Key Findings

Global leaders appear poised to approve the creation of a new financing mechanism for pandemic preparedness and response (PPR) activities. Support for such a mechanism grew as the profound fault lines exposed by the COVID-19 pandemic became clearer. The U.S. government has strongly supported the idea of creating a financial intermediary fund (FIF) for PPR at the World Bank, a proposal now endorsed by the G20, the WHO, and others, with the World Bank expected to vote on such a proposal this month. Despite this momentum, however, many questions remain about a new FIF including its governance and operations and the extent to which civil society will be formally included. A white paper on the FIF, recently released by the World Bank, contains a brief mention of civil society as potential observers to a FIF governing board, though some have critiqued that as insufficient. To help inform ongoing discussions, we sought to examine and draw lessons from existing institutions on how they engage with civil society formally, as part of their governance, as well as through other avenues. We analyzed 14 major multilateral global health and related institutions to assess how civil society, including from the global South, has been engaged in their governance, implementation/programming, and monitoring. We examined the following metrics of civil society inclusion to assess more formal engagement: board representation; voting rights; global South representation required; formal representation on committees; support for participation in governance; and requirements to fund civil society as part of program implementation. For those institutions that included formal board representation, we also looked at the share of seats reserved for civil society. Our key findings are summarized as follows:

• Civil society inclusion and engagement in the governance and operations of multilateral global health institutions has grown over time, especially since the Millennium Development Goals era, and as part of the global HIV movement in particular.
• The degree and nature of civil society engagement varies considerably. Three of the 14 institutions met all six metrics of formal civil society inclusion assessed (the Global Fund to Fight AIDS, Tuberculosis and Malaria; the Global Partnership for Education; and the Stop TB Alliance) and three met five metrics (GAVI, UNAIDS, and Unitaid). On the other end of the spectrum, three institutions met none (the Coalition for Epidemic Preparedness Innovations; the RBM Partnership to End Malaria; and the World Health Organization).
• On board representation specifically, six of the 14 institutions have formal seats for civil society, the strongest measure of inclusion, ranging from 3.5% to 15% of board seats. Five of the six provide voting rights, and four of the six specify that at least some portion of civil society representation be from the global South. In addition, the six with formal board seats also require civil society representation on their primary governance committee(s).
• All 14 multilateral global health initiatives, including those with no formal civil society representation on their governing board or committees, provide other opportunities for civil society engagement. Specific approaches and processes employed can bolster or limit civil society’s influence in governing decisions. For example, civil society representatives who are able to participate in advisory or working groups, or regional subgroups, can feed into and shape institutional governance. Other avenues, such as those that are more ad hoc, are seen as providing fewer opportunities for engagement or influence.
• At the same time, and even among those initiatives with formal representation on governing boards, civil society representatives confront a number of challenges, including a lack of financial and administrative support while managing a substantial burden of work, a steep learning curve for new representatives, and difficulties representing broad constituencies fairly and effectively.
• To address some of these challenges, some initiatives, but not all, have created mechanisms to directly support civil society engagement in governance, implementation and/or monitoring activities. Many of these have been instituted and expanded only in recent years.

Taken together, these findings offer new insights into how civil society has been included in major multilateral global health and related organizations that are in operation today, including the trend towards greater and more formal inclusion over time, and may inform ongoing global discussions about the creation of a new financing mechanism for PPR.

Introduction

Global leaders appear poised to approve the creation of a new financing mechanism for pandemic preparedness and response (PPR) activities. Support for such a mechanism, intended to coordinate and direct additional resources for PPR, particularly in low- and middle-income countries (LMICs),  grew as the profound fault lines exposed by the COVID-19 pandemic became clearer. For its part, the Biden Administration has strongly supported the idea of creating a financial intermediary fund (FIF) for PPR at the World Bank and has already pledged $450 million and requested an additional $4.75 billion more from Congress. Support from other donors was pledged at the second Global COVID-19 summit, convened by the U.S. and several other governments, and the idea has been endorsed by the G20 and the World Health Organization. Most recently, the World Bank released a white paper outlining how a FIF might function and a proposal to establish the mechanism will be submitted for approval to the Executive Directors of the World Bank this month, after which the fund could begin to operate by the end of 2022.

