Transnational Bureaucracies Under Pressure: Global PPPs’ Responses to the End of the Golden Age of Global Health

The global health field is experiencing a major crisis as key donors slashing their budgets, resulting in an estimated 20% reduction of development assistance for health between 2024 to 2025. In parallel, multilateral cooperation has come under increasingly strain, amid persistent yet uncoordinated proposals for global governance reform. This paper examines how global public-private partnerships (PPPs) for health respond to the current funding crisis and navigate the pressures arising from multiple, overlapping processes aimed at reforming the global health architecture. Focusing on global PPPs offers novel insights by highlighting how governance institutions with organizational models distinct from traditional UN and other intergovernmental organizations react to external threats. On the one hand, PPPs are often viewed as agile, adaptive, and less bureaucratic than UN agencies, which may enhance their capacity to cope with uncertainty. On the other hand, PPPs may be particularly vulnerable to external pressure, as they depend entirely on the voluntary participation and funding of their partners and lack a formal foundation in international law. The paper builds on my recent research (de Bengy Puyvallée 2024), in which I conceptualize global PPPs as “transnational bureaucracies.” I trace how PPP secretariats developed agency through three administrative practices: (1) diversifying funding sources and lobbying key donors; (2) expanding organizational mandates, and (3) acting as discrete actors in global policy processes and increasing cooperation with other PPPs. I extend this work by analyzing how these practices – developed during a period of sustained growth – perform under current conditions of financial and political pressures. To do so, I conduct a case study of five global health PPPs – Gavi, The Global Fund, CEPI, Find and Unitaid. Data sources include publicly available documents issued by these organizations, global health and development specialist media and blogs, and policy documents relating to ongoing efforts to reform the global health architecture. The findings show that PPP secretariats respond to this challenging context by mobilizing two of the administrative practices that previously strengthened their agency. First, they intensify efforts to diversify funding sources, notably by securing financing arrangements with multilateral development banks, and exploring new financing models, such as shifting from grants to loans, increasing co-funding requirements, or generating their own revenues. Second, PPP secretariats expand their engagement in global policy processes. They actively contribute to reform processes surrounding the global health architecture and incorporate key insights into their own organizational strategies. For instance, Gavi has launched its “Gavi leap strategy”, which implements elements of the African Union’s “Lusaka agenda” on the future of global health initiatives. Finally, in contrast to the growth era that facilitated mandate expansion, PPP secretariats are now recentering their activities on major donors’ core priorities and developing plans to gradually “sunset” their operations. Together, these administrative practices are mobilized to justify PPPs’ continued relevance in a period of crisis and transition. Overall, the paper concludes that global PPPs display notable resilience in the face of a deteriorating funding environment, driven by bureaucratic agendas and the entrepreneurial leadership within their secretariats.