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International partners in the Global Fund coordination mechanism in Cameroon: reconfigurations based on instrumentalized governance (eng)

Muriel SAME EKOBO et ABDOULKADRI

Texte intégral

1The formalization of Cameroon's health policy has been largely prescribed by international institutions for several decades. Emblematic of the era of governance and partnership in countries with limited resources (Guilbaud, 2015), it places the public sector in a paradoxical situation, where the State called upon to stimulate, lead and supervise public action must develop balanced relations with its partners. Between this partnership dynamic that governs the State (Eboko, 2015) and the process of extroversion that is the corollary of this situation (Bayart, 1999).

  • 1 Interviews with full and alternate members representing international development partners in Camer (...)

2This article is based on the Governance and AIDS in Africa project (ANRS 12315) and focuses specifically on international partners. This research is coordinated by the Paul Ango Ela Foundation for Geopolitics in Central Africa (FPAE) and led by a team of researchers that was composed of three pairs. Each pair was responsible for conducting surveys among the actors of each key sector identified, namely that of multilaterals, associations, civil society, the public or finance. The present text comes specifically from the binomial dedicated to Cameroon's international partnership relations within the CCM1.

3The Global Fund to Fight AIDS, Tuberculosis and Malaria makes a significant contribution in Cameroon - as in most of the 124 developing countries where it operates (Global Fund, 2019) - to the fight against these three major pandemics in terms of morbidity, mortality and even prevalence, namely AIDS (US$ 300 million), malaria (US$ 250 million) and tuberculosis (US$ 30 million). Since 2002, the country has received support from the Global Fund on several occasions, with 7 grants for AIDS, 5 for malaria and 3 for tuberculosis (Global Fund, 2019).

4Because of its functioning and organization, the Global Fund projects its National Coordinating Mechanism (CCM) as an essential actor in the health landscape. Usually referred to by its acronym CCM (Country Coordinating Mechanism), this body oversees the funding requests, implementation and use of grants awarded to local structures. The Cameroon CCM is composed of 55 members representing the public sector, private partners, civil society (civil or religious associations, non-governmental organizations) and external partners. The relationship between these members and the interplay of the institutions they represent therefore determines the efficiency and impact of disease control strategies.

  • 2 See in this dossier the contribution of Stéphanie Tchiombiano.

5Since 2014, the Global Fund's New Financing Model, which is more managerial and geared towards scaling up access to treatment and prevention, requires results and performance based on common indicators2. This leads to increased support for the most deserving countries and disinvestment from the "bad students". In this context of competitiveness and competition, dramatized by the decline in pledges and the possibility of Cameroon's downgrading (by falling into the category of "middle-income countries" it would lose eligibility as a "poor country"), the role of international partners, apparently discreet on the surface, is crucial.

6While the place of international partners may seem banal in its historicity (most of them have been present since the decolonization of Cameroon) and normalized by the requirements of the Global Fund, it nevertheless remains unique in Cameroon and gives rise to new configurations. On the one hand, they represent the main donors and international institutions in the field of health (Nkoa et al., 2010). In this sense, they appear to be the guarantors of compliance with Global Fund procedures. On the other hand, the Cameroonian State, which has already faced rejection of requests, remains concerned about its national sovereignty. It seeks to reduce the weight of foreign intervention in its public policies and in the national budget. This is reflected in the very small share of the "development partners" category within the CCM: between 6 and 9 members over the period 2002-2019, or between 10% and 15% of the total number of CCM members.

7To what extent does the participation of these development partners in the CCM still remain legitimate and effective? How do they support the functioning of the CCM? Between interference and indifference, how resilient are they?

Development partners, a fundamental role

8Since Cameroon's independence, foreign actors have had a recognized and effective role in development assistance, particularly in the health sector. Their integration into the CCM was undoubtedly imposed by the Global Fund's criteria, but it is neither surprising nor destabilizing for Cameroonian actors because they are the result of bilateral cooperation between States (Germany, United States, France) or multilateral (World Health Organization UNAIDS, a platform of international non-governmental organizations, Management Sciences for Health).

