists like Bill Gates, instead of lamenting how various global health funds and partnerships may have usurped the role of UN agencies, it is more productive to look at the positive side of such alternative health financing mechanisms.
At a time of massive cutbacks in official development assistance by governments, led by the world’s biggest donor, USA, and followed by many others, finding creative ways to increase overall investment in health – and other key sectors of development – through a diversity of funding mechanisms is especially welcome. In any case, it is worth noting that most of the additional resources provided by Gates through GAVI and BMGF – and the Global Fund and other partnerships – rely on the operational support of core UN agencies and governments for implementation at the country level. There is, of course, room for improvement, but no need to lament.
A Nobel-Worthy Contribution
I have long believed that Bill Gates deserves a Nobel Peace Prize for his enlightened commitment to reducing inequity. For a man who held the record of being the world’s richest person for nearly two decades, it is truly extraordinary that his greatest ambition is to give away all his wealth and to devote the better part of his adult life to reducing the greatest global inequity in human health.
Throughout human history, many wealthy people have set up charities and foundations to help various worthy causes, but to the best of my knowledge, none have committed to giving away virtually all their wealth and making the purpose of their life to helping the poorest people of the world with no apparent vested interest. A true measurement of Gates’ contribution is not just the nearly $100 billion that he and his foundation have already invested, and another $200 billion they plan to invest in the next two decades, but the number of lives saved and enriched by such investment.
Since its establishment in 2000, GAVI has helped vaccinate more than 1 billion children in the world’s poorest countries, which has prevented more than 17 million deaths. Child deaths have declined from over 10 million to just under 5 million. While many other actors – governments, donors, community leaders and health workers – were involved in this effort, a significant share of the credit goes to Bill Gates for these impressive achievements. Gates can also share some credit for even larger numbers of lives saved and health improved by the Global Fund to Fight AIDS, Tuberculosis and Malaria and to eradicate polio through his generous contribution.
Gates support for the Institute for Health Metrics and Evaluation has helped collect better data to invent new lifesaving tools, such as vaccines, and making sure that new and existing tools reach people in low- and middle-income countries.
The Gates funded Grand Challenges in Global Health, partnership to secure advance market commitment to drastically reduce the cost of some life-saving vaccines, and other cutting-edge research to solve critical health problems seek to ensure that the benefits of the latest medical advances reach the people with the greatest need in the developing world. For the future, Gates has committed to harness the power and potential of AI to bring about further advancement in health, education and agriculture, and women’s empowerment, especially in Africa.
Besides giving away their own wealth, Bill and Melinda Gates French partnered with Warren Buffett to launch The Giving Pledge to persuade many of the world’s wealthiest people to commit to giving away the majority of their wealth to worthy philanthropic causes either during their lifetimes or in their wills. Since its launch, more than 200 people from more than 25 countries have pledged to fund initiatives to combat infectious diseases, support education and research, promote women’s rights, and develop clean energy.
Over the next twenty years, Gates and his foundation have committed to work with other partners to ensure that no mom, child, or baby dies of a preventable disease; that the next generation grows up in a world without deadly infectious diseases; and that hundreds of millions of people break free from poverty.
Like most human beings, Bill Gates is not flawless. Many articles and books have been written about some unethical and cut-throat business practices of Microsoft, the main source of his wealth. The speculation surrounding the reasons for his divorce with Melinda French Gates have further tarnished his image. While many admire his brilliance, there are those who criticize his know-it-all “arrogance of power”. However, in the larger scheme of things, and compared to most other tycoons, these human flaws and foibles do not overshadow his service to humanity.
Surely a personality with a proven track record of such extraordinary contribution to saving the lives and improving the livelihoods of millions of people around the world, and who has made a commitment, backed up with enormous resources to devote his remaining life for such worthy causes, is worthy of the highest global award – The Nobel Peace Prize.
I wish more ultra-rich tycoons – and more governments too – would emulate Gates’ example.