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Public authorities in the Cameroon CCM: strategic over-representation (eng)

William TCHUINKAM

Résumé

Executive Summary

The Cameroon CCM, like all the others, is the product of a singular history whose restitution of the conditions of birth and the trajectory of institutionalization informs its current functioning. The Global Fund's Country Coordinating Mechanism in Cameroon is, in an emblematic way, the prism through which the Cameroonian State understands its place and role in general and implements the ethos of central government control over public action. Within this body, public authorities mechanically use the international multi-sector directive to be the most numerous on paper. Paradoxically, over time, their number reflects a virtual presence whose chronology of the CCM makes it possible to explain, between expectations of the past that are today's illusions in the context of a procedural and managerial framework operated by the Fund. This article is based on the hypothesis of "path dependency" in the creation of this CCM marked by government control.

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Texte intégral

  • 1 This expression is taken from the matrix of public action in Africa designed by Fred Eboko to syste (...)
  • 2 It should be noted that NGOs have attempted, in rounds 2 and 3, to submit proposals to the Fund wit (...)

1The CCM is the main channel through which requests for funding from the Global Fund in the form of Coordinated Country Proposals (CCPs) flow, although it also receives requests from Regional Coordinating Mechanisms (RCMs) or Rogional Organisations (ROs), or even so-called non-CCM requests (i. e. not from a CCM). However, the CCM is the policy dialogue agency1 and deliberative body that relays the work of the Global Fund and coordinates the implementation of the programmes it finances at the national level. In Cameroon, it is a CCM that plays this role of relay2.

  • 3 See The Framework Document of the Global Fund to Fight Aids, Tuberculosis and Malaria/The Global Fu (...)

2The CCM is composed of representatives of the government sector, civil society, the private sector, people living with the diseases, development partners and international organizations. 3The public authorities within the Cameroon CCM are made up of representatives of the public administration, namely the ministries, the Office of the Prime Minister and the presidency of the Republic, sometimes supplemented by a representative of academic institutions such as the Faculty of Medicine and Biomedical Sciences. Parliament is also taken into account as part of this governmental sector. Their method of appointment is based on a hierarchical principle in that they are appointed by the person in charge of their administration to sit on the CCM for the duration of the three-year term of office. In the case of parliament, it is the president of the chamber concerned who appoints one of its members (so far, parliament has only been represented on the CCM by members of the National Assembly). The representation of public authorities within the Cameroon CCM is generally made by civil servants or state agents mandated by their hierarchy for the cause. It is organized into thematic sub-sectors, with not all ministries represented as such. Thus, for example, only one seat will be occupied by the ministries concerned with the economy and finance, youth, education, employment and social security, etc., bringing the number of full and alternate members representing the public authorities to around 20 out of the 50 members of the CCM.

The representativeness in question

  • 4 This has been a consistent guideline since at least the 9th Board of the Global Fund held in Arusha (...)

3According to the Global Fund's guidelines, the CCM configuration should ensure that at least 40% of its members are from the non-governmental sector, including NGOs, community-based organizations, people living with the disease, key populations, the private sector and4academic institutions. This directive, which aims to ensure a better representation of the various CCM stakeholders, numerically induces a potentially more favourable balance of power for the government sector, depending on the interpretation made by the countries. Thus, while governments are the most numerically represented sector on CCMs worldwide, there is a trend towards a higher representation of this category on the Cameroon CCM compared to the global average, both worldwide and in Africa, as shown in the tables below, based on the Global Fund's figures for CCM membership worldwide in 2016. The analysis of the figures over 10 years ago shows the same trend.

Figure: Comparison of CCM membership worldwide in 2016

Source: Based on Global Fund data (https://www.theglobalfund.org/​en/​archive/​country-coordinating-mechanism/​)

  • 5 Nearly 75% of the financial resources invested in this policy in Cameroon come from development aid (...)

4This phenomenon had already been highlighted by a report of a mission to evaluate the functioning of the Cameroon CCM, commissioned by the Global Fund in April 2004. This report already noted, among other things, the risks associated with the imbalance in decision-making, with the voice of the administration always being predominant when resolutions are voted on. However, should this be seen as a dysfunction of the Cameroon CCM? What are the political and institutional mechanisms that explain the composition and distribution of actors (national, international, public, associative, private, etc.) and justify that the representation of public authorities, which is already on average higher than that of other sectors in general, is so high in Cameroon? How can we understand and interpret this configuration of actors that seems to work in favour of the State to the detriment of the other components of the CCM, whose deliberations are supposed to be guided by a concern for autonomy and equity? Should this be seen as a desire for control by the public authorities in an opportunistic logic? In other words, does the place and role of government in the CCM provide information on public action against AIDS, tuberculosis and malaria in Cameroon, the Cameroonian state and how it interacts with an international organization such as the Global Fund? What is it that fundamentally characterizes Cameroon's mode of intervention in this public policy under influence or even extroverted5? It should be stressed that the State is not considered here as a monolithic bloc, but is viewed through the prism of the actors who act on its behalf within or outside the CCM and can sometimes hold contradictory positions, even contrary to the general interest or even counterproductive in relation to the objectives pursued.