A significant financial weight

9As the United States, France and Germany are the main donors to the Global Fund with respectively US$15 billion, US$4.6 billion and US$2.8 billion in cumulative contributions, representing more than half of the total contributions (US$41.6 billion) between 2002 and 2019 (Global Fund, 2019), the participation of their representatives in the Cameroon CCM carries strong economic and political significance, linked to the cooperation treaties undertaken between Cameroon and these States since the 1960s. Germany and France are the main donors to national sectoral health programmes and finance several local branches of their own agencies involved in the field of health (Centre Pasteur, Agence nationale de recherche sur le sida et les hépatites (ANRS), Institut de recherches pour le développement (IRD), Agence universitaire pour la francophonie (AUF) etc.) )

10The Cameroonian state allocates only 5% of its budget to health, which is far from the Abuja commitment (at least 15%) and the effort made by other African states to achieve a similar Gross Domestic Product (GDP). It finances only 16% of total health expenditures, with external resources accounting for 13% and private expenditures (mainly households) 71% (National Strategic Plan for Malaria Control (NMCP), 2018). Indeed, the contribution of the Global Fund is essential for disease control policy. In 2014, the Global Fund provided almost half of the funding for the fight against AIDS (47%). Even if Cameroon has been able to demonstrate its "willingness to pay" up to 28%, i.e. the country share required in the Global Fund's new financing model, this remains below that of other countries of similar profile, such as Senegal or Côte d'Ivoire.

11The association of bilateral partners/multilateral partners representing major international health institutions, such as the World Health Organization and UNAIDS, gives the category "development partners" a central place in the CCM mechanism, unrelated to the small number of members and unique compared to other categories of similar size (civil society organizations, private sector, affected communities).

Proven expertise capacity

12Development partners represent a crucial financial contribution for Cameroon, and they also have experience of international mechanisms or health systems in other countries that adds significant expertise in terms of technical assistance.

13Several of the members participating in the Cameroon CCM have extensive experience in international institutions, including health and the UN system. Some have even worked in other CCMs before being posted to Cameroon, Chad or the Central African Republic, for example. They have a good knowledge of other disease control financing mechanisms (PEPFAR, GAVI, UNITAID, CCIA, Roll Back Malaria...), in which they are often involved. They are involved in many activities peripheral to health structures, medical and health governance programmes, university training, scientific research, medical advice, etc. In fact, these members are able to have a global vision of the functioning and impact of health policies, both regionally and internationally.

14This advantage is reinforced by an informal soft power. Indeed, the porosity of social and personal ties specific to expatriate environments, in an environment where the number of interlocutors is limited and often wear several hats, is a reality. Professional or diplomatic relations between representatives often lead them to develop personalized relationships. Their way of life often provides opportunities for informal encounters. They are thus used to pool their knowledge on the various stakeholders upstream and downstream, in other international institutions, in the pharmaceutical and medical sector, non-governmental organizations or patients' associations, among others. They are able to set up formal or informal networks to cross-reference information. Personal trajectories reveal very different paths, ranging from a deep or superficial knowledge of Cameroonian society to an old or recent practice of international development institutions. Many of these members are directly connected to their embassies, as employees and resource persons, which adds a strategic dimension to their participation in the CCM.

An ambivalent look

15However, the use of different terms to describe Cameroon's international partners reflects the vague contours of the category assigned to them. They are referred to as "Technical and financial partners" in the language of the Ministry of Public Health and international organizations, "international development partners" or "multilateral and bilateral partners" in the CCM's organizational chart. Confusion is reinforced when the national/international border is not obvious. Through the interplay of incumbents and substitutes, some representatives of international institutions are Cameroonian. Bilateral cooperation representatives lead non-governmental organizations, which may be local branches of international structures, just as representatives of civil society organizations sit on behalf of national or international non-governmental organizations.

16In reality, most international partners seem to be confined to a nebula of foreign actors of different status, distinguished mainly by their quality. Due to their exogenous nature and professional culture, they often present a united front. However, they have different motivations, capacities to act and specific agendas. American, French and German cooperation has been supporting the Cameroonian health system for several decades (Gruénais, 2001), but they are not the only ones: China, Belgium, the Netherlands and Japan are developing various infrastructure, equipment and training programmes. The issues of visibility, originality and anchoring in the country are therefore becoming more and more important.

