(This post was co-written by Sandi Doughton)

Low-key grumbling from critics for some time has suggested that the Bill & Melinda Gates Foundation lacks sufficient transparency and accountability and places too much emphasis on high-tech solutions.

Now one of the world's premier medical journals is drawing some of the same conclusions after an analysis of the foundation's health spending over 10 years.

"The foundation's emphasis on technology... can detract attention" from the basic causes of health problems and can skew the health spending priorities of poor countries, the main author, David McCoy, writes in one of a series of articles coming out Friday in the medical journal The Lancet. McCoy is senior clinical associate at University College London.

As the largest private foundation in the world, the Gates Foundation itself defies precedent in its ability to influence global health. The foundation's spending on global health was nearly equal to the World Health Organization's annual budget in 2007.

Yet the Gates Foundation is not held accountable, nor is it open about the way it sets priorities and awards grants, according to the Lancet analysis.

"What are the foundation's future plans?" asks an editorial. "It's hard to know for sure."

The world's biggest philanthropy is upfront about being "driven by the interests and passions of the Gates family," but that's a "whimsical" way to exert such enormous power on the world stage, says an editorial accompanying the analysis.

"We think it's important that he (Bill Gates) hears some of the perspectives from others," said Robert E. Black, chairman of the department of international health at the Johns Hopkins Bloomberg School of Public Health, and the lead author of a commentary published along with the Lancet analysis. "He can choose to ignore it, if he wants, but honestly, I think he cares about doing things that really matter."

Black is in Seattle this week, attending a Gates-funded program on stillbirths and premature births, and said he hopes the Gates Foundation won't react defensively.

"I hope they take it in the constructive way in which it was meant," he said.

The analysis finds that more than half of the philanthropy's $9 billion in spending went to just 20 organizations. Among universities, about 60 percent of the foundation's research funding went to eight institutions in the U.S. and the U.K.

As a result those organizations and universities now have "privileged status" and are able to exert huge influence over global health policies worldwide, the articles say.

Gates Foundation spokeswoman Karen Lowry Miller said the foundation welcomed the article and its findings.

"We're totally open to this and will take all of this into consideration," she said. "Our strategy is constantly evolving."

Tadataka "Tachi" Yamada, president of the foundation's global health program, plans to meet with McCoy in the future, she said. The foundation is also preparing to publish more information on its Web site about its approach to grants, decision-making process and strategy, Miller said.

Over the past decade, more than a third of the funding went to research and development or basic sciences, "a technological bias that reflects the priorities of Bill Gates himself," McCoy writes.

Most childhood deaths result from a lack of access to basic needs such as food, housing, water and safe employment. Rather than looking for a clinical solution, "a better approach might be to view it as a public health problem that needs a social, economic or political intervention to ensure universal access to clean water and sanitation," McCoy writes.

"We think we have a strong global health strategy that really gets to the problems of the developing world," Miller responded. "We're not trying to be everything. We're trying to be where we can have the most value."

Black, of Johns Hopkins, has received Gates funding. And though he joked that he may not receive anymore, he said he's convinced that Bill and Melinda Gates are committed to improving health around the world.

"I know their motivations are good, and I hope their responsiveness is, too," Black said.

In his commentary, he said the foundation's emphasis on future solutions, like new vaccines and drugs, ignores the fact that treatments and health strategies that are known to work are not being implemented.

By promoting new vaccines, for example, the foundation puts pressure on developing nations to adopt those vaccines -- even though they may be expensive. As a result, countries may neglect things like basic treatment for pneumonia or promotion for breastfeeding.

The foundation could see a quicker payoff if it would instead focus on research on ways to improve delivery of health care, and the best ways to get people to take simple steps that boost health, like breast feeding their babies, he said.

"Two-thirds of global child deaths could be prevented if existing interventions were fully implemented," the commentary says.

The journal was not without praise.

"The Gates Foundation has added renewed dynamism, credibility and attractiveness to global health," the Lancet said in an editorial.

But McCoy's analysis concludes that grant making by the Gates Foundation seems to be largely managed through an informal system of personal networks and relationships rather than by a more transparent process based on independent and technical peer review.

The article singles out Seattle-based PATH, which was awarded nearly $1 billion, saying the amount "raises the question as to whether some organizations might be better characterized as agents of the foundation rather than as independent grantees."

It also brought up the question of accountability in grants to the International Finance Corp. and World Bank.

"The promotion of the private sector, including for-profit companies, raises a more fundamental question about the mandate and role of a foundation in promoting and shaping policies on core health systems issues... to whom is the Gates Foundation accountable for the promotion of such policies?"