A recent study in Lancet becomes the first study to pull back the curtain on the Bill and Melinda Gates Foundation and its impact on global health.

Since the money the Gates Foundation spends on global health (61% of its total $2.01 billion budget) is almost as large as the entire budget of the WHO, and because it is not a passive donor (it actively engages in policy making and agenda setting activities, including having representatives sitting on many global health groups), it’s about time someone followed the money.

The findings reveal a lot about the Gates Foundation’s profound influence in setting the global health care agenda and its contributions. It also raises questions about its priorities and opportunities for improvement.

The authors examined Gates foundation grants between 1998 and 2007. Among the things they learned:

* the Foundation awarded 1094 grants in that period
* the grants totaled $8.95 billion
* 60% of that total was shared by 20 organizations (the largest share of grants went to the Global Alliance for Vaccines and Immunizations, $1.5 billion in all )
* The biggest overall percentage of funds went to Non-governmental/non-profit organizations (36.8%)
* 82% of grant recipient were U.S.-based groups
* There were a couple of peculiar grants–to the World Bank and the International Finance Corporation, perhaps to help develop private-sector health care in developing nations.

The key question, though, is: What kind of projects does the foundation invest in?

* 36.5% goes into R&D and basic science investigations, the majority of it geared toward vaccine and anti-microbial development)
* 24.1% into health care delivery
* 17.6% help enable purchasing of drugs and vaccines
* 11.4% into public health research
* 3.5% into advocacy
* 2.6% food and agricultural research
* 1.9% into program and policy work
* 1.6% “other”
* 0.8% into “civil society development in developing countries”

In terms of allocation for specific diseases, HIV/AIDS was number one, followed by malaria, vaccine-preventable diseases, child health, TB, tropical diseases. Maternal illness and mental illness, the authors pointed out, were relatively underfunded compared to the burden of these diseases.

Some critics have looked that allocation, weighted toward new technologies and medicines, and argued that the Foundation would be better to shift its focus to “low cost, high impact” projects. For example, one of Bill and Melinda Gates’ goals from the outset has been to cut child mortality in half. While they are (and ought to) fund vaccine development, most kids die because the lack access to safe food and water, shelter and a safe community. Investments in the delivery and distribution of cheap antibiotics, oral rehydration solution and community health could quickly, cheaply and dramatically improve international pediatric care. So pushing those public health initiatives up the funding ladder might help the Foundation achieve that goal sooner.

In addition, the authors said the grant-making process, “seems to largely managed through an informal system of personal networks and relationships rather than by a more transparent process based on independent and technical peer review.”

Regardless, the study (by no means perfect, as the authors are clear about from the get go) and its comments should really be welcomed by the Gates Foundation. Bill Gates has long talked about having a “natural feedback loop” in the process of achieving world health. This study is a great first step to improving an already exemplary organization, one that’s taken the mission to improve global health to great new heights.

Rahul K. Parikh is a pediatrician and a writer.  He can be reached at his self-titled site, Dr. Rahul K. Parikh.