17At a more individual level, these representatives of development partners seem to have egalitarian relationships with each other, but the influence of socio-professional, gender or individual backgrounds in Cameroon does not put them at the same level and does not give them the same room for manoeuvre to play their role within the CCM. Gender (male/female) and origin differences (a majority of European women represent bilateral partners, a minority of Africans represent multilateral partners) and the diversity of professional experiences (large international agencies versus non-governmental organisations, managerial culture versus public service) certainly play an important role in the nature of the relationship between members representing development partners and in their relationship with other members of the CCM, mostly Cameroonian men. Also, the position as holder or substitute, the seniority and regularity of the participation give more weight to some than others.

18How do they play their role in the CCM?

International partners in the CCM: unbalanced multisectoral relationships

19During interviews conducted between June 2015 and February 2016 with members representing the international development partners of the Cameroon CCM, it became clear to us that the relationship between the different categories was notoriously unbalanced and that this imbalance fed many dysfunctions in terms of procedures and democracy.

Partnership governance or bipolarity?

  • 3 For an analysis of the role of public authorities within the Cameroon CCM, please refer to William (...)

20Quadripartite representation on the CCM is presumed to be balanced between the State, civil society, the private sector and external partners. However, in Cameroon, the over-representation of the public sector (more than 40% of members) often reduces decisions to a balance of power in favour or against the government3. Notwithstanding this imbalance, the nature of the relations between the different parties and the pro-activism of certain categories of actors do not offer the conditions for a real discussion prior to choices.

21While the voice of the private sector, represented by only four members who rarely sit, is inaudible, and that of faith-based organizations is discreet, that of communities affected by AIDS and malaria often echoes that of international partners. They are not fooled by a certain instrumentalization they assume civil society organizations expect international partners to support them, they stress, and they blame them for not doing it enough (Interview). Relations with civil society organizations have multiple dimensions. Considering that members of civil society organisations are the only ones to represent patients' voices in the Cameroon CCM, particularly powerful associations such as Positive Generation or Malaria No More, the international partners are attentive to their collaboration and underline their complementarity. It is also an alliance strategy to obtain a number of votes in balance with that of the public sector.

  • 4 The question of key populations is analysed in this dossier by Fred Eboko, Anicet Kabore and Cyrill (...)

22Nevertheless, most compromises on sensitive issues are reached outside the voting procedure. Thus, the definition of key populations systematically refers Cameroon to its contradictions between principles and pragmatism. A sensitive issue if ever there was one, penalized homosexuality in Cameroon theoretically leads the government to "legitimately" exclude homosexuals from access to care/treatment and it is almost impossible for international partners, who are extremely sensitive to human rights, to block this decision by voting because civil society organizations are divided on the position to be adopted on the subject. Several, particularly Catholic and Muslim associations, agree with the government's position. Others are advocating for decriminalization and gender recognition. In 2014, the World Health Organization, considering that more attention should be paid to "sufficient control of the subject" than to Cameroonian law, commissioned a study to assess key populations defined on the basis of international high-prevalence indicators (men who have sex with men, sex workers, drug addictions, etc.). In practice, as the President of the CCM had publicly stated that the care of homosexuals was not a subject of tension, opponents avoided speaking out when the issue was discussed, and then the concept note did not address the issue. On the other hand, the suggestion made by the representatives of the development partners to support alternative centers in Douala and Bafoussam, dedicated to support (medical, psychological, legal) homosexuals and associations, no longer appeared in the final version of the concept note (Interview)4.

23The drafting of the concept note in June 2015 also reflects the procedural vagueness of the CCM. A representative of the development partners was able to testify to his distress shared by others (Interviews). Why have some referents, such as those of the National AIDS Committee (CNLS), been excluded while others have been integrated? Who actually writes, which version is chosen? Who validates it? Who transmits it? What feedback is given to CCM members? The relatively short time between submission, validation and sending, and overnight convening, certainly encroached on the quality of the substantive reflection, with in addition to many technical points on which most members had no competence. Above all, members were alarmed that they had no means of control to know whether their comments had been taken into account, even when they took care to send a written transcript. For example, they asked that refugees be included in the target audience.

