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Public health, private approach: The Global Fund and the involvement of private actors in global health (eng)

Stéphanie TCHIOMBIANO

Résumé

Executive Summary:

The Global Fund, a financial instrument created to mobilize, manage and distribute funds dedicated to the fight against AIDS, tuberculosis and malaria, is a perfect illustration of the recent reconfiguration of the international health system and the emergence, since the end of the twentieth century, of international "public/private partnerships". What place do private sector actors really occupy within the organization, and to what extent does this participation change, or not, the way the Global Fund operates?

This article first describes and analyses the role played by private actors within the Global Fund, from defining institutional strategies to monitoring the successful implementation of grants. The second part of the text deals with the process of the Global Fund's appropriation of private sector logics and methods in the implementation of its own tools and working methods.

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  • 1 This article is fully in line with Auriane Guilbaud's work, by deepening the Global Fund's analysis
  • 2 Nous reprenons ici la définition d’Auriane Guilbaud, qui identifie 17 Partenariats Public/ Privé Sa (...)

1Private sector actors have long been involved in the health sector (Guilbaud, 2015)1. Nevertheless, the turn of the 2000s corresponds to an exceptional evolution of new actors and innovative strategies, with the emergence of many "public/private partnerships". While this new concept remains relatively vague (Buse, 2000), it refers to the principle of initiatives bringing together public (state) and private actors (whether or not they are for-profit), around a collective health good, with an independent governance structure in which public and private actors are represented2. The Global Fund to Fight AIDS, Tuberculosis and Malaria represents one of these new initiatives and embodies this reconfiguration of the international health system.

  • 3 Since its creation in 2002 and until 2018, the Global Fund has mobilized US$41.6 billion to fight t (...)
  • 4 It should be recalled that HIV-AIDS was the first disease to be the subject of a United Nations Spe (...)
  • 5 "The only way to end the epidemics of HIV, tuberculosis and malaria is to work together: public aut (...)

2Since its creation in 2002, the Global Fund has been an innovative financial mechanism to mobilize, manage and distribute funds dedicated to the fight against AIDS, tuberculosis and malaria3. A foundation with Swiss status, it claims an independent positioning from the United Nations system, more modern, less technocratic, more efficient and fundamentally linked to the private sector. Its creation is intended to meet both a major health need (the need to mobilize massive funding to respond to the health emergency4) and the need for aid effectiveness in all areas of development (Kindornay, 2011), driven by OECD countries and more specifically by Anglo-Saxon countries (Nay, 2017). It proposes a framework based on the four new international standards of "partnership", "ownership", "results-based financing" and "transparency" (Tchiombiano, Eboko, Nay, 2018). More specifically, it stresses the need to involve all actors5, including private for-profit sector actors, in the fight against the three diseases, in the name of their effectiveness and expertise.

3In contrast to the public sector, which is run by the State, the concept of the private sector broadly includes enterprises, privately owned banks, social economy actors (mutuals, cooperatives, associations) and non-governmental organizations.

4In this article, we will use the term private actor in a narrower sense, generally used in English, to refer to privately owned companies and financial actors operating for profit in the sectors of trade, industry, banking, insurance, consulting and finance, as well as their related philanthropic organisations.

  • 6 The Bill and Melinda Gates Foundation, created in 2008 by the American billionaire, is heavily invo (...)

5This article does not focus on the commercial relationships of private sector actors with the Global Fund (e.g. when they produce and supply medicines, impregnated mosquito nets or laboratory equipment purchased with Global Fund funding), nor the benefits they derive from them. Similarly, we will not attempt here to report on the influence exerted by these actors on strategic decisions (although there would be much to say, for example, on the weight and influence of the Bill Gates Foundation6). Rather, we will focus on how private for-profit sector actors have gradually been viewed as "partners", going beyond their role as suppliers. Can we say that private actors really participate in the fight, and in what way? What are the rationales behind this involvement? To what extent does this change the face and strategies of the fight against the three diseases?

6Our hypothesis is that the Global Fund is emblematic of a rise in the world of health aid of practices, techniques, representations and values inspired by management and finance. In terms of methodology, we worked on the basis of semi-directive interviews, observation, analysis of the Global Fund's institutional literature (primary documents and the Global Fund website), and scientific literature. We will repeat here the approach described by Eve Chiappello, who studies the circulation of market actors' standards: "This approach pays attention to the management tools, devices and instruments that equip the action, weigh on the situations with their own weight and escape, in part, the intentions and projects that led them" (Chiapello 2017), by asking us about the integration by the Global Fund of private sector standards. To what extent do the different tools set up by the Global Fund reflect the world views, knowledge and know-how of private actors? It should be noted that this trend is not specific to health and also affects, for example, education (Chiapello, 2017) or agricultural development (Gabas, Vernières, 2017).

7We will first study the role played by private actors within the global fund, from the definition of institutional strategies to the monitoring of the proper implementation of grants, then we will see to what extent the Global Fund has appropriated the logic and methods of the private sector to set up its own tools and working methods and what effect this may have had on the practices of actors in a country like Niger.

What role(s) for private sector actors within the Global Fund?

8Institutional discourse gives private sector actors an important place and role within the Global Fund. Peter Sands, the Global Fund's new Executive Director, explains: "Our fight to end AIDS, tuberculosis and malaria can only be successful if we work with partners in the private sector. (...) We need the resources, innovation and expertise of the private sector to counter the threat of drug resistance, expand our sphere of influence and build stronger health systems - all of which will save more lives7. Beyond the affirmation of principle, what is the concrete involvement of private actors?

