Gates Foundation Chief Executive Officer Mark Suzman released his 2026 Annual Letter on Tuesday, warning that 2025 marked the first year this century where more children died than the previous year and outlining a 20 year roadmap to restore momentum amid severe funding constraints.
The letter, titled The Road to 2045, comes as foreign aid has fallen sharply by more than 25 percent and low income countries face mounting debt burdens constraining investment in their populations. The Gates Foundation announced plans to accelerate its work and sharpen focus at a moment when global need is expanding rapidly.
Suzman stated that an estimated 200,000 additional children died in 2025 compared to 2024, reversing decades of continuous progress in reducing preventable child deaths. The increase brought total child mortality to approximately 4.8 million deaths from 4.6 million the previous year, according to modeling conducted by the Institute for Health Metrics and Evaluation (IHME) at the University of Washington.
The foundation attributes the reversal primarily to dramatic cuts in development assistance and health funding from wealthy nations. Global development assistance for health fell by approximately 27 percent in 2025, dropping from around 49 billion dollars in 2024 to 36 billion dollars, with the United States, United Kingdom, France, and Germany implementing significant reductions.
Suzman emphasized that the setback need not be permanent. Recent reversals driven by declining development assistance and growing debt burdens remain serious but addressable through renewed political will, sharper prioritization, and sustained investment, he explained.
The letter builds on Bill Gates’ May 2025 announcement committing the Gates Foundation to spend 200 billion dollars over the next 20 years before closing on December 31, 2045. This represents the largest philanthropic commitment in history and roughly double what the foundation spent during its first 25 years of operation.
Suzman reaffirmed three core goals guiding the foundation’s final two decades of work. The first goal calls for no mother or child to die from preventable causes. The second envisions the next generation growing up in a world without deadly infectious diseases. The third aims for hundreds of millions of people to break free from poverty, putting more countries on paths to prosperity.
The foundation recently announced a historic 9 billion dollar annual payout as evidence of both urgency and disciplined stewardship. This elevated spending level represents a significant increase from previous years and will be maintained consistently through 2045 to maximize impact.
Over 70 percent of foundation funding focuses on maternal and child health and infectious disease reduction, with that share likely to grow during the final two decades. The organization will concentrate accelerated spending on scaling proven interventions including immunization, nutrition, and maternal health care while investing in new tools to combat malaria, tuberculosis, and other infectious diseases.
Vaccines remain central to the strategy. The foundation believes immunization represents the best investment in global health, with every dollar spent on vaccines returning 54 dollars in economic and social benefits. Through Gavi, the Vaccine Alliance, more than 1.2 billion children have received lifesaving vaccines since 2000, helping avert an estimated 20 million deaths.
The foundation committed 2.5 billion dollars to accelerate research and development focused on five chronically underfunded areas of women’s health. These priorities include obstetric care and maternal immunization, maternal health and nutrition, gynecological and menstrual health, contraceptive innovation, and sexually transmitted infection diagnosis and treatment.
Pre eclampsia represents one critical focus area. The common condition causes complications during pregnancy and delivery, yet doctors do not understand its cause and have virtually no treatment options besides early delivery. The foundation supports innovations including screening tools to identify risk early, affordable blood tests enabling clinic based diagnosis and management, and promising drug candidates that could finally treat the disease itself rather than merely managing symptoms.
On infectious diseases, Suzman expressed confidence that by 2045 the world can eradicate polio and malaria while bringing tuberculosis and human immunodeficiency virus (HIV) under control as manageable conditions. These outcomes depend on innovations currently in development reaching the people who need them.
The foundation highlighted significant progress against HIV, once the deadliest pandemic on earth, which is becoming easier and more affordable to prevent. Researchers continue working toward a potential cure within current lifetimes. Twenty million people walk today who would otherwise have been paralyzed by polio, though the virus must be eliminated globally since polio anywhere represents a threat everywhere.
Malaria eradication by 2045 stands as an incredibly ambitious goal but remains achievable, Suzman stated. The foundation supports a new generation of tools offering protection before mosquito bites, during exposure, and after infection. Harnessing science to stop mosquitoes from transmitting malaria to humans could finally end the disease.
