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Côte d'Ivoire, a case study of power relations PEPFAR - Global Fund (eng)

Anne BEKELYNCK

Résumé

Executive Summary

Today, the Presidential Emergency Plan for AIDS Relief (Pepfar) and the Global Fund to Fight HIV/AIDS, Tuberculosis and Malaria contribute 67% and 21% respectively (including 30% from the United States) to the fight against HIV/AIDS. Despite different principles, these two initiatives are generally presented as complementary and united towards the same common goal: ending the HIV epidemic. This contribution analyses the power relations of these two actors in the field, through the case study of Côte d'Ivoire, which has the particularity of being mainly financed by Pepfar (70-80%), although not a priority; while being a priority country of the MF, although it only finances 10% of the AIDS budget. It is the result of qualitative research, combining observations from meetings of the Country Coordinating Mechanism - CCM (16) and interviews with members of the CCM Executive Board, civil society, international cooperation (French, American, Unicef) and the public sector. Within the CCMs, we have observed a dominance of the participation of international cooperation actors, and a relative minority of American partners in their positions, compared to an informal coalition of French and/or Francophones. Real influence is exerted outside the CCMs, through high-level negotiations that generate decisive scoping effects on CCM decisions; as well as through the Pepfar's operational mode of action, based on autonomy and the implementation of its own priorities, which devotes the FM to a reactive position. Since the adoption of the New Funding Model (NMF), the functioning of the FM has converged with that of the Pepfar. The risk is that it combines the disadvantages of both approaches, with the procedural and time-consuming nature of multilateral and "learning" organizations, without being able to justify a short-term impact equivalent to that of Pepfar.

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Introduction

  • 1 PEPFAR (President Emergency Plan for AIDS Relief) was founded in 2003 by US President George W. Bus (...)
  • 2 https://www.unaids.org/fr/resources/fact-sheet

1In the early 2000s, two initiatives - one multilateral and one bilateral - were launched successively to address the urgency of the epidemic: the Global Fund to Fight HIV/AIDS, Tuberculosis and Malaria created in 2002 and the Presidential Emergency Plan against AIDS (Pepfar)1 one year later, in 2003. Today, these two initiatives contribute 88% of the international funding allocated to the fight against HIV/AIDS, with 67% from Pepfar and 21% from the Global Fund (Kates et al., 2019). Thanks to the contribution of these two donors, 23.3 million people living with HIV receive antiretroviral (ARV) treatment worldwide, out of the 37.9 million people infected with HIV2. The United States is also the largest contributor to the Global Fund (30%) - far ahead of France (13%) and the United Kingdom (12%) - with US funding accounting for almost three-quarters (73%) of total international HIV aid funding (Kates et al., 2019).

Source: graph produced by the author from data from (Kates et al. 2019)

  • 3 See also Stéphanie Tchiombiano's contribution to this volume.
  • 4 accessed 5 September 2019

2When the Global Fund was created, its promoters aimed to develop an organisation that was different from traditional bilateral cooperation organisations, criticised for their top-down nature and bypassing local public authorities3. When the Pepfar was designed a year later, the priority was to respond effectively to the urgency of the epidemic, through the deployment of a vertical system. The FM is defined as a financial instrument (and not as an operator), without a presence in the countries where it operates - unlike Pepfar, whose offices are located in US embassies. The FM wants grants to be developed and monitored by the Country Coordinating Mechanism (CCM), following the principles of partnership and ownership, while the Pepfar develops its projects in which local actors have an advisory role. FM grants have a longer duration than Pepfar grants, although this has been reduced, with the transition to "concept notes", of 3 years (instead of 5-year "Rounds") for more flexibility; while Pepfar has been developing its Country Operational Programme (COP) on an annual basis since its inception. At the recipient country level, Pepfar initially focused on the 15 countries most affected by the epidemic (with an expansion to 32 countries today), while the Global Fund has funded more broadly, with 134 countries having already received funding for HIV, with a current tightening (76 countries currently funded4). The Global Fund therefore finances countries with relatively low epidemics and concentrated on populations, although it has been in a "transition" phase since 2012, to withdraw from countries considered to have the capacity to support their epidemics (according to income, prevalence, etc.) and has developed a classification in terms of impact and contexts.