9Olivier Nay identifies four different levels where the presence of market actors is strengthened in what he calls "a public role of private actors": the construction of development agendas (governance), the financing of international programmes, the delivery of technical assistance and, finally, consulting, audit and evaluation activities with public aid actors (Nay, 2017). We will add a fifth level for the Global Fund: the concrete implementation of interventions since the Global Fund sometimes entrusts grants to a private actor (rather than to a public prosecutor, or to an NGO) to set up a programme or grant.

10In this first part, we will therefore review all five levels of private sector involvement in the Global Fund, from governance to technical assistance, financing, implementation and audit of interventions.

Private actors in the governance of the Global Fund

11Private sector actors are primarily involved in the governance of the Global Fund and participate in the development of the organization's strategies. Of the 20 voting seats on the Global Fund's Board of Directors, the Articles of Association provide for one seat to be allocated to the private for-profit sector (e.g. Goodbye Malaria in 2019, alternating with Merck Pharmaceutical) and another seat to be allocated to private foundations (e.g. in 2019, the Deputy Director of the Bill Gates Foundation, alternating with a representative from the Kaiser Foundation). Each delegation defines its own selection procedure.

  • 8 The role of these CCMs is to (1) coordinate the preparation and submission of funding applications; (...)
  • 9 The Global Fund's guidelines state:"Given the breadth of expertise and resources that the private s (...)

12The private sector is also represented at the country level of the Global Fund's operations, in the country coordinating mechanisms (CCMs8). These private actors can be large for-profit companies that have "demonstrated their commitment" to the three diseases, organizations representing small and medium-sized enterprises and the informal sector, business associations involved in the fight against HIV, tuberculosis and malaria, representatives of exposed industries, private practitioners and directors of for-profit clinics, or philanthropic foundations created by large companies. While the participation of private sector actors in the CCM is not a prerequisite for access to funding, as may be the case for civil society (which must represent 40% of members), private sector actors are included in the pre-established list of non-governmental constituencies to be included in the CCM9, and the Global Fund strongly encourages countries to stimulate this participation (Bekelynk, 2015).

13While the Board plays a central role in the governance and strategy development of the Global Fund, it is also interesting to look at those who have led the organization since its inception. Three of the five Global Fund directors had a strong relationship with the private sector: Richard Feachem (2002-2006), the first Global Fund director, from the World Bank, who headed the scientific board of the Investing in Health report; Gabriel Jaramillo (2012-2013), a Brazilian who was Chairman and CEO of Sovereign Bank before assuming the role of intermediary at the head of the Global Fund; and Peter Sands (Executive Director since November 2017), an English national director of Standard Chartered PLC. Peter Sands is perhaps the most mobilized of all on the importance of the private sector, making numerous statements in collaboration with private actors. At the World Economic Forum in Davos in 2018, a partnership with alcohol producer and distributor Heineken was announced. Many voices were immediately raised to10 denounce the incompatibility of such a partnership (finally aborted), for reasons of coherence and public health, to which Peter Sands responded with the following words: "the global health community needs to engage the private sector more rather than less" (Marten, Hawkins, 2018). He also said "we must find better models of collaborating with the private sector. I don't have a magic wand to achieve this, but I can promise that under my leadership the Global Fund will take a big picture view of its mission, and a collaborative approach towards achieving its goals11. The other two directors had academic profiles: the French Michel Kazatchkine (2007-2012) and the American Mark Dybul (2013-2017). This presence of private for-profit sector actors on the Board of Directors, and the presence of several personalities from the financial world at the head of the organization, help to explain how the Global Fund approaches health issues.

The private sector's financial contribution to the Global Fund: a minority share

14The second role played by the private sector within the Global Fund is that of a financial contributor.

  • 12 Source Global Fund. It should be noted that these are private and non-governmental actors (includin (...)
  • 13 For example, the contribution of private sector actors was US$359 million for the three-year cycle (...)
  • 14 For the period 2017-2019, private sector actors have committed $850 million to the Global Fund.
  • 15 The official launch ceremony was preceded by a private sector engagement sequence, co-organized wit (...)
  • 16 The Gates Foundation's overall contribution since the inception of the Global Fund is just over US$ (...)
  • 17 Since its launch in spring 2006 and until 2019, (RED) has generated approximately $420 million for (...)

15Between the creation of the Fund in 2002 and July 2019, private sector actors had contributed US$2.73 billion to the12 Fund's resources. This private sector contribution has increased steadily since the inception of the Global Fund, in line with the increase in the total budget of the Global Fund13. It has remained a very small minority. While this role as a donor is the first role to which private sector participation is associated, this amount, in relative volume, represents only about 5% of the Global Fund's overall funding14. While partnership with private for-profit sector actors therefore does not substantially increase the volume of resources, it is interesting to see that the private sector remains a key target: at the sixth Replenishment Conference in Lyon in October 2019, the objective is to raise an additional $14 billion, including at least $1 billion (more than 7% of the total) from the private sector for the next three-year cycle. The replenishment campaign was launched in September 2018 in Paris, at the Quai d'Orsay, highlighting the partnership with the private sector15. A more detailed analysis of the nature of the funding presented as coming from the private sector shows that it comes mainly from the Bill and Melinda Gates Foundation (75% of all private sector contributions16). Apart from the Gates Foundation, the second contributor is the partnership launched by Bono and Bobby Shriver Product (Red). Linked to the One Campain association (campaign and advocacy organization), the principle of (RED) is to collaborate with brands (such as Air Asia, Apple, Starbuck, Beats, Gap or Telcel) that develop products and services bearing the (RED) sign. A percentage of the income related to these outputs is then systematically allocated to the Global Fund (for targeted programs)17. Chevron Corporation is the third largest private contributor. The American oil company was considered a "champion" in 2008, but its contribution then declined steadily.

  • 18 The HER initiative was launched at the annual meeting of the World Economic Forum in Davos, Switzer (...)

