Gates Foundation won’t take a stand on universal health coverage

A funny thing happened at the World Bank the other day.

The international financial institution devoted to fighting poverty and advancing economic growth in the poorest parts of the world held an event last week, Toward Universal Health Coverage by 2030.

That wasn’t the funny part. What was funny (or, well, funny-strange maybe) was watching the Bill & Melinda Gates Foundation work so hard to avoid taking a position on this goal of ensuring all people have access to affordable, basic health care.

World Bank President Jim Yong Kim  gestures while speaking at the forum Endpoverty 2030 during the IMF/World Bank Spring Meetings at IMF headquarters in Washington,  Thursday, April 10, 2014.

World Bank President Jim Yong Kim gestures while speaking at the forum Endpoverty 2030 during the IMF/World Bank Spring Meetings at IMF headquarters in Washington, Thursday, April 10, 2014.


As Humanosphere has noted, there’s a lot of enthusiasm around the world today for universal health coverage. Even many of the hard-pressed health and finance ministries of poor and middle-income countries are enthusiastic, largely because a number of analyses and expert studies have shown that getting everyone reliable access to basic health services contributes to long-term economic development, social stability and poverty reduction.

“There’s a consensus out there that universal health coverage is a critical development goal,” said Robert Marten, a global health policy expert for the Rockefeller Foundation.

One piece of evidence increasingly cited showing how powerful health is as an anti-poverty tool is a report in The Lancet dubbed Global Health 2035. It found, among many things, that between 2000 and 2011, nearly one-quarter of the significant economic growth experienced in poor and middle-income countries could be attributed to improved health, reductions in mortality and disease.

The Bill & Melinda Gates Foundation sponsored the Lancet study, which also made the case that universal health coverage is critical for reducing the financial barriers that prevent access to health care services and for making further progress in global health.

“We will not end poverty without universal health coverage,” said Margaret Chan, director-general of the World Health Organization, which co-sponsored the event at the World Bank on Friday.

“There is a growing body of evidence that the most equitable and sustainable way to achieve the health outcomes we all want is through universal health coverage,” said World Bank President Jim Yong Kim.

A peculiar moment for many at the event was the ambiguous stance taken by the Gates Foundation. Chris Elias, chief of the development program for Gates, refused to answer a direct question as to whether or not the philanthropy supports universal health coverage.

   Chris Elias

Chris Elias

Elias, who was on the first panel about ‘equitable access’ at the World Bank-WHO event, weighed in with opening remarks talking about the need for more innovation in delivering health services. He noted that the Gates Foundation initially emphasized, and continues to believe in, technological innovations like new drugs or vaccines. But Elias said the philanthropy has recognized, and been re-organized, to also push for accompanying innovations in financing, business models, behavior change and other non-technical means that can also improve health or help reduce poverty.

“As part of our reorganization, we’ve created an integrated delivery team to coordinate our activities across all disease programs,” Elias said. The goal is to look at all kinds of innovation – technological or policy changes – that can improve health outcomes, he said.

“So may I conclude that the rumor that Bill Gates is against universal coverage is not true?” asked the moderator, Suwit Wibulpolprasert, with the International Health Policy Program Foundation of Thailand.

Asked this (at minute 52 in this WB video) above, Elias ducks the question. He said the goal of universal health coverage is “important” but that “the question is about the specifics” and then went on to explain that the Gates Foundation invests in goals that have solid data and evidence of impact.

“As you know, we have an above-average appetite for data and analytics,” said Elias, adding that what they want to support is specific interventions that are easy to measure. Wibulpolprasert asked again for clarity on the foundation’s position, but didn’t get any. The implication of Elias’ answer, however, is that universal health coverage is neither specific or easy enough to measure to be something the Gates Foundation can support.

Humanosphere asked the same question of the Gates Foundation and was told the philanthropy ‘has no position’ on universal health coverage.

So where’s the rumor of opposition come from?

It may just come the fact that the world’s largest philanthropy and driver of much of the global health agenda fails to offer its support for universal health coverage as a top priority.

Or it may come from this paper Health in the Post-2015 Development Agenda written by the Gates Foundation’s policy and advocacy specialist Carol Welch outlining the philanthropy’s take on setting new goals after the 2015 expiration of the Millennium Development Goals. Here’s what they say about universal health coverage (UHC):

There is much to commend in UHC as an aspiration. Catastrophic health costs can entrench poverty or plunge people into poverty, and failure to access needed health services perpetuates poverty. However, UHC has limitations as a global development goal in a post 2015 framework. One is a lack of robust evidence of links between UHC (which is a means) and the desired impact of improved health outcomes. Several comprehensive studies find that universal coverage generally improves health access and offers financial protection benefits, but the evidence on health impact is mixed.

That position may seem a bit odd to participants at the World Bank event since The Lancet report the Gates Foundation sponsored was chock full of evidence that lack of access to affordable health coverage clearly undermines health outcomes and hurts poor people.

