How Should Bill Gates Spend $200 Billion?

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

Bill Gates recently announced that the Gates Foundation will spend down its endowment over the next 20 years, contributing approximately $200 billion to global health and development. This is a bold move— and one that invites reflection. Given the foundation’s impact over the past quarter-century, the question now is: How should Bill Gates spend $200 billion?

Over the past 25 years, the Gates Foundation has spent around $100 billion, achieving significant results at scale. It supported the development and deployment of lifesaving vaccines for diseases like rotavirus, pneumococcus, and meningitis. It invested in novel vector control techniques—such as Wolbachia-infected mosquitoes and gene drive—to curb the spread of dengue and malaria. It helped establish new models for procurement and funding like Gavi, the Vaccine Alliance, and the Global Fund to Fight AIDS, Tuberculosis and Malaria. It pioneered innovative financing tools, including the Global Health Investment Fund and performance-based payments for polio eradication. It also played a catalytic role in global health research and innovation, including through the Grand Challenges in Global Health initiative.

Bill Gates himself thoughtfully says:

That’s why I believe the breakthrough that transformed our foundation in the two-and-a-half decades since wasn’t a single vaccine or treatment—it was a revolution in the world’s understanding of childhood mortality. Through advances in how researchers collect and analyze global health data, we now know much more about what kills children, where these deaths occur, and why some kids are more vulnerable than others. By putting those insights to work, we’ve been able to save lives.

And yet, for all this success, sustainability has remained elusive. Health systems in many low- and middle-income countries continue to depend on external financing, procurement remains centralized and donor-led, and local innovation ecosystems are still underdeveloped. The looming 2045 deadline to dissolve the foundation is not just a capstone—it’s an opportunity. If used wisely, it can shift the focus from results at scale to sustainable results at scale.

Bill Gates doesn’t need my advice on how to spend his money. But as someone who has been an observer, admirer, and critic of the Gates Foundation for 25 years—through roles ranging from the early Grand Challenges in Global Health advisory board to CEO of Grand Challenges Canada to Special Advisor to the Director-General at WHO— here are my two cents on how the Gates Foundation can double down on sustainability as it spends its $200 billion.

1. Invest in Local Health Product Manufacturing

One of the clearest lessons of the COVID-19 pandemic is that self-sufficiency matters—especially when it comes to health products (vaccines, drugs, diagnostics, and devices). During global supply shortages, countries without domestic manufacturing were vulnerable. To build resilience, low- and middle-income countries must be able to produce vaccines and essential health products themselves, at least at the regional level.

The African Union has set a bold target: to produce 60% of all vaccines used on the continent by 2040 (up from less than 1% today). There are encouraging steps in this direction—BioNTech’s manufacturing site in Rwanda, an African Development Bank, International Finance Corporation, and US International Development Finance Corporation investment into the Institut Pasteur de Dakar in Senegal, and GAVI-backed investments into the Quantoom mRNA platform in Egypt and another investment in South Africa.

The Gates Foundation could play a central role in further accelerating these efforts—by de-risking investments, strengthening regulatory ecosystems, and, most importantly, guaranteeing markets (for example, through GAVI).

Two caveats will need attention. First, local production is not always an economic success. Finance Ministers may need to provide support, like they would for any infrastructure and especially that related to national security. Moreover, local production may need to be part of a comprehensive industrial strategy for the country, and ideally the region.

Second, as Dani Rodrik argues in this New York Times guest essay, innovation in the service sector may have an even greater role in development:

While manufacturing remains important, they need to upgrade domestic services such as care, retail and hospitality, where the bulk of jobs will be. The challenge that developing countries face is to create middle-class economies by creating better, more productive jobs in these services.

2. Redesign the Future of Gavi and the Global Fund

Together Gavi and the Global Fund have saved more than 80 million lives. They also have a strategy for “graduation” of countries. But there is no strategy for sunsetting of the initiatives themselves.

As Soji Adeyi has recently argued:

All things considered, health aid as practiced by US-funded agencies and the likes of Gavi and the Global Fund have been a strategic failure. In 2024, Justice Nonvignon and I posited that low and middle-income countries would be well served by a clear and determined transition out of foreign health assistance, with a sunset for the global health financing institutions. We noted that those institutions were established with no end date. That construct implicitly promised and encouraged expectations of indefinite financing for potentially limitless demand. The donors have been willing accomplices of African leaders who wax poetic about self-reliance while deriving a large part of their current health expenditure from foreign aid.

We proposed, on the one hand, that countries set explicit transition dates for exiting development assistance for essential health services and allocate their own domestic resources to fill mission-critical gaps. At the same time, we argued that donors should embark on a transition to a sunset date — we suggested 2030 — such that they gradually and predictably phase out the global health institutions.

Now might be the time to revisit his arguments.

3. Support a Grand Challenge on turning innovations into successful local companies

The Grand Challenges in Global Health initiative redefined how science is applied to global health problems. But in its early years, much of the research was done in high-income countries. This has changed, but there is still untapped potential for sustainability.

As I wrote a decade ago, marking the first decade of Grand Challenges:

Finally, there has been one great surprise – completely unanticipated by anyone, as far as I can tell: the spread of the Grand Challenges model around the world.

