Who’s leading WHO? A quantitative analysis of the Bill and Melinda Gates Foundation’s grants to WHO, 2000-2024

Abstract

Introduction

The Bill and Melinda Gates Foundation (BMGF) has been the World Health Organization’s (WHO) second biggest source of funding in recent years, contributing 9.5% of WHO’s revenues between 2010 and 2023 through voluntary contributions. It is widely assumed that BMGF’s financial power allows it to exert considerable influence over WHO. However, very little empirical research has been undertaken into the BMGF-WHO relationship. Our study investigates how the money that BMGF gives to WHO is spent.

Methods

We constructed a dataset of BMGF grants to WHO for the period 2000–2024 by extracting and coding data retrieved from BMGF’s website. The dataset was analysed to examine the number and value of grants, and the diseases or health issues and activities that were funded.

Results

BMGF made 640 grants worth $5.5 billion to WHO between 2000 and 2024. This is 6.4% of all BMGF’s grants by value in the period. Grants worth $4.5 billion focused on infectious diseases. This amounts to 82.6% of all BMGF contributions to WHO by value. Of these, $3.2 billion (58.9%) went to polio. $2.9 billion – 53.3% of the money BMGF disbursed to WHO – funded vaccine programmes and projects. Relatively little BMGF funding went to non-communicable diseases, strengthening health systems, and broader determinants of health, despite their importance to WHO strategy and global health more generally.

Conclusion

WHO’s reliance on earmarked voluntary contributions means that global health challenges favoured by major donors’ are well funded while other issues receive insufficient funding. As one of WHO’s biggest donors, BMGF contributes to this problem by pursuing its narrow approach to global public health – one that focuses on technical solutions to infectious diseases – through WHO.

WHAT IS ALREADY KNOWN ON THIS TOPIC

• The Bill and Melinda Gates Foundation (BMGF) is the World Health Organization’s (WHO) second biggest source of funding, contributing 9.5% of WHO’s revenues between 2010 and 2023.

WHAT THIS STUDY ADDS

• BMGF made 640 grants worth $5.5 billion to WHO between 2000 and 2024. This amounts to 6.4% of all money disbursed by BMGF in the period.

• $4.5 billion or 82.6% of all BMGF contributions to WHO went to infectious diseases, of which $3.2 billion (58.9%) went to polio – despite polio accounting for an insignificant proportion of the global burden of disease.

• A small proportion of the money BMGF gave to WHO goes to strengthening health systems, non-communicable diseases, and broader determinants of health, despite their importance to WHO’s strategy and global health more generally.

HOW THIS STUDY MIGHT AFFECT RESEARCH, PRACTICE OR POLICY

• Our study emphasises an important point for global health practice and policy: without flexible and sustainable sources of funding WHO will struggle to achieve its strategic aims.

Background

WHO’s funding crisis

The World Health Organization’s (WHO) constitution is notable for setting out the principle that ‘the highest attainable standard of health is one of the fundamental rights of every human being’ and defining health as ‘a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity’.¹ On paper at least, WHO is still committed to these values. Its Thirteenth General Programme of Work, which describes the organisation’s strategy for the period 2019 to 2025, notes that ‘people everywhere continue to face a complex mix of interconnected threats to their health and well-being − from poverty and inequality to conflict and climate change’.² It lists three main priorities: ‘ensuring healthy lives and well-being for all at all ages’; ‘achieving universal health coverage’; and ‘addressing health emergencies and promoting healthier populations’. For each of these priorities, WHO aims to improve the situation for one billion people by 2025.

WHO’s ability to fulfil its strategic goals is inhibited by the way it is funded. One problem is the amount of money at its disposal. WHO’s biennial budget for 2024 and 2025 is $6.8 billion.³ This is simply inadequate to achieve its objectives.4,6 Another issue is the way WHO is financed. Its budget comes from two sources. Assessed contributions or regular budget funding are paid by member states, with the amount calculated according to a country’s wealth and population. The World Health Assembly (WHA) – in which each member state has one vote regardless of the size of their contributions to WHO – decides how these resources are used. (This distinguishes WHO from international organisations such as the International Monetary Fund and World Bank, in which members’ voting power is weighted according to the size of their contributions, or the United Nations Security Council, in which the five permanent members can veto resolutions.) Voluntary contributions or extra-budgetary funding come from member states and non-state actors. Currently around nine-tenths of these are ‘earmarked’, i.e., given on the condition that they fund activities and projects defined by the donor.⁶ In other words, unlike assessed contributions, in almost all cases the donor rather than WHO specifies how voluntary contributions are spent.

