In some cases, salary increases targeted to certain types of care "may have had a distorting effect," Kazatchkine acknowledged. But the AIDS crisis justifies such dislocations, he said. "We are a global fund for AIDS, TB and malaria. We are not a global fund that funds local health."
Botswana offers an example of how a special Gates initiative, narrowly applied to a specific disease, may have disrupted other healthcare.
In 2000, the Gates Foundation joined with the drug firm Merck & Co. and chose Botswana as a test case for a $100-million effort to prove that mass AIDS treatment and prevention could succeed in Africa.
Botswana is a well-governed, stable democracy with a small population and a relatively high living standard, but one of the highest HIV infection rates in the world.
By 2005, health expenditures per capita in Botswana, boosted by the Gates donations, were six times the average for Africa and 21 times the amount spent in Rwanda.
Deaths from AIDS fell sharply.
But AIDS prevention largely failed. HIV continued to spread at an alarming pace. A quarter of all adults were infected in 2003, and the rate was still that high in 2005, according to the U.N. Program on HIV/AIDS. In a 2005 survey, just one in 10 adults could say how to prevent sexual transmission of HIV, despite education programs.
Meanwhile, the rate of pregnancy-related maternal deaths nearly quadrupled and the child mortality rate rose dramatically. Despite improvements in AIDS treatment, life expectancy in Botswana rose just marginally, from 41.1 years in 2000 to 41.5 years in 2005.
Dean Jamison, a health economist who was editor of Disease Control Priorities in Developing Countries, a Gates Foundation-funded reference book, blamed the pressing needs of Botswana's AIDS patients. But he added that the Gates Foundation effort, with its tight focus on the epidemic, may have contributed to the broader health crisis by drawing the nation's top clinicians away from primary care and child health.
"They have an opportunity to double or triple their salaries by working on AIDS," Jamison said. "Maybe the health ministry replaces them, maybe not.
"But if so, it is usually with less competent people."
Yamada, the Gates Foundation official, said research was needed to determine whether "vertical" aid, such as the foundation's Botswana program, had contributed to brain drain and higher mortality.
To bolster basic healthcare in Africa, he proposed that universities in rich nations help found medical schools on the continent. And he challenged African nations to spend at least 15% of gross domestic product on health.
As of 2004, only 13 countries worldwide spent as much as 10%, and only one African country, Malawi, is among them.
Yamada said the foundation had asked Botswana to focus more on AIDS prevention -- including circumcision, which can reduce susceptibility to HIV.
"I don't know what to do there, frankly," to reduce unsafe sex, short of "changing the hearts and minds of the people," he said.
Issues of food and health
Malerotholi moleko says her problem is not AIDS. Thanks to the Global Fund, she gets medicine.