"Health delivery systems in Africa are now weaker and more fragmented than they were 10 years ago," said a 2006 report commissioned by the Global Fund and the World Bank. The weakening has been "exacerbated as the Global Fund and other programs now promote universal access to [AIDS] treatment."

To turn this around, the report concluded, the Global Fund needs help from the World Bank to "provide the human support needed to balance the massive financial contribution."

Using the most authoritative available data, maternal and child mortality and life expectancy show no statistical relationship -- for better or worse -- to Global Fund grants or to overall Gates Foundation spending in Africa.

Key health measures in countries that received less money per capita have been just as likely to improve or decline as in countries that received more money, according to data from the World Health Organization, World Bank and UNICEF.

Mosilo Motene, the chief nurse at Queen II, expressed frustration with the Global Fund and other donors whose grants don't supply basic needs such as oxygen valves or 3-cent gloves to protect nurses from the AIDS virus. "Conditions are going from bad to worse," she said, "despite what is given."

Pregnancy-related deaths often have been the highest in nations where most aid has gone to treat AIDS, TB and malaria, said Dr. Francis Omaswa, special advisor for human resources at the WHO. "People find it easier to talk about AIDS, about malaria."

Donations "could be five times more beneficial," Omaswa said, if they better supported health systems.

"Who chose the human right of universal treatment of AIDS over other human rights?" asked economist William Easterly, co-director of the New York University Development Research Institute, in his book "The White Man's Burden." He added: "A nonutopian approach would make the tough choices to spend foreign aid resources in a way that reached the most people with their most urgent needs."

The Global Fund has given 1% of its funds to strengthening overall health systems directly and says that almost half of its AIDS money goes for training, monitoring and evaluation, and administration -- indirectly strengthening basic healthcare.

In Rwanda, the Global Fund money has added buildings, refrigerators and power to rural clinics, supported universal health insurance and subsidized cellphones for lay health workers. In addition, some HIV/AIDS nurses whose salaries are paid for by the fund provide care for other ailments as well.

But benefits take time to trickle down. "Everyone agrees to subscribe to fairy tales about how investments in this or that top-down mandate will lead to collateral benefits elsewhere," said Robert Steinglass, a 30-year global health veteran and now technical director of Immunizationbasics, a U.S.-funded project that operates in three African nations.

"But much of the rhetoric is bogus," he said.

Should the Global Fund underwrite essentials such as food, exam gloves and oxygen valves? "Yes, yes, yes," Kazatchkine, the director, said. "Should, could, will,"

Last month, the fund invited new proposals for health systems support.

But the support had to directly attack AIDS, TB or malaria. In general, Kazatchkine said, health systems and food must be each government's responsibility, with the fund playing "a catalytic role." The Global Fund "cannot resolve all the problems of all the people."

Yamada at the Gates Foundation called sustainable food supplies central to the foundation's strategy. It has a large research and development program to improve agriculture in Africa and has donated $70 million to the Global Alliance for Improved Nutrition, which uses market-based approaches to feed developing nations, including seven in sub-Saharan Africa. It also plans to boost research and development for early-childhood nutrition.

"We want to have something that has a lasting impact," he said, "for the countries to be able to support themselves."

Beyond vaccinations

Unintended consequences also are a problem in vaccination drives.

Mamoraturoa Polaki trekked for hours down rocky paths to the mountain village of Semongkong, near the center of Lesotho, to get her son Huku, 2, a measles shot.