At the start of the 1970s, assessed contributions accounted for approximately three-quarters of WHO’s revenues.³ Since then, the organisation has become increasingly dependent on voluntary contributions. Wealthy member states – led by the USA – have repeatedly refused to increase their assessed contributions in line with WHO’s needs. This was in response to concerns over what they perceived to be WHO’s growing radicalism, as European colonies in Asia and Africa won their independence and WHO’s membership grew from 55 in 1948 to 146 three decades later.⁷ WHO’s perceived radicalism reached its apogee in 1978 with the Alma-Ata Declaration, which forcefully argued that WHO’s objective of ‘the attainment of the highest possible level of health’ required economic and social development ‘based on a New International Economic Order’.³ In other words, ‘Health For All’ could not be achieved by technical changes in the way that healthcare was delivered; rather, it needed to be part of a much more fundamental transformation in power relations between rich and poor. This vision was, however, quickly undermined by powerful member states, most notably the USA.⁷

By the early 1990s, voluntary contributions overtook assessed contributions as WHO’s main source of funding.^{3 4} They now account for almost nine-tenths of revenues.⁵ WHO’s growing dependence on voluntary contributions allows a small number of wealthy, powerful donors to use earmarked voluntary contributions to bypass the democratic decision-making processes of the WHA.^{7 8} This has created what WHO refers to as ‘pockets of poverty’ in its budget, as activities and areas that are of interest to donors receive lots of voluntary contributions, whereas those that are not of interest do not.⁹ The end result of the increased importance of voluntary donations to WHO is ‘a mismatch between formal sovereign equality of its member states and informal power exercised by the main financial contributors’.¹⁰

The Bill and Melinda Gates Foundation and the WHO

Backed by an endowment that currently stands at almost $78 billion, the Bill and Melinda Gates Foundation (BMGF) has become one of the most influential actors in global health since it was started in 2000.¹¹ BMGF has used its vast wealth to create several global health partnerships that bring WHO and other UN agencies together with governments, pharmaceutical companies, and other private and public actors to focus on specific health challenges. These include: GAVI, the Vaccine Alliance; the Global Fund to Fight AIDS, Tuberculosis and Malaria; and, more recently, the Coalition for Epidemic Preparedness Innovations (CEPI). BMGF continues to fund these organisations and its representatives sit on their boards.^{8 12}

BMGF quickly became one of WHO’s biggest funders. According to the organisation’s ‘Voluntary contributions by fund and by contributor’ documents, the foundation’s donations amounted to $4.0 billion between 2010 and 2023 – 9.5% of WHO’s total revenues ($42.0 billion). See table 1A in the web online supplemental appendix. (Pre-2010 data is not available from WHO’s website. Data for 2024 was not available at the time of writing.) This makes BMGF the organisation’s second-largest funder, contributing more than any other country or organisation except the USA – which, in January 2025, announced its intention to withdraw from WHO. Germany and the UK are third and fourth respectively. The fifth biggest donor to WHO is GAVI. BMGF is a founding partner of and a major donor to GAVI, having committed $4.6 billion to date to the alliance – about one-fifth of all its funding.¹³ It is not simply the amount of money that BMGF gives to WHO that is significant, but how this money is deployed. A recent study describes how BMGF influenced WHO by paying for the cost and donating the time of management consultants to advise on the organisation’s reform processes.¹⁰

Table 1. Number and total value of grants awarded by BMGF to WHO, 2000–2024.

Year	Number of BMGF grants to WHO	Value of BMGF grants to WHO (million $)	Total number of all BMGF grants	Total value of all BMGF grants (million $)	Number of BMGF grants to WHO as % of all grants	Value of BMGF grants to WHO as % of all grants
2000	2	20.0	1587	1321.8	0.1	1.5
2001	2	6.4	1528	791.8	0.1	0.8
2002	7	30.2	1939	723.3	0.4	4.2
2003	5	9.6	1361	1270.4	0.4	0.8
2004	12	66.7	476	979.2	2.5	6.8
2005	18	48.6	638	1823.7	2.8	2.7
2006	18	158.1	655	2832.2	2.7	5.6
2007	18	137.3	602	4027.0	3.0	3.4
2008	17	760.5	869	4114.9	2.0	18.5
2009	15	72.2	1017	3560.8	1.5	2.0
2010	16	44.0	919	1751.0	1.7	2.5
2011	24	75.4	1243	4280.8	1.9	1.8
2012	17	203.7	1262	2390.2	1.3	8.5
2013	25	400.8	1476	3369.6	1.7	11.9
2014	44	642.7	1489	4269.3	3.0	15.1
2015	38	196.3	1665	4905.3	2.3	4.0
2016	25	119.4	1575	6449.6	1.6	1.9
2017	29	234.1	1461	5015.4	2.0	4.7
2018	36	279.6	1703	3682.5	2.1	7.6
2019	41	219.7	1859	3621.9	2.2	6.1
2020	43	299.9	2128	4790.0	2.0	6.3
2021	38	317.0	2047	5804.9	1.9	5.5
2022	42	344.2	1959	5304.1	2.1	6.5
2023	62	450.3	2394	7064.1	2.4	6.4
2024	46	327.2	2548	5266.3	1.8	6.2
Total	640	5463.9	36 400	85 788.2	1.8	6.4

Source: BMGF website (https://www.gatesfoundation.org/about/committed-grants)

Note: The numbers in the ‘Value of BMGF grants to WHO’ column in table 1 differ from those in the ‘BMGF contributions to WHO’ column in table 1A because the former refers to the value of BMGF grants awarded to WHO in a particular year – with these grants often paid out over several years – whereas the latter captures the actual amount of money paid to WHO by BMGF in a given year.