Tuberculosis, which kills more people than HIV, acquired immune deficiency syndrome (AIDS), and malaria combined, faces renewed attention through development of the M72 vaccine candidate. If successful, this would be the first new tuberculosis vaccine in over 100 years. Suzman announced plans to visit South Africa next month with the foundation’s board to observe the trial site.
The foundation also committed 1.4 billion dollars over four years at the 30th United Nations Climate Change Conference (COP30) to help millions of smallholder farmers adapt to climate challenges. Agriculture growth proves two to three times more effective at reducing poverty than growth in any other sector, with greatest benefits accruing in the poorest households.
Generative artificial intelligence represents a game changing tool the foundation lacked during its first 25 years. The technology can revolutionize virtually every field in which the organization works, Suzman explained. In January 2026, the foundation announced Horizon 1000, a partnership with OpenAI bringing artificial intelligence tools to 1,000 primary health care clinics and surrounding communities across sub Saharan Africa.
The region faces a shortage of nearly six million health care workers, forcing professionals to care for too many patients with insufficient support. Artificial intelligence tools can support health workers with tasks from patient intake and triage to follow up care, helping deliver more efficient, high quality services to more people.
The foundation will invest in ensuring artificial intelligence is designed with equity in mind so benefits reach people too often left behind. Technology must be paired with equity, strong public institutions, and local leadership to deliver lasting impact, Suzman emphasized.
Several foundation programs will conclude before 2045. The Inclusive Financial Systems program will end in 2030 after helping hundreds of millions of people gain access to banking and digital finance. The United States Economic Mobility and Opportunity program graduated in 2025 with a final investment in co creating a 1 billion dollar partnership to expand economic opportunity through innovation and artificial intelligence.
On United States education, the foundation maintains focus on helping all students succeed, especially those furthest from opportunity including students from low income backgrounds and underrepresented communities. Investments concentrate on mathematics because students passing Algebra 1 by ninth grade prove far more likely to graduate, pursue college, and earn family sustaining wages.
Progress in United States education has fallen short of hopes during the past 25 years. On such complex, system level challenges, artificial intelligence can play transformative roles. Used thoughtfully, artificial intelligence tools can help teachers save time on administrative tasks like grading and lesson planning, allowing greater focus on engaging directly with students.
When designed responsibly, artificial intelligence can offer students more personalized, adaptive learning experiences functioning as personalized tutors. Realizing these benefits requires strong focus on accuracy, safety, and security along with commitment to ensuring tools help every student thrive, not just those with most access or resources.
Suzman underscored that none of the progress during the past 25 years would have been possible without partners. The foundation will remain beside partners until its final day, supporting efforts to save and improve lives. For partners to solve problems on greater scales, they need stronger systems and sustained support.
The foundation will focus on deepening existing coalitions and forging new ones during its final 20 years. This requires working with governments in low and middle income countries as they strengthen capacity to sustain progress and stretch limited resources efficiently. It also means bringing in other donors and philanthropists to carry work forward long after the foundation closes.
Suzman called for a new era of cooperation centered on saving and improving lives. Most Western taxpayers still support foreign aid when told money will be spent effectively to save children’s lives, he noted in accompanying interviews. Articulating that case in human, deliverable context represents a key part of reframing messaging to rebuild support for targeted, high impact aid.
The foundation CEO acknowledged that philanthropists are currently losing the argument regarding the value of international development assistance. It has become very easy in rich countries to target foreign aid as a large expenditure competing with pressing domestic needs, he explained.
Looking ahead, Suzman expressed hope that future generations will look back on 2025 as a small spike, an almost forgotten moment when progress hung in the balance before the world got back on track. When the foundation closes its doors, he remains confident that where a child is born will no longer determine whether they live, learn, and thrive.
The Gates Foundation was established in 2000 and operates under the belief that every life has equal value. The organization works to help all people lead healthy, productive lives. In developing countries, the foundation partners to create impactful solutions enabling people to take charge of their futures and achieve full potential.
Based in Seattle, Washington, the foundation is led by Chief Executive Officer Mark Suzman under direction of Bill Gates and the governing board. The foundation currently maintains an endowment of approximately 77 billion dollars with Gates pledging to contribute the difference between current endowment and the 200 billion dollar spending goal through future contributions.
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