Table Comparison Global Fund / Pepfar

Global Fund

Pepfar

Year of creation

2002

2003

Piloting

By the country via CCMs (country-driven)

Multilateralism

By the donor-driven

Bilateralism

Type of actions

Funding only (the FM is defined as a financial instrument, without representation in the beneficiary countries)

Funding and implementation (with offices in beneficiary countries)

Beneficiary countries

Large (134 countries have already received FM funding and 76 currently)

Focus on the most affected countries (15 at the beginning, 32 today)

Duration of grants

3 years (and 5 years initially)

1 year

3Generally, the Global Fund and Pepfar are presented as interdependent, complementary and successful initiatives, each armed with strengths and weaknesses that should be best exploited (Summers, 2017). Pepfar would be more effective in addressing the epidemic in countries with the highest HIV burden, thanks to their immense technical capacity and broad network (US government agencies and implementing partners); while the Global Fund would finance inputs and treatments, develop strategies more tailored to country needs and respond in countries less affected by the epidemic (Oomman, Bernstein, and Rosenzweig, 2007; Bilimoria, 2012). For example, Pepfar's presence in Tanzania would have enabled the Global Fund to use its funding more effectively, thanks to the technical support of the bilateral donor on the ground: accurate epidemiological data, a clear understanding of the country's bottlenecks and needs, assistance in building the capacity of health providers and in managing the entire drug supply chain (Bilimoria, 2012).

4To achieve this complementarity and avoid duplication, the two donors coordinate on different aspects (governance, programme development and implementation, technical assistance), at international, national and local levels. As the largest contributor to the Global Fund (30%), Pepfar holds a central position in decision-making bodies in Geneva (permanent seat on the Global Fund's Board of Directors, management positions for US government officials, Pepfar's participation in the TRP). For example, Pepfar organizes annual coordination meetings with the Global Fund on topics such as purchasing and the supply chain. At the country level, the two donors are mutually involved in strategy development, either as CCM members for the Pepfar or by being consulted in the development of the FM COPs. PEPFAR is the largest donor of technical assistance to support Global Fund activities, through activities such as support for the development of national strategic plans and grant proposals, capacity building (governments, CCMs), support to countries to mobilize increased national resources for HIV/AIDS and strengthening national supply chains to provide inputs and medicines (Summers, 2017).

5While the complementarity of the two donors is generally displayed, both of which are oriented towards a common objective, the coordination of international cooperation constantly faces significant obstacles in terms of duplication, blindness and competition (Severino and Ray, 2012). In this particular case, the issue of full collaboration is of particular interest, as Pepfar holds a dominant position as the main funder of the fight against HIV/AIDS on the one hand, and as the main contributor to the MF on the other. How do these relationships materialize on the ground? We will analyse here the collaboration, competition and instrumentalization of the two main donors in the fight against HIV/AIDS, based on the analysis of a case study, Côte d'Ivoire.

6Côte d'Ivoire has various characteristics with high heuristic value. First of all, it is the only French-speaking country to have benefited from the support of Pepfar since its creation. In the early 2000s, Côte d'Ivoire was the epicenter of the epidemic in the West African sub-region, with an epidemic estimated at 7% (at the time, it was estimated at 12%). The share of HIV funding from the two donors reflects relatively well that observed at the global level, with 72% of the fight funded by Pepfar and 17% by the FM for the period 2015-20175. Since then, donor investment and political commitment, coupled with the deaths of infected people and successive statistical readjustments, have significantly reduced the epidemic, now estimated at 2.6%. Côte d'Ivoire presents an ambivalent situation: less attractive for Pepfar, with actions considered to have a lower impact than in the southern and eastern African countries with higher epidemics; it was defined as one of the two "high-impact" countries in French-speaking Africa by the Global Fund in 2012, alongside the Democratic Republic of Congo. While the share of FM funding is relatively low compared to Pepfar in this country, Côte d'Ivoire remains the second most funded French-speaking country in West and Central Africa, behind Cameroon. This country is also marked by the still strong presence of the second largest contributor to the FM, France, which has still strong economic interests and cultural influence. Pepfar's continued presence on Ivorian soil is also due to its institutional and national proximity to the Center for Disease Control (CDC), whose Ivorian branch was created in 1987 to initiate a project on retroviruses: CDC Retro - CI6. Both the CDC of Côte d'Ivoire and the Pepfar are under the leadership of the United States Embassy7.

Source : site internet Pepfar ; site internet Fonds Mondial ; REDES 2010/2011 ; COP 2017 de Côte d’Ivoire ; National Health Accounts, funding request submitted to the Global Fund ; External – country reported, OECD DAC CRS.

  • 8 At the time of the survey, the Côte d'Ivoire CCM had the particularity of being structured into the (...)

7This research is based on an in-depth survey conducted by the CCM of Côte d'Ivoire between 2015 and 2017, using a qualitative methodology. We conducted observations of 16 CCM meetings (HIV/AIDS Committee8, General Assemblies, Extraordinary Meetings), as well as a meeting of the Working Group of the CCM Hub at the FM headquarters in Geneva (16-17 March 2016) and the sub-regional CCM consultation workshop, organised by the FM and Initiative 5% (Expertise France) which brought together 21 French-speaking African countries (12-15 September 2017). Semi-directive interviews were also conducted with members of the CCM Executive Board, civil society, international cooperation (French, American, Unicef) and the public sector.