16As private companies are generally more interested in targeted funding for specific activities and locations, the Global Fund seeks to encourage them through the establishment of common platforms such as the HIV Epidemic Response (Her) Initiative for18adolescent girls and young women in 13 African countries.

  • 19 Tribune "Le défi sanitaire mondial est aussi l'affaire des entreprises", Les échos, 16 May 2019.

17This mobilization of private sector actors is also reflected in the creation of business coalitions grouped around health issues, whether at the global, regional or national level. The model of the Global Business Coalition on Health, founded in 2001, as part of the process of creating the Global Fund, was then applied at the regional level. The European initiative "Business for Global Health / Entreprises pour la santé mondiale", created in May 201919 or the A4A partnership (Africans for Africa) as well as at national level (with for example "Santé en Entreprises" in France are examples of this. In line with this approach, in 2017 the Global Fund signed an agreement with the French Council of Investors in Africa.

  • 20 We can also quote the former Director of External Affairs of the Global Fund, Christopher Benn:"Inn (...)
  • 21 This system, implemented in 2010, aimed to make antimalarial treatment affordable.
  • 22 Since the inception of the scheme in 2007, three countries have agreed to cancel their debt on cond (...)
  • 23 Establishment of a regional health fund by the Asian Development Bank in partnership with the Globa (...)
  • 24 A pilot project is underway, in partnership with the Union to fight tuberculosis in India, by mobil (...)
  • 25 We can also think here of the "pandemic Bonds" set up at the time of the Ebola infection epidemic, (...)

18Private actors also contribute to the emergence of innovative financing. Indeed, in view of the increasing increase in needs and the difficulty of mobilising constrained public funding, the creation of new sources of funding is presented as a real solution20. Just a few months after taking over the Global Fund, Peter Sands already mentioned them: "Innovative financing mechanisms (from impact bonds, to blended finance, matching funds and results-based funding) can all play "a significant and important role in what we're doing both in terms of improving the effectiveness with which we deploy existing funds and in attracting new monies" (Saldinger, 2017). These innovative financing initiatives can be initiatives aimed at mobilising new financial resources, such as the Product (Red) partnership, grant programmes, such as the Fund for affordable antimalarial drugs, AMFm21. They can constitute debt2Health schemes based on the idea that a "donor" country can cancel a national debt on condition that the money is partly reinvested by the debtor State in health programmes linked to the Global Fund22. Other initiatives such as "mixed financing", combining grants with public borrowing23 or "development impact bonds" are also being tested by the Global Fund24. The principle of these schemes is to raise capital from the market sector to finance health programmes, with a view to reimbursement provided that the objectives of the programme are met. Generally presented as a solution to the depletion of public funding, some of these innovative financing25, such as social impact bonds, raise many questions: the difficulty of regulation and control; the ethical issues related to the fact that financial investors can make profits through health interventions affecting the most vulnerable; the risk of public authorities being disempowered; the potential drift in targeting interventions towards more "profitable" populations, easy to reach and take charge of, and not towards the most marginalized groups, among others.

19

Empowerment of private sector actors in the implementation of subsidies

20In some cases, Global Fund financing is entrusted to private for-profit sector actors, companies or banks to implement health programmes. Presented as a last resort26, and generally in the name of their effectiveness or management capacity, this option to entrust grant management is quite specific to the Global Fund. About 2% of Global Fund grants were awarded to private for-profit sector companies between 2002 and 201927. A few examples illustrate this situation: Anglogold Ashanti Bank in Ghana and Argentina, Sogebank Bank in Haiti, or SEIB28 in Benin.

21This possibility of contracting directly with private for-profit actors helps to reposition them in the field and strengthen their social legitimacy. This type of contract with international organizations, linked to management fees that can be comfortable, gives them what Olivier Nay calls a public role (Nay, 2017). This interweaving of one (private) domain into the other (public) effectively blurs the border between them and both public authorities and "traditional" operators such as non-governmental organizations.

Private actors in the technical support of other actors

22This role has three levels: support, advice to the Global Fund secretariat itself; capacity building for local actors, including on issues of procurement, financial management and technological innovation; and "monitoring" of results achieved as well as compliance with Global Fund procedures.

  • 29 One example is the Boston Consulting Group, which supported the Global Fund to develop its new fund (...)

23First, several private for-profit actors and consulting firms are mandated by the Global Fund, either to support it in defining its operational strategies29 or to advise it on its internal organization. For example, the risk management system was designed with the support of the insurer Munich Ré.

  • 30 The 5% Initiative, set up by France Expertise International (FEI / now Expertise France), a structu (...)
  • 31 Created in 2007, the US technical assistance project "Grant Management Solution" linked to USAID cl (...)

24In addition, many private actors carry out technical expertise missions "in the field" in the countries of intervention. A large market for technical assistance has gradually developed around the Global Fund, due to the complexity of its procedures, which often requires "national" actors or international partners from these countries to seek expert support for access to and management of Global Fund financing. This contract is subcontracted to private service providers, individual experts or consulting firms, who are responsible for providing technical support and strengthening the skills of those working in the field. The creation of the Global Fund and the availability of significant resources in line with its mandate have thus led to the emergence of a new professional field of expertise. The latter are no longer only experts in epidemiology, public health or patient diagnosis and care. They are primarily experts on the Global Fund and its operating procedures. While this role of mobilizing private expertise is largely carried out by bilateral mechanisms such as the 5% Initiative (30France), the Back Up Programme (German GIZ) or previously by GMS31 (United States), the Global Fund also directly mobilizes individual technical experts or private consulting firms.

  • 32 Coca Cola project, implemented in 2010, in partnership with the Global Fund, the Bill and Melinda G (...)
  • 33 Platform set up in 2019 coordinated by the Global Business Coalition on Health (GBC Health).