Sharing territory and delegation: fragile compromises

24It is not common to find compromises. Relationships of mistrust give rise to avoidance strategies that lead to a kind of territorial sharing. Public sector representatives feel attacked by international partners. Their sensitivity manifests itself when a question is asked by a representative of development partners (Interview). Sometimes they get irritated and leave the room with a question they think is inappropriate: questions about medical care, requesting an evaluation grid, checking indicators, etc. Also, representatives of development partners regularly use abstention to avoid being charged. It is in this sense that they refused the proposed vice-presidency of the CCM, arguing that they were first and foremost there to accompany, observe or advise.

25On the other hand, public sector representatives are often absent at the time of the periodic review of grants, perhaps a way to show disdain for an exercise controlled by international partners. These "enormous tensions", noted by all our interlocutors, are not specific to the relationship between internal and external partners within the CCM. They reflect Cameroon's governance problems. "Every country on the CCM it deserves" was able to exclaim a member representing development partners in 2015.

26While development partners agree among themselves on the priorities to be defended (in particular the relay of civil society), they are not systematically able to agree on the modalities. Some members are in a strong, even procedural claim (recourse to a blank vote, veto, quorum requirement, etc.), while others are in consensus at all costs, to the point, for example, of refusing to freeze the subsidy to a beneficiary who is unscrupulous, having covered up accounts and results. The controversy over the choice of beneficiaries of the Global Fund grant that broke out in late 2015 in the Cameroon CCM also revealed differences between international partners. Some felt that the recipient could fully choose the recipient. Others wanted the CCM to designate the primary and secondary beneficiaries, contrary to the Global Fund's requirement that the primary beneficiary choose the secondary beneficiary. While everyone thought that a control mechanism was essential, they did not agree on whether or not it came from the CCM. Behind this dispute, the main question was whether this prerogative would strengthen or weaken the CCM.

27Another phenomenon that reflects the weakening of relations is that of delegation between members representing development partners (Interviews). Some donor states consider that they have financial but not technical capacity and rely on other partners: "you choose, we pay". Others find themselves torn between their positioning for the CCM and their action in other long-established health coordination or cooperation bodies in Cameroon (Steering and Follow up Committee of Debt Reduction-Development Contract (COS-C2D), German cooperation (GIZ), American cooperation (USAID), etc.). ) or non-governmental organizations, and which do not necessarily have the same approach to the questions asked. They are then tempted to give power of attorney to their peers or to withdraw so as not to find themselves in a conflict of interest. To some extent, this is all part of the inertia of the CCM.

28France, Germany and the United States, which each have a specific bilateral relationship with Cameroon because of their historical ties and which have, on the same account, a specific bilateral relationship with each other, sometimes embarrass their representatives. The line between the delicate interplay of diplomatic representation, foreign policy relations and health issues is extremely fine, and it is not always possible during a tense session of the CCM to respect it.

The Cameroonian State and international partners: between failures and resistance

29Tensions between a centralizing power and actors who consider themselves participatory thwart the possibilities of coordination. Why do they lock the Cameroonian state into contradictory failures with its desire to keep its hand?

Objectives at half mast

30Administrative mismanagement and poor performance seem to dominate the Cameroonian health landscape and mask the initiatives of public agents in the field to compensate for shortcomings and invent responses to the urgency of situations. Apart from the tuberculosis programme, almost all the objectives of the national AIDS and malaria programmes have not been achieved for 20 years, while other countries with similar profiles, such as Senegal or Kenya, have shown real success. Statistics are underestimated or overestimated to hide their discrepancy with the "Millennium Development Goals". Several scandals have exposed cases of corruption, embezzlement, personal enrichment, leading to the shortage of antiretrovirals in 2012, or the misuse of insecticide-treated nets in 2015, to name but a few examples. However, their media coverage, their judiciarisation and the inclusion of monitoring and evaluation in the agenda of programmes to combat epidemics show that transparency is relatively taken into account.

31The administrative reports of the various national plans to fight AIDS, malaria or tuberculosis all report a low rate of budget implementation of programmes. Currently, less than two-thirds of the health budget is consumed by the deadline (NSNMP, 2018). This concerns more specifically the budget lines dedicated to care, epidemiological surveillance, advocacy and mass media or social communication. These elements betray the failures of the entire health system.

