Subsidiarity in Global Health Governance: 'Two Publics' and Defiance in the Global Fund’s Operations in Uganda

Abstract

The Global Fund to fight Aids, Tuberculosis and Malaria (GFATM) was established in 2003 to disburse funds to the poorest countries to be utilised in fighting these three major diseases. It has a unique organisational structure which is part of a new breed of public private institutions (PPIs) within international law that have been established to achieve specific health objectives. The Fund consists of a Board (19 voting and 4 non-voting members), supported by a secretariat and six committees. Of the 19 voting members, there is an equal mix of donor and non-donor countries (developing countries) thus ensuring that developing countries are represented in the decision making process. Country level structures include the Country Co-ordination Mechanism (CCM), Principal Recipient (PR) and the Local Fund Agent (LFA). Countries secure Global Fund resources via a competitive grant application system. In this paper we focus on the effectiveness of the subsidiary relationship between the GFATM and the countries in which it operates. We argue that for the most part, the GFATM is successful in ensuring that developing countries gain access to medicines. This is what we term as deference to the GFATM. However, we argue that the corruption affecting its activities in many developing countries can also in part be explained as defiance by subsidiary organisations at the local level. Defiance arises when the subsidiaries adhere to their own set of priorities/values/principles that do not necessarily coincide with those of the GFATM. We propose that this defiance is enabled or perpetuated by the existence of “two publics in Africa” that have differing and opposing values and expectations.