25The Global Fund has signed several agreements with companies to benefit from their "know-how" in specific areas. The first area affected by this type of partnership is procurement, including the "Last Mile32" project with Coca Cola. Beyond the skeptical reactions that point to the complexity of associating a multinational corporation with the Global Fund and its sulfurous reputation, and whose sodas are known to be partly responsible for the global obesity epidemic, this project consists in logistically and technically supporting ten African countries so that they are able to distribute drugs to the most inaccessible populations, who also easily access a bottle of Coca-Cola. Procurement issues are considered by the Global Fund as a major obstacle to achieving results and a dedicated "Logistic for health33" platform now brings together the companies invested in this subject.

26The second area in which companies are called upon to provide technical assistance is of course financial management expertise. For example, a partnership with Ecobank was signed by the Global Fund in 2014 to strengthen the financial skills of Global Fund grant recipients in 20 African countries34. This project is a continuation of another partnership signed in 2008 with Standard Bank, which focuses on building the capacity of local actors in financial management. Finally, the Global Fund is advised by the German insurer Munich Re, to develop its risk management policy.

  • 35 https://www.theglobalfund.org/media/8708/publication_privatesectorempowerproject_focuson_en.pdf

27The third, more limited area of expertise concerns technological innovation. In particular, a partnership was signed with IBM on a pilot project for new technologies to improve the quality of care in India, using digital tablets (eMpower programme35).

28Of course, the tensions caused by the signing of agreements with Heineken (finally repealed) or Coca-Cola (maintained) have contributed to the establishment of a number of "safeguards" and the Global Fund put in place a framework document on private sector engagement in March 201936.

Delegation of control procedures to private actors

  • 37 The Swiss Tropical and Public Health Institute (or Swiss TPH), formerly known as the Swiss Tropical (...)
  • 38 The Big Four are the four largest financial audit groups in the world: Deloitte Touche Tohmatsu, EY (...)
  • 39 At the end of 2017, for example, KPMG was present in 11 countries and PWC in 82 of the 143 countrie (...)

29The Global Fund delegates procedures for monitoring the achievement of results and the proper use of grants to private actors. The Fund signs contracts with several consulting firms as "LFA" (Local Fund Agents), responsible for assessing the operational and budgetary performance of grants and organisations. As it does not have an office in the countries of intervention, the Global Fund delegates its control to these private providers. The latter must be "his eyes and ears", to use the consecrated expression, generally used by all the actors. While some LFAs also have technical skills in the field of health (such as the Swiss Tropical Institute37), the vast majority of LFA missions are carried out by large audit and accounting firms: KPMG and PWC, which are part of four "Big Four38" companies, were responsible for auditing more than half of the missions at the end of 201739.

30The most active private sector actors within the Global Fund are ultimately neither pharmaceutical companies nor multinationals based in recipient countries, but a relatively heterogeneous group, marked by the growing presence of financial actors such as private banks, insurance companies, and audit firms that are moving beyond their traditional sectors of intervention - new technologies, economic development, support for micro-credit, etc. - to become involved in social sectors.

  • 40 Private for-profit sector actors are not the only ones: other new actors have gradually emerged as (...)

31Ultimately, private sector actors are present at all levels of the Global Fund: board seats, advisory missions to the secretariat, technical support contracts, capacity building for local actors, monitoring and evaluation of grant implementation. While this dynamic is not specific to the Global Fund and cuts across all public policy networks in the development world40, the role of private sector actors is particularly important within the Global Fund, compared to other international organizations. This diverse and important presence has an impact on the operation of the Global Fund.

Appropriation of private sector logics and methods by the Global Fund

32The purpose here is not to review the major strategic issues that affect the Global Fund, nor to analyse the strategic positions of private sector actors and measure their influence on the decisions taken. Our purpose here is to analyse, in a non-exhaustive way, the informal influence that these actors have on the functioning and philosophy of the organisation. Can it be said that the Global Fund is part of a broader movement to integrate private sector approaches by aid actors? We will focus on measuring the importance of financial logic in the Global Fund's discourse, as well as in its distinctive operating modalities, such as results-based financing in particular. Then we will discuss the effects of these practices on the actors and on the intervention areas. In the same way that Béatrice Hibou proposes to make a political economy out of the World Bank's speech (Hibou, 1998), it would be wise to make a political economy out of the Global Fund's speech.

33The analysis of the Global Fund's discourse, as expressed in the mouths of its leaders, in the framework documents that constitute it or on its website, illustrates this process of integrating the logic of the private sector, whether by the words chosen, the arguments deployed or the justifications on which the decisions taken are based.

34The Global Fund primarily uses terminology directly inspired by the private sector: implementing actors are called "recipients", they generally form teams called "management units", their direct interlocutor within the secretariat is a "portfolio manager", etc. Not only are these words not neutral, but they also convey a certain vision of aid in the health sector. The fact that an organization like the Global Fund has chosen these terms, rather than others, illustrates its axiological vision, its cognitive framework and the way in which the Fund analyses problems and priorities for itself and others.

  • 41 The number of lives saved in a given country in a given year is estimated using modelling technique (...)
  • 42 Report of the High Level Commission on Healthy Employment and Economic Growth, June 2016, https://a (...)
  • 43 Document prepared in advance of the conferences that the Global Fund organizes every three years to (...)
  • 44 "Each dollar invested generating 19 US dollars in health advances and economic spinoffs", Accelerat (...)
  • 45 It should be noted that this logic had already been in place for a long time since the name of the (...)
  • 46 For example, the Global Fund website states,"The impact of health investments is measured in many w (...)
  • 47 Christopher Benn, Director of External Relations of the Global Fund until 2018, said in an article: (...)