BMGF, Bill and Melinda Gates Foundation.

Some observers have commended BMGF for helping to fund the shortfall in WHO’s budget, but others have raised concerns over the former’s influence over the latter.^{8 11 14} One problem relates to the legitimacy of BMGF. It is governed by its board, which until recently consisted of: Bill and his now ex-wife Melinda; William Gates Senior – Bill’s father and a wealthy corporate lawyer in his own right; and Warren Buffett, the billionaire investor who pledged a significant portion of his wealth to the foundation. BMGF’s board was criticised for being too small and too narrow for an organisation that has such an impact on the global health system and the lives of billions of people living in the ‘majority world’.1,4 In the last couple of years, things have begun to change at the top of BMGF. In 2020, Gates Senior died aged 94 and the following year 90-year-old Buffett stepped down as a BMGF trustee. Since 2022, BMGF has appointed six new trustees with the aim, according to its website, ‘to enhance representation across gender, geography, and expertise’.¹⁵ There remain, however, limited options for holding BMGF’s board accountable for its decisions and actions.

A second concern relates to BMGF’s strategy. The foundation is a notable proponent of ‘philanthrocapitalism’, an approach that aims to apply business skills, acumen, and tactics to philanthropic giving, and harness the power of the market to generate social and financial returns from philanthropic ‘investments’.^{16 17} Such an approach is also characterised by a disregard for and mistrust of governments, international organisations, and non-governmental organisations, all of which are seen as inefficient and ineffective because they are not subject to market discipline. This sentiment is apparent in Bill Gates’ recent comment about WHO’s staff: ‘If you’re not very good, you’ll stay working there for a long time’.¹⁸

The so-called ‘Gates approach’ to global health concentrates primarily on targeted technical solutions that have clear, measurable outcomes in the short term.^{12 19} The most obvious example is its focus on developing and delivering vaccines for a few priority infectious diseases. In 2011, Bill Gates told the WHA: ‘As we think about how to deploy our resources most effectively, one intervention in particular stands out: vaccines… At Microsoft, we dreamed about powerful and simple technologies. Well, vaccines are such a technology’.²⁰ The following year, WHA adopted a ‘Global Vaccine Plan’ co-authored by BMGF. The foundation’s focus on vaccines is part of a broader paradigm characterised by Anne-Emanuelle Birn as a ‘narrowly conceived understanding of health as the product of technical interventions divorced from economic, social and political contexts’.¹⁹

BMGF funding to WHO is important, therefore, not only due to the large amounts of money involved but also because of concerns about the foundation’s legitimacy as a global health actor and because BMGF’s approach to global health appears to clash with that of WHO. Despite this, very little empirical research has been undertaken on the topic. Our study aims to contribute to the literature on the relationship between WHO and BMGF by constructing a dataset of BMGF grants to WHO for the period 2000–2024 and analysing what diseases or health issues and activities were funded.

Methods

Research design

WHO’s financial documents state the total amount of money that BMGF and other contributors give to the organisation each year, but these data do not specify what the money is spent on. This paper uses data collected from BMGF’s official website, which details over 36,000 individual grants across its programmes.²¹ For each grant, BMGF provides information including the date, amount and duration of award, the identity and location of the grantee, and a brief description of the grant’s purpose. We constructed our unique dataset by first identifying all grants awarded to WHO, and then classifying each grant according to ‘type of activity’ and ‘disease or health issue’. These categories are adapted from those used by David McCoy and collaborators in their widely cited article on BMGF’s grant-making programme for global health.²² For a breakdown of the categories, see table 2A in the web appendix. Our coding was checked by both authors to ensure consistency and accuracy.

Table 2. Top 10 BMGF grants awarded to WHO by value, 2000–2024.

