Over the past decade, aid groups such as the Bill and Melinda Gates Foundation have spent tens of billions of dollars battling deadly infectious diseases. Some public health experts want them to stop.

Such groups “are doing more damage than good; I want the world to hear it,” said Salman Rawaf, a professor at Imperial College London and an adviser to the World Health Organization.

“They’re very generous,” Rawaf said. “But they should move away from disease-specific funding into health-system strengthening.”

While Rawaf’s views are particularly strident, many officials say spending billions of dollars to fight ailments such as AIDS, malaria, and polio rather than supporting basic health services has left nations unprepared for epidemics like Ebola. Critics say that more resources should go to general health infrastructure such as training for doctors and nurses, ensuring supply of medicines, or developing a system to detect outbreaks.

“Ebola provides a very sharp focus on why health systems matter,” said Kara Hanson, a professor at the London School of Hygiene and Tropical Medicine.

The Gates Foundation and other aid groups say that while they indeed focus largely on specific diseases, some money goes to broader programs and ultimately any investment in health helps to shore up basic systems.

“It’s a false choice,” said Chris Elias, president of the Gates Foundation’s global development program. “What do you need to manage HIV treatment? Continuity of care. That’s what you need for diabetes as well. HIV can be the scaffolding upon which you build a broader health system.”

Salary Gap

A primary concern is the salary gap between NGOs and state clinics. In Guinea, where the Ebola epidemic started a year ago, a physician employed by the government earns $300 to $400 a month, said Mohamed Lamine Yansane, a policy adviser at the country’s Health Ministry. The same doctor could get as much as $2,000 working for a foreign-backed non-governmental organization, he said.

In the public system, “people are badly paid and equipment is lacking,” Yansane said. “NGOs offer a more attractive work environment.”

Since 2002, the Geneva-based Global Fund to Fight AIDS, Tuberculosis and Malaria has distributed more than $25 billion to slow the spread of AIDS, TB and Malaria and says it has saved more than 6.5 million lives. GAVI, the biggest funder of vaccines for poor nations, has supported vaccinations for a half billion children, saving about 6 million lives. And the Gates Foundation has disbursed $31.6 billion since its inception in 2000.

In Liberia, foreign assistance for health increased almost 20-fold in the decade after 2002, to $110 million in 2012, according to the WHO. That year, 43 percent of the aid went toward combating malaria, HIV and TB, versus 2 percent in 2002. Yet the country, whose fragile health system was further weakened by two civil wars between 1989 and 2003, had only eight hospital beds for every 10,000 people in 2012, versus 29 in the U.S. and U.K.

In one Liberian county, just half the population had access to general health services, and only a third had a health clinic within an hour’s walk, according to a Harvard University study published this year. An earlier Columbia University study, by contrast, found that everyone in the county could get malaria treatment.

Another Harvard study, of Global Fund grants, found little coordination between the group and officials from national health programs, leading to duplication, inefficiency, and excessive spending on educational seminars. The study found that some physicians would attend multiple training sessions to boost their income through daily allowances, which in turn cut the time they spent with patients.

Faking HIV

Alan Brooks, a GAVI director, said the group tries to support health priorities set by countries receiving aid, and that its efforts are run by local health-care workers who also deal with patients with a range of diseases.

The Global Fund says that while the bulk of its funding does focus on specific diseases, it hasn’t skimped on general health. About 10 percent of the $25 billion the group has disbursed since 2002 has gone toward strengthening health systems, said Christoph Benn, the fund’s external relations director. And spending on HIV, malaria and TB indirectly bolsters public health by freeing up capacity, he said.

Benn acknowledged that services for non-communicable ailments such as cancer and heart disease have gotten less attention. There’s anecdotal evidence that people with such maladies falsely claim to have HIV to get access to better treatment, he said.

David Evans, director of the WHO’s health systems department, confirms that. Foreign money has gone toward labs and clinics that diagnose and treat a single disease, rather than providing basic health services, he said.

“You get treatment if you’re a woman with malaria or if you’re a woman with HIV, but if you’ve got cervical cancer or cardiovascular disease, you’re not covered,” Evans said.

Focus on Results

The distorting effect of foreign aid on health systems has worsened as donors have grown more focused on outcomes, Evans said. The U.K. has since 2011 ranked aid recipients. The Global Fund and GAVI are both rated as having “very good” value while the WHO, which typically works on less tangible projects such as treatment guidelines and advising health ministries, is deemed “adequate.”

Politicians in wealthy countries are more interested in supporting groups that produce measurable results such as the number of lives saved by vaccinations than in less-quantifiable goals such as building health infrastructure, said Nils Daulaire, the Obama administration’s representative on the WHO board from 2010 until last February.

“You’d get more for your money if you supported a broad range of health system-strengthening activities,” Daulaire said by phone from Oslo, where he’s a visiting scholar at the Norwegian Institute for Public Health. “That’s a much more difficult message.”