8We will study in particular the participation and role of Pepfar in the CCM of Côte d'Ivoire (1st part), to then analyse how his strategic influence outside this arena governs him directly (2nd part), to finish on his use of soft power (3rd part).

Within the CCM: domination of international cooperation and relative minority of the Pepfar

Formal composition of the CCM-CI: FULL compliance with the recommendations of the FM

  • 9 Following the election of the Executive Board of the GA on 19 November 2015

9In the composition of its members, the CCM of Côte d'Ivoire respects the Global Fund's guidelines, which call for representation of all stakeholders in the fight against the three pandemics (public sector, civil society, private sector and bilateral and multilateral partners in the countries), with a minimum requirement of 40% of civil society representatives. On paper, digital power rests with civil society organizations (42%), followed by the public sector (24%), and bilateral and multilateral partners (20%). At the level of key positions, within the Executive Bureau, the Presidency is held by the government sector (Presidency of the Republic), while the three Vice-Presidents for the private sector (Chamber of Commerce and Industry of Côte d'Ivoire), civil society (Union syndicale des travailleurs, UGTCI) and technical and financial partners (Pepfar), with a representative of people affected or affected by one of the three diseases (RIP+)9. For some CCM members, this choice of Pepfar is perceived as more of an imposition than an election: "The real question is why among the TFPs, we were imposed on the Americans as VPs. Because in fact, we were made to understand in an informed way that we were going to choose this person (...) There were no other nominations (...) The Pepfar was always in the Vice-Presidency of the CCM" (CCM observer). Within the AIDS Committee, the representative of Pepfar is its President and, in order to balance the contribution of the two most dynamic international cooperations, the representative of France was proposed and appointed Vice-President of the Committee, under cover of an election by show of hands without opposing candidates at a meeting. This presence of donors as chairpersons of the Committees is, although honorary and pragmatic, indicative of the power relationships within the CCM.

From theory to practice: role reversal

  • 10 World Health Organization (WHO), United Nations Children's Fund (UNICEF), Ivorian site of the Agenc (...)

10In order to analyse, in practice, the "active participation" of CCM-CI members, we systematically took notes of 16 CCM meetings (11 HIV Committees, 2 General Assemblies (GAs), 3 country dialogues/concept note). The speeches were systematically quantified for each sector represented. This method of calculation is not totally representative, since it does not make it possible to take into account either the duration of the interventions or their quality. In addition, this technique is based on manual notetaking, with necessary omissions. However, the objective was to report a general trend, this estimate allowing to know the proportion of actors who intervene, animate and feed the exchanges. This analysis showed that the trend was reversed, with exchanges dominated by international cooperation representatives (Pepfar, Coopération française, UNAIDS, WHO, UNICEF, PAC-CI10 and independent observers), with an estimated 50% speaking time, while civil society representatives participated in 14% of the exchanges, which were mainly due to its two members serving as Vice-Presidents in the Executive Bureau and 6% of the national public sector. VS speaking board CCM representation (Figure1).

Figure Formal and effective participation in the CCM of Côte d'Ivoire

11The spatial organization of the CCM meeting room accentuates this contrast. Broadly speaking, a first circle of tables and chairs is more invested by the international partners who lead the debates; a second circle is occupied by representatives of civil society, the national public sector and the private sector who play a more spectator role.

12The main reason for the low participation of civil society and the public sector in CCMs is the inadequacy of the members' own characteristics (human, technical, financial and human resources) in relation to the mechanism created by the Global Fund. While the principle of "multisectorality" is attractive on paper - the fight against these epidemics requires the involvement of the whole society - it is translated into practice by inequalities in the interests, knowledge and skills of its members. Representatives of universities, trade unions, religious organizations or ministries other than the Ministry of Health (economy and finance, national education, family) are making up the numbers. Civil society members directly involved in HIV/AIDS are generally NGOs receiving funding from Pepfar and/or the Global Fund, limited by these power relationships and unwilling to oppose their donors. They usually intervene to present a specific project but participate little or not at all in the debates. In addition, Ivorian community mobilization has also always encouraged collaboration for smooth changes in confrontation with national public authorities and donors - in the same way as the community sector against HIV/AIDS in Francophone Africa (Broqua, 2018). If bilateral and multilateral partners dominate the exchanges (50%), followed by representatives of the CCM and the FM (20%), it is also largely because they master the complexity of the procedures and operations of the constantly evolving Global Fund. The FM is part of these Global Health Initiatives (GHI) which have their own institutional architectures, funding mechanisms and management systems, subject to iterative changes that require continuous training for the actors involved. Especially since the FM was created very quickly (in 6 months) and conceptualized as a "learning organization" for more flexibility and transparency (Bartsch, 2005), which poses an additional difficulty for actors whose primary function is not this, i.e. actors other than international cooperation representatives and CCM agents. Their job descriptions generally include this representation on the CCM - if not their major function, as is the case for the Pepfar "liaison officer" at the Global Fund, whose role is to ensure technical coordination between the two donors or for the regional health advisor in France.

