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Deciding modalities of global health governance: What facilitates or hinders public-private partnerships?

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Content i
Deciding Modalities of Global Health Governance:
What Facilitates or Hinders Public-Private Partnerships?
by
Mao Suzuki
A Dissertation Presented to the
FACULTY OF THE USC GRADUATE SCHOOL
UNIVERSITY OF SOUTHERN CALIFORNIA
In Partial Fulfillment of the Requirements for the Degree
DOCTOR OF PHILOSOPHY
(Political Science and International Relations)
May 2021
ii

Acknowledgements

First and foremost, I want to thank my dissertation committee: Saori Katada, Wayne Sandholtz,
and Heather Wipfli. All the three members have been always supportive and understanding, and
I cannot imagine finalizing this dissertation without their help. I thank Professor Katada for her
academic, professional, and mental support throughout my PhD life. She has always encouraged
me to pursue whatever opportunities that interest me, and I am truly lucky to have her as my
chair. I could think freely and learn widely because I could always feel her warm support.
Without my broad-minded advisor, I probably could not pick up this challenging topic (the
formation of PPPs is so complicated!) for my dissertation. I am grateful to Professor Sandholtz
for his invaluable advice, especially to clarify theoretical framework and to connect my argument
to a broader range of scholarly fields. Discussions and brainstorming with him were always very
eye-opening for me. I owe special thanks to Professor Wipfli, whose mentorship in the field of
global health has been instrumental for the development of my case studies and policy-oriented
thinking. I still remember how we traveled across the globe together – from WHO headquarters
in Geneva to small villages in Uganda. All those field experience really assisted me with
clarifying what I want to study.
It is impossible to raise all the names, but I thank the POIR community for providing me with
supportive and friendly environment. I could not survive a big transition from Japan to California
without those nice and warm people. I would like to express my deep gratitude to Veri Chavarin
for always helping me solve whatever problem I had, and special thanks to my brilliant
colleagues and friends, including Jenn Rogla, Stephanie Kang, Shiming Yang, Alex Lin, Suzie
Mulesky, Ronan Fu, Phoebe Tang, Jihyun Shin, Jiun Bang, In Young Min, David Somogyi,
Ellen Kim, Steffi Neumeier, and Anne van Wijk. I am also grateful to my amazing friends, Nana
Tsukada and Kaori Inuma. I would like to express my deep gratitude to Mingmin Yang. Your
kindness (and food) have always cheered me up. Thank you for being patient even when I was
frustrated and behaving like an irritated cat…
Last but not least, I want to thank my family. My father has let me pursue a career for which I
have passion, and he has always assisted me from the distance. I could count on my brother
about family matters, and I thank him to be a communication hub in our extended family.
Finally, even though I cannot chat with her again in this life, I know my mother is always
watching me from somewhere, and I think it is my privilege that I can feel her love wherever I
live. In the past, I felt pressure to do something great for her. Now, I believe I can do something
great with her. I dedicate this work to my father and mother, and I am thrilled to continuing my
journey with my loved ones in the coming years.

iii
Table of Contents

Acknowledgements ....................................................................................................................... ii
List of Tables .................................................................................................................................. v
List of Figures ............................................................................................................................... vi
Abbreviations .............................................................................................................................. vii
Abstract ......................................................................................................................................... ix
Chapter 1. Introduction: Investigating the Creation of Global Health Partnerships from a
Comparative Perspective .............................................................................................................. 1
1-1. Overview ............................................................................................................................................ 1
1-2. Historical Background: The Evolution of Global Health Partnerships ............................................. 7
1-3. Setting the Scope of Analysis .......................................................................................................... 15
1-4. Current Status of Global Health Partnerships .................................................................................. 18
Chapter 2. Theory: Drivers of Public-Private Partnerships ................................................... 23
2-1. Exiting Explanations: Interests of IGOs, Corporations, and Both ................................................... 23
2-2. CSOs as Veto Players ...................................................................................................................... 26
2-3. Scenarios of the Conflicting, Overlapping, and Diverging CSOs-Business Preferences ................ 29
2-4. Some Theoretical Caveats ................................................................................................................ 36
Chapter 3. Demonstrating Heterogeneity of Global Health PPPs .......................................... 38
3-1. Case Selection .................................................................................................................................. 38
3-2. Network Comparison of Global Health PPPs .................................................................................. 40
3-3. Methodological Strategies for the Case Study ................................................................................. 63
Chapter 4. Non-Communicable Diseases: Conflicting Interests between “Health-Harming
Industries” and Civil Society ...................................................................................................... 65
4-1. Background ...................................................................................................................................... 66
4-2. Vector of Diseases and the Historical Hostility ............................................................................... 74
4-3. Are Conflicting Views Blocking the Creation of PPPs? ................................................................. 80
4-4. The Consequence of Starkly Conflicting Preferences ..................................................................... 92
Chapter 5. Neglected Tropical Diseases: Welcoming “Profitable Gifts” from
Pharmaceutical Companies ........................................................................................................ 95
5-1. Background ...................................................................................................................................... 96
5-2. Building Trust through an Early Engagement in Drug Donation PPPs ......................................... 104
5-3. Engaging at the Even Deeper Level through Product Development Partnerships ........................ 120
iv
5-4. How Could It Be Possible? Overlapping Preferences of the Stakeholders ................................... 132
Chapter 6: HIV/AIDS: Affecting the Calculations of Big Pharma to Gain Life-Saving
Medicines .................................................................................................................................... 139
6-1: Background .................................................................................................................................... 141
6-2. Diverging Preferences over the Access to AIDS Treatment ......................................................... 150
6-3. From Diverging to Overlapping Preferences: The Power of CSO Activism ................................. 159
6-4. What It Tells about Economic and Legal Licenses to Operate ...................................................... 176
Chapter 7. Conclusion ............................................................................................................... 181
7-1. Summaries of the Argument and Findings .................................................................................... 181
7-2. Contributions of the Dissertation ................................................................................................... 185
7-3. Limitations and Future Directions ................................................................................................. 188
References .................................................................................................................................. 191
Appendix: List of PPPs ............................................................................................................. 206

v

List of Tables

Table 1-1: Types of Actors …………………………………………………………………….15
Table 3-1: Selected Issue Areas ………………………………………………………………..38
Table 3-2: Summary Statistics of Network Features …………………………………………..50
Table 3-3: Nodes with the Highest Degree Centrality …………………………………………58
Table 3-4: Variation in the Core-Periphery Analysis ………………………………………….60
Table 3-5: QAP Correlations …………………………………………………………………..62
Table 4-1: Timeline of the NCDs Governance ………………………………………………...71
Table 4-2: Number of Documents Submitted by Each Type of Actors ………………………..82
Table 4-3: Fifteen Topics in the NCDs Governance …………………………………………...84

vi
List of Figures

Figure 1-1: The Eight Millennium Development Goals ………………………………………17
Figure 1-2: Number of PPPs …………………………………………………………………..19
Figure 1-3: Number of Participants ……………………………………………………………20
Figure 1-4: Business Sector Network in the Global Health PPPs ……………………………..21
Figure 2-1: Contrast between Theoretical Explanations ………………………………………23
Figure 2-2: Summaries of Three Scenarios ……………………………………………………33
Figure 3-1: All Issue Areas and the Number of PPPs in Each Area …………………………..44
Network Figure 1: All Issues ………………………………………………………………….46
Network Figure 2: Non-Communicable Diseases …………………………………………….47
Network Figure 3: Neglected Tropical Diseases ……………………………………………...48
Network Figure 4: HIV/AIDS ……………………………………………...............................49
Figure 3-2: Number of PPPs and Participants ……………………………………………….. 52
Network Figure 5: All Issue before 2000 ……………………………………………...............53
Network Figure 6: Neglected Tropical Diseases before 2000 ……………………………… 54
Network Figure 7: HIV/AIDS before 2000 ……………………………………………………55
Figure 3-3: Composition of Participants by Type ……………………………………………..57
Figure 3-4: Industry Compositions …………………………………………………………….61
Figure 4-1: NCD Death Rate (per100000), 2016 ………………………………………………70
Figure 5-1: Geographic Distribution of Lymphatic Filariasis and Onchocerciasis …………...101
Figure 6-1: People Living with HIV …………………………………………………………..143

