The Gates Foundation’s Global Reach Expands, to Mixed Reviews

Conor here: The world is increasingly the billionaires’ playground. As the following piece shows, Gates role in the World Health Organization will only grow as the US government’s diminishes as billionaires take over their niche markets in what was previously state roles. As Gates infamously said about India and its cooperation with his foundation, it’s “a kind of laboratory to try things.” One wonders if Gates role in US health will increase as the government withdraws, as evidenced by Trump’s “big, beautiful bill.”

By Ramin Skibba, an astrophysicist turned science writer and freelance journalist who is based in the Bay Area. He has written for WIRED, The Atlantic, Slate, Scientific American, and Nature, among other publications. Originally published at Undark. 

In May, Bill Gates, once the world’s richest person, announced that he would give away “virtually all” of his wealth through the Gates Foundation over the next 20 years. The foundation’s endowment is roughly $77 billion.

The move will likely solidify the foundation’s outsized role in global health, particularly as the United States, the United Kingdom, France, and several other European countries have slashed their global health and aid budgets. The U.S. in particular has seen steep cuts. In just the past few months, the administration of President Donald J. Trump has announced the country’s departure from the World Health Organization; dismantled the U.S. Agency for International Development, or USAID; enacted sweeping cuts of the President’s Emergency Plan for AIDS Relief, or PEPFAR; and made broad cuts within the Department of Health and Human Services, effectively blocking millions in funding for global health security and maternal health programs worldwide.

Those cuts and withdrawals have left a vacuum of an estimated $10 billion or more in global health. That makes the Gates Foundation — formerly known as the Bill & Melinda Gates Foundation, which served as a major player in global health since the 1990s — a de facto world funding leader. And its influence, along with that of a few other philanthropies, is set to grow.

The charity has drawn praise among global health experts, as well as some scrutiny over what some call “philanthrocapitalism,” a market-based, for-profit approach. Critics point out that the approach puts mostly unaccountable power in the hands of wealthy donors while depriving treasuries of taxes that would enable governments and the public sector to take more action.

Notably, in recent years, the Gates Foundation, the colossal endowment of which dwarfs the GDP of several countries it serves in, has been among the top two or three contributors to WHO, whose members include 194 countries, along with a handful of private or nongovernmental contributors. Now, the foundation is poised to become the health agency’s chief funder.

Both the Gates Foundation and independent global health experts stress that the foundation can’t fill the void left by the U.S. For example, even with the foundation’s increased contributions, WHO had to bump up membership fees and its next budget has dropped by 10 percent, to around $6.2 billion. A recent initiative called Project Resource Optimization, or PRO, began connecting donors with programs cut by USAID, but it’s a small and short-term effort, and it can’t restore everything. (PRO is hosted by the Center for Global Development, which receives Gates funding.)

The foundation also contributes to health and research funding outside WHO, such as grants focused on polio, malaria, tuberculosis, and HIV. However, these are typically smaller than the previous U.S. government-funded programs, such as PEPFAR and the President’s Malaria Initiative, both overseen by USAID.

In another example, of medical research in South Africa, “Gates is regarded very much as a supplement to the basic research we do in this country,” said Salim Abdool Karim, director of the Center for the AIDS Program of Research in South Africa and a global health professor at Columbia University, as well as a Gates Foundation scientific adviser. He said that the top research funders in South Africa have been the National Institutes of Health, USAID, and the U.S. Centers for Disease Control and Prevention.

“No one can replace them,” he said. “Nobody has that kind of money.”

And the Gates funding also won’t necessarily support the same type of work as the U.S. previously did. For instance, the foundation’s contributions to WHO aren’t like the lump sums that come from the member governments. Private money from philanthropies are usually earmarked for specific projects like polio eradication, which won’t help with shortfalls in other areas, said Lawrence Gostin, a global health law expert at Georgetown. He added that because the Gates Foundation “has such deep pockets, [it] tends to set the global health agenda for much of what WHO does, which some global health advocates resent, because they think it’s undemocratic and that that should be a matter for WHO to set its own priorities.”

Overall, it’s a difficult historical moment in all funding, including for the Gates Foundation, said J. Stephen Morrison, director of the Global Health Policy Center at the Center for Strategic & International Studies (which has received Gates funding): “They now have to rethink, ‘What is our purpose?’ when the U.S. government is not the partner, and it’s out feeding these things into the wood chipper.”