At the discursive level: domination of an informal coalition of French/Francophiles and outnumbering of the Pepfar

  • 11 For example, at the meeting on 7 March 2017, where COP 17 was presented to the AIDS Committee.

13There is an atmosphere of mutual goodwill among the members of international cooperation, with the common objective of resolving the dysfunctions of the CCM, for a better impact of this collaborative tool and Global Fund funding. The CCM is first and foremost a forum for sharing general information on the state of the fight against these diseases in the world and in Côte d'Ivoire, which can serve in particular as a forum for sharing Pepfar strategies and their national operational programmes (Country Operational Plan - COP)11. The CCM gradually replaced the meetings between "technical and financial partners" that were formerly organized under the aegis of UNAIDS, but in which the silence of the Pepfar - despite being the main information holder - was criticized by the other stakeholders. Indeed, since 2014, Pepfar has been working towards greater transparency in the exchange of information with other bilateral and multilateral partners as well as with its information in general, as evidenced by the creation of the website https://data.pepfar.gov/​, which allows all indicators to be monitored in real time. The creation of the "Pepfar-Global Fund" liaison post reflects this clear commitment to better coordination.

14Concerning the positions taken within the CCM, the Pepfar tends to express a strategic vision that is more oriented towards impact research. This vision has relatively little resonance with an "informal coalition of French/French speakers" that has a vision that is more sensitive to multilateralism, "national ownership" and equity. Indeed, while French cooperation is directly present (regional health adviser and Service de coopération et d'action culturelle), other representatives of international partners or independent observers are French or have transited through the French system (UNICEF, PAC-CI, independent observer, European Commission) and reflect its values.

Agenda Questions

  • 12 Côte d'Ivoire benefited from Round 9 in 2009, initially for a period of 5 years (3 years, renewable (...)
  • 13 AGM of 25.02.2016

15We will present here a revealing and symptomatic example of the situation described above: HIV testing. Since COP 14 (October 2014 - September 2015), Pepfar has been advocating for the cessation of screening in the general population, in order to develop targeted screening for people likely to be infected with HIV, in order to achieve better performance (or a high "seropositivity rate"), and to put an end to what it considers a waste of inputs. However, until 2018, the Global Fund maintained population-based HIV testing strategies, with a vision of testing that benefits both HIV-negative people (because it leads to behaviour change) and HIV-positive people (because it involves behaviour change and treatment). However, this gap is not so much a result of a gap in strategic visions between the Global Fund (which would give priority to accessibility) and the Pepfar (focused on impact) as it is of a gap in agendas. With its system of annual COPs, Pepfar's strategies are evolving rapidly, incorporating new UNAIDS recommendations, unlike those of the Global Fund which, at the time of the survey in Côte d'Ivoire (2016-2017), were still based on those of Round 9, drafted in 200912. At a General Assembly13, a representative of the Pepfar asked the CCM about the need to document test positivity rates, in order to avoid "spending a lot of money" on tests that would not identify people with HIV. These recurring invective on this issue is hardly echoed within the CCM, both on the lack of sharing of this impact-based vision with regard to a vision favouring equity in access to screening - regularly reaffirmed by the national party - and on the CCM's inability to integrate new indicators and new guidelines during the grant period, the contractual indicator being the number of counselling and testing.

16Another example is data management tools. Pepfar is advocating for the adoption of their own system - called SIMS (Site Improvement Through Monitoring Systems) - which would allow a homogenization of HIV indicators in Côte d'Ivoire. There is talk of bringing the FM system into line with the Pepfar system, while French cooperation prefers a simplified approach that is integrated into the national system. Expertise funded by the 5% Initiative has thus been mobilized to develop strategic monitoring tools adapted to the context. However, the CCM is more a space of cognitive dissension where certain principles (verticality/integration, bi/multilateralism, impact/equity) are opposed than a decision-making space where strategic issues are really at stake.