The renowned Harvard economist Larry Summers, the lead author of the Global Health 2035 report, was on the closing panel at the World Bank event.

Summers noted that the economic return on investment in health is something like 20-to-one in low-and middle-income countries (and about half that in richer countries). He and his co-authors said that universal health coverage, removing financial barriers to basic health care, is a critical component to achieving global health equity over the next few decades.

While we citizens of the world’s wealthiest country – with the most expensive and, arguably, most inequitable and inefficent of health non-systems – struggle to expand access to health insurance using a market-based conservative think-tank scheme re-branded as socialist Obamacare, many see the potential for the most real progress on this front in the middle-income or even poor countries.

The Gates Foundation, despite its claim to have no position, is seen by many as skeptical of making universal health coverage a top priority for the international community. Critics say it’s not always clear what anyone means by universal health coverage.

For that reason, it’s not universally accepted as a goal for the international community’s new development agenda. But the concept is no longer being pushed simply as a noble, humanitarian or ‘right-to-health’ cause. It’s become, to its advocates at least, a critical and evidence-based feature that must be incorporated into the overall battle to improve health and reduce poverty worldwide.

The question many in the aid and development field are asking after the World Bank event is if the Gates Foundation will step up and take a leadership position on this critical question, one way or the other. Or if they will just continue to dodge the question.


About Author

Tom Paulson

Tom Paulson is founder and lead journalist at Humanosphere. Prior to operating this online news site, he reported on science,  medicine, health policy, aid and development for the Seattle Post-Intelligencer. Contact him at tom[at] or follow him on Twitter @tompaulson.

  • philippeboucher

    My bet is they’ll continue to dodge. I wish I could be wrong but they are so ‘technical fixes’ oriented without any inclination to go anywhere near basic policy measures that would somehow criticize the US capitalist system… That explains the dodging dance… pathetic and rather harmful for they credibility but what do they care about that? They probably think the $ billions protects them from serious image consequences… The reality is their image/credibility is going to deteriorate despite the billions. It’s too bad Buffet decided to give all his money to Gates and it’s even too bad that Gates put all his money (or a big chunk) in only one organization, ‘too big to fail’, too big to admit its mistakes, too big.

  • Ardent proponent of health

    I agree with the Gates Foundation. UHC is a low priority in developing countries. Improving health status of the population is the highest priority. UHC is not — definitely Not — the best way to improve health of poor people.

    Watch panel four of the World Bank conference in April. You will see the high-level panel casting serious doubt on the very notion of UHC. Neither prof. Larry Summers nor Mayor Bloomberg spoke up for UHC. They said many times that public health measures (reducing smoking, eliminating indoor air polution) and investment in education of girls are the highest priority .

    Byinvesting in sanitation and water many more lives can be saved and disease burden lowered than by spending the same money on access tocare centers. The UHC campaign never mentions prevention, seemingly does not care about the daily carnage on roads. Or the huge setbacks from preventable infectious disease outbreaks (think Haiti cholera, avian flu in E Asia that already cost $3 billion in just 2 years). Preventing premature deaths and disease is demonstrably not the goal of UHC activists because if it were, they would advocate for tobacco taxes, environmental risk reduction like pollution of air, water, aflatoxin contaminated food and livestock, sugar, tobacco, indoor coal cooking. It is these things that generate the disease burden on the poor. Not absence of UHC.

    Besides, if policy makers choose not to prevent disease, no developing country will be able to afford UHC . It is far more kind to preventdisease than to have policies that lead to people being ill and then offering them “universal health care”. Prevention of disease has to be the utmost priority if poor people are to have better health in 2030. UHC favor patients today over investments (in sanitation, road safety etc) in the health of our children’s generation. That is not fair toward our children. It is also a fiscal recklessness.

    The health sector policy makers are responsible for unsafe roads, poluted water, microbes in food, spreading disease outbreaks, low tobacco taxes, sugared softdrinks everywhere in rural Africa, etc. They are responsible for policies that impact the health of the population. Unsafe water, dangerous roads, obesity, TB, malaria do not fall from the sky but their severity is caused by government policy (or lack of it, which is also a policy) that the Health Minister is responsible for. If they do not work for health (and instead only cry for UHC, the finance minister will be sceptical – listen to the Nigeria minister in the World Bank high level panel). They can barely be heard on public health, and they do even less, and instead wantmore money for equipment, HCW, vehicles for UHC, that is their own ministries and medical colleagues and friends. The cure pays off for them far better than prevention. For the poor, prevention is far better than the cure. Gates Foundation appears to agree. If health policy makers who push UHC cared about health, they would be focused on preventing disease.

    As Mayor Bloomberg said at the event, all it takes is leadership. UHC as a goal for poor countries is evidence of lack of leadership, with a hefty dose of populism.