Year awarded	Grant recipient	Grant value (million US$)	Grant term (months)	Purpose of grant
2008	WHO Headquarters	676.3	100	‘Intensification of the Global Polio Eradication Initiative’
2014	WHO Headquarters	307.0	82	‘2014–2019 support to the Global Polio Eradication Initiative’
2013	WHO Headquarters	224.3	72	‘2013 Global Polio Eradication Initiative’
2018	WHO Headquarters	121.4	53	‘mOPV2 Stockpile Maintenance’
2017	Nigeria Country Office	114.8	55	‘WHO Nigeria programme support’ (polio)
2022	WHO Headquarters	105.0	12	‘WHO polio outbreak campaigns support and surge capacity’
2012	Nigeria Country Office	89.2	72	‘Enhancing Technical Assistance to Support Nigeria’s Polio Eradication Plan’
2023	WHO Headquarters	87.0	16	‘to support the Polio Eradication Initiative (GPEI) for in-country Human Resource (HR) outbreak surge support and polio campaign implementation.’
2014	Pakistan Country Office	86.9	61	‘WHO Pakistan Surge’ (polio)
2018	Pakistan Country Office	70.9	40	‘2019 WHO Pakistan Surge’
Total value of top 10 grants		1882.8

Source: BMGF website (https://www.gatesfoundation.org/about/committed-grants)

As McCoy et al, note, the classification process is not straightforward for three main reasons.²¹ First, some grants could be placed in more than one category. In such situations, we assign the grant to more than one category and assume that funding is evenly divided between the categories. Second, we were unable to generate a set of discrete classifications. For example, there is unavoidable overlap between maternal health, neonatal, and child health and malnutrition, or funding for vaccine programmes and surveillance, monitoring, and health information management. Similar to above, in such situations we assign the grant to several categories and split the money evenly between each. Third, the description of many grants in BMGF’s online database is brief and sometimes vague. Often, it was necessary to undertake further research, or to make an educated guess based on the grant description or knowledge of the recipient.

Patient and public involvement

As this study analyses data that were extracted from BMGF’s website to investigate the relationship between BMGF and WHO, it was not appropriate to involve patients or the public in the design, conduct, reporting, or dissemination plans of our research.

Findings

BMGF distributes money across six programmes: Global Health; Gender Equality; Global Development; Global Growth and Opportunity; Global Policy and Advocacy; and the U.S. Programme. All but the U.S. Programme provide grants to WHO. BMGF made 640 grants worth $5.5 billion to WHO between 2000 and 2024 – see table 1. This is a lot of money for BMGF: it accounts for 6.4% of the value of all the foundation’s 36,400 grants disbursed in the period.

All the 640 grants are earmarked for specific purposes. The size of individual grants varied substantially. The smallest awarded was $1000 in 2023 ‘to contribute to global child health and to the goals of the Global Polio Eradication Initiative, including the interruption of poliovirus transmission globally’; and the largest was $676 million in July 2008 to fund polio eradication efforts. The amount of funding awarded fluctuated over the period, with the lowest year for funding being $6.4 million in 2001 and the highest $760.5 million in 2008. 508 out of 640 grants, adding up to $4.3 billion or 78.5% of the total value, were given to WHO headquarters in Geneva. The rest went to WHO’s various regional ($277.3 million or 5.1%) and country offices ($852.4 million or 15.6%), as well as the International Agency for Research on Cancer ($47.3 million or 0.9%) – which is part of WHO and based in Lyon, France.

The 10 largest grants awarded by BMGF to WHO are shown in table 2. Together they account for 34.5% ($1.9 billion out of $5.5 billion) of the value of all 640 grants awarded by BMGF to WHO. All grants relate to efforts to eradicate polio through mass immunisation. Six of the top 10 grants went to WHO headquarters, and two each to WHO’s Nigeria and Pakistan country offices.

Table 3 sets out the allocation of BMGF grant funding to WHO by disease or health issue – also see figure 1. Grants relating to polio add up to $3.2 billion (58.9%) of the value of all grants to WHO. The amount of money disbursed in polio-related grants fluctuated over the period – see figure 2. From 2000 to 2004, and in 2007 and 2009, no money at all went to polio; whereas it accounted for 88.9% of all BMGF grants to WHO in 2008, 82.0% in 2014, and 74.9% in 2018, 73.6% in 2021, and 79.8% in 2022. The figures for 2023 and 2024 were 56.6% and 69.0%, respectively. Polio grants are quantitatively different from other grants: the mean value of the 108 grants that mention polio is $30.4 million, whereas the mean value of the 532 grants that do not mention polio is $4.1 million.

Table 3. Allocation of BMGF grants to WHO by disease or health issue, 2000–2024.

Disease or health issue	$ million	%
Polio*	3220.9	58.9
Maternal, neonatal, and child health	449.3	8.2
Mosquito-borne diseases*	296.9	5.4
Respiratory diseases*	269.0	4.9
General health†	251.5	4.6
Sexually transmitted diseases*	240.2	4.4
Vaccine-preventable diseases (unspecified)*	210.7	3.9
Neglected tropical diseases*	117.5	2.2
Malnutrition	70.7	1.3
Gastrointestinal disease*	60.2	1.1
Infectious diseases (other or unspecified)*	53.6	1.0
Tobacco	51.8	0.9
WHO operational expenditure	49.4	0.9
Health systems strengthening	37.4	0.7
Family planning	30.6	0.6
Anti-microbial resistance*	26.1	0.5
Ebola*	16.2	0.3
Water and sanitation	11.8	0.2
Total	5463.9	100.0
Total infectious diseases*	4511.3	82.6

Source: BMGF website (https://www.gatesfoundation.org/about/committed-grants)

^* refers to infectious diseases.