Material: U.S. financial support for the high but invisible CCM

  • 14 Source: CCM of Côte d'Ivoire

17USAID is the largest contributor to the functioning and capacity building of the Côte d'Ivoire CCM (€455,000 per year), far ahead of the government (€166,000 per year), the FM (€115,000 per year)14 or France (€95,000 in 2017 in technical support through the 5% Initiative). The FM refuses to allocate too much direct funding to CCMs, which must be provided by the national party. However, US funding is not provided directly to the CCM, but mainly through the US NGO Management Sciences for Health - which funds technical advisors (including one full-time), site visits and workshops - making this money invisible to the CCM:"I have just learned that USAID is contributing $500,000 per year, but I don't see the color. It is invisible money, distributed by MSH, but diluted in administrative and other costs" (interview, member of the Executive Board, CCM-CI). The CCM therefore has very little financial autonomy, with little control over American and French technical support, and limited by the FM, which refuses to allocate too much direct funding out of respect for the principle of national ownership (so-called "counterpart" funding), as well as by the State, which, although mainly financing the salaries of contract staff (12 in Côte d'Ivoire), seconded officials (5 programme officers) and rent, does not fully support this ad hoc institution created exclusively for the FM. Thus, the Pepfar sometimes fills the gap in funding provided by the FM - for example, by funding site visits, since the FM only provides 4 for the 3 grants per year - which ultimately puts pressure on technical and financial partners (Bartsch 2005).

PEPFAR's domination outside the CCM

Non-CCM negotiations and scoping effects

18Pepfar, the Global Fund and the national side hold high-level negotiations outside the CCM arenas. These exchanges take place at different moments in the "life" of the CCM. In its "daily life", the FM tends to ignore the CCM, in favour of direct exchanges with the Pepfar, the national party and its principal recipients. For a long time, when the country team came on mission to Côte d'Ivoire, it did not visit the CCM, due to a busy agenda and the non-priority nature of the CCM (the country team is not evaluated on the performance of the CCM), which is no longer the case today. The CCM also has very few direct links with the Pepfar, their direct interlocutor being the NGO MSH and the Global Fund Liaison Officer. The Executive Bureau and the CCM secretariat complain that they do not have access to all strategic information, including that relating to Pepfar. Meetings between the Pepfar Country Office and the FM take place at the US Embassy, behind closed doors, while the country team meets with French cooperation during more informal meetings.

19A striking example of these "scoping effects" produced by high-level preliminary negotiations is the drafting of Phase 2 of Round 9 in 2013. At that time, donors were spread across Côte d'Ivoire, like a mosaic, whose coordination was becoming a major problem. The two main recipients of the MLF had received a severe evaluation from the Local Fund Agent (LFA) (B2 and C), which questioned the effectiveness of the MLF grants. It is in this context that a workshop was organised by the CCM to draft 0 this extension request (May 2013). Pepfar, in his capacity as Vice-Chair of the CCM, announced in the preamble that major decisions had been taken in a restricted circle: in particular, 70% of the funding would now be allocated to the purchase of inputs - a less "risky" and more impactful budget item, via the Global Fund's Voluntary Pooled Procurement mechanism. This meant that, given the limited amount dedicated to programmatic activities (community support, training, capacity building of laboratories and care facilities, etc.), it was decided to focus on only one of Côte d'Ivoire's 22 health regions (South Comoé). As a result, Pepfar became the only technical support for the clinical sector in the other 21 regions. Few voices were raised against these decisions - civil society being very dependent on the Pepfar and de facto bilateral actors absent. Despite ex-post attempts by French cooperation to influence this decision, it was ultimately non-negotiable - because it was decided between the Pepfar, the FM and the national party - and was implemented from 2013.

20This episode highlights several elements. On the one hand, the closed-door meeting held between the Pepfar, the national side and the Global Fund generated a strong "scoping effect", paralysing any further discussion. The CCM has been relegated to the role of a registration chamber for decisions taken outside the CCM, which goes against the original principle of participation and alignment of grants with country needs. This is a classic criticism of participatory mechanisms, which tend to focus more on staging a deliberative process, which is part of an aesthetic of itself, whose symbolic significance takes precedence over the added value of collaborative decisions (Gourgues, 2018).

21On the other hand, the asymmetrical power relations between the Pepfar on the one hand - which holds a hegemonic position in the fight against HIV/AIDS in Côte d'Ivoire and within the FM - and the national party, civil society, other bi- and multilateral partners and the Global Fund on the other hand, are reflected within the CCM. Although the CCMs are based on the principle of equal participation among all its members, this episode highlights how this naïve vision tends to deny the power relationships in place, as do many participatory mechanisms (Cooke and Kothari, 2001). A heavy dependence on it paralyses civil society organizations and the National Programme to Combat HIV/AIDS (PNLS), which it funds for key positions. In addition, the FM is under pressure to disburse its funding in order to justify the renewal of grants. There are few counter-powers, except for certain international cooperation actors (notably French) who struggle to play a substantial role in strategic decisions, within this configuration that is unfavorable to them. We also see here that Pepfar can take over the Global Fund, using it to serve its interests: thanks to the massive purchase of FM inputs, Pepfar can display an apparent geographical dominance of Ivorian territory.