32The "moral, social, economic deregulation" induced by the capture of internal and external resources and the mobilization of administrative elites is used by the regime in place for three decades to maintain its power (Eboko, Awono, 2018). It is not surprising that the CCM is seen as a potential cog, in a fantasized or real way, because the configuration of the political system values political allegiance more than the success of public action. Understanding this "perpetual government" (Owona Nguini & Menthong, 2018) is cruel to understand the relationship between public authorities and their partners.

33Enclosed in a system of clientelism that determines their personal trajectories, public sector representatives on the CCM remain vulnerable to any challenge, particularly from representatives of development partners, who they often consider too offensive. Thus, by not acting on the development partners' proposal to merge drug stocks from different donors because it preferred to present three programmes rather than one, the Ministry of Health showed that it was more committed to display than to the effectiveness of its policy.

34Far from instilling a constructive dynamic, "statements by public sector representatives are limited to showing what works well and using ambiguous sentences to evoke what does not work," reproached one of our interlocutors (USA interview). It is true that the personality of the four successive ministers of health and their unequal investment during their terms of office and the Global Fund's "rounds" are part of a sawtooth dynamic of the CCM (Entretien Oms), between activism and wait-and-see attitude.

Is it a question of sovereignty, incompetence or resistance?

35The slowness in administrative follow-up, systematic delays in meetings, postponed sessions and the recurrent absenteeism of more than 40% of government members disempower other members, particularly those representing development partners (Interview). Is it an empty chair policy, a form of passive resistance or an incompetence of the CCM's public actors?

36The representatives of the development partners were fairly unanimous in their view that there was not enough deliberation and genuine use of voting in the CCM. Meetings are time-consuming and inefficient because they are not organized. Information is not shared, there are no preparatory documents and minutes of meetings are never transmitted. "The CCM seems to be meeting to respond to the donor's request, but not with the conviction that it is necessary," said one member, taking stock of two years of participation (Interview). There is no team feeling, let alone the feeling of participating in something important for the country, for society," he concluded. Here too, this form of wait-and-see attitude relegates the CCM to the status of a poster agency. It also reflects the disinvestment of Cameroonian civil servants in the face of what they perceive as instructions coming from "above" or from outside without them being able to appropriate them.

Between opacity and confidentiality

37The attitude of public sector representatives constantly places the functioning of the CCM in a situation between opacity and confidentiality. Surprised, and perhaps even offended, by the refusal of representatives of development partners to participate in the Monitoring and Strategy Committee that had to be set up at the end of 2014 to comply with the Global Fund's new standards, they did not follow through on their proposal to develop an evaluation grid. Some of the representatives of development partners, for example, being at the head of structures providing antiretroviral drugs, felt that they could not be judges and parties. A sensitivity to conflict of interest that was not perceived as such by the public sector: eight months later, the development partners and other members of the CCM convened at a meeting on the conclusions of the Strategic Monitoring Committee were surprised not only by its constitution (on what basis ? On the basis of which reference documents?), but also by its activities (where and under what conditions had they been carried out?), without the meeting being able to give them clear answers (USA interview).

38At the same time, they regret not being used in the light of their experience. A member, who was in charge of the Global Fund's "country files" for five years before his assignment to Cameroon, reported that he had been welcomed with suspicion and mistrust rather than relief. He is surprised that he had never been asked to write - although laborious - Cameroon's concept note in 2015. Others, which could have had the concept note verified by bilateral cooperation professionals, were ignored. The World Health Organization is dismayed to have so little interaction with civil society organizations in Cameroon. This is largely due to the lack of anticipation and effectiveness of the CCM.

39Unlike other countries, the reform of the CCM has not been concrete in Cameroon. The dynamics of support, resource mobilization and relaying proposals to the Global Fund are not effective. The inaction that makes it possible to produce political order in a "stationary state" (Eboko, Awono, 2018) undermines the efficiency of the CCM and perhaps even the emptiness of its meaning. Are international partners coping with it?

The uneven resilience of international partners

40While the representatives of development partners in the Cameroon CCM have a common approach that leads them to criticize the dysfunctions of the CCM, they also analyze the Global Fund's requirements with some hindsight. Is the Global Fund meeting the needs?

A common approach

41Development partners are probably the most frequent members of the CCM and a source of proposals. They attend almost all meetings, as full members, although they have a high turnover due to their agendas and the duration of their mission in the country.