5 CCM activities are based on programs that reflect national sovereignty and respect the wording and procedures established by countries. It is also required that the coordination mechanism thus established be placed at the highest national level responsible for development planning, multi-partner and multisectoral and chaired by a senior official. The Global Fund leaves it up to States to define the size of their CCM according to their specific context, but while ensuring that all stakeholders are as broadly representative as possible. Thus, what appears a priori to be a dysfunction may simply be related to the way in which Cameroon manages the room for manoeuvre it has in its relationship with the Global Fund. However, the analysis of the institutional trajectory of the Cameroon CCM provides further insight into the role of public authorities.

Incremental institutionalization: from role confusion to empowerment?

  • 6 The configuration of the Global Fund Board includes with voting rights public authorities of States (...)

6At the outset, it should be noted that the standards and guidelines that apply to CCMs are built not only collectively, involving the recipients of the CCMs6, but also over time, in a trial and error approach where these guidelines are adjusted as field implementation evaluation reports and other recommendations are taken into account. Thus, it must be understood that a situation that appears normal at a given moment later comes to be considered as posing a conflict of interest and leads to the eviction of the Minister of Public Health from the presidency of the Cameroon CCM. This is therefore not a case where standards are built in Geneva and then transposed to the recipient countries in an import-export logic, but a more complex process of co-construction by margin adjustments, an incremental evolution. The notion of incrementalism (Lindblom, 1959) refers to the idea of public policy in which changes are made at the margin, through successive adjustments, in order to improve existing public action without calling it into question.

  • 7 See Kofi Annan's speech at the OAU Summit in Abuja in April 2001. See also Kofi Annan's testimony i (...)
  • 8 The latter told us in an interview in 2016 in his office that he was the author of the statutes of (...)

7The collective mobilization that led to the creation of the Global Fund in January 2002 clearly indicated the importance of the financial challenge. Indeed, UN Secretary-General Kofi Annan had put all his weight behind his calls for the establishment of a kind of "war chest", an innovative financing mechanism that would live up to the challenge posed by the AIDS pandemic. It also invited African heads of state and other leaders to assume their leadership role and take the lead in mobilizing against this scourge7. In Cameroon, this call was soon reflected in the political discourse that placed the fight against AIDS as a priority on the agenda. On December 31, 2002, during his traditional "message to the Nation", the President of the Republic Paul Biya, said he had launched "a real crusade against this scourge of modern times" and announced the availability of the "most effective therapies[...] within reach of a large number of patients". On the occasion of a ministerial reshuffle in April 2001, a new minister, Mr. Urbain Olanguena Awono, took over as head of the Ministry of Public Health from the Ministry of Economy and Finance, where he held the post of Secretary-General, which he combined with that of Chairman of the Technical Committee for Monitoring Economic, Financial and Social Reforms. From these positions, he would have developed a strong capacity to mobilize financial resources, which he then put to good use, in particular by taking the initiative to follow the opportunity of this powerful dynamic that was being set up under the aegis of the United Nations. This initiative has also met with considerable resistance from the Cameroonian authorities and some members of the CCM based on the fact that at the same time there were other financing sources, in particular from the World Bank (Abdoulkadri, 2013), which were already causing problems in terms of absorption of funds. This reluctance did not slow down the Minister of Public Health in his efforts. In this dynamic, he would later serve not only as head of the Cameroon CCM but also on the Global Fund's Board of Directors. In his approach, he was accompanied by a young doctor and economist, expert in charge of the health sector at the Advisory and Monitoring Committee on HIPC resource management, and familiar to this type of institution, which channels funding from international donors 8. It is in this context that the Cameroon CCM was created by Ministerial Decision No. 0366/D/MSP/CAB of 9 August 2002, as the Joint Coordination and Monitoring Commission of the National Committees to Fight AIDS, Tuberculosis and Malaria. This decision set the framework for the functioning of the CCM without consultation with other stakeholders in a forum that was intended to be inclusive and participatory.