^† ’General health’ is a broad classification that covers grants that do not fit into other categories. See text for examples.

Figure 1. Allocation of BMGF grants to WHO by disease or health issue, 2000-2024 Source: https://www.gatesfoundation.org/about/committed-grants Notes: * refers to infectious diseases. ’General health’ is a broad classification that covers grants that do not fit into other categories. See text for examples. The total of all grants is $5.5 billion.

Figure 2. Value of all BMGF grants and BMGF polio-related grants to WHO, 2000-2024 Source: https://www.gatesfoundation.org/about/committed-grants.

In total, infectious diseases account for $4.5 billion, 82.6% of BMGF funding to WHO. In addition to polio this figure includes: $296.9 million (5.4%) to mosquito-borne diseases (mostly malaria); $210.7 million (3.9%) to vaccine-preventable diseases (general or unspecified); $240.2 million (4.4%) to sexually transmitted diseases (mostly HIV-AIDS); $269.0 million (4.9%) to respiratory diseases (mostly tuberculosis); and $117.5 million (2.2%) to neglected tropical diseases.

In contrast, only a small amount of grant money went to non-communicable diseases. $51.8 million (0.9%) was spent on issues related to tobacco smoking. $70.7 million (1.3%) went to nutrition but these grants focused on food safety and child malnutrition. The only grants mentioning cancer relate to cervical cancer and concentrate on the link with HPV and the development of vaccines ($58.8 million, 1.1%). These are included in the sexually transmitted diseases category. Mental health is not mentioned at all.

Other categories accounting for 2.0% or more of BMGF funding to WHO were: $449.3 million (8.2%) to maternal, neonatal, and child health; and $251.5 million (4.6%) to general health, a broad category that covers grants that do not fit into other categories and includes everything from support for an Institute for Health Metrics and Evaluation (IHME) conference to a journalism fellowship scheme.

$49.4 million (0.9%) went to WHO’s general operational expenditure. Some of the grants in this category directly target WHO’s Director Generals: $5 million for ‘JW Lee support’ in June 2003, the month after Lee Jong-Wook was elected; $4.5 million in November 2006 – the month that Margaret Chan was appointed – for ‘Transition Support for WHO Director-General Elect’; another $5.0 million in 2009 ‘To support strengthening of WHO Director General priorities’; and $3.0 million in September 2017 – the month after Dr Tedros was elected – to ‘support and catalyse projects or immediate needs that will significantly contribute to advancing WHO Director-General’s agenda’. (However, this entry has been changed to ‘WHO Strategic Grant 2017–2019’ in more recent versions of BMGF’s grants dataset). Other grants in the general operational support category focused on WHO reforms. Descriptions include phrases such as ‘reform grant, ‘transformation agenda’, ‘improving business systems‘, and ‘change management process’. As noted above, qualitative research demonstrates that BMGF exerts influence over WHO by paying for management consultants to advise on WHO’s reform processes.¹⁰ These two examples indicate that although the amount of money BMGF spent on general operational support is relatively small, it is likely to have had a disproportionately large impact on WHO.

It is also interesting to look at what BMGF grants to WHO did not fund. The broader determinants of health are more or less ignored. Just $11.8 million (0.2%) went to water and sanitation. A relatively small amount of money, $37.4 million (0.7%) went to health systems strengthening. However, $17.9 million (47.9%) of this funding was awarded since 2019 when WHO’s latest Programme of Work began and $30.0 million (80.2%) since 2015 when the Sustainable Development Goals were launched. This suggests that BMGF may be responding to the emphasis on universal health coverage in these two documents. WHO’s most recent Programme of Work mentions the ‘complex mix of interconnected threats to their health and well-being − from poverty and inequality to conflict and climate change’. The terms ‘poverty’ or ‘poor’ were mentioned once each, the two grants totalling $1.4 million (0.03%). Another, three grants adding up to $17.4 million (0.3%) refer to ‘TDR’, the Special Programme for Research and Training in Tropical Diseases, which is ‘a global programme of scientific collaboration that helps facilitate, support and influence efforts to combat diseases of poverty’.²³ Equality is mentioned in two grants in the context of ’advancing gender equality’: one from 2023 worth $2.0 million (0.04%) and another from 2024 worth $2.5 million (0.05%). ’Equity’ comes up three times in grants adding up to $17.0 million (0.3%). Neither ’inequality’ nor ’inequity’ feature at all. ’Conflict’ is mentioned twice ($1.3 million, 0.02%), while violence is mentioned once ($2.5 million, 0.05%) – in the context of gender-based violence. No grants refer to ‘war’, ‘peace’ or ‘humanitarian’. Only one grant focused on issues broadly associated with climate change – a $1.0 million (0.02%) grant in 2011 ‘Emergency Health Assistance to People Affected by the Drought in the Horn of Africa’.