35Beyond the words used, the Global Fund's approach to health issues in the fight against AIDS, tuberculosis and malaria therefore carries a certain ideology. The Global Fund measures the overall impact of its investments in health through several indicators, including the "number of lives saved", the "number of deaths prevented" and the "number of new infections prevented"41. The Global Fund is of course not the only organization that presents health as a "profitable investment", including for economic actors. The report of the High Level Commission on Healthy Employment and Economic Growth, hosted by France in March 2016, stated, for example, that "about a quarter of economic growth between 2000 and 2011 in low- and middle-income countries came from improvements in health", estimating the return on investment in this sector at 9 to 1, and specifying that an additional year of life expectancy increases GDP per capita by about 4 per cent42. This rationale is reflected in the "investment rationale43" and, for example, in the rationale for the sixth Global Fund replenishment conference in October 2019, this calculation of a 19:1 return on investment44. In all the Global Fund's institutional documentation, health is fundamentally presented as an investment45 and the "good health" of the population as a criterion for economic growth and development46. Not only does the Global Fund regularly adopt this approach47, but it is one of the organizations that most strongly supports this vision of health.

  • 48 The Global Fund has established a three-year allocation system. It sets an overall available budget (...)
  • 49 One of the particularities of the Global Fund is the creation of an Inspector General, independent (...)
  • 50 Advisory Report of the Office of the Inspector General of the Global Fund:"Grant Implementation in (...)

36Regardless of this vision of health "useful" to the economy, new approaches are emerging at the Global Fund, as in most United Nations agencies: the systematic search for "leverage effects" or the provision of "catalytic financing" aimed at mobilizing other financing. Financial rationales and the dominance of management criteria are also explicit in the calculation methods that the Global Fund uses to decide whether a country is eligible to receive funding or to define the financial envelopes available per country and per disease48. It is also interesting to note that the Principal Inspector49 assesses the adequacy of the secretariat's human resources to the needs of different geographical areas using a "full-time equivalent per hundred million US dollars50" ratio.

  • 51 The main principles of the "new public management" (New Public Management) are the delegation of re (...)

37This management logic is reflected in the mechanisms specifically put in place by the Global Fund, whether they are tools related to results-based financing or instruments related to risk management. The modalities for implementing these two principles contribute to aid standardization mechanisms and illustrate the importation of New Public Management methods into51 the Global Fund.

Results-based financing", a pillar of the Global Fund's operations.

38The general idea of this principle ("performance-based funding" - PBF) is to condition the level of funding granted to countries on the achievement of predetermined results set at the time of project writing, within what the Global Fund calls "performance frameworks". Several elements are then considered each quarter or semester to assess the effectiveness of the grant: the achievement of the quantified objectives defined by indicators, the percentage of planned activities carried out and the capacity to absorb and disburse the funding received. The payment of each funding tranche is subject to the analysis of the performance report of each grant. This funding may be reduced for the next financial tranche if the results are not as significant as expected. It is therefore not a performance incentive system but rather a system designed to sanction performance that is deemed unsatisfactory in relation to the objectives set. It is a translation from an obligation of means to an obligation of results.

  • 52 These constraints will be exercised in different forms, as Olivier Nay explains: know-how, rites, m (...)

39This type of "data-driven monitoring" is obviously based on quantitative, standardised indicators that do not reflect the complexity of the contexts and are based on data whose reliability is not always guaranteed (Paul E, 2018). In addition to health-related indicators, this type of system primarily assesses the ability of beneficiaries to comply with budgetary rules and procedures. It contributes to the "managerialization" of the fight against the three pandemics, which must be quantified and calculable and can be analysed as a set of binding measures52 since it is a sine qua non condition for obtaining successive tranches of funding. The implementation of a performance evaluation system and the system of contractualization with stakeholders on precise quantified objectives are symptomatic of the advent of New Public Management in the field of international health aid. The Global Fund's risk management system, developed with the technical support of the insurer Munich Re, is also based on managerial logic.

40The application of these techniques from the world of health management will have an impact on public policies to fight the three diseases in the countries of intervention (Tchiombiano, Eboko, Nay, 2018). This approach has repercussions on the positioning and distribution of the actors involved in the fight against the three pandemics in the countries of intervention. The effects of the introduction of Global Fund standards on the conduct of programmes to fight AIDS, tuberculosis and malaria are significant. The example of a country like Niger in West Africa is an appropriate illustration of this phenomenon. Since Niger is mainly dependent on Global Fund funding to fight AIDS, tuberculosis and malaria, the integration of Global Fund methods has largely contributed to "managing" its public action and strengthening what Beatrice Hibou calls a bureaucratization phenomenon, linked to the systematic use of new rules, procedures and formalities (Hibou, 2013).

Management practices reconfigure power relations

  • 53 Restated data. Source Global Fund Data Explorer, https://data.theglobalfund.org/home, accessed Sept (...)

41The Global Fund's contractualization logic leads to a reconfiguration of power relations. This principle of empowering, in each country and for each of the three diseases, an "umbrella" organization (called the main beneficiary) responsible for managing and redistributing funding to other actors (called sub-beneficiaries), requires particularly important management capacities for the person who will play this role. A good "lead beneficiary" will be above all a good financing manager and an organisation that respects the rules of the game, with a good "disbursement" rate. A redistribution of roles will therefore often take place, to the benefit of international NGOs with a significant financial base, such as Population Services International-PSI, Save the Children or Plan International. The same is true for some United Nations agencies. For example, since the creation of the Global Fund and until 2019, UNDP (United Nations Population Programme) has managed 197 Global Fund grants, with an average budget of US$38 million53), at the expense of public actors, whose national programmes to fight AIDS, tuberculosis or malaria do not always have sufficient management capacity. A new redistribution logic is being organized ipso facto. The various actors are no longer directly linked to the Global Fund but under the responsibility of a managing organization (the lead beneficiary) that acts as an intermediary with the Global Fund. All actors will therefore "report" to these primary beneficiaries who are responsible for synthesizing all the data for transmission to the Global Fund, rather than to health authorities, undoubtedly weakening the leadership capacity of national authorities, and blurring the border between the public and private sectors.

