Every year, new health products and know-how become available: statins, new antibiotics, telemedicine, insurance know-how, imaging techniques, and genomics, to name a few. At the same time, major barriers to transferring information and technology between countries are falling with expansion of the internet and online health training programmes, the growth of information about the relative effectiveness of different technologies,1 and the liberalisation of trade. It might be reasonable to expect that global transfer of health technologies would take place more rapidly and in greater quantity to benefit “haves” and “have nots” alike. There is no evidence, however, that this is taking place. On the contrary, appropriate health technologies may become more unequally distributed than ever. Why?