42They generally prepare in advance (meetings, telephone exchanges), aware that "consensus cannot be reached in the room" (WHO interviews, France, USA). When they meet in session, they "carry the same message", prove their mastery of the subject and try not to show their differences. It is all the easier for them to adopt a common position if they always agree, as a last resort, to align themselves with the main objectives of the World Health Organisation: the interest of the patient and civil society at the end of the implementation chain, the adequacy of national directives with international health rules, the greatest possible transparency in the processes.

The CCM trapped by the Global Fund

43The members we were able to meet all had a nuanced speech on the CCM. While they do not hesitate to denounce its instrumentalization, they stress that a significant part of its weakness is due to the requirements of the Global Fund itself. The technicality of the files, for example, is a problem. Unlike the Global Fund, CCM members do not necessarily have the expertise to address certain technical elements, even representatives of development partners from major international institutions at the country or regional level. The CCM secretariat needs to be strengthened, particularly in terms of human and financial resources. And the Global Fund's new funding model has added even more complexity to this situation rather than simplifying it: "the new standards are indigestible for secretariats". "It is a simplistic vision of the Global Fund to believe that capacity and competence are there, on the ground" (USA Interview).

44Paradoxically enough, the CCM finds itself trapped by the Global Fund, which does not allow it any room for manoeuvre to move the main lines of health. Even countries with a functional CCM suffer from its procedures that they consider inhibitory, rules that they find too coercive, the excessive power of the Technical Secretariat, Geneva etc. All representatives of development partners are suspicious of the new Global Fund model. They find that the eligibility criteria exhaust the meagre strengths of the Cameroon CCM. They consider that the national counterpart required is too high (at least 20%). Moreover, the requirement of this counterpart is in line with the Cameroonian government's requirement to be the sole recipient. What is the purpose of the CCM in these conditions, they ask themselves? (Interviews)

45The lack of transparency in the functioning of the Cameroon CCM can also, to some extent, be addressed to the Global Fund, they consider. Thus, the activities of the LFA (Local Fund Agency), which is the audit structure for accounts and programmatic results, are not known to the CCM. Its report addressed to the headquarters of the Global Fund in Geneva is not communicated to the CCM, which nevertheless requests it on the occasion of the missions of the Global Fund's experts to Cameroon. (Responsible interview of a multilateral organization WHO)

46The Global Fund is directive, at the same time, it does not give the CCM the means to be able to react or sanction abuses or failures on the ground. This has led the Cameroon CCM to avoid the problem of falsification, denounced by some health and civil society actors, of the distribution rates of antiretroviral drugs and impregnated mosquito nets (a coverage rate of 80% claimed, nearly 340,000 nets declared distributed, while field observations are far from corroborating these figures). This falsification is a defect punishable by suspension of the subsidy and non-renewal. "We do not want to take the risk of seeing patients deprived of treatment", defended some representatives of development partners accused of playing the game of opacity and turning a blind eye to corruption cases. "The only weapon is the recommendation" summarized one of our interlocutors (Interview Oms). However, when CCM members report on their supervision, there is no mechanism to monitor the implementation of their recommendations. Apart from the threat of suspension or withdrawal of funding, the CCM lacks the tools to impose better ways of doing things and arbitration mechanisms: "the CCM does not have sufficient authority" (Interview in charge of a multilateral organization).

47New partnerships, which could be called "private-private" partnerships, are a new response to the challenges of the Global Fund's Coordinating Mechanism. Some international NGOs report that they understand each other better and work more easily with patient representatives (as in the case of the NGO "P" for AIDS or MNM for malaria) than with CCM managers or Principal Recipients (PR). One international NGO coordinator described the above-mentioned dysfunctions as follows: «There is a great tension between the Principal Recipient and the others. This is even more aggressiveness in the context of the CCM. I thought I would be solicited in Cameroon as in other countries, it's quite the opposite. Is the functioning of the Cameroon CCM weakened? Who would benefit from this weakening?