42The constant search for the most "cost-effective" option of the most profitable investment, combined with the need to comply with international recommendations, leads to a standardisation of national strategies and a form of depoliticization of the fight against the three diseases. The decision to target certain populations rather than others (e.g. pregnant women, young people, men who have sex with men, truck drivers or drug users) is no longer considered a political decision. If it is to be financed by the Global Fund, it must be fully consistent with the international recommendations of UN agencies, perfectly rational and based on a demonstration of cost-effectiveness.

  • 54 This has been the case in Niger, for example, and in many countries in West and Central Africa.

43Another effect of this system is that it leads to a large amount of codification of information, a permanent quantification of interventions and, by the same token, a real "obsession with the indicator". Specific collection systems are often set up in54 parallel with national health information systems, based on the filling of media specifically created to meet the Global Fund's monitoring and evaluation requirements, without any connection with the "traditional" monitoring of data from health centres and national health information systems. In several countries such as Niger, contractual data entry operators have been recruited to record, manage and analyse this data (largely from the public health system) and a wide range of data production modalities (forms, registers, software development, surveys, monitoring missions, etc.) have been created, partly in response to this primacy of documentation and quantitative monitoring.

44Finally, this need to produce codified data, linked to standardized indicators, can only encourage stakeholders to prioritize activities that will enable them to achieve good quantitative results - number of beneficiaries reached, number of screening tests carried out, number of nets distributed, etc. - rather than activities that are more structuring (Kerouedan, 2015), or that target populations that are more difficult to reach and interventions whose results are generally less easily documented or not visible in the short term or more complex to achieve.

Conclusion

45The Global Fund embodies these new hybrid institutions, giving private actors an increasing role in global health governance. It is significant for a general evolution of international health aid and international aid in general, integrating market methods, representations and practices or based on a management logic.

46Our article successively shows: the presence and strengthening of the role of private actors at all stages of the Global Fund's financing mechanism (from governance to monitoring activities); the use of principles and methods from the private sector such as contractualization, financialization, results-based financing, effectiveness evaluation; and, finally, the impact of these new standards on the practices of actors in resource-limited countries, such as Niger. These developments reflect the emergence of a new culture of performance and efficiency in a health sector that was not necessarily familiar with these organizational standards.

  • 55 On the emergence of the concept of "partnership" in the field of development policies, see in parti (...)

47The key variables that emerge from this situation are illustrated by the multiplicity of roles played by private sector actors within the Global Fund, the diversity of their modalities of involvement and the evolution of the way they are viewed. The term "stakeholder" that has long characterized them has gradually been replaced by that of "partner", a polysemous expression conferring co-responsibility and co-development in the conduct of Global Fund policy55. The very low financial contribution of companies, compared to that of States, does not seem to call into question their participation in the governance of the organization and their legitimacy within the public-private partnership seems ultimately based above all on their "know-how", their "efficiency" and their "technical skills" rather than on their financial investment. However, this technical "added value" of private sector actors remains to be demonstrated in the field of global health and it will be important to monitor the evolution of the sector in the coming years.

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Notes

1 This article is fully in line with Auriane Guilbaud's work, by deepening the Global Fund's analysis.

2 Nous reprenons ici la définition d’Auriane Guilbaud, qui identifie 17 Partenariats Public/ Privé Sanitaires Internationaux (PPSI) : Accélérating Access Initiative (AAI), International Trachome Initiative (ITI), Drug neglected Diseases Initiative (DNDI), Stop TB partnership (Stop TB), International Aids vaccine Initiative (IAVI), Malaria Vaccine Initiative (MVI), Roll Back Malaria (RBM), Global Alliance to eliminate Leprosy (GAEL), Global Alliance to eliminate Lymphatic Filiariasis (GAELF), Médecine for Malaria Venture (MMV), African Comprehensive HIV / Aids Partnership (ACHAI), Global Alliance for TB Drug Development (TB Alliance), Fonds mondial de lutte contre le sida, la tuberculose et le paludisme (GFATM), Meetizan donations programm (MDP), AERAS Global TB Vaccine Foundation (AERAS), Children without worms (CWW), Foundation for Innovative New Diagnostics (FIND).

3 Since its creation in 2002 and until 2018, the Global Fund has mobilized US$41.6 billion to fight the three diseases. Global Fund Sources, 2019 Report. https://www.theglobalfund.org/media/8754/corporate_2019resultsreport_report_fr.pdf?u=637045670120000000 (accessed September 26, 2019).

4 It should be recalled that HIV-AIDS was the first disease to be the subject of a United Nations Special General Assembly in 2001.

5 "The only way to end the epidemics of HIV, tuberculosis and malaria is to work together: public authorities, civil society, affected communities, technical partners, the private sector, faith-based organizations and other donors. All actors involved in the disease response must be involved in decision-making processes. Global Fund website[http://www.theglobalfund.org/fr/overview/] accessed 11 June 2019.

6 The Bill and Melinda Gates Foundation, created in 2008 by the American billionaire, is heavily involved in global health issues, particularly within the Global Fund. It represents 75% of private sector funding and Bill Gates himself is heavily involved in advocacy for the Global Fund. It should be recalled that it is also the second largest donor to WHO after the United States and well ahead of Great Britain.

