Civil Society Participation in Global Public Private Partnerships for Health

"As global partnerships exert ever more influence over the policy space in many low- and middle-income countries, understanding the linkages between their civil society engagements at the global and national levels...becomes imperative."

Global public-private partnerships (PPPs) for health address challenges ranging from HIV/AIDS to road traffic accidents, malnutrition, and lack of access to vaccines and other health commodities. In the early years of partnerships like Gavi, the Vaccine Alliance, critics expressed concern about power imbalances within this new form of governance. Inviting civil society representatives into PPPs and giving them a "seat at the table" has been a way to respond to such critiques. Based on a structured analysis of publicly available documents, this article critically examines the notion of "civil society engagement" within 18 of the major PPPs for health.

Selected partnerships focus on a wide range of topics, such as the development of vaccines (e.g., Gavi, The Vaccine Alliance), the promotion of handwashing (e.g., the Global Handwashing Partnership) and the use of clean cook stoves (e.g., the Global Alliance for Clean Cook Stoves), or the fight against specific diseases (e.g., Roll Back Malaria). These partnerships are headquartered in the main global centres of power, including Geneva, Switzerland, and its region (n = 11), Washington, DC, United States (US), and its region (n = 3), New York City (US), Ottawa, Canada, Seoul, South Korea, and Tokyo, Japan (n = 1), and were founded primarily in the late 1990s to early 2000s.

Findings - based on analysis a structured review of documents that are publicly available on the partnerships' own websites, conducted in October and November 2017 - include, in brief:

• Almost all of the 18 partnerships surveyed refer to the term "civil society" on their websites and in official documents, but only The Global Fund to Fight AIDS, Tuberculosis and Malaria (The Global Fund) explicitly defines the term. Most partnerships use the term to describe non-governmental organisations (NGOs) and "affected communities", the former often representing the latter in practice.
• Although their definitions of "civil society" are often vague, many of the partnerships emphasise the value of civil society participation in their work. The most commonly specified role is as implementing partners at the country level (n = 15). Many also emphasise civil society's advocacy role (n = 14), which can entail both raising awareness about the partnership's issue and raising political and donor support. In addition, several partnerships (the International Vaccine Institute, Drugs for Neglected Diseases Initiative [DNDi], SUN, the Global Alliance for Clean Cook Stoves, the Global Fund, and Stop TB) have set up "support committees", "champions", "ambassadors", or "friends" networks to mobilise high-level individuals, including some from "civil society" such as artists and celebrities, to advocate for the partnerships. Moreover, most of the partnerships expect their civil society partners to broker knowledge (n = 14), which often implies providing feedback from the ground to ensure effective implementation of partnership-funded programmes. Despite the emphasis on representation and local knowledge, less than half of the partnerships explicitly state that civil society has a role in influencing decision-making at the global level (n = 8). Similarly, only some (n = 5) explicitly refer to civil society's "watchdog" function in ensuring accountability and transparency, whether in governance processes or in programme implementation.
• "The impression that civil society partners' role is largely to support the partnerships rather than to shape or challenge decision-making is reinforced by their relatively low level of representation within formal decision-making bodies....The Global Fund has perhaps the most sophisticated arrangements for civil society engagement..." Furthermore, "only 7 out 274 seats (2.6%) across the 18 partnerships are held by individuals speaking on behalf of the millions of patients and others directly affected by the diseases and health issues they target. Two of these seven seats are held by medical doctors classified as 'patients advocates' (DNDi) rather than as representatives of civil society organizations for affected individuals....NGOs and affected communities' combined representation within the decision-making bodies (10.3% of the voting seats) puts them in a weak position relative to other partners." For example, private-sector actors have a representation of 23.7%.

Among the conclusions that can be drawn from the analysis: "Many of today's leading partnerships make laudatory claims about the value of 'engaging' civil society. Gavi (2017a), for instance, credits civil society with reaching the unreached, contributing to health system strengthening, influencing public policy, supporting resource mobilization and enhancing transparency and accountability. Yet, the partnerships' publicly available documents do not provide evidence of direct and substantial impact on the partnership's global decision-making. Rather, civil society partners' main role seems to be to advocate and raise funds for the partnerships, as well as discuss best practices to implement programmes more effectively. We cannot, then, take at face value claims by leading partnerships like Gavi, that by participating in its governance at the global level, civil society organizations 'provide input to ensure that its programmes and policies are robust and that the Vaccine Alliance maintains a high level of transparency, accountability and responsiveness' (Gavi, 2017a)."

In closing, the authors argue: "What is needed now is better in-depth understanding of whether and how civil society actors participate in developing public-private partnerships' organizational strategy, designing the funding model, overseeing the work of the secretariat and establishing - and indeed challenging - policy. This requires going beyond the analysis of the formal power they are afforded through representation...and examin[ing] the more subtle processes through which civil society actors mobilize more diffuse normative and epistemic power. This implies a need for research into how and why the actors representing 'civil society' - and those seeking to influence them from outside - come to differ in their values, in how they convene and deliberate, in their financial interests, and indeed in their relationships with donors and their constituents..."