8Article 2 of this constitutive text made it an advisory and support body to the action of the Minister of Public Health, who therefore chaired it, while the vice-presidency was automatically vested in a representative of the President of the Republic, contrary to the recommendations of the Global Fund, which called for their election by the members of the CCM according to a procedure adopted by consensus. Thus, the CCM appeared more like a governmental structure under the supervision of the Minister of Public Health, on whom it depended financially, than a consultative body with a certain autonomy and supposed to play a role of control and supervision of the use - including by the State through the Ministry of Health - of the resources allocated by the Global Fund. At first glance, this structure appeared to have been hastily built to meet at least the Global Fund's requirements for submitting a funding proposal for Round 2. This was done a month later but ended in failure. It is interesting to note that at the time of the creation of the Cameroon CCM, several options were on the table, based on the Global Fund's guidelines. The latter was indeed quite flexible on its requirements in terms of structuring the CCM. In addition to the flexibility given to countries to define the size of their CCM, it was possible - or even strongly suggested - to support the CCM to be created preferably on the basis of an existing body. However, the Minister of Public Health chose to create a new institution from scratch when, at the same time, there were many similar coordination bodies, even within the Ministry of Health, that could have met the criteria. This situation underlines the importance of understanding the process of the birth conditions of the Cameroon CCM.

Ambivalent conditions for creation

  • 9 Interview with a former CCM member representing the public authorities on 15/09/2017.

9The institutional trajectory of the Cameroon CCM depends on how well it has adapted to the transformations of the Global Fund, while gradually affirming a desire for autonomy over the supervision of the Ministry of Public Health. Its initial configuration, in addition to the specific conditions of its creation, reflected a congenital confusion of role, with the Ministry of Health potentially receiving grants on the basis of a choice made by the body chaired by the Minister of Health. Moreover, CCM meetings have long been held on the Ministry's premises9, adding to the confusion. This did not prevent the Cameroon CCM from submitting proposals to the Global Fund and obtaining grants for the third round of funding in 2003. This clear benevolence of the Global Fund towards the Cameroon CCM was only denied when, following numerous reports and discussions within its Board, the Global Fund raised the issue of conflicts of interest and urged the CCMs to take the necessary steps to prevent or resolve them. Since 2005, the presidency of the Cameroon CCM has therefore been the subject of a vote by the members of the body, without the Minister being eligible to be elected. He is no longer even a member of the CCM and now only attends meetings on an exceptional basis and by invitation. In the same spirit of empowerment, there was a very edifying scene during the visit to the Cameroon CCM by the newly appointed Executive Director of the Global Fund in 2007. During a working session, the President of the CCM (who was no longer the Minister of Public Health but a representative of the Presidency of the Republic) openly complained to the Executive Director of the Global Fund about the absence of an operating budget for the CCM that made him dependent on the generosity of the Ministry of Public Health. In response, the Executive Director of the Fund had made a commitment if the CCM formally requested it to provide financial support for the functioning of its Secretariat. Further adjustments have taken place at the Cameroon CCM, which now reflect its image as a body with some authority and a greater role in the public response to AIDS, tuberculosis and malaria in Cameroon. As a formal illustration, a decision by the Minister of Public Health in June 2010 repealing the founding text of the Cameroon CCM explicitly designates it as the National Coordination Mechanism for Global Fund financing in Cameroon. Unlike the 2002 text, it simply validates the constitution of the CCM as the result of consultation between its members, whereas in the past the administrative act, an expression of public authority, did not suffer from any questioning.

10The CCM now has its own premises and no longer depended, from that moment on the Ministry of Public Health for its operation. The organization and conduct of its meetings as we have participated in them clearly demonstrate the affirmation of the autonomy, or even the authority, acquired by it. The CCM exercises control over the way in which Principal Recipients and Sub-Recipients use the funds allocated to them. In particular, during quarterly review meetings, they must present to the CCM "Commissioners" the progress of their work, the difficulties encountered, and answer their questions when they need clarification or explanation on one or other aspect of their work.

11These exchanges generally result in recommendations from the Commissioners, which serve as a roadmap for the recipients to follow in the performance of their missions. The CCM, for its part, reports to the Global Fund, which monitors the use of the funds through the CCM.