vii
Abbreviations

AAI Accelerating Access Initiative
ACT UP AIDS Coalition to Unleash Power
AIDS Acquired immunodeficiency syndrome
AMC Advance market commitment
APOC African Program for Onchocerciasis
ASH Action on Smoking and Health
AZT Azidothymidine
BAT British American Tobacco
CDC US Centers for Disease Control and Prevention
CDTi Community Directed Treatment with ivermectin
CEDAW Convention on the Elimination of all forms of Discrimination Against Women
CEPI Coalition for Epidemic Preparedness Innovations
CESCR International Covenant on Economic, Social and Cultural Rights
CRC Convention on the Rights of a Child
CSO Civil society organization
CSR Corporate social responsibility
DALY Disability-adjusted life year
DFID UK Department for International Development
DNDi Drugs for Neglected Diseases initiative
ESPEN Expanded Special Project for Elimination of Neglected Tropical Diseases
EU European Union
FCA Framework Convention Alliance
FCA Framework Convention Alliance
FCTC WHO Framework Convention on Tobacco Control
FDA US Food and Drug Administration
FENSA WHO Framework of Engagement with Non-State Actors
FIND Foundation for Innovative New Diagnostics
GAVI Global Alliance for Vaccine and Immunization
GFATM Global Fund to Fight AIDS, Tuberculosis, and Malaria
GHIT Global Health Innovative Technology Fund
GPA WHO Global Porogramme on AIDS
GSK GlaxoSmithKline
HAART Highly active antiretroviral therapy
HIV Human immunodeficiency virus
ICC International Chamber of Commerce
IFPMA International Federation of Pharmaceutical Manufacturers and Associations
IGO Intergovernmental organization
INB Intergovernmental Negotiating Body
viii
IPR Intellectual property rights
IVCC Integrated Vector Control Consortium
J&J Johnson & Johnson
JTI Japan Tobacco International
LMICs Low- and middle-income countries
MDA Mass drug administration
MDGs UN Millennium Development Goals
MEC Mectizan Expert Committee
MSF Médecins Sans Frontières
NATT Network for Accountability of Tobacco Transnationals
NCDs Non-communicable diseases
NIEO New International Economic Order
NIH National Institute of Health
NTDs Neglected tropical diseases
ODA Official development assistance
OPEA Onchocerciasis Elimination Program for the Americas
PhRMA Pharmaceutical Research and Manufacturers of America
PMA Pharmaceutical Manufactures’ Association
PPP Public-private partnership
PRV Priority review voucher
QAP Quadratic Assignment Procedure
SDGs UN Sustainable Development Goals
SPA WHO Special Programme on AIDS
TAC Treatment Action Campaign
TDR Special Programme for Research and Training in Tropical Diseases
TFI Tobacco Free Initiative
TRIPS Agreement on Trade-Related Aspects of Intellectual Property Rights
UHC Universal health coverage
UN United Nations
UNAIDS Joint United Nations Programme on HIV/AIDS
UNF United Nations Foundation
UNFIP United Nations Fund for International Partnerships
UNFPA United Nations Population Fund
UNICEF United Nations Children’s Fund
USAID United States Agency for International Development
WBCSD World Business Council for Sustainable Development
WHO World Health Organization

ix
Abstract

Background: Multinational corporations have increasingly participated in governance of various
global issues. One notable trend in this process is the proliferation of transnational public-private
partnerships (PPPs), such as the Global Fund to Fight AIDS, Tuberculosis and Malaria.
However, only some of the numerous global issues have attracted such cooperative initiatives
between public and private donors. Why do public and private actors cooperate to deal with
certain issues? How does this pattern of PPP creation reflect the changing roles and authority of
different types of actors?

Argument: In contrast to other scholars who have emphasized multinational corporations or
intergovernmental organizations as key actors driving the creation of transnational PPPs, this
dissertation sheds light on the role of a usually neglected stakeholder in the creation of
transnational PPPs: civil society organizations (CSOs). I argue that transnational PPPs are less
likely to be created in an issue area where CSOs are pursuing regulations of activities of
industries rather than a greater provision of specific goods.

Methods: The previous studies have focused on analyzing “successful cases” where large-scale
PPPs were created, hence they leave unexamined the cases in which such partnerships have not
been generated. This dissertation fills this gap by closely investigating both the cases in which
many PPPs have been created and the cases where such high levels of PPP usage cannot be seen.
This dissertation first conducts a social network analysis to measure the variations in the
dependent variable: the level of PPP usage across different issue areas. I then combine a
conventional qualitative case study with the computational text analysis to identify the factors
that affected the creation and non-creation of PPPs in three issue areas: non-communicable
diseases, neglected tropical diseases, and HIV/AIDS.

Results: The analysis demonstrates that CSOs in the issue area of non-communicable diseases
have strongly advocated for international regulations on industrial activities instead of a greater
provision of certain products. CSOs are active in international discussions on the governance of
non-communicable diseases, and they have vocally pursued taxations and other regulations on
health-harming products such as tobacco, alcohol and sugary food and beverage. In contrast,
CSOs in the issue area of neglected tropical diseases have advocated for a greater provision of
effective medicines. They were thus welcoming when the manufacturers of such medicines –
large pharmaceutical companies – proposed drug donation PPPs. The mutual trust between CSOs
and the business sector, entrenched through the success of the drug donation PPPs, has further
led to the creation of product development PPPs in this issue area. PPPs, however, cannot
emerge only from the preference of CSOs. The case of HIV/AIDS shows that PPPs did not
flourish until CSOs successfully altered preferences of the business sector. The creation of PPPs
requires overlapping preferences between the business sector and CSOs.

Conclusion: In essence, this dissertation makes the case that “the rise of private actors” in global
governance is restricted to the extent that another type of non-state actor – civil society
organizations – plays a role as veto players in policy debates. Although the business sector has
increasingly engaged with global governance of various issues, it cannot unilaterally takeover the
decision making when international communities decide a modality of global governance.
1
Chapter 1. Introduction:
Investigating the Creation of Global Health Partnerships from a Comparative
Perspective

1-1. Overview

The rise of private actors in global politics has been one of the most significant phenomena in
international relations over the past few decades.
1
With increased globalization and
liberalization, private actors such as multinational corporations have enhanced and deepened
their engagements in governance on various global issues. One notable trend in this process is
the proliferation of transnational public-private partnerships (PPPs), such as the Global Fund to
Fight AIDS, Tuberculosis and Malaria and the Global Alliance for Vaccine and Immunization
(GAVI). However, only some of the numerous global issues have attracted such cooperative
initiatives between public and private donors, while others are left in the hands of governments
or are neglected entirely by the international development community. Why do public and
private actors cooperate to deal with certain issues while they work separately without explicit
coordination elsewhere? How does this selection of governance modalities reflect the changing
roles and authority of public and private actors?

1
This notion has fueled the development of the global governance literature. The global governance
literature attempts to go beyond the traditional international relations scholarship, which has
predominantly focused on inter-state relations. For great summaries of the rise of non-state actors in
world politics, see Risse (2014).
2
In contrast to other scholars who have emphasized bloated commercial interests of
multinational corporations or the leadership of intergovernmental organizations as drivers of
transnational PPPs, I highlight the role of a usually neglected stakeholder in the creation of
transnational PPPs: civil society organizations (CSOs). I argue that transnational PPPs are less
likely to be created in an issue area where CSOs are pursuing regulations of activities of
industries rather than a greater provision of specific goods. By conducting a comparative case
study of health issues that have generated different levels of PPP usage, this dissertation
illustrates how the preferences of CSOs actually facilitate or hinder the creation of transnational
PPPs in the health sector. By incorporating the role of CSOs, this dissertation argues that the
politics of whether creating transnational PPPs or not is more of an outcome of dynamic
interactions among different types of stakeholders rather than a dominance of certain kind of
actors in the decision making.
Empirical assessments of the emergence of transnational PPPs are fairly limited, and the
existing studies have focused on “successful cases” where large-scale PPPs were created.
Though these in-depth case studies provide rich insights into the detailed process of partnership
making, they leave unexamined the cases in which such partnerships have not been generated.
This gap in the existing literature motivates this dissertation to provide a theoretical framework
to explain the creation – and non-creation – of transnational PPPs.
By exploiting techniques of social network analysis, this dissertation first demonstrates that
there are indeed different usage patterns of transnational PPPs across various health issue areas. I
then conduct a comparative case study to compare the issue areas that have generated many
large-scale PPPs with other issue areas that have not seen much usage of PPPs. The issue area of
neglected tropical diseases (NTDs) is assessed to demonstrate why some health issues have
3
produced high levels of PPP usage, while the area of non-communicable diseases (NCDs) is
examined to illustrate why certain issue areas have generated very limited levels of PPP usage.
The case of HIV/AIDS reveals how an issue area that did not initially attract many PPPs could in
the end see a full-blown usage of PPPs.
The comparative analysis found that CSOs in the area of non-communicable diseases have
strongly advocated for the use of international regulations on activities of the tobacco, alcohol,
food and beverage industries, while the business sector has pursued the creation of PPPs. In
contrast, CSOs in the field of neglected tropical diseases are prioritizing a greater provision of
medicines, and they welcome the engagements of the pharmaceutical industry, including drug
donations and research and development of more effective and easy-to-use medicines. These
findings support my major argument, showing that CSOs can veto the creation of transnational
PPPs even when the business sector prefers such a policy intervention. The creation of PPPs can
be blocked when CSOs are pursuing regulatory measures as a more appropriate intervention to
address the given health issue. At the same time, the findings also suggest that CSOs can work
with the industry through partnerships when they consider it appropriate in order to achieve their
priority intervention to improve a provision of certain products, such as medicines for neglected
tropical diseases.
It is not to say that CSOs can unilaterally decide governance modalities in the global health
sector. The case of HIV/AIDS highlights economic calculation of the business sector as an
important factor affecting the creation of PPPs. During the early era of global HIV/AIDS
governance, pharmaceutical companies did not see any economic benefit in contributing to a
greater access to treatment, and the industry had a clear stance that profits, not patients in
developing countries, are their priority. Therefore, even though CSOs clearly preferred a greater
4
provision of AIDS medicines as a measure to address the global AIDS crisis, transnational PPPs
did not flourish until the beginning of 2000s – when CSOs successfully altered economic
calculations of the industry by demonstrating large-scale social movements and threatened the
market situation. This case hence reveals that it requires overlapping preferences between CSOs
and the business sector to see a full-blown use of PPPs in a given issue area.
These findings have important theoretical implications for the prolonged debate on the
relative power balance between the state and the market in global politics. Starting with the
famous arguments on whether the state has retreated or not (Strange 1996; Held et al. 1999), the
growing literature on global governance has assessed the causes and consequences of the rise of
“private authority” in international affairs (Cutler et al. 1999; Higgott et al. 2000; Hall and
Biersteker 2002; Grande and Pauly 2005; Risse 2014). A large part of the literature, however,
has conceptualized the rising private authority as the growth of self-regulations by non-state
actors and thus overlooked a wider range of corporate activities, such as their growing
collaboration with governmental and intergovernmental organizations in the provision of goods
through transnational PPPs. This omission in the existing literature is rather surprising, given that
global governance is often defined to include both the making of regulations and the provision of
public goods (Risse 2011; Risse 2013; Ruggie 2004),
2
and that the provision of goods is perhaps
more prevalent than regulations in various fields of international development, such as health and
education (Liese and Beisheim 2011; Borzel and Risse 2005). By analyzing the conditions under
which transnational PPPs are created, this dissertation demonstrates that the rise of private actors

