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In recent years the Bill & Melinda Gates Foundation has made enormous investments in global health. As a private foundation, it can decide its agenda, yet because of the huge influence it has, especially on research that addresses the major health problems of low-income countries, its decisions and priorities have become the subject of intense interest by the global health community. In The Lancet today,1 David McCoy and colleagues' description of the grant commitments by the Foundation provides an opportunity for analysis that may form part of a "natural feedback loop" that Bill Gates said in his first annual letter was currently missing.2 Such informal scrutiny could assist the Foundation to assess whether its investments are consistent with its mission and appropriately balanced to achieve optimum results.
The mission of the Foundation to improve maternal and child health with a philosophy that "every life has equal value" is an admirable commitment to global equity. We will use the Foundation's major focus on reducing child mortality and related research to illustrate points, although we believe that they apply generally to the Global Health Program of the Foundation. Gates has stated a goal of reducing the current 10 million annual child deaths by half in the next 20 years.2 This is less ambitious than the Millennium Development Goal 4 target of a two-thirds reduction in child deaths by 2015. For a Foundation that indicates that the current number of child deaths is unacceptable and needs to be addressed urgently, this point is surprising but consistent with the Foundation's focus on the development of new health technologies, which usually require decades.
The Foundation has provided substantial funds for service delivery, mainly through support for the supply of vaccines and medicines.1 While commendable, these funds might be better provided by national governments and international donors or agencies. We believe that the role best served by the Foundation is in research to advance global health, particularly research that is "high-reward", in their terminology.2 In the Foundation's statements, this term is usually preceded by "high-risk", but even more appealing would be research that is "lowrisk and high-reward".2 The funding of the Foundation...