Two decades ago, global health partnerships proliferated as an alternative governance model to the World Health Organization (WHO), deemed overtly political, bureaucratic and inefficient. Partnerships were designed instead as lean and efficient “networks” or “alliances” bringing together public and private partners to achieve a clearly specified objective.

Over time, however, global health partnerships have taken on new missions, their budgets have become ever larger, and the same goes for their staff. In its early days, Gavi operated from a UNICEF basement with a handful of individuals. The partnership now has over 600 staff members. Similarly, The Global Fund currently employs over 1300 people.

In a paper recently published in Policy & Society, I argue that global health partnerships have become powerful organizations whose secretariats have acquired substantial, but often overlooked, capacity to shape policy processes. This trend can be found across many of the largest global health partnerships, but Gavi exemplifies it perhaps best. Gavi’s secretariat has indeed played an important role in expanding the organization’s activities from childhood immunization to pandemic preparedness and response during the past decade and, most visibly, during the covid-19 pandemic.

Gavi’s investments in global health security before covid-19

Since 2006 Gavi has invested in vaccine stockpiles to respond to outbreaks of Yellow Fever, Cholera and Meningitis. These stockpiles, however, accounted for less than 1% of the organization’s total budget until 2015. My research shows that this changed with the Ebola crisis of 2014-2015. During the fall of 2014, Gavi’s secretariat developed a report – in less than 8 weeks – proposing that Gavi invest in an Ebola vaccine stockpile. The board approved an envelope of $300 million to establish an Ebola vaccine stockpile and granted the secretariat considerable autonomy to implement the response.

In the aftermath of the Ebola crisis, global health security rose on the political agenda and donors became interested in funding preparedness activities. Although global health security was not formally one of the organization’s strategic priorities, Gavi’s secretariat elaborated a series of reports and proposals that were presented to its board in 2018. These included projects on yellow fever diagnostics (which might be unexpected for a vaccine alliance), pandemic influenza vaccines and the Ebola response in DR Congo. Gavi also joined the polio eradication program and started to channel funding to the Coalition for Epidemic Preparedness Innovation (CEPI) for research and development of pandemic vaccines.

Interestingly, many of these projects raised unusual controversies and debates in Gavi’s board, with several board members expressing minority positions and “concerns” about some of the proposals. This may indicate that the secretariat has been pushing for these global health security investments before a consensus had been reached. Nevertheless, Gavi’s board officially recognized global health security as a strategic priority in 2019 by adding two related objectives in its 5-year strategy, Gavi 5.0 (2020-2025).

COVAX’s legacy

Gavi was therefore ideally placed to play a leading role in the global vaccine response when covid-19 hit. Gavi’s secretariat proactively contributed to the development of COVAX by setting the agenda, formulating policy proposals, building policy coalitions, fundraising, and implementing the response. It ended up coordinating “the largest global rollout of vaccines in history” by raising the equivalent of USD 17.6 billion and distributing over 2 billion vaccines.

Gavi’s secretariat organized multiple rounds of fundraising, including a replenishment event as late as April 2022, which now has long-lasting consequences. With vaccine demand plummeting throughout 2022, the organization is expected to have a colossal USD 5 billion (!) of unspent covid funds by 2025.

Over the past two years, Gavi’s board has held heated discussions behind closed doors on the allocation of this surplus money. The New York Times quoted one board member, saying “the important thing is, we don’t want them to use these funds to broaden their mandate.” In effect, this extra funding does create a lock-in mechanism that further encroaches Gavi’s position in the future governance architecture of pandemic preparedness and response.

The rising influence of global health partnerships

Gavi is not the only organization to have expanded its portfolio of activities over the years – I found a similar trend occurring across the largest global health partnerships. The influence of these organizations’ secretariats has also been strengthened, I argue, by developing some degree of financial autonomy vis-à-vis key donors, as well as by increasingly cooperating with each other, which dilutes accountability – as argued elsewhere in the case of ACT-A and COVAX.

Overall, my paper shows how the largest global health initiatives have become powerful organizations whose secretariats increasingly shape policy. By so doing, global health partnerships relegated their governing bodies to a more distant position of control, and increasingly well positioned to challenge WHO’s authority. It might be time to pay closer attention to their doings.

The full paper is available in open access: https://academic.oup.com/policyandsociety/advance-article/doi/10.1093/polsoc/puad032/7582336?searchresult=1#437014475