The weight of habit

12 Observation of the functioning of the Cameroon CCM shows that it remains marked by the seal of the conditions of its creation and its institutionalization trajectory. While it is undeniable that the then Minister of Public Health played a key role in the creation of this body and that his personal commitment is a key to understanding Cameroon's performance in terms of mobilizing Global Fund grants, it also reflects a degree of government control over the functioning of the CCM. For example, in addition to the fact of numerical domination, it is not insignificant to observe that the presidency of the CCM has always been held from the beginning by a representative of the presidency of the Republic when it was no longer the Minister of Health. The vice-presidency was able to alternate between the public authorities, the private sector and civil society. In addition, the autonomy displayed by the CCM seems to be more deliberate than real. Indeed, its recommendations are not always followed up and, for example, the drafting of the Concept Note is often entrusted to the Ministry of Public Health on the grounds that the CCM does not have the necessary expertise. However, tensions can be noted within this government sector itself under the helpless gaze of other sectors, as was the case in 2013 when, according to corroborating evidence from several CCM members, the vote for the appointment of the CCM chair had to be resumed without a valid explanation, whereas the Commissioners had chosen a representative of the Prime Minister's office. Thus, the representative of the Presidency of the Republic was finally appointed head of the CCM, thus winning the "match" between the Prime Minister's office and the Presidency of the Republic. It may be observed that bureaucratic autocracy, understood as the tendency for civil servants and public agents to have a strong influence in decision-making by public bodies at the expense of other social components, particularly civil society, remains prevalent in Cameroon (Kontchou Kouomegni, 1984).

Conclusion

13By exporting the theory of "path dependence" from economics to political science, public policy analysis has been significantly expanded since the 1990s (Pierson, 2000). The emphasis on the "weight of choices made in the past and that of political institutions on current decisions" (Palier, 2014: 411). This article is in line with this lineage and the draft historical sociology of the Cameroon CCM is an illustration of this. Between the principles laid down at the supranational level by the Global Fund and the trajectory of the Cameroonian State's institutional response to the risk of the three diseases to which the Fund is dedicated, the mechanisms of absorption, resistance, conformation and dissonance are read, which also attest to the existence of African States, often described or thought of as empty shells. The particular case of Cameroon accentuates this "path dependence" insofar as the public authorities occupy and claim a place in it which is not related to the specificity of the stakes. In the context of health and in particular the CCM, the trajectory of this institution depends on the balance of power between sub-sectors of the public service, which brings a representative of the Presidency of the Republic to the forefront of the CCM scene, beyond the CCM's internal procedures and unrelated to the effectiveness thought by the Fund. The point is to print the brand and ethos of public action control, including at times when a delegation of authority would have been more in line with the Fund's requirements. Since nothing is irreversible, it is quite possible to renegotiate the roles of each other, especially in a situation of rupture or the beginning of a crisis. The fact that one of the arguments put forward by the Presidency representative to keep control of the CCM was the assurance of obtaining counterpart funds that each country must provide (at least 20% of the grant) and that this deadline has not been met to date, produces a window of opportunity to bring the actors closer to the main logic guiding the Fund: "save lives". In this context, Cameroon opposes to the Fund's directives a relative contradiction of the notion of "conflict of interest" insofar as the central health operator is the Ministry of Public Health, which has the expertise and authority to do so. On the other hand, the Cameroonian CCM's thwarted procedures for the election of the CCM chairperson undermine the argument of counterpart funds guaranteed by assumption by state summits whose it is not the role, and which have political files of absolute urgency to manage. The CCM's emergency is health. It is illusory to place the ministry dedicated to it in the position of observer-beneficiary because it is the only institution for which public health is the only emergency. This incise probably corresponds to the recent conclusions of the Inspector General of the Global Fund, who proposes that the international operator adapt as much as possible to the different contexts in which it operates. This is the path dependence, taking into account the specific historicity of African States (Bayart, 1993), without questioning the acuity of international standards.

Bibliographical references

Books, scientific articles and press articles

14Annan K., 2012, « Dix ans de combat pour la santé globale « Un trésor de guerre » », Le Monde Diplomatique, Janvier 2012 ;

15Bayart J.-F., 1989, "L'Afrique dans le monde : une histoire d'extraversion", Critique internationale, n° 5, P. 97-120.

16Bayart J.-F, 1993, The state in Africa: the politics of the belly (2nd ed.). London : Longman.

17Eboko F., AbÉ C. & Laurent C. Christian (Eds), 2010, Accès décentralisé au VIH/sida : évaluation de l’expérience camerounaise, Paris, ANRS, Collection Sciences sociales et sida, 324 p.

18Eboko F., 2015, Repenser l’action publique en Afrique. Du sida à l’analyse de la globalisation des politiques publiques, Paris, Karthala, 262 p.

19Eboko F., Hane F., Demange E. & Faye S., 2015, « Gouvernance et sida en Afrique : instruments de l’action publique internationale, l’exemple du Fonds mondial », Mondes en Développement, Vol.43-2015/2-n°170 : 59-74.