The Global Fund traps the Cameroonian government

48From the leverage it was able to provide for health policies at the beginning of the 21st century, the Global Fund seems to have become a containment tool, out of step with the expectations and needs of the Cameroonian population. The assignment to the three specific pandemics of malaria, AIDS and tuberculosis, and to certain categories of patients in the target audience, can certainly be justified by the impact of these diseases. Despite this, two decades of dedicated funding and programmes have not had an impact on major health issues, particularly child and maternal health (Ministry of Public Health, 2016). Female mortality in childbirth or abortion remains excessively high: it is six times higher than the target of 100 per 1000. Neonatal mortality, ranging from 29 to 31 per 1000, is not declining (PSNLP, 2018). The rise of non-communicable diseases (cardiovascular diseases, cancers, diabetes, kidney failure, etc.) is being masked while communicable diseases are not yet under control.

49It is probably in the light of this observation that bilateral cooperation between Germany, France and the United States in Cameroon has evolved in recent years. Programmes are readjusted in line with Global Fund contributions, with a focus on public health, maternal and child protection, reproductive health, and support for the training of health workers. This consistency does not appear among other cooperation actors not represented on the CCM, whose projects may compete with each other or duplicate experiments already carried out. But a unambiguous consistency, the objective being above all to redeploy saved resources rather than to allocate additional ones.

50While structural adjustment policies have long required the withdrawal of the state and even "de-statetization", public action to be coordinated by the state suffers from a lack of resources. However, the demand for state services is relatively high in Cameroonian society. Criticisms of public sector failures and deficiencies also reflect an expectation of specific actions or arbitration by the state. By forcing governments and all other actors to fit into its governance framework, and consequently disqualifying those who do not master the exercise, the Global Fund is penalizing this demand for a strong state. In addition, the success of the tuberculosis control programme, which was put in place long before the creation of the CCM, raises questions. Is it linked to an "old-fashioned" formulation, in the tradition of postcolonial medicine, or to the additional resources deployed to combat opportunistic AIDS diseases or co-infections offered by the Global Fund? The answer, probably halfway through, in all cases questions local ownership of the Global Fund's approach.

Conclusion

51International partners have a special position in the Cameroon CCM, between leadership, benevolence and monitoring. Aware that their attitude, both discreet and proactive, is confronted with power relations that go beyond the CCM, they do not question the relevance of the CCM, but they consider that it suffers from tense relations, born of the State's difficulties in "good governance" and assumed public action. In fact, in Cameroon, the deconcentration of state services and the entry into force of decentralization laws binding on the delegation of powers and competences of public authorities over the past two decades have not meant the relegation of the state (Samé Ekobo, Iyebi Mandjeck, 2011). The power relations that are being reconfigured in the eyes of a government that is stalling to gain stability also question the nature of relations between partners that are potentially competing for visibility in public opinion or in the diplomatic game.

52The analyses resulting from our survey corroborate previous studies in the context of financing the fight against AIDS, such as the IDA/World Bank project in Cameroon in the early 2000s. The weaknesses and aporias noted in the regulation of the Joint Monitoring Committee (JMC) are almost identical to those we identified in 2015 with the Global Fund and the Cameroon CCM (Abdoulkadri, 2014).

53The main donors have changed, time has passed, some actors have left the system, but habits have remained and the NACP continues to "dominate" the CCM, as it once "influenced" CMS. The State seems to be lagging behind the administration of its health system, which remains "under-administered" (Gruénais, 2001). On another level, our conclusions are also in line with those of Séverin Cécile Abega (2007) who explained that development aid brings more problems and few solutions to the beneficiary populations and the State, reducing them to the position of perpetual beggars

54Beyond the dysfunctions of various kinds, the lack of control and arbitration mechanisms, the lack of political and technical skills deprive the CCM of a certain authority. It is also a fragility that the new Global Fund standards accentuate. Instead of acting as a pivot, the CCM, when not paralyzed, acts as a buffer. While it claims a more flexible approach, both closer to the field and more managerial, the Global Fund remains too prescriptive because its vertical structure complicates the appropriation of its approach at the local level. Beyond the reports and statistical monitoring, it is finally its ability to provide a global vision of health issues that is questioned and solicited by the various actors in Cameroon.

Bibliographical references

55 Abdoulkadri A., 2014, Les politiques de lutte contre le sida au Cameroun : de l’impréparation institutionnelle à la démobilisation locale, Thèse de doctorat Ph.D en Sciences Sociales, Cameroun, Université Catholique d’Afrique Centrale.

