Bill Gates spends $200 billion: Readers respond

Source: https://www.gatesfoundation.org/about/leadership/bill-gates

Last week, I published a blog on how Bill Gates should spend $200 billion as he sunsets his foundation by 2045. My overarching point was that during the past 25 years the Gates Foundation had achieved results at scale, and in the next 20 years it should pivot to achieving sustainable results at scale.

I proposed five specific ideas—investing in local manufacturing, redesigning Gavi and the Global Fund, supporting local innovators and entrepreneurs, scaling innovative finance, and reforming the WHO—framed by a focus on long-term sustainability.

Overall, the blog resonated, and readers offered thoughtful insights.

Justin Sandefur, a development economist, said “it is good to see external commentary on what Gates should do going forward, opening up the internal deliberations.” Kevin Watkins, former CEO of Save the Children UK, called it “an important debate made more urgent by the withdrawal of the US from global health funding.”

Vinod Diwan, Professor Emeritus at Karolinska Institute, reminded us that the goal of sustainable results is to foster self-reliance of countries. Along similar lines, Olusoji Adeyi, a consultant formerly at the World Bank, whom I quoted in the blog, said: “One thing I would push for is a substantial shift in what the Gates Foundation seems to be optimizing for. For example, shifting from its simplistic focus on "saving lives" largely on terms preferred by the Foundation to a more strategic "enabling countries to build the functional, multifaceted capacity to sustainably improve health and save lives on their own terms."

Below, I share highlights of reader feedback and some related postings, organized under the same headings as my original post, with further thoughts from me.

1. Invest in Local Manufacturing

Several readers applauded the idea but questioned assumptions about how to do it well.

Olusoji Adeyi advocated for an “all-in effort in local manufacturing of quality-assured products… not beholden to technologies preferred by… the Foundation.”

Jeff Sturchio, Chair of the Friends of the Global Fight against AIDS, TB, and Malaria, emphasized markets over factories: “If there are strong, competitive markets, companies will build the plants they need and sustain local supply chains.”

Jocelyn Mackie, former co-CEO of Grand Challenges Canada and now partner at Gilbert’s, a firm focussed on innovation, finance and impact, offered a concrete example: “there are some interesting approaches like Brazil's PDP model that could be supported in other countries. Models that have a good chance of success often involve market-creating incentives for established companies in the near-term, followed by meaningful tech transfer to local industry.”

But not everyone was convinced. Andre Beaulieu, Chair of the Public Policy Forum in Canada, asked, “How does the local manufacturing idea help? Is there a risk it will waste vast effort and money without improving outcomes? Having production in-continent does not guarantee access.”

These are important questions about local manufacturing. Is it cheaper (it’s often more expensive)? Is it sustainable between pandemics?

What always amazed me is that countries invest in militaries in peacetime but seem unwilling to pay for the national security aspects of pandemic preparedness.

On the economic side, the market in Africa for health products is vast, but the ability to pay is limited. Using procurement strategies such as GAVI and Global Fund, or regional procurement, could help. This could be part of a smart transition plan for GAVI and Global Fund (see below).

Countries need to invest to develop. While Western countries have often picked up the science and innovation stick from the science end, Africa has an opportunity to start at the manufacturing end and move upstream to science and innovation.

It could be especially important to look for opportunities in the service sector, including clinical trials, since export-led development is an unlikely path in health products, especially in the short to mid-term.

2. Redesign Gavi and the Global Fund

This was the most debated recommendation.

Justin Sandefur pushed back: “I’m not convinced that ‘sustainability’ is a useful concept for health aid to low-income countries—much less that Gavi or the Global Fund should end by 2030. These funds are incredible value for money, and kids will still be dying in 5 years.”

In a separate blog, Pete Baker, of the Center for Global Development, proposed pragmatic reforms: “Review allocation models to ensure limited grant resources focus on countries that need them most… revise transition and cofinancing policies… bring more financing on budget… lay the groundwork for a New Compact approach, with governments financing top priorities and Gavi/Global Fund supporting the expansion.”

Olusoji Adeyi highlighted that “Sunsetting Gavi and the Global Fund by 2030… means giving up two of the channels via which the Foundation exerts control.”

Misaki Wayengera, Chief Scientific Officer at Restrizymes Biotherapeutics in Uganda, made an even broader point: “Not just GAVI and Global Fund, I think all ODA should take the path of setting timelines for achieving milestones and exiting. One of the things we are struggling with is how to get AU member countries to appreciate the value of investing in R & D for health. No doubt this mentality is rooted in the expectation that ODA would stay forever.”

These comments highlight the key tension around GAVI and Global Fund: They save a lot of lives, but they also perpetuate dependency of countries.