Despite this momentum, however, many questions remain about a new FIF, including its governance and operations and how representative and inclusive it will be. Some global health stakeholders have raised questions as to whether and how civil society might be formally engaged in the governance of the FIF, as well as its design, implementation, and monitoring. The primary global health structure set up to respond to COVID-19 – the Access to COVID-19 Tools Accelerator, which includes COVAX, it’s vaccine arm designed to accelerate the development and manufacturing of COVID-19 vaccines and provide equitable access – has been critiqued for its lack of formal and meaningful civil society and community engagement, especially of representatives from the global South. In May of this year, the Independent Panel on Pandemic Preparedness and Response found that consultations to date with non-state actors on policy-making processes for pandemic preparedness have been “rushed, pro forma, and frankly, abysmal.”

In its white paper on the FIF, the World Bank states that it seeks to balance “inclusivity with simplicity and efficiency, to support streamlined and efficient decision-making and implementation”. The white paper contains a brief mention of civil society, as potential observers to the FIF governing board but not as formal members, as follows: “the observer pool could be broadened out, as needed, to include other multilateral institutions, civil society organizations (CSOs) and/or the private sector” and that “CSO observers could be included through a constituency-based approach”. The Bank solicited input on its white paper, and several critiques, including calls for ensuring substantive and formal civil society engagement in the governance and design of a FIF, have been submitted. The U.S. government, in its submitted comments, has been less clear on this point, saying that the FIF “should balance inclusivity and agility” and that non-governmental stakeholders could be included either as Board members or observers.

To help inform discussions regarding the creation and design of a global pandemic preparedness fund, we analyzed major multilateral global health and related institutions to assess how civil society, including global South organizations, has been engaged in their governance, implementation/programming, and monitoring. We examined 14 such institutions ranging from those that are affiliated with the United Nations, FIFs based at the World Bank, and/or independent organizations. For purposes of our analysis, we defined civil society to include representatives from non-profit or otherwise non-commercial actors who are not directly affiliated with a government and who are not acting in a solely individual capacity. Our analysis is based on a literature review, a review of official governance and other institutional documents, and interviews with a range of stakeholders (see methodology for more detail).

Methodology

We performed a broad literature review on civil society and global health governance and identified 14 prominent, ongoing multilateral global health and related initiatives for inclusion in this analysis (see Table 1). Overall, five of the 14 models examined are FIFs housed in some manner at the World Bank. The others are multilateral efforts that are either independent (6) or part of the United Nations (3), although some of the independent entities are formally hosted by Unite Nations agencies. While we focused on multilateral initiatives, it is important to note that some bilateral donor governments have also made efforts to engage civil society in development planning and programming, including for global health. PEPFAR, the U.S. global HIV/AIDS program and largest initiative focused on a single disease, stands out in particular in this area, given both its size and because it has moved to enhance the engagement of civil society in its bilateral program implementation over time. As such, it also may offer some lessons and models for future PPR efforts (see Box 2).

For each of the global health initiatives included in this analysis, official governance documents (e.g. by-laws, terms of reference of governing bodies, website information regarding governing and advisory bodies) were studied to ascertain if, how, and to what extent civil society is officially included in the organization’s governance, implementation, and monitoring. This document review was supplemented by interviews with 22 individuals who are either involved in or have working knowledge of the governance processes of these organizations. The interviews provided additional details on the dynamics of the governing bodies, other avenues for civil society input into decision-making, particular challenges and opportunities experienced by civil society with respect to engagement in governance, and ways that civil society may be engaged (beyond governance). Both during the document review and key informant interviews, the analysis paid particular attention to the engagement of civil society representatives from the global South, which includes the bulk of countries that are the recipients of outside assistance. We examined the following metrics of civil society inclusion to assess more formal engagement: board representation; voting rights; global South representation required; formal representation on committees; support for participation in governance; and requirement to fund civil society as part of program implementation. For those institutions that included formal board representation, we also looked at the share of seats reserved for civil society.

For the purposes of this analysis, civil society was defined to include representatives from non-profit or otherwise non-commercial actors who are not directly affiliated with a government and who are not acting in a solely individual capacity. Multilateral institutions or public-private partnerships affiliated with multilateral bodies were not considered as civil society. Likewise, major private funders of organizations (such as private foundations) were not considered civil society for our purposes here. Organizations were deemed to have formally included civil society on their board only if governance documents specifically reserved seats for civil society representatives.