7 Global Fund website: https://www.theglobalfund.org/fr/updates/other-updates/2019-09-02-focus-on-private-sector-partnerships/, accessed June 10, 2019.

8 The role of these CCMs is to (1) coordinate the preparation and submission of funding applications; (2) designate the principal recipient(s) to manage the grants and monitor their results; (3) ensure strategic monitoring of the implementation of approved programmes, (4) approve any requests for revision; and (5) ensure that there is correspondence and coherence between programmes funded by the Global Fund and other national programmes for health and development.

9 The Global Fund's guidelines state:"Given the breadth of expertise and resources that the private sector can provide, CCMs can benefit significantly from the inclusion of companies and organizations representing the major components of the private sector, including the following types of organizations: large for-profit companies with a proven track record in the fight against the three diseases, organizations representing small and medium-sized enterprises and the informal sector, business associations involved in the fight against HIV, tuberculosis and malaria, representatives of exposed industries, private practitioners and for-profit clinics, philanthropic foundations created by large companies. In policy on Country Coordinating Mechanisms, approved by the Board of Directors GF/B39/DP09, May 10, 2018, accessed September 11, 2019: https://www.theglobalfund.org/media/7479/ccm_countrycoordinatingmechanism_policy_fr.pdf

10 The Norwegian Government had raised the possibility of withdrawing its contribution if this agreement with Heineken was not cancelled.

11 Site du Fonds mondial, consulté le 9 septembre 2019 : https://www.theglobalfund.org/en/blog/2018-02-02-making-the-world-safe-from-the-threats-of-emerging-infectious-diseases/

12 Source Global Fund. It should be noted that these are private and non-governmental actors (including research institutes, chambers of commerce, philanthropic foundations, etc.).

13 For example, the contribution of private sector actors was US$359 million for the three-year cycle 2011-2013, US$627.9 million for the 2014-2016 cycle and US$850 million for the 2017-2019 cycle. Sources Global Fund.

14 For the period 2017-2019, private sector actors have committed $850 million to the Global Fund.

15 The official launch ceremony was preceded by a private sector engagement sequence, co-organized with the organization (RED) founded by Bono and in partnership with the French Investors Council for Africa and Salesforce France, to encourage French and international business leaders to invest in global health.

16 The Gates Foundation's overall contribution since the inception of the Global Fund is just over US$2 billion at the end of 2019. 2019 Global Fund data, restated.

17 Since its launch in spring 2006 and until 2019, (RED) has generated approximately $420 million for the Global Fund (source: Global Fund).

18 The HER initiative was launched at the annual meeting of the World Economic Forum in Davos, Switzerland, in January 2018, under the leadership of activist Malala Yousafzai and Bill Gates.

https://www.theglobalfund.org/fr/news/2018-01-24-global-fund-and-partners-launch-her/, accessed June 6, 2019.

19 Tribune "Le défi sanitaire mondial est aussi l'affaire des entreprises", Les échos, 16 May 2019.

20 We can also quote the former Director of External Affairs of the Global Fund, Christopher Benn:"Innovation will be at the heart of the success of our approach to malaria. But it is not just a question of identifying the next breakthrough that will make the headlines. Rather, we must seek to inject new energy into the malaria control effort by considering alternative funding mechanisms. Benn C, "We won't beat malaria unless we rethink our financing mechanisms", in Devex, September 13, 2018. https://www.devex.com/news/opinion-we-won-t-beat-malaria-unless-we-rethink-our-financing-mechanisms-93416, accessed 11 June 2019.

21 This system, implemented in 2010, aimed to make antimalarial treatment affordable.

22 Since the inception of the scheme in 2007, three countries have agreed to cancel their debt on condition that the indebted countries undertake to reinvest it in health: Germany (with Indonesia, Côte d'Ivoire, Egypt and Pakistan), Australia (with Indonesia) and Spain (with Cameroon, the Democratic Republic of the Congo and Ethiopia)

23 Establishment of a regional health fund by the Asian Development Bank in partnership with the Global Fund and Asia Pacific Leaders, offering a combination of loan and grant mechanisms.

24 A pilot project is underway, in partnership with the Union to fight tuberculosis in India, by mobilizing additional financing from financial actors (investors seeking to have an impact, high net worth individuals, sovereign wealth funds and pension funds, banks, asset management companies, or development financial institutions). Social impact bond projects are also being launched in South Africa and Fiji according to an article in Aidspan magazine: "The Global Fund opens consultations on innovative finance mechanisms", Global Fund Observer, 7 August 2018.

25 We can also think here of the "pandemic Bonds" set up at the time of the Ebola infection epidemic, mentioned by Guillaume Lachenal without his article "Tombola Ebola", Libération, 6 June 1918: https://www.liberation.fr/debats/2018/06/06/tombola-ebola_1657098

26 The selection of PRs is made by the CCMs, which must then have this decision validated by the Global Fund. The general principle is to designate principal beneficiaries from among the "national actors". However, in practice, grant management is often entrusted to United Nations agencies, international NGOs and, more marginally, private sector companies.

27 Aidspan sources, restated data. http://www.aidspan.org/page/grant-performance-analysis

28 Industrial and Building Electricity Company.

29 One example is the Boston Consulting Group, which supported the Global Fund to develop its new funding model in 2014.

30 The 5% Initiative, set up by France Expertise International (FEI / now Expertise France), a structure attached to the Ministry of Foreign Affairs and International Development, aims to respond to requests from French-speaking countries for high-level technical expertise to help them design, implement, monitor and evaluate and measure the impact of grants allocated by the Global Fund. In concrete terms, 5% of France's contribution to the Global Fund, or €18 million per year, is managed by this initiative.

31 Created in 2007, the US technical assistance project "Grant Management Solution" linked to USAID closed its doors in December 2017.

