If you only ever read media coverage of the Bill & Melinda Gates Foundation, you would assume everybody loves it.

In contrast to the scrutiny of, say, the Koch brothers' philanthropy, the Gateses' foray into global public health attracts mostly uncritical adulation. A sample headline: "Bill and Melinda Gates the most generous humans ever."

So it's surprising to wade into academic journals and find that many political scientists and development scholars are actually quite skeptical about the Gates Foundation's outsize impact on global health. In numerous papers over the past decade, researchers have raised concerns about the foundation's lack of transparency, its veto power over other global health institutions, and its spending priorities. Some experts worry that the Gateses’ health philanthropy has become too big to scrutinize.

To be sure, plenty of experts think the Gates Foundation does important work in fighting neglected diseases and boosting vaccinate rates in children. The foundation has taken private funding for global health to an unprecedented level, giving away more than $30 billion with an emphasis on data-driven decision-making. Bill and Melinda have also been applauded for encouraging others in their position to do the same.

But precisely because the private organization is so large and influential, some researchers say, critical analysis is so much more important.

The Gates Foundation spends more on global health every year than most countries

There's no doubt the Gates Foundation has had a profound impact on global health. The sheer scale of its charitable giving is astonishing. It's the largest philanthropic foundation in the world, with an endowment worth $42.9 billion — roughly double the GDP of Uganda. To date, the foundation has paid out $33.5 billion in large grants to do everything from design better condoms to develop off-the-grid water sanitation technologies.

The foundation's funding was instrumental in setting up the GAVI Alliance, which has played a major role in boosting immunization rates around the world. The foundation helped launch the Institute of Health Metrics and Evaluation in 2007, now the preeminent source of global health statistics and an important tool for evaluating the impact of programs like vaccine rollouts and cancer screening. The Gateses have distributed billions to fight crippling infectious diseases like HIV/AIDS, tuberculosis, and malaria, and to improve maternal health and childhood mortality.

All told, the foundation now spends more on global health every year than the World Health Organization — not to mention more than most countries on the planet. The foundation is also the second-biggest funder of the WHO, after the United States, and a major contributor to other UN agencies and key global health players, like the Global Fund (which finances treatment and prevention for infectious diseases like HIV/AIDs, TB, and malaria) and the World Bank.

In fact, explained Jeremy Youde, a professor of political science at the University of Minnesota Duluth, many organizations are reliant on Gates Foundation funding. "If they were to decide that GAVI is not what they're going to do any more," he said, "that would put an organization like GAVI into real peril."

The foundation's money has undeniably been a huge boon to global health efforts. But because the private organization is so wealthy and large, some researchers have argued that it wields a disproportionate influence on global health — with little accountability.

"You may have foundations with assets larger than almost 70 percent of the world’s nations making decisions about public policy and public priorities," Georgetown Public Policy Institute's Pablo Eisenberg told Nature, "without any public discussion or political process."

It's hard to measure the Gates Foundation's effectiveness

As a private organization, the Gates Foundation is only accountable to its three main trustees: Bill, Melinda, and Warren Buffett. And that troubles many critics.

"The first guiding principle of the Foundation is that it is 'driven by the interests and passions of the Gates family,'" noted an editorial in The Lancet. "Is this kind of governance really good enough?"

To be sure, existing global health organizations are hardly perfect. The WHO, in particular, is broken and in need of reform. But without accountability and transparency, there will always be questions of whether private foundations like Gates, however well-intentioned they may be, are a superior alternative. "For all the flaws that exist within the WHO, there is still some measure of transparency that can exist," Youde said. "And that simply isn’t present for what Gates does."

When I asked University of Essex sociologist Linsey McGoey — who has studied the foundation — about all the good work Gates has done, she said, "I honestly don't know, and that’s the scary thing." Fundamentally, she added, it's very difficult to measure a private foundation's efficacy.

Some academics have questioned the Gates Foundation's priorities

This lack of accountability is a concern because over the years, some experts have questioned the foundation's spending priorities.

One 2008 article by two Oxford researchers, published in The Lancet, argued that the Gates Foundation was "misfinancing global health" — paying most of its grants out to rich countries and prioritizing infectious diseases (such as HIV/AIDS and malaria) over major chronic killers such as obesity, cancer, and diabetes.

Another 2009 paper in The Lancet, by a group of University College London health and development researchers, found that despite the Gates Foundation's emphasis on improving the lives of the poor, its grants didn't actually reflect the burden of disease that the poorest face.

An example: the Gates Foundation has received lots of positive press for its role in financing the eradication of polio. And yet, even that campaign had its critics, says McGoey. In her research, she found key stakeholders in some of the countries that were the focus of the campaign expressing the view that "this was really a priority of wealthy nations and not necessarily developing ones, many of which were more preoccupied with battling illnesses that created a far greater health burden in their nations [such as diarrhoeal diseases in India]. They were compelled to emphasize polio [eradication] against their will."

Others argue the foundation puts too much emphasis on technology

Another concern that comes up in the academic literature is that the Gates Foundation is too focused on drugs, vaccines, and other technological solutions for global health problems. But many researchers, by contrast, would prefer a focus on the less exciting but crucial work of strengthening the health systems of poorer countries.

The need for stronger health systems became quite clear during the Ebola epidemic, when the regions hardest hit by the virus happened to be the ones that had spotty surveillance networks to track diseases, run-down and poorly supplied hospitals, and bad infrastructure to move people around. Bill Gates himself noted — in a New England Journal of Medicine article — that this was one of the lessons of the epidemic.

