Eleven months ago, in response to demands by recipient governments, GAVI created a $500-million fund to expand its approach by improving general health delivery and training, as well as immunization services.
The program is designed for "broader, integrated child survival," Lob-Levyt said. "We're learning as we go."
But he defended GAVI's vaccine emphasis, saying that research had shown that preventing one disease improved overall survival.
Vaccinations, widely seen as cost-effective, numbered more than 15 million in five years against measles, diphtheria, tetanus and pertussis, and 99 million against hepatitis B, yellow fever and hemophilus influenza B, which causes meningitis.
Bill Gates told CNBC earlier this year that GAVI vaccinations had "saved several million lives."
But experts in global vaccination programs said such claims were hard to validate because so many children in developing nations die of conditions for which no vaccine exists.
According to GAVI's website, most of the vaccinations were for prevention of hepatitis B, which can cause cancer and liver failure.
The vaccine was widely used, Lob-Levyt said, because it could be offered rapidly at reasonable cost. Hepatitis B, however, rarely kills children, and many African children die of other ailments long before the vaccine could have saved them.
"You can't say any life was saved until they are older," said William Muraskin, a professor of urban studies at the City University of New York and author of a book about GAVI.
Citing a recent study in the Lancet, Yamada agreed that rates of child mortality in much of Africa had been flat to worse due to such problems as diarrhea, malaria and pneumonia.
"We can't rest on our laurels," he said. "The low-hanging fruit didn't necessarily have the outcome that we would have hoped."
The foundation is supporting research on vaccines against pneumonia and diarrheal illnesses. If these become available, he said, "you'll start to see an impact on child mortality that may be the next phase of GAVI's success story."
The failure to support basic care as comprehensively as vaccines and research is a blind spot for the Gates Foundation, said Paul Farmer, recipient of a John D. and Catherine T. MacArthur Foundation fellowship, and founder of Partners in Health, which has received Gates Foundation funds for research and training.
"It doesn't surprise me that as someone who has made his fortune on developing a novel technology, Bill Gates would look for magic bullets" in vaccines and medicines, Farmer said. "But if we don't have a solid delivery system, this work will be thwarted.
"That's something that's going to be hard for the big foundations," he said. "They treat tuberculosis. They don't treat poverty."
Still, Farmer, who knows the Gateses, said they had a deep personal commitment to understanding and addressing the needs of developing countries. He said he expected the Gates Foundation to increase its support for health delivery systems.
Yamada called delivery of care "a key strategic issue for us." The foundation will not provide care, he said, but has begun to study regulation, financing and how markets can improve delivery.
"What we do is we catalyze" -- develop tools to help governments improve, he said. "We are not replacement mothers."
Piller reported from Lesotho, Rwanda, Switzerland and Seattle; Smith reported from Los Angeles. Times staff writer Edmund Sanders, staff photographer Francine Orr, data analyst Sandra Poindexter and researcher Maloy Moore contributed to this report.
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Total since inception:
Selected grants and pledges:
Global Fund to Fight AIDS,
TB and Malaria:
Partners in Health:
*As of September 2007. Assets held by the Bill & Melinda Gates Foundation Trust; includes approximately $27.6 billion pledged by Warren E. Buffett but not yet received.
Source: Bill & Melinda Gates Foundation.
About this report
This story, the latest installment in an 18-month investigation of the Bill & Melinda Gates Foundation, is based in part on a review of hundreds of foundation grant descriptions, policies, evaluation reports and tax returns.
Reporting included more than 130 interviews with patients, medical professionals and administrators in Lesotho, Rwanda and other African nations and with global health experts in Europe, Africa and the United States.
More than 240 scholarly articles, books and studies on health conditions in Africa were reviewed, along with thousands of pages of financial and performance data, reports and evaluations from the Global Fund to Fight AIDS, Tuberculosis and Malaria, the GAVI Alliance and other financing groups and aid organizations.
Statistical data on health conditions in Africa were obtained from the World Health Organization, the World Bank and UNICEF, as well as national ministries of health and nongovernmental organizations.
Previous articles about the Gates Foundation are available at latimes.com/gates.