Pepfar works, Global Fund reacts

22Since Pepfar holds a hegemonic position in Côte d'Ivoire - and in the HIV field more generally - it is in a position to develop its own strategies, so that other partners - including the FM - can align themselves with its decisions. At the end of Round 9, the CCM was invited to propose an application to extend this grant. Indeed, in September 2016, a 16-month latency period had opened until the new concept note following the New Funding Model (NMF) began in January 2018. The drafting of this note began at a pivotal moment: the Pepfar had just announced its new strategy, COP 15, where it differentiated between health districts according to their expected impact. It now offered minimum service packages in the so-called "maintenance" districts (40 out of 79 health districts they support), where the objective was to keep HIV-positive people on treatment, without enrolling new ones, and developed more intensive strategies in the so-called "scale up to saturation" and "aggressive scale up" districts. This request to extend Round 9 became an opportunity for the national party - and the CCM - to fill the districts left by the Pepfar. The drafting committee drafted three successive versions in this spirit, each of which was rejected by the Global Fund, which did not wish to fill the gaps left by the Pepfar and carry out actions in so-called "low impact" districts. The extension was finally granted in the same format as the previous phase (Phase 2 of Round 9), i.e. with technical support only granted in the South Comoé health region. The writing of an article in Transversal magazine, describing this process in detail (Bekelynck et al. 2016), generated strong reactions from the FM Country Team, stating during a visit to the Côte d'Ivoire CCM that their role was in no way to finance equitable access to services.

23This episode highlights several facts. Defining its action programmes on an annual basis, in the form of a Country Operational Plan (COP), it has greater flexibility in its orientations, readjusting from one year to the next its priority areas, populations and strategies as well as its objectives. Despite the adoption of the more flexible format of the "concept notes", over a three-year format, the FM is struggling to keep pace and is doomed to a reactive position. This problem also occurs in the field. For example, even if discussions lead to a distribution between community NGOs, Pepfar and FM operating in common health districts, the variability of Pepfar's budgets and priority areas leads to a fragile balance that needs to be rebuilt each time the area and strategy change.

24At the time of writing the extension request, the FM had the opportunity to adapt to the country's needs, especially since the drafting of the 2016-2020 National Plan to Combat HIV/AIDS had just been completed. However, this window of opportunity has not been seized, due to more structural issues. If Pepfar is the first donor to the FM and both donors show their collaboration, there is competition between the two donors in a race for the best impact. This approach was accentuated in the early 2010's, with the stagnation of international resources (United Nations 2018). In 2012, the MLF adopted its New Funding Model (NMF), which aimed to have a greater and more sustainable impact in the fight against the three pandemics. Two years later, Pepfar launched its Program "Pepfar 3.0: Controlling the Epidemic: Delivering on the Promise of an AIDS-free Generation", targeting strategic investments for greater impact and efficiency. While there is convergence between the two donors on common practices, it is more a convergence of the FM towards those of the Pepfar, where the justification of disbursements and efficiency takes precedence over the principles of national ownership and partnership (Tchiombiano, Nay, and Eboko 2018).

Cognitive and symbolic power

25Finally, the power plays are observed at the soft power level, particularly in the production of scientific knowledge and the control of indicators. Pepfar must justify the effectiveness of its actions to US taxpayers and Congress to renew its funding each year and the Global Fund to its donor countries, particularly at the replenishment conference. At the country level, portfolio managers must ensure that funds are disbursed for the country for which they are responsible, based on their performance, in order to renew future disbursements and grants. While their actions are intertwined and complementary, these two donors face the thorny question of the authorship of indicators, or even the "race for indicators" (Salais, 2004). On a presentation of their COP 15, the Pepfar claimed to support 98% of people on ARVs in Côte d'Ivoire; while the FM, through the CCM's strategic monitoring tools - dashboards - and the Global Fund website, it is the national data that is collected on their behalf (despite the 10-15% contribution from the FM).

26To assert its cognitive domination, the Pepfar uses what Philippe Zittoun defines as a "formidable weapon": cards. (Zittoun 2006, 12). Among the "instruments of public action", the maps (and the indicators on which they are based) cover three main functions: 1) it is a tool for objectification, simplification and problematization, which contributes to the construction of a phenomenon into a "public problem"; 2) it is a means of legitimizing both the phenomena in question and the experts who support it; 3) it is a decision-making tool, which promotes action (Lascoumes and Le Galès 2005).

  • 15 The MAP, Multi-country AIDS Programme, is the World Bank's programme against AIDS, launched in the (...)

27At the end of the 2000s, Côte d'Ivoire faced a certain "polyarchy" of its donors against HIV/AIDS. In 2009, the World Bank reinitialized its Multisectoral Emergency Programme to Combat HIV/AIDS (PUMLS, MAP15funds) by focusing on prevention and care activities in four regions (Mountains, Savannah, Lagoons, South Comoé) ($20 million). In 2010, the Global Fund made a strong comeback, with the signing of Round 9 for allocated budgets of $39 million for Phase 1 (2011 - 2013) and $94 million for Phase 2 (2013 - 2015). The objective of this grant was to cover 100 health sites in 29 health districts (20 of which had been managed by Round 2). Unicef was also active in mother-to-child transmission and the care of orphans and vulnerable children (OVCs), while Pepfar was in the process of decentralizing its activities, with financial domination.

