Gates Annual Letter: Where’s the policy?

In recognition of how little we talk about global health, I am turning my attention back to my roots for today’s post.

On Jan 22nd, Bill and Melinda Gates launched their annual letter. For those readers who live fully under a domestic health policy rock, Bill and Melinda Gates are co-chairs of the Bill and Melinda Gates Foundation, which donated more than $1 billion in 2013 to global health activities. Aside from that enormous sum, the foundation is commonly looked upon as an example of what strategic philanthropy can do.

The 2015 Annual Letter, launched on January 22nd, resembles previous letters insomuch as it strikes an optimistic tone about the progress made to date and makes bold claims about the future impact of the foundation. Specifically, the Gates’ tell us that they are aiming to have impact in four areas in the next 15 years – health, farming, banking and education. In the area of health, the letter specifies a focus on several specific projects, including cutting the number of children who die before 5, reducing the number of women who die in childbirth, wiping polio and three other diseases out entirely, finding the secret to the destruction of malaria and forcing HIV to a tipping point.

For our purposes, what’s most interesting about the letter is what it doesn’t say. It makes no mention of law or policy and makes only passing reference to regulation and governance. What is this about?

The apparent oversight may actually be an implicit part of the Foundation’s strategy. While some global health actors, like the Clinton Health Access Initiative, try to work directly with governments, the Gates Foundation more often aims to work around government to create change. In this year’s letter, for instance, we see evidence of a growing interest in funding basic research on vaccines and antibiotics. And if the past is any indication, when it comes to deploying these solutions, the Foundation will continue to make grants primarily to civil society actors on the ground.

The philosophical question at hand is whether it is reasonable to think that widespread gains in global health can be made without spending time developing the structures – such as laws, policies, regulations and courts – to protect and sustain innovation? To Gates, time spent working on these structures would likely be seen as diverting resources from directly disseminating simple and efficacious solutions like breastfeeding, injectable antibiotics, and umbilical cord care. Meanwhile at least one political scientist, Associate Professor, Chris Blattman of Columbia University, has suggested that even the most straightforward solutions can require more government involvement than the Gates’ care to admit.

In a world of limited bureaucracy, politicking and corruption and unlimited resources, many of us might agree that working through government would be optimal for ensuring long-term sustainability. Short of these conditions, each actor in the global health landscape is forced to make tough choices about where it thinks it can have the most impact. Given its impressive track record to date, it appears the Gates Foundation has found a workable strategy for itself in largely sidestepping the law. However, it remains to be seen how long these policy-free solutions will continue to produce impact before more complex interventions are required.

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