This makes countries vulnerable to shocks, such as the recent disintegration of US funding for foreign aid. It may also encourage countries to use their domestic resources for other purposes.

I am in favour of sunsetting, but with two caveats. First, there are a set of low-income countries, particularly those engulfed in conflict, that will not be able to mobilize domestic resources for even very cost-effective interventions like vaccines. It makes sense to support these countries, but ideally with no single donor providing more than say 10% of the costs which could be borne regionally.

Second, the sunsetting should be gradual. With the Gates Foundation’s 20-year timeline, it may make sense to sunset GAVI and Global Fund over a 10-year period, constantly monitoring and encouraging domestic financing along the way.

A 10-year sunsetting plan which ends up with domestic support of vaccines and HIV, malaria and TB drugs in most countries and support for very low-income countries embedded in regional bodies — all linked to local manufacturing — would be a good outcome.

3. Support Local Company Creation (and Growth) Through Grand Challenges

This idea drew interest—especially around connecting innovation to delivery.

Dan Carucci, Former Global Chief Medical Officer at McCann Health, warned: “Supply without demand means important health innovations won’t be taken up … We need to transform ‘beneficiaries of development aid’ to ‘empowered health consumers.’” He illustrated with sharp anecdotes: In Ghana, “a manufacturing plant produced 50,000 units of nutritious sprinkles, but no one tracked community uptake. At a kiosk, the local brand sat behind the Mentos display. The seller said she made more on Nestlé’s product.”

Andrew Kanter, from Columbia University, argued for the ongoing support of global goods: “For local ownership to work, and for community-based support to flourish, there are fundamental dependencies on global commons. Whether open source, community/crowd-supported resources and infrastructure, or just volunteer domain-specific expertise, someone needs to support these global goods.”

Tore Laerdal, Chairman at Laerdal Medical, highlighted the Safer Births Bundle of Care program in Tanzania — which had been implemented in almost 300,000 deliveries at 30 district hospitals. It showed “an estimated risk of perinatal death that was 18% lower overall after implementation of the Safer Births program than before. The reduction was driven by a decrease in the risk of neonatal death within the first 24 hours after birth, which appeared to be almost 40% lower…” According to Tore, “… to become sustainable innovations must be strongly locally owned and providing evidence that they are so cost-efficient that they deserve to be embedded in national health care plans and budgets.”

These points highlight the key role of social / service delivery innovation in development, as I described in a recent blog on the “Seven Deadly Sins of Innovation”:

Yet not all innovations are “game-changing” products like vaccines. Incremental improvements in service delivery can also yield massive results. In 2011, the Gates Foundation launched their “Reinvent the Toilet” challenge, aiming for a revolutionary solution to global sanitation. Around the same time, Grand Challenges Canada funded over a dozen social enterprises in water and sanitation (for examples see here, here and here). As of now, more lives have likely been saved and improved through GCC’s approach to sanitation, although both approaches are complementary.

To use a baseball metaphor, scoring home runs is not the only way to win the game; scoring enough doubles and triples can also be a winning strategy. Ideally, integrated innovation—combining scientific, social, and business approaches—offers a holistic way to address complex health challenges.

The creation (and growth) of social enterprises is an important path forward. Unlike when I started in global health 25 years ago, when there was a limited pipeline of innovation, the situation now is lots of innovation (stimulated by Gates Foundation and others like Grand Challenges Canada) with limited capture of its economic value. A Grand Challenge — which tackles a specific barrier between where we are and where we want to be — would be a clever way to accelerate the growth of homegrown social enterprises.

4. Scale Innovative Finance

Readers supported this idea—with a focus on domestic finance.

Awa Coll-Seck, former Minister of Health of Senegal, called for “sustainable domestic financing… through taxes on products that are harmful to health.”

A similar point was made by Kalipso Chalkidou, Director of Health Finance and Economics at WHO, in a post on the recent World Health Assembly resolution on domestic finance: “On the journey to self-reliance, domestic health financing is not an optional extra.”

The call for health taxes was also made in a letter responding to an essay I published in the New York Times by Mary-Ann Etiebet, President and CEO of Vital Strategies: “In low- and middle-income countries, this revenue could increase health budgets by up to 40 percent, offering a powerful means to strengthen health systems and advance self-reliance.”

However, as Jocelyn Mackie observed, “scaling innovative finance needs philanthropy to address market failures, at least in the short-term (and likely medium-term in some contexts).”

These comments remind us that domestic financing is the foundation of innovative finance. Philanthropy is catalytic. Development Banks have a key role. And ultimately private capital is needed. This is the ‘capital stack’ proposed by the Health Finance Coalition. But what are some concrete examples?