2
Risse (2011) defines governance as “various institutionalized modes of social coordination to produce
and implement collectively binding rules, or to provide collective goods” (p.9). Ruggie (2004) defines
what he calls “new global public domain” (the concept close to what we now recognize as global
governance) as “an increasingly institutionalized transnational arena of discourse, contestation, and action
concerning the production of global public goods, involving private as well as public actors” (p.504).
5
in a broader sphere of global governance cannot be understood as a simple competition between
the state and the market. In essence, this current study makes the case that the rise of private
actors (the market) is restricted to the extent that another type of non-state actor – civil society
organizations – plays a role of veto players in the creation of PPPs.
The dissertation proceeds as follows. In the following sections of this chapter, I summarize
the history of public-private partnerships, define the scope of this dissertation, and depict the
empirical puzzle that this dissertation tackles: the variations in the usage patterns of transnational
PPPs across different health issue areas. Chapter 2 summarizes the existing theoretical arguments
and develops my own theoretical framework for the creation – and non-creation – of
transnational PPPs. Chapter 3 provides a detailed empirical assessment for how the use of PPPs
varies across different health issue areas. By relying on the basic concepts and visualization
techniques of social network analysis, this chapter demonstrates that some health issue areas
such as neglected tropical diseases have very dense and well-connected networks of PPPs, while
other issues such as non-communicable diseases have much smaller PPP networks. This chapter
also explains the case selection and describes the overall methodological strategies for a
comparative case study.
Chapters 4 through 6 report the results of the case study. In line with three theoretical
scenarios developed in the theory chapter, Chapter 4 illustrates the case of non-communicable
diseases as an example of scenario A of conflicting preferences between CSOs and the business
sector. It employs both computational topic modeling and qualitative narrative analysis to
showcase that the CSOs’ strong emphasis on regulations has hindered the creation of PPPs in
this issue area. Chapter 5, in contrast, takes a closer look at the case of neglected tropical
diseases as an example of scenario B of overlapping preferences between CSOs and the business
6
sector. This case reveals that CSOs are willing to work with the business sector when they are
pursuing a greater provision of certain products as a priority intervention in the give issue area.
This case also shows that the business sector has its own structure of decision making, based on
short- and long-run economic calculations.
Chapter 6 illustrates the scenario C of diverging preferences between CSOs and the business
sector. The early era of HIV/AIDS illustrates this scenario – the mega PPPs did not emerge in
this issue area until the AIDS activists successfully convinced the business sector that improving
access to AIDS medicines does not necessarily harm the bottom line of the pharmaceutical
industry; rather, inaction would harm the industry because a whole system of the protection of
intellectual property rights might be altered if the industry remained blind to the human costs of
the AIDS crisis. Since the early 2000s, the issue area of HIV/AIDS is one of the most popular
destinations of PPPs. This case thus illustrates that these three scenarios are not “static”: an issue
area can move from one scenario to another as the preferred intervention of CSOs and the
economic and legal calculations of the business sector change. This chapter also looks at the
current relationship between CSOs and the pharmaceutical industry in the issue area of non-
communicable diseases. This helps demonstrate that a single health issue can have multiple
layers of relationships between CSOs and different industrial sectors. The hostile relationship
between CSOs and the tobacco, alcohol, and food and beverage industries has resulted in a very
limited use of PPPs in the issue area of non-communicable diseases (as Chapter 4 reveals).
However, in the same issue area of non-communicable diseases, CSOs that are advocating for
greater access to (and provision of) medicines like insulin and cancer drugs would probably be
willing to create partnerships with pharmaceutical companies. Hence, the theoretical arguments
7
that I develop in this dissertation explain the creation – and non-creation – of PPPs with certain
industries in a given issue area.
After reviewing the major findings of the comparative case study in line with my theoretical
framework, Chapter 7 concludes this dissertation by discussing major theoretical, empirical and
social contributions of this research and summarizing implications for the future research.

1-2. Historical Background: The Evolution of Global Health Partnerships

This dissertation focuses on public-private partnerships as a relatively new modality of global
governance, which has evolved over the past two decades and proliferated in many issue areas of
global health and in a broader sphere of international development. This section offers a brief
historical background of the evolution of PPPs. The review suggests that there has been a grand
shift from the use of regulatory measures such as international laws to the reliance on more
voluntary measures of governance, crystalized as the proliferation of public-private partnerships.
This shift could possibly be interpreted as a weakening or softening of global governance, to the
extent that binding regulations have been replaced by voluntary, non-binding PPPs. It poses an
important question of why, then, some issue areas remain tolerant to this grand shift, retaining a
stricter modality of global governance such as the making of international regulations. In the
next chapter, I will develop a theoretical framework to explain this puzzle by focusing on the
role of civil society actors. But before that, this section depicts the recent evolution of PPPs as a
general trend in global governance during this century.
8
To be clear, cooperation between governmental bodies and the business sector is not new.
Even cooperation between the UN organizations and non-state actors at the international (or
transnational) level is not a new phenomenon. As several authors have already indicated, non-
state actors have been interacting with the UN since its founding (Nelson 2002; Tesner with Kell
2000; Bull and MacNeill 2007). Several business associations and union groups showed an
interest in attending the UN founding Conference in San Francisco in 1945, and one of them –
the International Chamber of Commerce (ICC) – immediately received accreditation to the UN
under Article 71 of the Charter. The ICC has been officially interacting with the UN since then.
Tesner (2000) argues that the UN did not intend to be anti-business at the beginning, but this
image came to be attached to the organization later during the Cold War. With the independence
of formerly colonized countries, the overall UN attitude towards large business became stricter
and more hostile, and so did the attitude of big business towards the UN, especially under the
New International Economic Order (NIEO) framework.
However, the past two decades witnessed a marked increase in the scale and impact of the
interactions between the business sector and various intergovernmental organizations. Since the
early 1990s, representatives of the business sector have been invited to attend and make inputs
into major global conferences. The famous examples of such business involvement include the
1992 UN Conference on Environment and Development, the 1995 World Summit on Social
Development, and the 2002 World Summit on Sustainable Development (Zammit 2003). A
change in the UN attitude towards partnerships with the private sector was first observed at the
United Nations Conference on Environment and Development (Earth Summit) in Rio de Janeiro
in 1992, where the Conference’s Secretary-General invited the newly formed World Business
Council for Sustainable Development (WBCSD) to write the recommendations on industry and
9
sustainable development. Ten years later in 2002, the World Summit on Sustainable
Development in Johannesburg experienced the “unprecedented” level of presence of the private-
sector actors in the UN summit context (Bjorkelo 2005). The 2002 Summit resulted in the launch
of more than 200 partnerships involving the business sector and other kinds of actors.
Many authors have pointed out that what is new in this recent trend are 1) the number of
partnerships formed between the business sector and governmental/intergovernmental bodies,
and 2) the direct engagement of the business sector in the decision-making process of major
global governance institutions (Zammit 2003; Nelson 2002). As the number of partnerships
increases, the issue areas where the business sector engages have expanded. The private sector is
now working with public entities in various areas ranging from “peacekeeping and disarmament
to human rights, good governance, sustainable development and poverty eradication” (Nelson
2002). Various functions of the UN have opened up for cooperation as well. Non-state actors are
now involved in policy making, standard-setting, operational activities, and advocacy work.
This fundamental expansion of the public-private interactions was at least partly driven by the
leadership of the UN Secretary-General Kofi Annan, who stayed in the office from 1997 to 2006.
Only four weeks after assuming the office in February 1997 Annan participated in the World
Economic Forum in Davos and declared that there was now “a new universal understanding that
market forces are essential for sustainable development.” In September of the same year, the
Time Warner Vice-Chairman Ted Turner gave a historic gift of US$1 billion to the United
Nations, which led to the creation of the United Nations Foundation (UNF) and later the United
Nations Fund for International Partnerships (UNFIP) (Bull and McNeill 2007; Richter 2004). In
the following year, again in Davos, Annan gave a speech and strongly emphasized the necessity
of partnership between the UN and the business sector:
10
“If reform was the dominant theme of my first year in office, the role of the private sector
in economic development was a strong sub-theme. A fundamental shift has occurred. The
United Nations once dealt only with governments. By now we know that peace and
prosperity cannot be achieved without active partnerships involving governments,
international organizations, the business community and civil society. In today’s world
we depend on each other. The business of the United Nations involves the business of the
world.”
(Annan 1998)

