> That is more than enough money to solve structural issues.

But that's the thing, the money is not helpful when it comes to policy issues. As the Gates Foundation MO and your dad's experience probably shows, lasting change comes down to political will. I can only surmise that the reason more US non-profits don't achieve lasting change is because they are not able to or they are not trying to.

This is not to say they are deliberately being ineffective, e.g. consider that inner city infant mortality rates have socioeconomic and racial factors, so solving that would require "solving" poverty and racism. Offhand, I really can't see how non-profits would be able to address these with even billions of dollars.

Of note, a sibling comment mentions the book "Winner Takes All" and links its wikipedia page which has this quote:

> The Aspen Consensus, in a nutshell, is this: the winners of our age must be challenged to do more good. But never, ever tell them to do less harm. The Aspen Consensus holds that capitalism's rough edges must be sanded and its surplus fruit shared, but the underlying system must never be questioned. The Aspen Consensus says, "Give back," which is of course a compassionate and noble thing. But, amid the $20 million second homes and $4,000 parkas of Aspen, it is gauche to observe that giving back is also a Band-Aid that winners stick onto the system that has privileged them, in the conscious or subconscious hope that it will forestall major surgery to that system – surgery that might threaten their privileges. The Aspen Consensus, I believe, tries to market the idea of generosity as a substitute for the idea of justice."

Not saying I agree entirely, but that is the kind of thing that could lead to billions in spending without achieving lasting structural changes.

> As the Gates Foundation MO and your dad's experience probably shows, lasting change comes down to political will

Lasting change comes down to data-driven programs that work and the money to implement them. As long as you’re not asking for money and meet the community you’re working with where they are,[1] politics is mostly a red herring. My dad worked on projects that achieved incredible results in Bangladesh, for example, even though the government of the country was a complete clusterfuck the entire time.

> socioeconomic and racial factors, so solving that would require "solving" poverty and racism.

The way to eat an elephant is one bite at a time. There may be overarching “factors” that contribute to a result, but there’s usually an immediate cause of a problem that you can tackle directly with an effective program.

Mississippi, for example, is now #3 in the country for NAEP 4th grade reading and math scores for black students. It’s #1 for reading and #2 for math for Hispanic students: https://mdek12.org/wp-content/uploads/sites/59/2025/01/NAEPR.... Mississippi didn’t “solve poverty and racism.” It implemented a program that identified the immediate cause of certain problems and fixed them.

[1] Effective programs avoid creating political problems. When my dad was designing maternal health programs for Bangladeshi villagers, he met them where they were instead of where he thought they should be. For example, it turns out rural women wouldn’t use newly built clinics for giving birth because they didn’t trust “big city doctors.” So the program developed relationships with local midwives and traditional healers, who the women already trusted, and had them get training from the doctors and refer high risk pregnancies to the clinics while handling routine deliveries in the traditional way.