Table 4 shows the type of WHO activities funded by BMGF – also see figure 3. $2.9 billion (53.3% of all BMGF global health grants) was spent on vaccine-related programme and project support. The vast majority of this money – $2.8 billion (95.6%) – was for programmes and projects related to polio eradication efforts. Grants for vaccine-related programmes and projects are quantitatively different from grants for other types of activities: the mean value of the 108 grants for vaccine-related programmes is $32.8 million, whereas the mean value of the other 532 grants is $4.1 million.

Table 4. Allocation of BMGF grants to WHO by type of activity, 2000–2024.

	All grants		Infectious diseases grants
	$ million	% of all BMGF grants to WHO	$ million	% of ‘All grants’ column
Programme and project support: Vaccine	2912.7	53.3	2899.5	99.5
Programme and project support: Non-vaccine	343.7	6.3	236.4	68.8
Agenda setting activities and creation of technical guidelines	344.6	6.3	189.5	55.0
Surveillance, monitoring, and health information management	306.1	5.6	245.1	80.1
Stakeholder coordination and partnership development	153.6	2.8	62.0	40.4
Applied health research	253.5	4.6	84.0	33.1
Research and development: Diagnostic equipment	14.7	0.3	10.4	70.6
Research and development: Medicines	103.5	1.9	21.0	20.2
Research and development: Vaccines	79.9	1.5	75.8	94.8
Research and development: Other	4.2	0.1	0.0	0.0
Enabling the supply and purchase of: Diagnostic equipment	81.4	1.5	78.4	96.3
Enabling the supply and purchase of: Medicines	88.0	1.6	81.0	92.0
Enabling the supply and purchase of: Vaccines	301.3	5.5	296.7	98.5
Enabling the supply and purchase of: Other	1.2	0.0	0.2	20.7
Regulation and qualification of: Diagnostic equipment	54.8	1.0	39.5	72.0
Regulation and qualification of: Medicines	89.7	1.6	36.5	40.7
Regulation and qualification of: Vaccines	71.2	1.3	56.1	78.8
Regulation and qualification of: Other	11.0	0.2	0.4	3.5
General organisational support	77.1	1.4	7.0	9.1
Political lobbying and advocacy	79.1	1.4	34.2	43.2
Training, education and capacity building	57.2	1.0	37.2	65.0
Communication with public	19.8	0.4	13.3	67.1
Convening scientists (meetings, conferences, working groups)	15.5	0.3	7.2	46.3
Total	5463.9	100.0	4511.3	82.6

Source: BMGF website (Source: https://www.gatesfoundation.org/about/committed-grants)

BMGF, Bill and Melinda Gates Foundation.

Figure 3. Allocation of BMGF funding to WHO by type of activity, 2000-2024 Source: BMGF website (https://www.gatesfoundation.org/about/committed-grantshttps://www.gatesfoundation.org/about/committed-grants) Notes: The total of all grants is $5.5 billion.

Many BMGF grants to WHO that did not directly fund vaccine-related projects and programmes worked to support these activities. For example, vaccine purchase and supply amounted to $301.3 million (5.5% of all BMGF grants to WHO by value), vaccine research and development $79.9 million (1.5%), and vaccine regulation and qualification $71.2 million (1.3%). In total, grants that involve vaccines in some way add up to $3.5 billion, 64.1% of all BMGF’s grants to WHO.

Many BMGF-funded WHO activities that did not directly support vaccine-related projects and programmes still concentrated on technical interventions to tackle infectious diseases. $343.7 million (6.3% of all BMGF grants to WHO) went to non-vaccine programme and project support, $236.4 million (68.8%) of which focused on infectious diseases. $344.6 million (6.3%) went to agenda-setting activities and creation of technical guidelines, $189.5 million (55.0%) of which concentrated on infectious diseases. Of the $306.1 million (5.6%) spent on surveillance, monitoring, and health information management, $245.1 million (80.1%) focused on infectious diseases. $153.6 million (2.8%) was allocated to stakeholder coordination and partnership development, $62.0 million (40.4%) of which was spent on activities related to infectious diseases. $253.5 million (4.6%) went to applied health research, $84.0 million (33.1%) of which went to infectious diseases.

Discussion

Too much focus on polio?