In September 1998, the International Chamber of Commerce held a Business Roundtable
Dialogue in Geneva and the leading UN figures and 450 CEOs got together to discuss the future
direction of their cooperation. As a result, a joint UN-ICC statement was made, which proposed
raising the productive potential of poor countries by promoting the private sector (Buse and Walt
2002). In January 1999, Annan launched an idea of a “global compact of shared values and
principles” in Davos, and due to the enormous response to the initiative, the famous United
Nations Global Compact was established directly under the Secretary-General. Annan’s effort to
change the narrative regarding the UN-business partnerships can also be seen in his speech to the
Chamber of Commerce of the United States: “Confrontation has taken a back seat to co-
operation. Polemics have given way to partnerships.” The emphasis on the necessity of such
partnerships got even stronger in the 2001 speech made at the World Economic Forum, where
Annan mentioned “for the UN, engaging with the private sector was not an option, but an
imperative.” Tesner with Kell (2000: 2) emphasize the crucial role Annan played in changing the
direction of the UN-business relationship: “Kofi Annan brought with him an understanding of,
11
and an appreciation for, the private sector that none of his predecessors had ever displayed. His
business education constitutes, in and of itself, a radical departure from the traditional
government and diplomatic background of every UN secretary-general before him.”
In a seminal report issued by the Secretary-General in 2000, We the Peoples: The role of the
United Nations in the 21
st
Century, Annan stressed that the challenges faced by the UN could not
be solved without a close cooperation with the private sector (UN 2000a). This led to the
inclusion of the statement, “develop a global partnership for development” in the UN
Millennium Development Goals as Goal 8 (UN 2000b). The promotion of such partnerships as a
“goal” (not “means” to achieve more substantial improvement in development indicators) was
succeeded by the UN Sustainable Development Goals (UN 2015). Witnessing this clear push
towards the UN-busines partnerships, member states started showing growing support as well as
increasing concern about the various risks such partnerships may pose for the UN. To address
such interests and concerns, the Secretary-General issued the UN Guidelines for Cooperation
with the Business Community in 2000. During the following five years, the UN General
Assembly issued three resolutions regarding partnerships with the private sector. These
resolutions expressed general support for partnerships, but also raised concerns regarding the
compatibility of such partnerships with UN integrity (Bull and McNeill 2007). Zammit (2003)
mentions that G77 expressed a number of reservations and caveats that are reflected in the
resolutions.
A similar pattern can be seen for the relationship between the WHO and the business sector.
Just as the UN Secretary-General Kofi Annan played a role of major catalyst, the Director-
General of the WHO, Gro Harlem Brundtland, shifted the organization’s attitude towards the
private sector. As soon as she was elected for the Director-General in 1998, Brundtland placed a
12
strong emphasis on building a relationship with industries other than tobacco and sugar. A series
of roundtable discussions has taken place between the WHO and the International Federation of
Pharmaceutical Manufacturers and Associations (IFPMA) since October 1998 (Mitchell et al
1993; Buse and Walt 2002). A former Prime Minister of Norway and a leader of the World
Commission on the Environment and Development, Brundtland thought it was a natural
direction to closely work with the private sector, otherwise it would be hard to push up health
issues higher on the global political agenda (Bull and MacNeill 2007).
In January 2000, the Director-General presented a new Corporate Strategy for the WHO
Secretariat, encouraging “collective action and partnerships.” She also established the
Commission on Macroeconomics and Health in the same year (Richter 2004). In December
2001, the Commission’s report stressed the benefits of PPPs as “new funding mechanisms” and
promoted the pharmaceutical industry as a key player in voluntary and cooperative arrangements
with governments, donors and international organizations that would enable poorer people to
gain access to essential medicines. The narratives that Brundtland promoted are quite similar to
those advocated by UN Secretary-General Kofi Annan. At the World Health Assembly in 2002,
Brundtland made the following speech, reflecting the notion of necessity to make partnerships
with the private sector:
“In a word filled with complex health problems, WHO cannot solve them alone.
Governments cannot solve them alone. Nongovernmental organizations, the private
sector and Foundations cannot solve them alone. Only through new and innovative
partnerships can we make a difference. And the evidence shows we are. Whether we like
it or not, we are dependent on the partners… to bridge the gap and achieve health for all.”
(WHO 2002)
13

Existing studies on the history of transnational PPPs have pointed out several factors that
pushed the UN and the WHO to open themselves up to the private sector. One of the most
popular factors raised by several authors is the budget constraints the UN organizations were
facing around that time. Already in the 1980s, the US State Department clearly communicated its
strong position that the WHO should not be involved in efforts to regulate or control the
commercial practices of the industries, even when the products such as infant food products,
pharmaceuticals, tobacco, and alcohol may raise health concerns (Richter 2004). In fact, in 1986
and 1987, the US withheld a large part of its contributions to the WHO when the health
organization tried to produce Ethical Criteria for Medicinal Drug Promotion. In 1997, the UN
was also brought to the brink of bankruptcy by the deliberate withholding of the $1.5
billion contribution by the United States. Facing budget constraints, the UN Secretary-General
asked business leaders to speak up to persuade the US Senate and Congress that the UN is good
for business (Richter 2004; Zammit 2003).
In addition to the budget constraints, the UN organizations were facing institutional
competition. With the growing presence of the Bretton Woods institutions, the UN role in the
economic sphere had been eroded during that time. Particularly in the health sector, the World
Bank was expanding its presence, and the legitimacy of the WHO as a specialized agency
responsible for public health was waning. On the other hand, companies were also interested in
pursuing partnerships with the UN organizations. There was a surge of protests from those who
were not benefiting from the current form of globalization, and large companies were more
exposed to harsh criticism in the anti-globalization tide. Under such circumstances, initiatives
14
like the UN Global Compact provided an opportunity for the business sector to representing
itself as a good global citizen (Zammit 2003).
As I discuss in the theory chapter (Chapter 2), this is just part of the story. The growth and
proliferation of transnational partnerships cannot be understood merely as a win-win solution for
intergovernmental organizations and the business sector. There are some issue areas that have
not produced many PPPs even though both IGOs and the business sector show interests in
creating such partnerships. Yet, in the big picture, there has been an overall trend towards
voluntary governance modalities involving non-state actors from stricter measures such as
international regulations. As Zammit (2003) suggested, “[I]n the ideological climate prevailing
from the early 1980s onwards, government regulation of business became unfashionable,” and
“[D]eregulation and privatization have become policy mantras, and voluntary or self-regulation
by the business sector itself has been regarded by business and governments as a more flexible
approach that fits the new climate of greater international competition” (Zammit 2003:38).
This indicates an intriguing connection between binding regulations and voluntary PPPs – the
two major modalities identified in the global governance literature. However, the connections or
interactions between these two modalities have not been seriously examined by existing studies.
In the theory chapter, I will elaborate the potential zero-sum relation between these two
modalities of global governance (at least from the perspective of civil society actors) as an
important perspective to better understand the variations in the use of PPPs across different issue
areas.

15
1-3. Setting the Scope of Analysis

Defining Public-Private Partnership
The term “public-private partnership” is confusing, and even the distinction between public and
private actors is not as obvious or simple as it appears at first glance (Risse 2011). In this
dissertation, I consider the states (governments) and IGOs as public actors, and the business
sector (for-profit companies and business associations) as private actors. Some authors consider
PPPs to be an actor (see, for example, Fidler 2010), but this dissertation treats PPPs more as a
forum or arrangement in which other public and private actors interact and work together than as
an actor per se. When I use the term “private donors,” I refer to the business sector. In contrast,
the term “CSOs” refers to not-for-profit civil society organizations, and I consider civil society
as a third category (society) which is different from “public” (governmental) and “private”
(market) actors. Another important category in global health governance is philanthropic
foundations, such as the Bill and Melinda Gates Foundation. As I discuss more in detail in
Chapter 3, I treat philanthropic foundations as a fourth type of actor which is different from the
business sector (for-profit companies) and CSOs.

Table 1-1: Types of Actors

Type of Actor Examples
Government USAID, PEPFAR, US Department of State
Intergovernmental organization WHO, World Bank, EU
Business sector Johnson & Johnson, Coca-Cola, PhRMA, IFPMA
Not-for-profit civil society organizations Oxfam, Médecins Sans Frontières, NCD Alliance
Philanthropic organizations Gates Foundation, Wellcome Trust
State
Non-State
16
There are multiple labels and definitions of the cooperative initiatives between different types
of actors: “multi-stakeholder initiatives,” “corporate citizenship initiatives,” “public-private
interactions,” to raise just a few. One of the most famous and frequently used definitions is the
UN definition, which states that public-private partnerships are the “voluntary and collaborative
relationships between various parties, both state and non-state, in which all participants agree to
work together to achieve a common purpose or undertake a specific task and to share risks and
responsibilities, resources, and benefits” (UNGA 2005, cited by Bull and McNeill 2007).
Drawing on this broad definition, I specify the types of partnerships that this dissertation
includes in the analysis. First, PPPs need to involve both public and private actors. I focus on the
partnerships that include either IGOs or government, and at least one actor from the business
sector. This means that my analysis does not include partnerships between, for instance, the
business sector and civil society, as it does not incorporate public actors. Second, partnerships
need to be based on voluntary and collaborative relationships among the involved actors. This
notion helps distinguish PPPs from other forms of public-private relationships such as
compulsory license or public facilities contracts with the business sector. Third, by forming a
partnership, public and private actors agree to work together to achieve a common purpose.
While “a common purpose” could be anything in the broad UN definition, I specify this term in
that the ultimate goal of the partnerships is to improve health outcomes in less developed parts of
the world. Collaboration between the states and the market first started at the domestic level in
highly industrialized countries (Savas 2000; Rosenau 2000), but these partnerships are not
included in my analysis because they contribute to the “national” level of governance. The
partnerships of my concern are those in which donors and recipients have different nationalities
and are thereby “transnational” in character.
17

Reason to Focus on Global Health
I focus on global health issues instead of a more diverse set of global issues for two reasons. The
first is related to the substantive policy importance of the global health sector. Global health has
been considered a key sector in a broader international development agenda. As is well-known,
three out of eight UN Millennium Development Goals (MDGs) were allocated to the
improvement of health specifically (Goals 4, 5, and 6, as indicated in Figure 1 below), and other
goals were also closely related to the improvement of health (UN 2000b). The importance of
health is retained in the post-MDGs agendas of the Sustainable Development Goals,
incorporating even broader health issues such as environmental health to the list (UN 2015).
3

Figure 1-1: The Eight Millennium Development Goals

Second, the past two decades saw a surge in PPPs in the global health sector despite the
conventional view that health is a representative case of market failure, providing an intriguing

3
For the full list of health targets in SDGs, see https://www.un.org/sustainabledevelopment/health/
18
opportunity to assess the changing roles of public and private actors in global governance. In
recent history, improvement of population health has been seen as something that states and
IGOs such as the WHO have to take care of (Packard 2016). Yet, the two most remarkable
“mega” PPPs (Global Fund and GAVI) were created in the health sector. Engagements from the
private sector in global health governance have been booming since around mid-1990s (Harman
2012). Probably the most eye-catching in this regard is the Bill and Melinda Gates Foundation’s
heavy focus on global health. The Gates Foundation – the world’s largest private grant-making
foundation – gave more than 60% (equivalent to $1.22 billion) of its grant to global health in
2007 (McCoy et al. 2009). More in general, the business sector has contributed increasing
amount of assistance for health, and it poses a question of how the business sectors came to
participate in global health governance – a domain in which the role of public actors has been
traditionally emphasized.