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Capitalizing on his wealth accumulated since co-founding the technology giant Microsoft, which he led for 25 years, Bill Gates has spread his influence across not just global health, but education policy, agricultural development, clean energy technologies, and climate policy. The Gates Foundation has provided millions of dollars of funding to numerous newsrooms around the world, too, from NPR and Der Spiegel to Al Jazeera, and African outlets as well. Bill Gates has also provided numerous grants to leading universities (including MIT, whose Knight Science Journalism Program publishes Undark, which is editorially independent). Furthermore, the foundation disburses considerable funding for public-private partnerships like Gavi, the Vaccine Alliance — for which the U.S. is now withdrawing its own financial support — and numerous other health groups. It also funds research at institutions; every university featured in this piece has received at least one Gates Foundation grant.

The Gates Foundation is headquartered in Seattle, near Microsoft, with one other U.S. office in Washington D.C., and nine branch offices outside the U.S., including in Delhi, Beijing, Nairobi, and Dakar. The foundation has also provided more than half a billion dollars of support to the World Bank, another institution that has wielded influence among numerous governments in the Global South.

The Gates Foundation has long enjoyed a leading role at WHO as well. Much of that agency’s budget comes from what are called assessed contributions from its 194 member countries — funding from governments that the WHO governing bodies can use as they see fit. Nevertheless, WHO receives substantial funding in the form of voluntary contributions in which the money contributed must be spent on certain areas, especially polio eradication and childhood vaccinations.

Between 2022 and 2023, the Gates Foundation was the third largest independent funder, providing $830 million of WHO’s $6.7 billion budget. The U.S. was the largest. But in the last year, the order shifted: For the first time, the Gates Foundation was the largest funder. The U.S.’s portion, which will drop over the next biennium due to the country’s exit, was $698 million.

Of Gates’ influence, many global health experts and health researchers have overwhelming positive views, at least in public. But the high marks may partly stem from a “Bill Chill,” in which the foundation’s vast investments create conflicts of interest, making recipients reluctant to criticize it, said Jeremy Youde, a Portland State University political scientist. Some criticisms have emerged over the years, however, including in prominent books like “The Bill Gates Problem” by journalist Tim Schwab and “No Such Thing as a Free Gift” by sociologist Linsey McGoey. McGoey, for example, makes the case that Gates’ and other philanthropic funding deprives governments of tax revenues and erodes support for government spending.

One critique leveled by Gostin, as well as by McGoey, is that the foundation has limited accountability compared to other global health donors — namely, governments. In one recent example, the Gates Foundation was controversially granted diplomatic immunity in Kenya last year through the country’s Privileges and Immunities Act, which appears to have included immunity from legal action while performing duties for the foundation within the country. In November 2024, Kenya’s High Court temporarily suspended the foundation’s privileges.

The Gates Foundation did not grant Undark’s requests for an interview, although various spokespeople provided statements or directed the magazine to previously published statements. About this Kenya episode, the foundation’s Africa Director Paulin Basinga previously said: “the legal proceedings related to the Host Country Agreement have shifted attention away from our core mission. To remain focused on our work and partnerships in Kenya, we will continue operating our branch office while transitioning away from the Host Country Agreement.”

Some global health experts say this is an example of Bill Gates and the Gates Foundation being treated like a head of state, even though it’s a private entity. “It acts often as a country representative in these global spaces, so it has outsized influence,” said Marlee Tichenor, a medical anthropologist at the University of Edinburgh who has published research assessing the influence of private philanthropic interests. In a similar vein, she said, the Gates Foundation’s vast sway could undermine WHO’s independence.

On questions of transparency, Kate Davidson and other Gates Foundation spokespersons pointed to its grants database, which provides data on how much money was disbursed, when, and to whom. But the database includes no information about who was involved on either side in the process, nor does it include details or internal reports about how the funding was actually spent, unlike government agencies and the World Bank, Tichenor said.

Other researchers, like David McCoy at United Nations University’s International Institute for Global Health (which has received Gates funding) in Kuala Lumpur, Malaysia, have documented how the majority of the Gates Foundation’s funding, at least in its early years, didn’t actually go directly to poor countries. In 2009, McCoy and his colleagues analyzed a decade of more than 1,000 grants between 1998 and 2007, and published their findings in The Lancet. He has subsequently continued to track the foundation. “The overwhelming number of recipients of Gates Foundation grants were based in the Global North,” McCoy said, referring to institutions based in the U.S., Europe, Australia, and Canada. A separate 2023 analysis comes to similar conclusions about Gates and two other foundations, favoring grant recipients in high-income countries.

McCoy also noticed other trends among the Gates Foundation’s grants. “A lot of what the Gates Foundation funds is focused on downstream interventions,” he said. “It’s a particular approach to health improvement that is quite reductive and technologically focused.” That meant focusing on things like vaccines, drugs, and devices, he said, while neglecting the broader context of poverty and lack of access to health care, housing, and other structural problems.