BMGF gave $5.5 billion to WHO between 2000 and 2024. This is a significant sum for BMGF, amounting to 6.4% of all the money disbursed by the foundation in the period. It might seem surprising that BMGF donated so much money to WHO, given the apparent clash between the two organisations’ approaches to global health and the disparaging comments that Bill Gates made about WHO’s staff. However, as all BMGF’s grants to WHO are earmarked, the foundation can work through the organisation – benefiting from its status as the UN specialised agency for health – but retain tight control over how the money is spent. In other words, the money that BMGF gives furthers its own agenda, rather than that of WHO.

$3.2 billion – almost 60% of the money BMGF gave to WHO – was spent on polio eradication projects and programmes. This figure could be misleading if BMGF financed programmes and projects targeting infectious diseases other than polio through organisations other than WHO. The data does not support this assertion. WHO was not the only organisation through which BMGF funded programmes and projects focused on specific infectious diseases. In the period 2000 to 2024, for example, BMGF made 16 grants worth $6.1 billion to GAVI and 39 grants worth $3.9 billion to the Global Fund. However, BMGF also disbursed significant funds for programmes and projects that target polio through organisations other than WHO. Of BMGF’s top 10 grants focusing on polio, only three worth $1.2 billion went to WHO. The remaining seven grants, totalling $3.1 billion, were to Rotary International (two), UNICEF (one), European Investment Bank (one), GAVI (one), PATH (one), and the World Bank’s International Development Association (one).²¹

As Sophie Harman points out, there is a clear link between BMGF’s interest in polio and WHO choosing to prioritise its eradication as a ‘programmatic emergency for global public health’.⁸ This is apparent when one looks at the numbers more closely. In 2022 and 2023 – the latest years for which comparable data is available – BMGF committed $529.6 million to WHO’s polio eradication efforts. This figure is 56.5% of the $937.6 million that WHO’s spent on polio projects and programmes in these two years.²⁴ In other words, if it wasn’t for BMGF, then WHO’s contribution to polio eradication would be unrecognisable.

Polio is a curious disease for BMGF to concentrate on as it is no longer a major global health concern. In the mid-1980s, polio paralysed an estimated 350 000 people each year across 125 endemic countries, according to WHO estimates.²⁵ Over the last 40 years, however, the incidence decreased markedly as a result of mass immunisation. By 2000 – the year that BMGF was formed – the number of cases in the world was 719.²⁶ In other words, the major fall in polio occurred before BMGF’s involvement. The decline in polio cases has continued since then, but BMGF still provides WHO with vast amounts of money to tackle the virus. There were just 12 cases in 2023, all of which occurred in Afghanistan and Pakistan; and yet BMGF gave over a quarter of a billion dollars to fund WHO’s polio eradication efforts that year. There were 98 cases in these two countries in 2024, with BMGF donating $225.8 million.

It would be a remarkable achievement to eradicate polio, but it will have an imperceptible impact on the global burden of disease. Several other infectious diseases have a much larger effect on health. According to the figures from the Global Burden of Disease Study, malaria kills about 0.6 million people every year, HIV-AIDS 0.9 million and diarrheal disease 1.5 million²⁷; but each of these receives just a fraction of the funding that BMGF lavishes on WHO’s polio eradication programme. The large amounts of money that BMGF spends on polio through WHO might actually harm broader efforts to improve public health. For example, in conflict-affected areas of Pakistan, the realisation that the resources that global health actors devote to polio eradication are not commensurate with its health impact piqued militant suspicion that immunisation drives were in fact a smokescreen for espionage activities, creating mistrust and animosity towards healthcare workers.²⁸

More generally, BMGF’s funding to WHO concentrates on supporting, both directly and indirectly, programmes and projects that use vaccines to tackle infectious diseases. This reflects BMGF’s ‘narrowly conceived understanding of health as the product of technical interventions divorced from economic, social and political contexts’.¹⁹ It is understandable that a billionaire who made his fortune in information technology places his trust in the power of technology to solve major global health problems. However, the historical record shows that developing and administering vaccines and other medicines is not necessarily the most effective way to improve health outcomes – at least on its own. Rather, a combination of broad-based economic growth and pro-poor social policies played a very important role in reducing the burden of infectious diseases in most countries that have passed through the epidemiological transition.²⁹ Our results show that BMGF funding to WHO ignores these areas.

