Cost effectiveness is flavour of the week, whether in relation to the NHS, global health or politics. It makes sense to optimise use of limited resources, particularly public goods (e.g. taxpayers’ money). The Gates Foundation (GF) has changed the global health landscape both in terms of scale of funding and policy agenda. This week’s Lancet focused on the GF’s efficiency, based on an analysis of its funded projects [1-3]. It awarded 1094 global health grants over the last decade: a massive US$8·95 billion, of which $5·82 billion (65%) was shared by only 20 organisations. 40% of all funding was given to “supranational” organizations such as the World Health Organisation. Of the remaining amount, 82% went to recipients based in the USA. Just over a third ($3·27 billion) of funding was allocated to research and development (mainly for vaccines), or to basic science research [1].