1-4. Current Status of Global Health Partnerships

Based on this definition of public-private partnership, my originally compiled dataset on global
health partnerships finds that health issues such as malaria, neglected tropical diseases, and
women’s health have produced many PPPs or PPPs with a large number of partners, while other
health issues including non-communicable diseases, nutrition, and universal health coverage
have not generated as many and large-scale PPPs as the former issues have. The following
paragraphs present some major findings from the analysis of the original dataset. To my
knowledge, this is the first empirical assessment that compares the level of PPP usage in various
19
health issue areas, and a more detailed comparison of PPP networks across selected health issue
areas will be presented in Chapter 3.

Figure 1-2: Number of PPPs

1
1
1
1
1
3
3
5
5
8
9
9
11
16
0 2 4 6 8 10 12 14 16 18
Biosafety
Road Safety
Other non-infectious diseases
Other Infectious Diseases
Universal Health Coverage
NCDs (Four Risk Factors)
Water and Sanitation
Nutrition
Women's Health
Vaccine Preventable Diseases
Tuberculosis
Malaria
HIV/AIDS
Neglected Tropical Diseases
20

Figure 1-3: Number of Participants

Figure 1-2 shows the number of PPPs created in 14 health issue areas in the dataset, and
Figure 1-3 shows the total number of public and private donors participating in these PPPs. In
both figures, infectious diseases (black bars) appear on the top, while NCDs, nutrition, and cross-
cutting areas such as universal health coverage have not attracted as many PPPs and participants
as infectious diseases and women’s health have.
Figure 1-4 depicts participation trends in the business sector. Squared-nodes indicate the
issues and the circled-nodes indicate the donors (companies or business associations). There is a
link from a circle to a square if the donor (circle) participates in more than one PPP in that issue
area (square). The donors and links are colored by the industries: Red (pharmaceutical and
biochemical industries), purple (healthcare industries such as manufacturers of medical devices,
and the industries that produce bed nets), blue (alcohol and food and beverage industries), light
8
9
14
26
28
32
35
48
79
86
102
145
154
181
0 20 40 60 80 100 120 140 160 180 200
Biosafety
NCDs (Four Risk Factors)
Water and Sanitation
Road Safety
Other Infectious Diseases
Other non-infectious diseases
Universal Health Coverage
Nutrition
Vaccine Preventable Diseases
Neglected Tropical Diseases
Women's Health
Tuberculosis
HIV/AIDS
Malaria
21
green (extractive industries such as oil companies), yellow (automobile-related industries) and
white gray (others). The size of the circles indicates a degree centrality, showing that the larger
circles are connected to a greater number of health issues.

Figure 1-4: Business Sector Network in the Global Health PPPs

22
What is remarkable in Figure 1-4 is the centrality of the pharmaceutical industry in this
network, with big pharmaceutical companies such as GlaxoSmithKline (GSK) and Johnson &
Johnson (J&J) presented as large circles located in the center of the network. Some health issues
such as neglected tropical diseases (NTDs), HIV/AIDS, and malaria are densely connected
through the red links (meaning that many pharmaceutical companies engage with PPPs in these
health issue areas), and the active participation of the industry somewhat corresponds to the high
levels of PPP usage in these issue areas. A plausible inference from this observation is that there
are many PPPs when the pharmaceutical industry is willing to cooperate with the public sector.
However, this is not the whole story of PPP creation. We can clearly see that various
industries (depicted in various colors) are participating in PPPs in the area of women’s health –
not only red but purple, blue, yellow and white gray ties are surrounding the square of women’s
health. As Figures 1-2 and 1-3 show, women’s health is one of the most common destinations for
global health PPPs, and this illustrates that the engagement (or dominance) of the pharmaceutical
industry is not necessary for the creation of PPPs. The issue area of NCDs (placed at upper right
in Figure 1-4) is not well connected to pharmaceutical companies in comparison to infectious
diseases like malaria, but NCDs could have been a site of cooperation between governmental
donors and other industries as in the case of women’s health. Why is this not the case? By
focusing on the role of CSOs as veto players in the creation of PPPs, the next chapter develops a
theoretical framework to account for this empirical puzzle.

23
Chapter 2. Theory:
Drivers of Public-Private Partnerships

2-1. Exiting Explanations: Interests of IGOs, Corporations, and Both

Broadly speaking, the existing literature offers three types of arguments to explain the creation of
transnational PPPs. These explanations emphasize the agency of different types of actors as a
main driver of partnerships. Diagrams in Figure 2-1 compare these explanations with my own
argument.

A popular explanation attributes the creation of PPPs to the initiatives of public actors, mainly
IGOs such as the UN organizations. This “IGO’s leadership approach” (the left diagram in
Figure 2-1) argues that governments and IGOs are incapable of effectively dealing with global
challenges in the era of globalization, so they initiated PPPs as superior instruments that fill the
governance gaps (Reinicke and Deng 2000; Reinicke and Witte 2000; Nelson 2002; Backstrand
2006). This view is usually supported by proponents of PPPs, highlighting the cost-effectiveness
24
and the problem-solving capacity of PPPs (Borzell and Risse 2005; see for instance Brinkerhoff
and Brinkerhoff 2011). By focusing on how effective PPPs can be, however, this approach
disregards the motivations of actors to engage in such partnerships. Even if it is true that wealthy
industries are able to help states and IGOs govern various global issues more effectively, why are
they willing to lend a hand? It is naïve to believe that multinational corporations suddenly
became altruistic and started participating in global governance just because they have the
capacity. In other words, this approach largely ignores the agency on the side of private donors.
In contrast to this approach, many scholars have highlighted the power of the business sector
in global health governance, arguing that PPPs emerged out of a bloated commercial interest to
“stabilize the hegemonic capitalist worldview and to reproduce a corporate-friendly global
governance system” (Schaferhoff et al. 2009: 455) (the second from the left in Figure 2-1). Here,
PPPs are seen more as an instrument of business interests rather than as a governance tool
(Ruckert and Labonte 2014; Levy and Newell 2002; Utting 2002). This “corporate takeover
approach” further argues that the public sector has to rely on private resources to address global
issues because neoliberal policy reforms have led to a sharp decline in government revenues
(Ruckert and Labonte 2014). A volume edited by Rushton and Williams takes a similar position.
The rich collection of in-depth case studies illustrates that industries and philanthropic
foundations are enjoying the power to set global health agendas by brokering transnational
partnerships, and the power is based not only on their financial resources and political influence
but also on their increasing legitimacy as health governance actors (Rushton and Williams 2011).
What is interesting about this approach is that they do not just assert a simple intuition that
“money talks.” Instead, the authors attempt to reveal the interplay between material resources
(i.e. vast wealth) and ideological shift (i.e. belief in the efficiency of market) in explaining the
25
rising authority of the market, thereby bridging two different theoretical perspectives¾rational
choice and constructivist views of international politics. However, the empirical evidence is
mostly based on a small number of case studies, and a predominant focus is on the cases for
which prominent PPPs are created (Moran 2014; Rushton and Williams 2011). This leaves the
possibility that the argument cannot account for the cases for which PPPs are not created,
warranting further assessment of the cases where the “dog didn’t bark.”
Unlike the above approaches, what Schaferhoff and his co-authors call the “incentive-based
approach” (the second from the right in Figure 2-1) attempts to account for motivations of both
public and private donors to join transnational partnerships (Schaferhoff et al. 2009). It argues
that “PPPs will be formed when the interests of actors overlap, and each of them can expect
benefits” (Witte and Reinicke 2005: 46). Tesner (2000) argues that global partnership is a win-
win solution in which UN agencies can gain financial and other resources from the business
sector while corporations benefit from cultivating the bottom-of-the-pyramid markets. A virtue
of this approach is that it can avoid a partial view that the creation of PPPs is forcefully driven by
one kind of actor – whether it is IGOs or the business sector.
I take a similar view as the incentive-based approach in the sense that each stakeholder’s
agency is taken into consideration. However, while this approach focuses on the overlapping
interests between public donors and corporations, my theoretical framework emphasizes the
interests of CSOs. The authors in the incentive-based approach, as they insist that the
partnerships are generated based on the overlapping interests between public and private donors,
raise a normative concern that the formation of transnational partnerships is supply-driven,
reflecting the interests of powerful northern donors instead of the needs of developing countries
(Andonova and Levy 2003; Schaferhoff et al. 2009). I agree that it would be easier to create
26
transnational PPPs where wealthy northern donors – both public and private – have incentives to
form partnerships, but my framework insists it is not always the case.
Even when public and private donors share interests to create a partnership, CSOs can block
such initiatives if they believe that a governance instrument other than PPP is more appropriate
to addressing the issue of their concern. In this sense, my framework emphasizes the role of
CSOs as veto players in the creation of PPPs. This is the major contribution of my theoretical
framework: As is clear in Figure 2-1, none of the existing explanations recognizes the role of
CSOs in the creation of PPPs. I take the role of CSOs seriously and explain why some issues –
such as NCDs – have not generated much usage of PPPs even though IGOs and large
multinational corporations show interest in making transnational PPPs. Furthermore, in
articulating the scenarios in which “the interests of actors overlap” (Witte and Reinicke 2005:
46), I argue that a preferred policy intervention of CSOs and that of the business sector need to
overlap for a PPP to be created (the right diagram in Figure 2-1).