Not enough focus on non-communicable diseases

BMGF’s narrow approach to global health inevitably means that issues that are perceived as important in WHO’s broader conceptualisation of global health are overlooked in BMGF’s grants to WHO. One example of this phenomenon is health systems strengthening, which is the main policy instrument to achieve universal health coverage – one of the priorities set out in WHO’s most recent Programme of Work. BMGF grants aimed at strengthening health systems account for a relatively small amount of funding given to WHO ($37.4 million / 0.7%). The lack of funding going to WHO to strengthen health systems must be seen in the context of concerns among BMGF’s critics that its strategy of funding large numbers of non-governmental organisations (NGOs) and public-private partnerships to undertake disease-focused programmes and projects contributes to the fragmentation and disorganisation of health systems, and weakens ministries of health in countries that receive lots of funds from the foundation.¹² However, in this instance, BMGF’s lack of interest in health systems strengthening does not appear to have created an underfunded ‘pocket of poverty’ within WHO. The 2024-25 biennium budget allocated $2.0 billion out of $6.8 billion to ‘Universal Health Coverage’, indicating other donors have contributed to this issue.³⁰

The situation regarding non-communicable diseases looks more troubling. Less than 1% of BMGF’s funding to WHO is spent on non-communicable diseases, even though they are arguably the biggest problem in global health. Non-communicable diseases account for 74% of global deaths (just over 42 million a year according to the latest Global Burden of Disease study) and they are not just a rich world problem: 77% of these deaths occur in low- and middle-income countries.³¹ No BMGF grants to WHO focus on the consumption of ultra-processed, sugary and salty foods and drinks that drive obesity-related morbidity and mortality, or alcohol, which is a major cause of avoidable morbidity and mortality. While BMGF’s relative neglect of non-communicable diseases reflects a more general blind spot in global health,³² the foundation’s endowment points to a potential conflict of interest. BMGF holds or has held significant investments in companies that sell health-damaging goods, including Coca-Cola, McDonald’s, Kraft Heinz and Anheuser-Busch InBev – although some of these stocks are held via BMGF’s holdings in Berkshire Hathaway, Buffett’s conglomerate.^{33 34}

The WHO Foundation, which was established during the COVID-19 pandemic to maximise donations from the private sector, faced criticism for potential conflicts of interest related to non-communicable diseases in 2021 when it received $2.2 m from Nestlé to support its response to the COVID-19 pandemic.³⁵ Notwithstanding, non-communicable diseases are a strategic priority for WHO. To operationalise the goal of ensuring one billion more people enjoy better health and well-being set out in the 13th General Programme of Work, WHO emphasises the importance of addressing, inter alia, ‘nutrition… tobacco use, trans-fatty acids, harmful use of alcohol, obesity and physical activity’.³⁶ The exact amount of money spent on non-communicable diseases is not possible to ascertain from the most recent WHO budget documents. Stuckler et al’s decade-and-a-half-old estimate of 8% – vs 56% for infectious diseases, with the rest going to general expenditure – still seems reasonable.³⁷ The main lines in WHO’s 2022–23 budget that refer to non-communicable diseases are: ‘3.1 Safe and equitable societies through addressing health determinants’ ($96.4 million); ‘3.2 Supportive and empowering societies through addressing health risk factors’ ($165.4 million); and ‘3.3 Healthy environments to promote health and sustainable societies’ ($163.0 million). Together, these account for 6.9% of WHO’s total expenditure.³⁶ BMGF and other major donors’ lack of interest in non-communicable diseases appears to have created an underfunded ‘pocket of poverty’ within WHO.

Conclusion

What should WHO do?

WHO is an exceptional organisation in global health. As the UN’s specialised agency for health, WHO has a unique legitimacy. Its constitutional commitment to a broad, rights-based conceptualisation of health provides a valuable alternative to less political approaches. For several decades, WHO’s independence has been diminished by a perpetual funding crisis. Assessed contributions from member states are nowhere near the level needed to fund its strategic priorities, so WHO must rely on earmarked voluntary contributions from donors. Consequently, activities and areas that donors favour receive more resources than are required while those they are not interested in do not get enough.

As WHO’s second biggest funder, BMGF contributes to the suboptimal distribution of resources in WHO’s budget. The foundation’s emphasis on using vaccines to tackle infectious diseases means that it overlooks some major global health challenges that are of strategic importance to WHO. When other funders are willing to fund these – as with health systems strengthening – this is not a problem. But when neither BMGF nor other major voluntary donors give much money to an issue, it creates a ‘pocket of poverty’ in WHO’s budget. This is the case with non-communicable diseases.

It is easy to blame major donors like BMGF for undermining WHO’s independence and pursuing its agenda through WHO. Recent calls to decolonise global health have highlighted the character of private foundations like BMGF and their outsized impact on the sector in general, as well as the way that they influence WHO.¹⁴ We should not, however, lose sight of the fact that it is the member states’ failure to increase assessed contributions in line with WHO’s needs over the last four decades that has created a situation in which the organisation is forced to rely on voluntary contributions from donors like BMGF. WHO has asked for more flexible and sustainable funding, warning that without fundamental changes to the way it is financed, it will be unable to achieve its strategic aims. If the member states continue to ignore these exhortations, then WHO will remain vulnerable to the influence of external donors and will struggle to address the full spectrum of contemporary global health challenges.

Data availability statement

Data are available upon reasonable request.