(Photo by Richard Rudisill Photography/iStock) 

Extraordinary and expensive medical treatments are available to people in poor regions, thanks in large part to commitment and funding from Bill & Melinda Gates and other private foundations. But while antiretroviral therapies help millions with HIV live longer and healthier lives, their neighbors continue to die of simple diarrheal diseases.

Private foundations don’t fund the issues that people surveyed in 27 countries think should be the national priority, says Daniel Esser, assistant professor in the international development program at American University. “Whereas national financial assistance for global health shows a weak but at least significant response to preference,” says Esser, “private foundations seem to be responsive to neither preferences nor disease burdens at the national level.”

A 2007 Kaiser/Pew Global Health Survey of the public perceptions of health problems in developing countries let Esser compare disease burdens and local priorities with funding streams, both public and private. HIV/AIDS contributes only 3 percent of the total disease burden in Asia, but was the second most highly funded health category. Tuberculosis, malaria, and other infectious diseases are the lowest priority out of nine in the Middle East, but received the third most money from 2005 to 2007.

The diseases that get funded tend to be the ones for which funders can take credit, Esser says: They are infectious, highly visible, and in some way “ownable.” With a vertical aid architecture “every donor can plug into the supply chain somewhere, and they can quite easily claim a role and an impact within that supply chain,” Esser says—from financing a particular prevention campaign to providing a certain number of treatment kits or vehicles. Murkier areas like chronic disease and basic health systems strengthening are neglected.

Malaria, HIV, and tuberculosis do in fact kill a lot of people. “The real problem, though, is in the concept of other people deciding for other countries what is in their best interest,” says Eva Harris, professor of infectious disease at the University of California, Berkeley School of Public Health. “One needs to develop partnerships and listen, as opposed to tell.”

The Bill & Melinda Gates Foundation has become a phenomenal force. In 2007 it spent almost as much on global health as the World Health Organization’s entire annual budget. Esser worries that the Gates Foundation’s accountability has not grown as much as its influence. “Now that we have mobilized so much more money for global health,” says Esser, “and now that health is considered one of the key issues in international development, isn’t it time to have a critical look at what the real killers are?” That’s going to be different in every country, he says, and the challenge is to respond to actual local needs.

Daniel Esser and Kara Keating Bench, “Does Global Health Funding Respond to Recipients’ Needs? Comparing Public and Private Donors’ Allocations in 2005–2007,” World Development, 39, 2011.