The international context

AIDS in a multilateral and multipolar world: global challenges, global and national responses

AIDS governance is both fragmented and tightly integrated. Its fragmentation is due to the diversity in the types of actors (public, private, etc.) involved in the

AIDS and governance in Africa 53 fight against AIDS and the spaces (international, national) of their involvement. Its tight integration comes from the recurring presence of the same actors across different spaces. International organisations as well as non-governmental organisations, for example, are present in both the production of international AIDS policies and AIDS assistance in Africa. They are involved in both the production and the implementation of AIDS responses at the national level. Many of them circulate between these levels and participate in holding together this vast configuration of actors. The context is that of a fragmentation of governance, that we must first understand at the highest level, through the most important actors (Table 2.1).

Levels of governance and types of actors in the fight against AIDS

The growing involvement of international health actors is reflected in the multiplication of financing mechanisms for fighting against AIDS, which generates a complex global architecture. Three main global health initiatives are worth highlighting: the World Bank’s Multi Country AIDS Programme (MAP), established in 1999; the Global Fund to Fight AIDS, Tuberculosis and Malaria (GFATM. or Global Fund), established in 2001 by UN Secretary General, Kofi Annan; and the President’s Emergency Plan for AIDS Relief (PEPFAR), established in 2003 by President George W. Bush.1 “Between the three of them", Nkoa and colleagues have noted, these organisations "provide more than 80% of international AIDS assistance, which has grown dramatically from less than US$1 billion a year at the end of the last century to 7.7 billion dollars’ worth of disbursements in 2008 (with 8.8 billion dollars in commitments)” (Nkoa et al., 2010).

Table 2.1 Level of governance and types of organisations in the figlit against AIDS.

Type of organisation


Private not-for-profit

Private for-profit



International organisations (e.g. WHO)

European Union

International NGOs (e.g. MSF)

International foundations (e.g. Bill and Melinda Gates Foundation)




Bilateral aid (e.g.


Association networks

(e.g. Coalition Plus)

Consulting firms (e.g. ZeGoGroup)


State agencies, ministries (e.g. CNLS, Ministry of Health)

NGOs (e.g. Ruban rouge; SOLTHIS)


Source: Project Governance, Demange, 2012 Note: * May intervene nationally or internationally.

Besides these three, the UNITAID initiative was launched in 2006 by France’s President Jacques Chirac and Brazil’s Luis Inacio Lula da Silva (“Lula”) and several private funding sources, such as the Clinton Foundation and the Bill and Melinda Gates Foundation, whose financial contribution to the fight against AIDS now exceeds that of the World Bank.

For all of these actors, the international financial and economic crisis rekindled the question of the prospects, methods of allocation and management of resources at the international level, as well as in the beneficiary countries, especially the poorest and/or most affected ones, including the countries of sub-Saharan Africa. As a consequence, concerns about the decline in contributions to financing access to AIDS treatment coming from wealthy countries (World Bank, 2008), particularly from the Global Fund, the main provider of resources for African countries to purchase medicines, pointed to catastrophic scenarios of massive disruption in care (Eboko, 2009. 2010).


Around 2001, the economic paradigm that had questioned the possibility of efficient and "cost-effective” scaling-up was changing (Moatti, 2011). In 2001, the Secretary-General of the United Nations decided to launch a Global Fund to fight the AIDS pandemic, with the support of international, European, and African personalities. Building on this momentum, African Heads of State met on April 26, 2001 in Abuja, Nigeria, for a special session of the Organisation of African Unity (OAU) to discuss AIDS and other infectious diseases. Present were high level international leaders, namely UN Secretary-General Kofi Annan, the Executive Director of UNAIDS and the Director-General of WHO. In 2002, the Global Fund was officially launched and its initial funding was formalised at the G8 Conference in Okinawa that same year. In 2003, the first African movement for access to medicines (PATAM) was launched at the International Conference on AIDS in Africa in Nairobi; it was inaugurated at the conference by several demonstrations led by African patients.

In 2004, patients in Burkina Faso demonstrated for the first time in favour of maintaining the importation of generics from Indian pharmaceutical companies. A new cycle was beginning, which would bring exceptional hope and progress over the next ten years, but also new challenges and obstacles aggravated by the then current economic and financial crisis. The main problem was sustainability of access to care and to prevention programmes in sub-Saharan Africa.

Understanding this logic requires us to analyse each level of international, national, and local response in order to shed light on their interactions. The Global Fund is at the heart of this logic. In just a few years, the Global Fund established itself as a central and essential player in the global fight against AIDS. The second largest hinder of the AIDS response, just behind PEPFAR, the Global Fund contributed to the financing of antiretrovirals for about half of the patients in

AIDS and governance in Africa 55 treatment in low- and middle-income countries (Kerouedan, 2011). Its importance also grew in countries like Benin, Burkina Faso, Cameroon, Niger, and Senegal that did not benefit from PEPFAR.

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