56Abega SC, 2007, Le Retour de la société civile en Afrique, Yaoundé, presses de l’UCAC, 206 p.

57Bayart JF, 1999, « L'Afrique dans le monde : une histoire d'extraversion », Critique internationale, n° 5, 1999 : 97-120.

58Eboko F., 2015, Repenser l’action publique en Afrique. Du sida à l’analyse de la globalisation des politiques publiques, Paris, Karthala, 264 p.

59Eboko F. & Awondo P., 2018, « L’État stationnaire, entre chaos et renaissance », Politique africaine, 150 : 5-27.

60Eboko F., Abé C., & Laurent C., Eds, 2010, Accès décentralisé au traitement du VIH/sida. Evaluation de l’expérience camerounaise, Paris, ANRS (Collection Sciences sociales et sida), 324 p.

61Guilbaud A., 2015 « Les partenariats public-privé sanitaires internationaux : diffusion et incarnation d’une norme de coopération », Mondes en développement n° 170 : 91-104.

62Gruénais ME, 2001, « Un système de santé en mutation : le cas du Cameroun », APAD, Bulletin n° 21, 2001 : 1-7.

63Iyebi Mandjeck O., Samé Ekobo M., 2012, « Gouvernance territoriale et action publique au Cameroun », Yaoundé, Enjeux, n° 45-46 : 9-13.

64Ministère de la santé publique, 2016, Plan stratégique national de lutte contre le paludisme (PSNLP) 2014-2018, 120 p.

65Ministère de la santé publique, 2016, Plan stratégique national de la sante de reproduction, maternelle néonatale et infantile (PSN/SRMNI) 2014-2020, 120 p.

66Ministère de la santé publique, 2016, Stratégie sectorielle de santé 2016-2027, 167 p.

67Nkoa FC, Eboko F., Moatti JP, 2010, « Coopération internationale et financements de la lutte contre le sida en Afrique : le cas du Cameroun », In Eboko F., Abé C., & Laurent C., Eds, Accès décentralisé au traitement du VIH/sida. Evaluation de l’expérience camerounaise, Pari, ANRS (Collection Sciences sociales et sida) : 13-27.

68Owona Nguini ME, & Menthong HL, « « Gouvernement perpétuel » et démocratisation janusienne au Cameroun (1990-2018) », Politique africaine, 2018/2 (n° 150) : 97-114. 

69Rapport annuel du Fonds Mondial, 2019.

70Samé Ekobo M., mai 2009, « Lutte contre le paludisme et Sida : interactions et implications pour l’action publique en santé (Cameroun, Burkina Faso, Botswana) » - communication à l’atelier Les configurations d’acteurs dans l’action publique en santé en Afrique, programme CORUS, IRD/GRIL, Ouagadougou.

71Samé Ekobo M., Iyebi Mandjek O., novembre 2009, « Stabilités et instabilités des territoires de l’action publique : les secteurs de la santé et de la sécurité au Cameroun », communication au colloque international Stabilités et instabilités en Afrique centrale : logiques et dynamiques d’une configuration régionale complexe, FPAE, Yaoundé.

72Samé Ekobo M., novembre 2008, « Le paludisme à l'heure du sida: recompositions d'une politique publique de santé au Cameroun », rapport pour l’atelier Les relations internationales et l’action publique nationale contre le sida en Afrique, programme CORUS, IRD/FPAE, Yaoundé.

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Notes

1 Interviews with full and alternate members representing international development partners in Cameroon's national coordinating body between June 2015 and February 2016 (UNAIDS, World Health Organization, France, United States/Management Sciences for Health)

2 See in this dossier the contribution of Stéphanie Tchiombiano.

3 For an analysis of the role of public authorities within the Cameroon CCM, please refer to William Tchuinkam's text in this issue.

4 The question of key populations is analysed in this dossier by Fred Eboko, Anicet Kabore and Cyrille Enyu'u

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Muriel SAME EKOBO et ABDOULKADRI, « International partners in the Global Fund coordination mechanism in Cameroon: reconfigurations based on instrumentalized governance (eng) », Face à face [En ligne], 15 | 2019, mis en ligne le 10 octobre 2019, consulté le 14 octobre 2019. URL : http://journals.openedition.org/faceaface/1397

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