2-2. CSOs as Veto Players

Ample literature in the constructivism school of international relations has demonstrated the
power of civil society in affecting policy outcomes (Keck and Sikkink 1998; Risse, Ropp and
Sikkink 1999).
4
In the field of global health policy, Shiffman and his co-authors emphasize the
effectiveness of global health networks (mostly constituted of CSOs) as a key factor to explain
the issue creation (Shiffman et al. 2016). My framework is trying to explain the selection of

4
For great summaries of the IR works on non-state actors, see Risse 2014.
27
governance modalities (why some issues are governed through transnational PPPs) instead of
issue creation (why some issues attract political attention in general); hence, I deal with a more
downstream stage of the policy-making process
5
than the research by Shiffman does. Yet, it is
plausible to think that the role of CSOs remains important throughout the policy-making process.
When CSOs try to sell their issue to policy makers and donors, they do not merely stress the
importance of the issue but usually send a message as to how the issue should be addressed.
6
It
might be possible to have a long list of governance instruments that could possibly be employed
to address global health issues, but I focus on two broad categories: regulations or the provision
of goods and services through voluntary initiatives, namely PPPs. As I pointed out in the
introduction, the literature on global governance recognizes the two modes of governance
(regulations and the provision of goods), but the creation of transnational PPPs has been
analyzed mostly separately from the studies on international regulations. I do not think these two
modes of governance are completely separable. Rather, I argue that there is a perceived zero-sum
relationship between the making of international regulations and transnational PPPs: CSOs
believe that the creation of transnational PPPs hampers or slows down the making of regulations;
they are thus reluctant to create transnational PPPs and may try to block such initiatives when
pursuing the use of regulation as an appropriate governance instrument for the issue at hand.
Possible interactions between international regulations and PPPs are described by other
authors as well. In her recent book, Andonova (2017) suggests that PPPs “emerge as largely

5
Once an issue is “created” as an important global agenda, the point of contestation moves to how the
issue should be governed, and this is where governments, the business sector, and CSOs formulate
preferences as to whether they want to create PPPs.
6
In the discussion on the role of framing in policy making, Rushton and Williams (2012) define frame as
“linguistic, cognitive and symbolic devices used to identify, label, describe and interpret problems and to
suggest particular ways of responding to them” (Rushton and Williams 2012: 154, emphasis added). As
CSOs usually use a framing strategy in their advocacy efforts, it is reasonable to consider that they are
promoting particular policy interventions when they advocate for issues of their concern.
28
nonlegalized coalitions of like-minded actors” (p.10) and “[T]hus, partnerships can spur
incremental collective action toward global objectives in parallel to or in lieu of more
encompassing but slower intergovernmental efforts” (p.11, emphasis added). A similar argument
can be seen in the hard vs. soft law debate in the literature on international legalization.
7
A well-
cited article by Abbott and Snidal (2000) suggests that soft law is often created as an alternative
to hard law, which poses a higher sovereign cost for the governments.
Whether international regulations and transnational PPPs are actually in a complementary or
antagonistic, zero-sum relation is an open empirical question. What matters to this dissertation,
though, is the perception of the key stakeholders on this point. I consider that these two modes of
governance are at least being considered as a zero-sum by CSOs. This is a reasonable
assumption given the increasing awareness of the concept of conflict of interest within the global
policy community. Many UN agencies have established safeguard policies to avoid working with
the industries that have conflicting interests with their mandates. For instance, WHO’s
Framework of Engagement with Non-State Actors (FENSA) states that the organization does not
engage with the tobacco and arms industries (WHO 2016). This leads to the following pair of
propositions regarding the preference of CSOs:
Proposition 1a: CSOs would try to veto the creation of a PPP in an issue area where
they are pursuing regulations on activities of industries.
Proposition 1b: CSOs would support the creation of a PPP in an issue area where they
are pursuing a greater provision of specific goods.

7
Or alternatively, it might be similar to a more general discussion in the regime theory. Koenig-Archibugi (2002), in
advancing the framework provided by Young (1999) on the interplay among international regimes, points out that
multiple regimes can be embedded, nested, clustered, overlapping or “competing” with each other.
29
The policy preferences of CSOs, interacting with the interests of the business sector, would
lead to three possible scenarios in the creation vs. non-creation of transnational PPPs: In one
scenario, the interests of the two stakeholders conflict with one another and PPP would not
emerge (Scenario A). In another scenario, the interests of CSOs and that of the business sector
come to overlap and PPP would be created (Scenario B). In the third scenario, a policy
preference of CSOs diverges from economic interests of the business sector and PPP would fail
to emerge (Scenario C). Building on the license to operate model, the following sub-section
articulates how such scenarios proceed (see Figure 2-2 below for the summaries of the three
scenarios).

2-3. Scenarios of the Conflicting, Overlapping, and Diverging CSOs-Business
Preferences

Scholars in various fields have sought to explain why the business sector modifies its actions in
order to appease social demands. Three factors are frequently addressed in the existing literature:
The link between social performance and financial benefits (Myers and Gereffi 2010; King and
Pearce 2010), threats of government regulations (Haufler 2001), and pressures from activist
campaigns (Vogel 2008; Baron 2010). Gunningham and his coauthors (2003, 2004, 2009)
rephrase these three mechanisms in their license model. The authors argue that, first,
corporations change their behavior in line with societal demands either when they can gain
economic benefits by doing so or when the lack of action causes significant economic loss for
them (economic license). Second, the business sector tries to act in favor of societal demands
30
when there is a threat that the government might make a binding regulation on their behaviors
(legal license). Third, activists and the general public can pressure corporations in a variety of
ways such as naming and shaming (social license), but the social license usually can only be
enforced indirectly through economic or legal mechanisms (Gunningham et al. 2004: 334).
Following this explanation, I focus on the effects of legal and economic factors on the industry’s
preference regarding the creation of PPPs.
The finding that a legal threat is one of the key drivers of corporate behaviors suggests that
the business sector may agree or even take a lead in creating voluntary initiatives such as PPPs
when there is a movement towards regulation. From the perspective of the business sector, to be
regulated by governments is a worse scenario than contributing to PPPs because regulations
would restrain their operations and may negatively affect the bottom line. Thus, when the
industries face legal threats, they have incentives to create PPPs as a way to distract the attention
of policy makers and civil society from the making of regulations. This suggests the following
proposition:
Proposition 2a: The business sector would support the creation of PPPs in an issue area
where there is a movement towards regulation that restrains the industry’s activities.

Note that this proposition 2a is in direct conflict with the proposition 1a regarding the
preference of CSOs. The very fact that there is a threat of regulation for the industries indicates
that there are some actors (most likely CSOs) who are pursuing regulations. In this case, there is
necessarily a conflict between the preferences of the business sector and other actors (CSOs),
and this makes it harder for public donors, particularly IGOs like the UN, to legitimately pursue
31
the creation of transnational PPPs. Under this scenario, it is unlikely to see a PPP (a large-scale
partnership in particular) in this issue area.
In other words, scenario A indicates that a PPP is less likely to be created in an issue area
where CSOs are pursuing regulations as an appropriate policy intervention to address the issue.
The fact that CSOs advocate regulation induces incentives for the business sector to initiate a
PPP as a countermovement, but this situation of conflicting interests among stakeholders makes
it difficult for public donors to support the creation of transnational PPPs (Scenario A:
Proposition 1a + Proposition 2a = Non-creation of PPPs).

The other two scenarios – scenarios B and C – start with the proposition 1b raised above.
When CSOs prefer a greater provision of specific goods as a priority policy intervention, CSOs
do not work as veto players in the making of PPPs. CSOs might be supportive of creating
transnational PPPs or they might even be a major advocate for the use of PPPs in the issue area.
However, a PPP is not likely to be created unless the business sector sees a reason to engage with
the governance of the issue. This is where the “economic license” needs to be enforced. As
Gunningham’s license model suggests, the economic license has two aspects: economic gain
from action and economic loss from inaction. The former is based on a simple logic that the
industry has no reason to refuse cooperation if such activities bring economic gains for them.
This could happen when, for instance, the provision of their commodities (e.g. pharmaceutical
products) can help the corporations to cultivate emerging markets, or the provision of goods at
least does not harm the bottom line and they can anticipate mid- to longer-term financial gains
through an improved reputation. The other side of the economic mechanism is trickier to apply in
the context of global health because it is hard to boycott products such as essential medicines and
32
alcohol (if consumers are addicted). Yet, there is still a possibility that consumers might boycott
unhealthy products such as soda. This leads to the following proposition:
Proposition 2b: The business sector would support the creation of PPPs in an issue area
where the industry can benefit economically through the provision of the goods or
alternatively the industry cannot avoid financial damages from inaction.

Combining the propositions 1b and 2b, scenario B indicates that a PPP is more likely to be
created in an issue area where CSOs are pursuing a greater provision of specific goods and the
business sector can either benefit through such a provision or be financially damaged from not
helping the provision of the goods (Scenario B: Proposition 1b + Proposition 2b (yes) = Creation
of PPPs). This is the scenario in which the policy preference of CSOs (a greater provision of
goods) and the interests of the business sector (economic benefits) overlap and transnational
PPPs are successfully created.
On the flip side, scenario C suggests that a PPP is less likely to be created in an issue area
where the business sector does not economically benefit through a greater provision of the goods
or the industry does not anticipate financial damage from a lack of the provision. This would be
the case even if CSOs in the issue area are pursuing the greater provision of the goods and
advocating for the creation of PPPs (Scenario C: Proposition 1b + Proposition 2b (no) = Non-
creation of PPPs). Scenario C would occur if, for instance, CSOs failed to convince corporations
that helping a greater provision of their products would benefit the corporations.