32 Coca Cola project, implemented in 2010, in partnership with the Global Fund, the Bill and Melinda Gates Foundation and USAID (since 2014).

33 Platform set up in 2019 coordinated by the Global Business Coalition on Health (GBC Health).

34 Global Fund website: https://www.theglobalfund.org/en/private-ngo-partners/delivery-innovation/ecobank/ accessed June 12, 2019

35 https://www.theglobalfund.org/media/8708/publication_privatesectorempowerproject_focuson_en.pdf

36 https://www.theglobalfund.org/media/8382/core_privatesectorengagement_framework_en.pdf consulted on June 5, 2019.

37 The Swiss Tropical and Public Health Institute (or Swiss TPH), formerly known as the Swiss Tropical Institute, is a research centre based in Basel. For example, it was following 14 countries at the end of 2017.

38 The Big Four are the four largest financial audit groups in the world: Deloitte Touche Tohmatsu, EY (Ernst & Young), KPMG and PwC (PricewaterhouseCoopers).

39 At the end of 2017, for example, KPMG was present in 11 countries and PWC in 82 of the 143 countries followed by LFAs. Source Global Fund: "List of Global Fund Local Fund Local Fund Agent", updated to 15 December 2017.

40 Private for-profit sector actors are not the only ones: other new actors have gradually emerged as "partners": NGOs, activist associations, think tanks, universities, etc. This involvement of the private sector in the fight against the three pandemics perfectly illustrates the growing role played by those whom Olivier Nay calls market actors (economic and financial actors, transnational firms, private banks, investment funds, private foundations, etc.) in development aid (Nay, 2010).

41 The number of lives saved in a given country in a given year is estimated using modelling techniques, subtracting the actual number of deaths from the number of deaths that would have occurred in a scenario where Global Fund-supported interventions would not have occurred été́, basing the analysis on official estimates of the morbidité́ burden of each disease according to WHO, UNAIDS, Stop TB Partnership or Roll Back Malaria Partnership. On this subject, we can refer in particular to the article by Fred Eboko, following the appointment of Peter Sands in December 2017. F. Eboko, "Human lives are not only statistical units", Jeune Afrique, n° 2969, from 3 to 9 December 2017, p. 50.

42 Report of the High Level Commission on Healthy Employment and Economic Growth, June 2016, https://apps.who.int/iris/bitstream/handle/10665/250100/9789242511307-fre.pdf?sequence=3, page 9

43 Document prepared in advance of the conferences that the Global Fund organizes every three years to mobilize funding from different donors.

44 "Each dollar invested generating 19 US dollars in health advances and economic spinoffs", Accelerating the movement, investment case, p6. https://www.theglobalfund.org/media/8280/publication_sixthreplenishmentinvestmentcase_report_fr.pdf, accessed September 26, 2019. When advocating for new resources for the Global Fund, Christopher Benn regularly and explicitly used the term "return on investment". Benn C, "We won't beat malaria unless we rethink our financing mechanisms", in Devex, September 13, 2018. https://www.devex.com/news/opinion-we-won-t-beat-malaria-unless-we-rethink-our-financing-mechanisms-93416, accessed 11 June 2019.

45 It should be noted that this logic had already been in place for a long time since the name of the 2012-2016 strategy was entitled "Investing for Impact".

46 For example, the Global Fund website states,"The impact of health investments is measured in many ways, including the number of lives saved or the rate of decline of HIV, tuberculosis and malaria. More generally, the real impact of investments in health is illustrated by the vitality and economic strength of communities and countries in which the burden of disease is declining.

47 Christopher Benn, Director of External Relations of the Global Fund until 2018, said in an article: "The last 25 years have shown that the growth of gross domestic product per capita in countries not affected by malaria has been five times higher than in countries with a high malaria burden. Benn C, "We won't beat malaria unless we rethink our financing mechanisms", in Devex, September 13, 2018. https://www.devex.com/news/opinion-we-won-t-beat-malaria-unless-we-rethink-our-financing-mechanisms-93416, accessed 11 June 2019.

48 The Global Fund has established a three-year allocation system. It sets an overall available budget per country and per disease: "The amount allocated to each country is mainly based on its disease burden and economic capacity". The calculation is then refined to reflect important contextual factors, including the assessment of funding disbursement capacity, assessed through the results obtained on previous grants.

49 One of the particularities of the Global Fund is the creation of an Inspector General, independent of the Secretariat and reporting to the Board, to conduct investigations and audits of Global Fund grants.

50 Advisory Report of the Office of the Inspector General of the Global Fund:"Grant Implementation in West and Central Africa (WCA)", May 2019. Available on the Global Fund website, https://www.theglobalfund.org/media/8496/oig_gf-oig-19-013_report_fr.pdf?u=637001821120000000, accessed 19 May 2019.

51 The main principles of the "new public management" (New Public Management) are the delegation of responsibilities to decentralized and more autonomous units, the contractualization on precise quantified objectives and the implementation of performance evaluation systems.

52 These constraints will be exercised in different forms, as Olivier Nay explains: know-how, rites, models of action, forms of organization, codes, social conventions, routines, techniques, procedures (Nay, 1997), which will not necessarily be coercive or authoritarian (it will rather be normative or mimetic pressure) (Nay O. 1997)

53 Restated data. Source Global Fund Data Explorer, https://data.theglobalfund.org/home, accessed September 25, 2019.

54 This has been the case in Niger, for example, and in many countries in West and Central Africa.

55 On the emergence of the concept of "partnership" in the field of development policies, see in particular the article (Bailey, Dolan, 2011)

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Stéphanie TCHIOMBIANO, « Public health, private approach: The Global Fund and the involvement of private actors in global health (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/1418

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