  • 16 In 2010, Côte d'Ivoire received the Global Fund's Round 9 grant. However, very quickly, several dif (...)
  • 17 The "Pepfar system" is based on the mediation of partner NGOs (mainly American), responsible for tr (...)

28In order to coordinate this "polyarchy", avoid the traditional problems of development aid (duplication and blind spots) and overcome the tensions linked to the "paternity" of indicators, the main donors (Pepfar, FM, World Bank, Unicef) joined forces in 2009. The purpose of this ad hoc coalition was to develop several maps (one for each programmatic area), under the formal coordination of the State. This exercise was ironically renamed by local actors the "Ivorian Yalta", underlining the symbolic importance of international financiers' appropriation of territories, sometimes to the detriment of the principle of national sovereignty. The complexity of this division has created major difficulties in the operational implementation of activities. In addition, some donors have seen their activities reduced or stopped. Following the post-electoral crisis, the World Bank withdrew. In addition, the effectiveness of the Global Fund was questioned during the evaluation of Phase 1 of Round 916, which resulted in the sharing of the territory between Pepfar (19/20 health regions) and the Global Fund (1/20) for the clinical component (see above). In order to organize its activities, it distributed its seven implementing partners (PMOs) throughout its "area"17, using a map, which was then widely disseminated in the HIV/AIDS community, as reflecting the distribution of Pepfar/Global Fund activities (see map).

Figure Distribution of pepfar donors and implementing partners by Pepfar (2013)

A trompe-l'oeil map: a powerful optical illusion

29While the share of Pepfar funding remained relatively stable during this period (between 70-80%), the image that was produced, thanks to the support of the cards, was radically different. The 2009 maps depicted an ungovernable "puzzle", where the Pepfar was just one of many donors, while the 2013 map represents a precise and homogeneous delimitation of donors. This simplifying mapping gave the image of a clear, streamlined, controlled and effective coordination of actors. However, it has led to an overestimation of the United States' action. On the one hand, the role of the State has not emerged in terms of national and local coordination, human resources employed, infrastructure and equipment or input management. The role of the Global Fund was also minimized, as the map did not show the actions it continued to carry out throughout the country: purchase of 50% of ARVs, supervision of health districts and regions, "community" actions (prevention, screening, psycho-social care) carried out by the community principal recipient, Alliance-CI. These maps were not intended, a priori, to be representative of the role of the various actors in the fight against HIV/AIDS in Côte d'Ivoire, but to present the Pepfar's strategies. However, due to the lack of local "counter-expertise", whether from the State, the Global Fund or UNAIDS, they have been presented as such and rarely challenged, becoming an instrument of cognitive domination and legitimization of the American donor. From an optical illusion, this map has become a mark of American domination. The effects of this successful posture illustrated by this map were raised during the drafting of the concept note (2017). In order to restore a more realistic view of the situation, the CCM wanted to develop a new map, including one for advocacy with the Global Fund, to show them that the grant was not limited to a health region (South Comoé), "to visualize where they are, to tell them'this is where you are, and these are the gaps to fill in these areas'". (CCM Secretariat agent) (CF Card). This map surprised Geneva, realizing that the FM had many actions throughout the country. Thus, the analysis of the cognitive and performative power of these instruments allows us to put their apparent technicality and neutrality into perspective (Lascoumes and Le Galès 2005, 13).

Figure Distribution of donors in Côte d'Ivoire by CCM in 2017

30This quest for recognition of the actions financed also takes place at the local level, on the perception that the beneficiaries of these funds have of each partner at the international level. A CCM officer said,"Maybe there are TV ads on FM grants, but in the field, it's not known... We need to know it's the FM! The Pepfar, they're very good at it. They want us to know what they did, they impose themselves. It's as if they're the only masters. They took a good part of Côte d'Ivoire, depending on the area, I decide, and I leave regions and areas to the national part... You have to fish in areas where you know you can have fish... Everyone today is talking about the Pepfar. The FM must be known, so that people do not get this fear of the FM" (agent of the CCM Secretariat). Indeed, in its bureaucratic operation and in the adoption of risk management tools, the FM has acquired a bad reputation among its beneficiaries, preferring the more direct, albeit highly pressurized, operation of the Pepfar.