33

Figure 2-2: Summaries of Three Scenarios

Figure 2-2 summarizes the three scenarios discussed in this chapter. These three scenarios
altogether suggest that a PPP is likely to be created only when the policy preference of CSOs and
the interests of the business sector overlap. My explanation is thus similar to the incentive-based
approach in the way it emphasizes the overlapping interests of different types of actors as a
condition to create PPPs. Yet, my theoretical framework is unique as it incorporates the role of
CSOs in the picture, providing a counterargument to the corporate takeover approach: Powerful
multinational corporations cannot unilaterally decide to launch a PPP.
This novel emphasis on the role of CSOs has two implications. First, my argument provides a
caveat to the normative concern raised by the incentive-based approach. Based on the
understanding that PPP is an outcome of a win-win situation between wealthy industries and
IGOs, some scholars raised a normative concern that PPP is serving interests of Northern donors
rather than the needs of Global South. By highlighting the power of civil society in the politics of
creating PPPs, my argument points out that the creation of PPPs is not solely driven by the
34
overlapping interests of wealthy Northern donors. Civil society actors can reflect their voice as
veto players in the politics of making transnational PPPs. There is another question, of course, of
whether CSOs actually represent the voice of Global South, but my argument highlights that the
political process of making or vetoing the creation of PPPs is at least a little more democratic
than scholars of the incentive-based approach assume.
Second, my argument also helps understand the change in the use of PPP in a given issue area
over time. At a first glance, scenarios A and C might look the same given that they both expect
to see non-creation of PPPs and the preferences of two types of stakeholders do not overlap in
both cases. However, there is a crucial distinction between these two scenarios. On the one hand,
scenario A of conflicting preferences have a directly competing policy preferences between
CSOs and the business sector. Because CSOs already chose a regulatory measure over voluntary
provision of certain products as a priority (and appropriate) intervention to address the issue of
their concern, it is hard for the business sector to appease CSOs. It is highly likely that CSOs are
quite skeptical about whatever arguments made by the industry – they hear the arguments of
industry as an effort to confuse CSOs and subjugate them to the business interests. At the point
CSOs decided to pursue regulatory measures, the industry was identified as the subject or target
of regulation, not a collaborator. In other words, although it is not impossible, it is very hard to
change the course once the trajectory is set on scenario A. On the other hand, time to time, power
of civil society and social movements can effectively change the market situations and
successfully alter business behaviors. For instance, well-mobilized protests against sweatshops
changed the Nike’s corporate policy (Greenberg and Knight 2004). This means that preferences
of the actors – that of the business sector in particular – are malleable in political interactions
among these stakeholders. If civil society could change the preferences of the business sector by,
35
say, raising financial costs from inaction through protests, the scenario can be shifted from C to
B.
It is not to say that CSOs can unilaterally choose a governance modality; my argument is not
a “CSO takeover” approach. There need to be overlapping preferences between CSOs and the
business sector for a PPP to emerge. In this sense, it is not only CSOs who have veto power in
the politics of creating vs. not creating PPPs – the business sector can also block the creation of
transnational PPPs if the industry does not see any economic benefits through a greater provision
of their products or any economic damage from inaction. However, my theoretical argument
emphasizes the veto power of CSOs, because there is a greater possibility that CSOs change the
preferences of the business sector than vice versa, and in this sense, the veto power of CSOs is
stronger (hard to overcome) than that of the business sector.
Two factors provide a basis of the CSO veto power: moral authority and operational capacity
in the implementation fields. Although this is just a tentative explanation and empirical
assessments of this point require further elaboration, I posit that the veto power of CSOs works
through their influence on IGOs: CSOs can affect IGO decision making based on their moral
authority and operational capacity. When CSOs do not welcome a PPP, this initiative has neither
legitimacy as an appropriate governance instrument (because disapproval by CSOs indicates this
PPP lacks a moral foundation) nor a prospect of success (because the PPP cannot use resources
of CSOs in the fields of implementation). IGOs are reluctant to launch such a partnership, and
thus PPP is less likely to emerge in an issue area where CSOs argue against the creation of PPPs.

36
2-4. Some Theoretical Caveats

My theoretical explanation is specific to issue area and industrial sector. First of all, the licenses
to operate (that I argued above in 2-3) are industry-specific. Famously, companies manufacturing
consumer goods are vulnerable to activist campaigns such as boycott, and they become even
more vulnerable when highly branded (Baron 2010). Indeed, many of the first lead firms that
decided to go beyond legal compliance to appease social demands were highly visible consumer
brands, such as Nike and Starbucks (Mayer and Gereffi 2010). However, it is difficult or
impossible to organize boycott against certain industries, including the pharmaceutical industry –
Patients cannot boycott essential medicines. In such cases, it becomes difficult for social actors
to effectively impose their demands on reluctant companies (Gunningham et al. 2004: 334). Also
highly cited is a mobility of the companies. Immobile, locally oriented industries, such as mining
and mineral industries, are generally vulnerable to societal pressures (Luders 2006). A company
in this category has to manage relationship between local communities. Otherwise, neighbors
may actively demand more stringent legal controls or even try to close the plant down. However,
multinational pharmaceutical companies are, by definition, footloose and relatively unbounded in
terms of regulations. In this way, the power of “licenses to operate” varies depending on industry
characteristics. It is correctly pointed out that “uncompetitive, high-demanded, nonlocal markets
are shielded from external disruption” (Luders 2006).
Similarly, the licenses to operate are bounded by issue areas (issue-specific). Social
acceptance of corporate behaviors of a certain industry may vary across issue areas. For instance,
we can imagine companies like Coca-Cola is considered a valuable partner in an issue area in
which a greater provision of medicines is prioritized, given that the company can provide a great
37
logistical support for the provision. The same company, however, may be considered by activists
in the field of nutrition as an evil manufacturer of unhealthy beverage who is aggressively
marketing such health-harming products to children. Thus, whether CSOs consider a certain
industry a subject of regulation or a potential partner in a provision of goods differs across issue
areas.
Another important point worthy of mentioning is the heterogeneity of CSOs. Of course, there
are numerous and diverse organizations in the category of CSOs, even in one issue area. Thus, it
is theoretically possible that some civil society organizations in a give issue area prefer pursuing
regulations while other civil society actors in the same issue area prioritize a greater provision of
certain goods. With this caveat in mind, my theory presumes that these diverse groups of civil
society eventually aggregate their preferences into a reasonably coherent policy message when
they come to represent themselves at the international level. Many international forums such as
the UN multi-stakeholder consultations provide only a limited number of seats to the
representatives of CSOs, and civil society actors need to aggregate their preferences to a certain
extent so that they can send a meaningful message in the high-level policy consultations. Thus,
with acknowledging the heterogeneity within the single category of CSOs, I still hypothesize that
CSOs at the international level present a more or less single policy preference (either regulations
or provisions) as a priority intervention in an issue area of their concern, especially in relation to
specific industries.

38
Chapter 3. Demonstrating Heterogeneity of Global Health PPPs

3-1. Case Selection

In order to test the theoretical framework and to explain both the creation and non-creation of
transnational PPPs in the global health sector, I choose one case for each of the three theoretical
scenarios to be closely assessed in the comparative case study. The case of neglected tropical
diseases illustrates scenario B of overlapping preferences where many transnational PPPs have
been created, and the case of non-communicable diseases will substantiate scenario A of
conflicting preferences, where we cannot see proliferation of transnational PPPs. The case of
HIV/AIDS will show the shift from scenario C of diverging preferences to scenario B of
overlapping preferences, highlighting the malleability of stakeholders’ preferences in the
dynamics of making transnational PPPs.

Table 3-1: Selected Issue Areas

There are several reasons why these issue areas are good candidates for comparison. First,
and most importantly, this case selection can control the rival independent variables to a certain
extent. One of the existing arguments that I reviewed in the previous chapter focuses on IGO
Non-communicable diseases Neglected tropical diseases HIV/AIDS
PPP usage Low High Low -> High
Leadership WHO WHO WHO
Affected regions Worldwide Tropical and sub-tropical regions Worldwide
SDGs Yes Yes Yes
Related industries
Pharmaceutical, healthcare, food,
beverage, alcohol, tobacco
Pharmaceutical, chemical, water
supply
Pharmaceutical
Related regulations WHO FCTC
WTO TRIPS Agreement
WHO R&D Convention (faded)
WTO TRIPS Agreement
39
leadership as a driving factor in the creation of transnational PPPs. The WHO plays a central role
in the governance of all three issue areas I selected (Table 3-1). Of course, the WHO is not the
only IGO working in the issue areas, and the organization works together with many other IGOs.
But still, the WHO is considered a leading IGO in these issue areas, and hence I can control the
rival argument that the variation in outcome (the use of PPPs) is caused by the type of IGOs in a
leading position. The other rival explanation emphasizes the role of powerful industries. As
Table 3-1 shows, we can think of a few industries that have economic and/or regulatory stakes in
the governance of these health issues. What is worth mentioning here is that there is a wide range
of industries that have high stakes in the governance of NCDs, and yet this issue area has not
generated many transnational PPPs. Hence, my cases include a puzzling outcome that the
“corporate-takeover” approach cannot fully explain.
Second, these selected health concerns are all recognized as important issues in international
development (at least in the rhetoric) and they are incorporated in the UN Sustainable
Development Goals (UN 2015). Hence, this case selection can exclude the confounding
explanation that health issues which are recognized as development priorities have generated
many PPPs. The three issues are all considered important priorities in the current international
development agenda, which was agreed upon by the UN member states in 2015. To be clear,
HIV/AIDS is the only issue area among these three that was included in the previous UN
Millennium Development Goals (MDGs). This might give an impression that there are many
PPPs for HIV/AIDS because this disease was recognized as an important international issue
much earlier than other health issues. However, it is not the case. Probably the inclusion of
HIV/AIDS in the MDGs helped facilitate the growth of PPPs in this issue area after 2000, but the
issue of NTDs saw a development of many PPPs even before it was included in the SDGs.
40
Neglected tropical diseases could not win a recognition in the MDGs, but even without being
singled out in the MDGs, many PPPs were created in this issue area. Therefore, the inclusion in
the prominent UN development goals is neither necessary nor sufficient condition for the growth
of PPPs in a given issue area.

