Global health funding has quadrupled in less than two decades to almost $22 billion, boosted by U.S. public funding, corporate donations and giving from private foundations such as the Bill & Melinda Gates Foundation.

But imbalances remain in directing the money to best combat a range of diseases around the world, according to researchers from the Institute for Health Metrics and Evaluation at the University of Washington.

Well-heeled donors like Gates, corporations and ordinary people donating to their favorite charities are changing the landscape of global health funding, the UW researchers and colleagues from Harvard University reported in a study published today in the medical journal The Lancet. The study represents the first comprehensive picture of funding for global health projects, the authors said.

Besides pouring in more money, the Gates Foundation has changed the balance of power in global health, said Christopher Murray, director of the UW institute and one of the authors. The institute was founded with a $105 million donation from the Gates Foundation to do the type of rigorous analyses of health spending and programs that no one else was doing.

ERIKA SCHULTZ/SEATTLE TIMES

Christopher Murray, director of the Institute for Health Metrics and Evaluation at UW, in his office.

"I think their influence on the field and as a catalyst for other groups to engage has been very strong," Murray said. "The net effect is to bring more groups, more focus on global health and more viewpoints at the table."

The study tracked assistance to low and middle-income countries from 1990 to 2007. The money isn't always getting where it's needed most. "Twelve of the 30 countries with the highest disease burden aren't receiving as much aid as healthier, and, in some cases, wealthier countries," the study found.

For example, Nicaragua and Turkmenistan have roughly the same burden of disease, but Nicaragua receives 33 times as much health funding as the former Soviet republic. Ethiopia, which ranks second in health assistance funding after India, ranks 9th in terms of the level of disease and disability.

The Gates Foundation provides the largest source of private funding, increasing its global health commitments substantially since 2004, to nearly $2 billion in both 2006 and 2007. Private sources of global health funding grew from 19 percent of the total in 1998 to nearly 27 percent in 2007, corresponding to the Gates Foundation's emergence in the field.

Newer Gates-supported organizations such as the Global Fund to Fight AIDS, Tuberculosis and Malaria and the Global Alliance for Vaccines and Immunization (GAVI) now have a central role in mobilizing and channeling global health funds, while funding through institutions such as United Nations and development banks declined, according to the study.

Though international organizations like the World Health Organization and UNICEF have long been criticized for rigid bureaucracies that stifled innovation, their declining role may harm efforts to improve health around the world, the researchers say.

When those organizations are forced to compete for funding, they lose their status as "trusted neutral brokers between the scientific and technical communities on the one hand, and governments of developing countries on the other hand."

Of U.S.-based non-governmental organizations, the Federal Way-based Christian relief group World Vision was the fourth leading provider of overseas health funds, spending $826 million from 2002 to 2006. PATH, the Seattle based non-profit focused on health technology and solutions for the developing world, also made the list as the 15th largest global health funder with $389 million in expenditures.

In recent years, by far the biggest share of money has gone to AIDS/HIV programs. In 2007, $5.1 billion of assistance funding was devoted to AID/HIV. Slightly less than $1 billion was spent on bolstering health systems in developing nations. Malaria programs received $800 million, while efforts to combat tuberculosis received $700 million in 2007.

Murray said it was challenging putting the numbers together because of the difficulty tracing U.S. government funds.

"It's easy to get the budgeted amounts but to get the amount actually spent, the U.S. is not very good about reporting that," he said. "The U.S. needs to be more forthcoming on the details of where their funds go, and relating expenditures to what's achieved."

Data from U.S. based non-profits was easier to find because they are required to report it on their tax returns, he said.

A Lancet commentary on the analysis faulted it for failing to include money spent on water and sanitation programs. "The provision of clean water and sanitation would probably do as much to facilitate good health as dose the assistance provided to direct medical care," wrote Peter S. Heller of Johns Hopkins University.