Given the restricted fiscal space for health, we need to pay more attention to debt swaps, in which a creditor nation foregoes a loan in exchange for a debtor nation investing in a health programme. The Global Fund has used this mechanism extensively.

There is also the approach of financial guarantees, more than a dozen of which have been implemented by MedAccess for example.

Another mechanism is a blended finance fund, which de-risks private capital for investment. Examples include the Global Health Investment Fund (as I wrote about in my earlier blog), which has now been replicated into more funds under the Global Health Investment Corporation. It has also laid the groundwork for other funds such as Adjuvant Capital and Cross-Border Impact Ventures, as well as the more services-focused Transform Health Fund.

Finally, there is the pay-on-results model, examples of which are recent polio investments by Gates Foundation with the European Investment Bank and the Islamic Development Bank.

What would be incredibly helpful here is better measurement of the economic benefits of these investments — and in the very best-case scenario monetizing those benefits into a revenue stream that could be used to repay and reward investors. This is the holy grail of innovative finance.

5. Foster a More Results-Oriented WHO

This topic touched a nerve—especially around governance.

Dichai Shen, Founder of Bridge Beijing, a consultancy, said, “Gates has a responsibility to lead changes in global health partnerships… But the Foundation should not be the key player driving WHO reform—member states should be.”

Mukesh Kapila, Professor Emeritus at the University of Manchester, says, “A fundamental point is whether charity billionaires - however well intended can be allowed to implicitly direct public policy simply because of the influence of their vast resources.”

Katri Bertram, International Director of Impact and Advocacy at Light for the World, an NGO, raised a broader concern in a related blog: “There is nearly no area of global health… not directly funded or indirectly influenced by … Gates Foundation funds. If you take funds, you play by the rules… No single actor—billionaire—man—should have this much power and influence.”

Lara Brearley, an independent consultant, argued that the Gates Foundation should focus on stronger in-country accountability: only when “people are better able to hold their governments and public institutions to account for health spending … will there be "sustainability."”

I anticipated and appreciate these concerns. At the same time, I can see a clear path within the member-state governance of WHO for the Gates Foundation to help WHO become more results-focused.

By 2030, WHO intends to be 50% financed by assessed contributions from member states. The other 50% presents an opportunity to finance WHO using pay on results models.

The key here is WHO’s own Results Report, which has gotten better and better over the past 8 years. The 2024-25 Results Report lists 23 results that WHO has achieved under its triple billion targets (healthier populations, UHC, health emergencies) and more effective and efficient WHO pillar.

While WHO has become better at measuring results, it does not base funding decisions on these results. Unlike an entrepreneurial organization, it does not double down on results.

The Gates Foundation could simply adopt one or two of these measurable outputs from the Results Report and finance them based on future results. This might encourage other donors to follow suit. This scheme would lead to a much more results-based and accountable WHO.

In fact, the polio initiatives mentioned above have already taken a step in this direction, as has the Health Impact Investment Platform, both supported by multilateral development banks. More of this please!

A more results-focussed WHO could also address some of the concerns of the Trump Administration, as I argued in this recent New York Times guest essay.

Other ideas

Kristof Decoster, Editor-in-Chief of IHP newsletter, offered a more radical fix: “First, tax Bill properly … Then he can spend the rest … as he pleases.” In the current context, this seems short-sighted. Does he really think the US government would spend the taxed funds on global health and development? Does he think they would do so better than Bill Gates?

Derek Yach, a global health advocate, offered a bold new idea: Take $100 billion and create 200 Schools for Innovation and Public Health Gain in LMICs… Each school with an endowment, each focused on epidemiology powered by AI, bioscience, behavioral economics, ethics, and entrepreneurship. I like this idea, but perhaps not to the exclusion of others.

Conclusion

I am grateful for the frank, thoughtful, and passionate responses. As Craig Nakagawa, Director of Development and Strategy at Intentional Futures, put it: “Provocations like this will do more for sustainable impact than good intentions alone.” So let’s keep provoking — and acting.

One limitation is that most of these responses come from commentators in the global North. This week Bill Gates is visiting Africa. He “affirmed the Gates Foundation’s commitment to partnering with African countries on their development priorities” and announced that “the majority of the Gates Foundation’s future funding [i.e. $100 billion over 20 years] will go towards addressing the challenges in Africa.” Those are the right messages, and that’s the right place to get more feedback, especially on sustainability.

As Frederik Kristensen, Managing Director of the Regionalized Vaccine Manufacturing Collaborative, commented, this discussion “points to … the needed evolution of the ‘development industry,’ not only the Gates Foundation.” Indeed, sustainability is a key consideration for all. Coupled with innovation and entrepreneurship, that’s the future of global health and development.