20Hassenteufel P., 2008, Sociologie politique : L'action publique, Paris, Armand Colin, 294 p.

21Kontchou Kouomegni A., 1984, “Administration et politique en Afrique francophone ou de l'autocratie bureaucratique”, in CONAC Gérard (dir.), Les grands services publics dans les Etats francophones d'Afrique noire, Paris, Economica : 3-52.

22Palier B., 2014, « Path dependence (dépendance au chemin emprunté) », dans : Laurie Boussaguet éd., Dictionnaire des politiques publiques. 4e édition précédée d’un nouvel avant-propos. Paris, Presses de Sciences Po, « Références », p. 411-419.

23Pierson P., 2000, « Increasing Return Path Dependance, and the Study Politics », American Political Science Review, 94 (2) : 251-267.

24Porto de Oliveira O. & Pimenta de Faria C. A., « Policy Transfer, Diffusion, and Circulation. Research Tradition and the State of the Discipline in Brazil », Revista Novos Estudos – CEBRAP, Sao Paulo, Vol. 36, n° 1, Mars 2017, pp. 13-32.

Documents and reports

25CCM Cameroun, Secrétariat technique, Compte rendu de la réunion du 21 Décembre 2004, Yaoundé.

26CCM Cameroun, Secrétariat technique, Compte rendu de la réunion du 28 Février 2005, Yaoundé.

27CCM Cameroun, Secrétariat technique, Compte rendu de la réunion du 19 Avril 2005, Yaoundé.

28CCM Cameroun, Secrétariat technique, Compte rendu de la réunion du 25 Mai 2005, Yaoundé.

29CCM Cameroun, Secrétariat technique, Compte rendu de la réunion du 06 Juin 2005, Yaoundé.

30Fonds mondial, Bureau de L’Inspecteur général, Rapport consultatif, Mise en œuvre des subventions en Afrique occidentale et centrale (AOC), Surmonter les obstacles et améliorer les résultats dans une région difficile, Genève, Mai 2019.

31Fonds mondial, Missions d’Etudes sur le Fonctionnement des Instances de Coordination Pays (CCM) Cameroun, Rapport présenté devant le conseil d’administration du Fonds mondial en juin 2004.

32The Global Fund, Office of the Inspector General, Rapport d’audit, L’instance de coordination nationale du Fonds mondial, Genève, Suisse, 25février 2016.

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Notes

1 This expression is taken from the matrix of public action in Africa designed by Fred Eboko to systematize the configurations of actors found in programs funded by development aid in Africa. See Fred Eboko (2015).

2 It should be noted that NGOs have attempted, in rounds 2 and 3, to submit proposals to the Fund without the approval of the CCM. These were rejected as ineligible because they could not justify exceeding the CCM.

3 See The Framework Document of the Global Fund to Fight Aids, Tuberculosis and Malaria/The Global Fund to Fight AIDS, Tuberculosis and Malaria Framework Document.

4 This has been a consistent guideline since at least the 9th Board of the Global Fund held in Arusha in november 2004.

5 Nearly 75% of the financial resources invested in this policy in Cameroon come from development aid, more than half of which is provided by the Global Fund, while the share of development aid does not exceed 15% of the Cameroonian State budget. On the notion of extroversion linked to sub-Saharan Africa, see Jean-François Bayart, "L'Afrique dans le monde: une histoire d'extraversion", Critique internationale, n° 5, 1999, P. 97-120. In 2016, according to the IGO audit report on MF grants, Cameroon was one of the countries heavily supported by the Global Fund and received the 15th largest allocation in the world (US$288 million in 2014-2017).

6 The configuration of the Global Fund Board includes with voting rights public authorities of States Parties, civil society, disease-affected communities, the private sector, etc. For example, Cameroon, through its Minister of Health, was a member of the Fund's Board of Directors from January 2003 to April 2007 as a representative of the Central and West African zone. He also chaired the Fund's Portfolio Commission in 2006.

7 See Kofi Annan's speech at the OAU Summit in Abuja in April 2001. See also Kofi Annan's testimony in Le Monde Diplomatique (2012).

8 The latter told us in an interview in 2016 in his office that he was the author of the statutes of the Cameroon CCM.

9 Interview with a former CCM member representing the public authorities on 15/09/2017.

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William TCHUINKAM, « Public authorities in the Cameroon CCM: strategic over-representation (eng) », Face à face [En ligne], 15 | 2019, mis en ligne le 09 octobre 2019, consulté le 14 octobre 2019. URL : http://journals.openedition.org/faceaface/1381

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