But so far, health systems haven't been a focus of the foundation. Investing primarily in drugs or vaccines without strengthening systems can, in some cases, be counterproductive, says Youde. "You’ve got this great product, but then how do you get it to market, make sure it’s able to stay within that market?"

For similar reasons, the Gates Foundation's work on malaria drew criticism from some corners. In a 2013 article in Global Society, Youde pointed out that the head of WHO’s malaria research, Arata Kochi, sent a memo complaining that the foundation "was stifling debate on the best ways to treat and combat malaria, prioritising only those methods that relied on new technology or developing new drugs."

Still others have questioned the Gateses' views on IP laws

McGoey also argues that Bill Gates's views on intellectual property rights put him in conflict with many global health experts.

Gates, after all, has long been a proponent of strong IP protections in international trade agreements — something that benefited US companies such as Microsoft. (Microsoft helped lobby for the 1994 TRIPS agreement that allowed member countries to defend patents for at least 20 years after filing.)

Yet many health campaigners have argued that these protections can make it more difficult for poorer countries to replicate and manufacture cheaper generic versions of drugs. As an alternative, they've pushed for a system that would allow more competition among generics and promote innovation outside companies with existing patent monopolies.

"The Gates Foundation has played an extremely negative role in efforts to develop replacements for strong patent rights and high drug prices," James Love, the director of Knowledge Ecology International and a critic of the foundation, writes on his blog. Or as McGoey put it: "There’s immense concern surrounding the Gates Foundation’s position on intellectual property rights, and whether this major global health player is cognizant enough to ensure property rights are fair for citizens in wealthy and poor nations."

Critics are hard to find — most people are reluctant to say anything negative

While studying the Gates Foundation, Sophie Harman, an academic at Queen Mary University of London, noticed something peculiar. Even though the foundation is one of the single most powerful actors in global health, remarkably few people ever had anything negative to say about its work outside of skeptical academics.

"Perhaps that's because their projects are great, but that's never the case," Harman says. "Not all global health projects are 100 percent successful." Another explanation for the silence, Harman argues, is that "everyone is scared of challenging Gates and the foundation's role because they don't want to lose their funding."



"Unlike the Kochs, the Gates Foundation is not seen as trying to further its own interest"

In May, I attended the World Health Assembly — the world's largest annual health meeting — and began asking attendees for their views on the foundation. I noticed that often people wouldn't speak on the record because they were being funded by the foundation or because they had done some kind of work for Gates in the past. When they did speak, their views were usually glowing.

Of course, a lot of the praise for the Gates Foundation is completely warranted, Youde said. "They’ve brought a level of attention to some of these global health issues in a way that the WHO simply doesn't have the same public stature and recognition to do. They put global health issues on the international agenda in a way that they hadn't been before."

But because of the foundation's scale, McGoey argues, criticism is absolutely vital. "There's a tendency to see the Gates Foundation as benevolent force. Unlike the Kochs, it's not [seen as trying] to further its own interest. But if you want to rein in the influence of large philanthropic funders like Koch, then you have to pay attention to the role of Gates."

Would the world be better off without the Gates Foundation?

All these criticisms raise a bigger question, however: would the world be a better place without the Gates Foundation? And the answer is: probably not.

At the same time, these academics argue that we can't answer that question definitively. And this isn't a problem that's unique to Gates. The scale of the foundation's giving is part of a new trend toward supersize philanthropic spending, dubbed philanthrocapitalism, that's grown up in a lax regulatory environment. The gap between the rich and poor is growing, and so too is the number of billionaires — from the Kochs to the Gates — who set up private foundations to further their pet causes with little oversight.

When asked for comment for this story, a spokesperson for the Gates Foundation noted that "The question of accountability and transparency is not unique to the Gates Foundation, but is a concern about the role of philanthropy generally." He said the foundation shares data and information about its grants on its own website, as well as "through trusted third parties such as the International Aid Transparency Initiative, OECD and the Foundation Center."

Essex's McGoey argues that that's not enough, and that we need to get a better understanding of all foundations — treating the Gateses and the Kochs of the world with the same level of scrutiny. She argues that Congress ought to get involved, too. Starting in the 1950s, concerns about the outsize role of large philanthropic groups such the Carnegies and the Rockefellers prompted a rethink of political oversight. The Tax Reform Act of 1969 created new obligations for philanthropic groups, which led to requirements such as minimum yearly payouts of a foundation's endowments.

"But we haven't had an overhaul of legislation in the US that’s been that extensive since then, and a lot of scholars are calling for revised congressional attention [on the influence of foundations] — not just on global health but policy setting," she added.



Other critics, such as Inside Philanthropy founder David Callahan, have been asking questions like who will watch the charities? "The charitable sector is a bit like the Wild West," he wrote in a recent New York Times piece. "Foundations don’t have to prove that they’re making good use of billions of dollars of tax-subsidized funds, and nonprofits don’t have to identify their donors, as we’ve learned from the Clinton Foundation saga."

Reform suggestions include more public representation on foundation boards, increasing the payout requirements of their tax-exempt dollars, and even capping the permissible size of foundations.

For now, however, the work of Gates remains largely unscrutinized, said Harman. At a time when the global health community is so disproportionately reliant on Gates Foundation funding, this is worrisome, she added: "If they use their wealth for neglected areas of global health, great. But for me, that's not enough to be legitimate."