In 2008, Canada became the first country to propose a Grand Challenges approach in its development assistance, which resulted in the launch in 2010 of Grand Challenges Canada. Next, USAID launched its Grand Challenges for Development initiative, which demonstrates that the approach can be applied to a wide range of topics spanning health, agriculture, energy, education, and even governance and conflict. Norway, Sweden and the UK joined in the movement through Saving Lives at Birth and other Grand Challenges, the Global Development Lab, and the Global Innovation Fund. India and Brazil launched their own Grand Challenges initiatives … Israel, South Africa and Peru have launched Grand Challenges initiatives.

Since then, other countries like Ethiopia, Senegal, Thailand, and China, have launched Grand Challenges Programmes. An Africa-wide Grand Challenges initiative has matured as the Science for Africa Foundation. Related initiatives such as Villgro Africa have focused on commercialization and Investing in Innovation (I3) Africa has brought in multinationals to support scaling up companies, especially in the future of pharmacy.

These Grand Challenges organizations are firmly rooted in their own countries and have local ownership. They have launched common challenges; for example, on AI. They learn from each other. They have not all succeeded and their failures to my knowledge have not been studied — offering a rich source of knowledge for development.

These Grand Challenges organizations have also not really been considered as a strategic platform to develop companies, jobs, productivity, and prosperity in their countries. This could be the next phase in the evolution of the Grand Challenges initiative, lending sustainability to the Gates Foundation’s work — and more importantly to the development of countries themselves. One way to do so would be to launch a Grand Challenge, with these Grand Challenges and related organizations, working alongside Ministries of Finance in countries, on turning innovations into successful local companies.

4. Scale Up Innovative Finance

The Gates Foundation has helped pioneer blended finance models that combine public and private capital to tackle global health challenges. The Global Health Investment Fund, for example, brought together philanthropic, development finance, and commercial investors to fund promising health innovations. A notable example of its success is the investee company Eubiologics, which went public on the Korean stock exchange and by 2024 was the only producer of cholera vaccine for the global emergency stockpile. This model has now been replicated into more funds under the Global Health Investment Corporation, but also laid the groundwork for other funds such as Adjuvant Capital and Cross-Border Impact Ventures.

Another example is the 2023 investment in polio eradication with the European Investment Bank and European Commission. This initiative pays WHO and UNICEF based on implementation milestones. This led to another investment in 2024 on polio eradication with the Saudi organization King Salman Humanitarian Aid & Relief Centre and the Islamic Development Bank based on a similar model.

These models are still too small. The world needs billions more in additional health financing. But what we see already happening is the replication of successful models, bringing in new partnerships and more capital. The key here is using a “capital stack” approach as proposed by the Health Finance Coalition.

By acting as a multiplier, the Gates Foundation can amplify the reach and effectiveness of these models. It can play a pivotal role in standardizing best practices and impact measures and align key partners. It could also bring the same analytic rigour to this problem of scaling innovative finance as it brought to reducing child mortality.

Again, a caveat is to ensure that service delivery innovations also receive support, as the Transform Health Fund is doing.

Overall, scaling up innovative finance in global health will mean rapid learning and replication of successful models, rather than a big vision of “billions to trillions.”

5. Foster a More Results-Oriented WHO

Since this recommendation will be controversial, let me start by saying what I am not suggesting. I am not suggesting the Gates Foundation steer the priorities of WHO, which is governed by member states.

But WHO — and all global health actors — need to change to fill the America-shaped hole in global health. It will need to focus on Getting Stuff Done. A key part of that change is to become more results-focused and to adapt to a role of supporting innovation, data and entrepreneurship in countries themselves.

While WHO has developed tools for measuring results, these are rarely used in decisions around budgeting or governance. The solution is to link funding to results.

WHO is on track to guarantee one-half of its budget through assessed contributions (levied on countries based on economic size as a condition of membership) by 2030. The other half could be more results-based — results that are decided by member states themselves.

By scaling financial innovations like those in the previous section, alongside other philanthropies and development banks, and including WHO as a co-architect and beneficiary in these initiatives, the Gates Foundation could foster a more results based WHO —similar to what is already being tested in polio vaccination and primary health care. Linking funding to outputs and outcomes would encourage more focused, accountable, and impactful work. This would not only improve WHO’s effectiveness but also restore confidence among member states and donors.

Conclusion: It’s about sustainability

The Gates Foundation has itself identified three objectives for the next 20 years:

1. No mom, child, or baby dies of a preventable cause.

2. The next generation grows up in a world without deadly infectious diseases.

3. Hundreds of millions of people break free from poverty, putting more countries on a path to prosperity.

This last objective is focused on education, agriculture, digital public infrastructure and gender equality. I am talking about the same thing as the last objective but approaching it in a more integrated way.

Sustainability is a principle that cuts across all three objectives. What I propose in this blog are the “methods” for making the “content” of all three objectives endure.

As the Gates Foundation prepares to spend its last $200 billion, it faces a unique challenge—and a historic opportunity. The question is not only how to achieve more impact, but how to make that impact last beyond the life of the Foundation itself.

Ultimately, the future of global health rests not in the development of products, but in the development of countries.