Many health experts and health equity advocates, including Tichenor and Youde, also criticize the Gates Foundation’s longstanding emphasis on intellectual property since the 1990s. In the more recent case of Covid, these critics point out that, for seven crucial months, the Foundation rejected calls for a vaccine patent waiver, which had previously been done with HIV antiretrovirals. “From my perspective, because of Gates’ outsized influence, his opposition to waiving the patent rights actually was a big deal, it slowed down that process,” Tichenor said.

In response to Undark’s request for comment on this, a Gates Foundation spokesperson pointed to a statement by CEO Mark Suzman, which endorses a narrow IP waiver, on May 6, 2021, a day after President Joe Biden officially supported such access.

And while many health experts commend the Gates Foundation’s longtime efforts to eradicate polio and malaria, two objectives the foundation maintains today, Tichenor and others contend that those goals are unrealizable and involve an inefficient use of resources. In particular, eradication and control of a disease such as polio can be in contradiction with each other, while only the latter directs resources toward places that need it most. After all, global health groups previously targeted 2000 as the year for eradicating polio; today, the disease remains endemic in Pakistan and Afghanistan.

“The target’s always getting further and further away,” Tichenor said. “The amount of money and labor and infrastructure it requires ends up being, to me, questionable.”

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Regardless of the Gates Foundation’s perceived accomplishments and shortcomings, for the next two decades, the foundation will remain a heavyweight in global health. And Gates isn’t alone: He was recently joined on the philanthropic stage by Meta’s Mark Zuckerberg, through his Chan Zuckerberg Initiative, founded in 2015 to support biomedicine, disease research, and other projects. Other influential philanthropic interests supporting health organizations and medical research include The Rockefeller Foundation, the Wellcome Trust in London, and the Novo Nordisk Foundation in Denmark, which were founded in 1913, 1936, and 1989, respectively.

In this model of philanthrocapitalism, as McCoy and others have described it, foundations, often led by billionaires, are run somewhat like private corporations and wield power among their recipients. In fact, the Gates Foundation’s assets had grown for years, despite disbursing billions of dollars of annual grants. Gates’ personal fortune continued growing at the same time, despite his philanthropy, and only recently plateaued.

When one looks at Gates and other philanthropic efforts narrowly, it can be hard to argue with the measurable improvements in health and mortality they’ve produced, according to McCoy. But for him, the bigger picture looks different: Philanthropists “have not been able to adequately address poverty and underdevelopment.” In that view, concentrated wealth of billionaires like Gates, Zuckerberg, and John D. Rockefeller’s descendants is part of the problem, not the solution.

Katerini Storeng, a medical anthropologist at the University of Oslo, argues that problems with philanthropy today involve more than just the role of massive wealth. In her new research, she finds that the Gates Foundation’s influence extends beyond its many grants. She and her colleagues apply the concept of “network diplomacy” in this philanthropic context, where the foundation builds networks of influence, such as among donor governments, think tanks, and media organizations, institutionalizing its approach to global health. “We found that there has been a sustained territorial expansion into Europe over the past 15 years,” she said, and “the extent of it is sophisticated.” It has ultimately created alignment with the Gates Foundation’s agenda, she added, akin to an empire exerting soft power.

Extensive engagement by foundation officials in many sectors of society ensured that the U.K., France, and Germany would continue financing Gates priorities like Gavi and the Global Fund, Storeng added, eventually outpacing the foundation’s own funding.

But the future of philanthropy is also uncertain, with new calls for reforming wealth taxation and the philanthropic system itself. The Trump administration supports proposed legislation that would substantially raise taxes on endowments, taxing by 10 percent the investment income of large foundations with assets over $5 billion, while giving the Treasury the power to suspend nonprofits’ tax-exempt status. (The Senate version of the bill, which passed Tuesday, removed the foundation tax provision. The bill now heads back to the House.) Previously proposed reforms would target billionaires themselves, imposing a 3 percent annual wealth tax. Either kind of tax would affect philanthropists, including Gates, and limit their ability to aid health groups that are struggling to weather the loss of U.S. funding.

Youde, the political scientist, also wonders what global health might look like once the Gates Foundation eventually closes down — which it’s set to do in 20 years. But for now, he takes a pragmatic tack.

“There are lots of criticisms that can be levied and should be levied against the Gates Foundation, particularly around these questions of accountability and transparency. But I’d also rather have Bill Gates spending his money on this than buying massive superyachts that can’t even get out of harbors in the Netherlands,” he said, referring to billionaire Jeff Bezos’ half-billion-dollar vessel previously stuck in Rotterdam. “Better that this money is going into global health than something else.”