Conclusion

31The analysis of the Ivorian case highlights the extent to which the power struggles between the two donors, beyond their common objectives, are tinged with instrumentalization and competition. These power relations tend to turn to the advantage of the Pepfar, which, armed with its financial, strategic and cognitive power - and few counter-powers on the other side - develops its own orientations. This is one of the advantages of an asymmetrical bilateral relationship, which shapes the rules of the game, directing priority towards short-term impact. The latter takes precedence over issues of equity or national sovereignty. National actors - civil society and the public sector - are paralysed by their financial dependence. For its part, French cooperation is developing strategic options that are more oriented towards the long term and national ownership, in opposition to the dominant movement within the FM. As for the CCM, it cannot influence negotiations at the local level, ignored by the Pepfar, or when it is taken into account, acting as a registration chamber, with significant "framing effects". This decline of the MF towards the search for strategic investments since 2012 has given rise to some criticism, particularly of its tendency to become a more vertical, donor-centred mechanism, with a priority to demonstrate the impact of investments and an underestimation of systemic and sustainable issues (Kapilashrami and Hanefeld, 2014). The current risk of the FM is to combine the disadvantages of both approaches, with the procedural and time-consuming nature of multilateral and "learning" organizations, without being able to justify a short-term impact equivalent to that of the Pepfar.

32The reaffirmation of the founding principles of the FM is now more of a legitimate rhetoric. When asked about the functioning of the Pepfar, an FM agent in Geneva associated the functioning of the Pepfar with a step backwards, with "colonialism". The Replenishment Conference today gives the MLF an opportunity to re-affirm its own values on which it has based itself, as opposed to vertical approaches, and to assume responsibility for playing on another field, that of equity, real ownership, with strong trust in national actors, while agreeing to produce less immediate and more sustainable results.

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Notes

1 PEPFAR (President Emergency Plan for AIDS Relief) was founded in 2003 by US President George W. Bush. Until the end of its mandate, this program was commonly referred to as the "Bush Plan".

2 https://www.unaids.org/fr/resources/fact-sheet

3 See also Stéphanie Tchiombiano's contribution to this volume.

4 accessed 5 September 2019

5 consulted on 24 September 2019; the remaining 11% is supported by the national part

6 CDC Retro-CI: https://www.cdc.gov/globalhealth/countries/cote-d-ivoire/pdf/Cote-D-Ivoire_Factsheet.pdf

7 Most of Pepfar's funds in Côte d'Ivoire are managed by the CDC and the U.S. Agency for International Development (USAID), with contributions from the Department of Defense (DoD), the Department of State (DoS), the Administration des Ressources et Services de Santé (HRSA), and the Institut National de la Santé (INS), https://ci.usembassy.gov/fr/our-relationship-fr/pepfar-fr/quest-ce-que-le-pepfar/

8 At the time of the survey, the Côte d'Ivoire CCM had the particularity of being structured into thematic committees (HIV/AIDS, malaria, tuberculosis, health systems strengthening, finance).

9 Following the election of the Executive Board of the GA on 19 November 2015

10 World Health Organization (WHO), United Nations Children's Fund (UNICEF), Ivorian site of the Agence nationale de recherche sur le VIH/sida et les hépatites virales française (PAC-CI)

11 For example, at the meeting on 7 March 2017, where COP 17 was presented to the AIDS Committee.

12 Côte d'Ivoire benefited from Round 9 in 2009, initially for a period of 5 years (3 years, renewable for 2 years). Following various delays and crises (initial signature delayed, post-electoral crisis in 2010-2011, Global Fund crisis in 2011), the Round 9 grant ran until September 2016 (Phase 1: 2010-2013; Phase 2: 2013-2016), with an extension granted until January 2018.

13 AGM of 25.02.2016

14 Source: CCM of Côte d'Ivoire

15 The MAP, Multi-country AIDS Programme, is the World Bank's programme against AIDS, launched in the early 2000s for renewable five-year periods.

16 In 2010, Côte d'Ivoire received the Global Fund's Round 9 grant. However, very quickly, several difficulties slowed down its implementation: a post-electoral crisis, the country's administrative capacity considered insufficient by Geneva, the significant turn over of the principal recipients, the Ministers for the fight against HIV/AIDS, the presidents of the CCM (Country Coordinating Mechanism) and the portfolio managers of Côte d'Ivoire (4 in 2 years). In the end, the funds are only released in 2012. Ad hoc cooperation platforms are being set up to manage these gaps created by this latency period. In addition, a whole group of NGOs and associations are technically unemployed.

17 The "Pepfar system" is based on the mediation of partner NGOs (mainly American), responsible for training and providing technical and material support to health centres (public and private), as well as community-based (CBO) or faith-based (FBO) organizations. In 2009, 80% of international funds were allocated to international NGOs and multilateral agencies' country offices, 8% to other national private organizations, compared to 12% allocated directly to the public sector (CNLS Côte d'Ivoire 2010).

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Anne BEKELYNCK, « Côte d'Ivoire, a case study of power relations PEPFAR - Global Fund (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/1413

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