3-2. Network Comparison of Global Health PPPs

As a starting point in the empirical assessment, this chapter employs the basic techniques of
social network analysis and demonstrates that different health issues have distinctive networks of
transnational PPPs. This serves the purpose of systematically examining whether the dependent
variable of this thesis (the level of PPP usage) actually varies and how much it varies across
health issues. The existing literature of transnational PPPs has a strong tendency to focus on
cases in which large PPPs are created, and as far as I know, there is no empirical study that
systematically compares the level of PPP creation across different issue areas. This chapter
attempts to fill this gap by demonstrating that each health issue has a PPP network that is
distinctive from other issue areas.
In this chapter, network comparison of three issue areas will be provided: non-communicable
diseases (NCDs), neglected tropical diseases (NTDs), and HIV/AIDS. The purpose of comparing
these three issues is to show the variation in my dependent variable (the level of PPP usage)
across these issues and to connect it to the case-study chapters from Chapter 4 to Chapter 6,
which analyze the process of facilitating or hindering the creation of PPPs in these three issue
areas.
41

Original Dataset
In order to conduct an empirical assessment of PPP networks across various issue areas, I
compiled an original dataset through the following procedure. I mainly refer to the publicly
available partnership information provided by WHO (2018b), UNICEF (2009), and the World
Bank (2011).
8
I started by looking at homepages of the partnerships on these three lists,
gathering the information on their participants, health issue area(s), history of the partnerships
and so on. Then I manually coded the type of actors participating in these partnerships
(governments, IGOs, the business sector, private philanthropic foundation, or others). I
eliminated the partnerships that do not have official websites or any other websites that provide
information on participants. Beyond these three lists, I added partnerships that I found in the
review of literature and by browsing the google search engine. This leaves a total of 124
partnerships in my sample. Among these, I keep the partnerships that include at least one public
donor (either or both OECD donor government or/and IGO) and at least one private donor from
the business sector.
As I already discussed in Chapter 1 (1-3), the distinction between public and private actors is
not as obvious as it is usually considered. In particular, the positioning of the Bill and Melinda
Gates Foundation and other philanthropic foundations requires clarification. Because the Gates
Foundation is itself a not-for-profit organization, some scholars consider it a non-profit private
actor (a category similar to the one I use for civil society organizations). On the other hand, some
scholars argue that the Gates Foundation should be recognized more as a business-sector actor
because it has many commonalities with the business sector, including the strong belief in the

8
For a similar procedure of compiling partnership data, see Andonova (2017).
42
power of science, principles and practices derived from business such as cost effectiveness and
efficiency, and the focus on measurable problems (David Williams and Rushton 2011: 9).
Although I echo the latter understanding of the Gates Foundation and other new type of
philanthropic organizations,
9
this current study treats philanthropic foundations as a third
category that is distinctive from both the business-sector actor and not-for-profit civil society
actor. Because my theoretical framework explains how for-profit companies and industries
determine their preferences based on economic and legal calculations, it would be stretch to
argue that this way of formulating preferences can be applied to philanthropic foundations – a
type of actor that is not as much concerned about short-term profits and the reaction of
shareholders as the for-profit business sector does. Therefore, “public-private partnerships” in
this study specifically refers to the partnerships between the business-sector actors – namely, for-
profit companies or industry associations composed of such companies – and public actors
(governmental and/or inter-governmental organizations). This means that partnerships that
include only public actors and the Gates Foundation, for instance, are not considered public-
private partnerships in my study, because they do not have “private” (business sector) partners.
There are pros and cons of treating philanthropic foundations in this way, but I believe this
makes the most sense given the scope of this current study. The role of the Bill and Melinda
Gates Foundation would probably deserve another book-length project. With that being said, I
fully acknowledge that the Gates Foundation and other philanthropic organizations have played
an important role in the development of transnational PPPs and in global health governance more
in general. My dataset and the visualizations thus incorporate philanthropic foundations as an

9
Moran (2014) argues that “new philanthropy,” unlike a more traditional philanthropy such as the
Rockefeller Foundation, has some distinctive defining features. The new philanthropy, exemplified by
second-generation foundations emerged after the technology boom of the 1990s, tend to be obsessed with
measurement (measurable outcomes) and a direct engagement in their funded projects.
43
independent category. This enables us to see how these actors are engaging with PPPs across
various issues in global health.
I filtered the partnership dataset following this definition of PPPs, and 56 partnerships are left
as PPPs. There are a total of 321 participants in these PPPs across 14 issue areas (listed in Figure
3-1 below).
10
These issue areas are not mutually exclusive and thus a single PPP can have
multiple issue areas: For instance, the Global Fund to Fight AIDS, Tuberculosis, Malaria has
three issue areas (HIV/AIDS, malaria, and tuberculosis). Because of this counting rule, the sum
of the partnerships in Figure 3-1 is greater than 56, a total number of PPPs in my dataset.
Although this sample is not exhaustive, it can still provide a basic notion for how PPP networks
vary across health issue areas.
Three issue areas of my focus (NCDs, NTDs, and HIV/AIDS) are indicated in green in Figure
3-1. These issue areas show different levels of PPP usage. While HIV/AIDS and NTDs have
large numbers of PPPs and partners, the issue of NCDs has very limited numbers for both. As I
will discuss, however, the issue area of HIV/AIDS did not have this level of PPP usage until the
early 2000s, when the landscape of global AIDS governance dramatically changed because of
the vocal social movements (see Chapter 6 for a detailed discussion).

10
The sample does not include participants from academic and non-profit civil society sectors as the
number gets too large and it makes it harder to see which donors participate in which health issue through
partnerships.
44

Figure 3-1: All Issue Areas and the Number of PPPs in Each Area

For each issue area, I first created a 2-mode network (also known as affiliation network)
which indicates both PPPs (events) and participants (actors) in a single network. The 2-mode
network is useful for visualization since we can immediately grasp how many PPPs are created
and who is participating in these PPPs in a single network graphic. On the other hand, another
1
3
3
1
1
1
1
5
8
16
5
9
11
9
8
9
14
26
28
32
35
48
79
86
102
145
154
181
0 20 40 60 80 100 120 140 160 180 200
Biosafety
NCDs (Four Risk Factors)
Water and Sanitation
Road Safety
Other Infectious Diseases
Other non-infectious diseases
Universal Health Coverage
Nutrition
Vaccine Preventable Diseases
Neglected Tropical Diseases
Women's Health
Tuberculosis
HIV/AIDS
Malaria
Number of Participants Number of PPPs
45
type of network (1-mode network)
11
is more useful for conducting social network analysis,
because it can directly capture who is connected with whom in which issue areas. I therefore
converted 2-mode networks into 1-mode networks to conduct all the analyses in this chapter.
The following pages show diagrams created from the 2-mode data. The nodes are colored by
the types of participants: rose (business donors), light pink (private foundations), yellow (donor
governments), orange (IGOs) and light purple (others, mostly multilateral partnerships that are
participating other PPPs). PPPs are indicated as gray squared-nodes, and the numbers indicated
in the squares correspond to the ID of PPPs (as being listed in the Appendix A). There is a link
from a circle to a square if the donor (circle) participates in the PPP (square). The size of the
circles indicates degree centrality, meaning how many links they have in a given network. The
bigger nodes signify higher degree centrality, showing that these nodes are connected to a larger
number of PPPs with a large number of participants in the network.

11
Unlike 2-mode networks, 1-mode networks contain only participants (actors) in the data matrix. This
directly indicates whether each pair of participants is connected (has a tie) in a network and it helps
extract, for instance, which participant has the largest number of ties in a given network.
46

Network Figure 1: All Issues

47

Network Figure 2: Non-Communicable Diseases

48

Network Figure 3: Neglected Tropical Diseases

49

Network Figure 4: HIV/AIDS

50
General Trends
Table 3-2 below shows the summary statistics of the PPP networks of three health issues, as well
as those of a whole network which contains all 14 issue areas in a large single network.
Networks in HIV/AIDS and neglected tropical diseases have high density, high degree
centralization, and small average path lengths. PPP network of non-communicable diseases has
lower density and degree centralization compared to the other two issue areas. The NCD network
has two components, meaning that not all the participants are connected in the network. As the
Network Figure 2 shows, there are two separated groups in this network. The other two issues
have only one component, hence all the participants in each network are connected directly or
indirectly with one another. Among all the four networks, the NTD network has the highest
degree centrality, meaning that there are some actors located at the central position in the
network. This possibly indicates that there are influential actors in the governance of NTDs,
driving the creation of multiple PPPs in this issue area.

Table 3-2: Summary Statistics of Network Features

All issues NCDs NTDs HIV
PPPs 56 3 16 11
Participants 321 9 86 154
Density 0.136 0.333 0.408 0.544
Degree centralization 0.537 0.214 0.547 0.449
Average degree 43.73 2.667 35.057 83.182
Average path length 1.894 1.444 1.595 1.457
Component 1 2 1 1

PPP networks of the three issue areas are different in terms of the size and the participation
patterns of donors. When looking at the size of networks, it is clear that NTDs and HIV/AIDS
have much larger numbers of participants compared to NCDs. Even though HIV/AIDS has a
51
lower number of PPPs than NTDs, there are a greater number of participants in the HIV/AIDS
network. This is because there is a mega PPP in the issue area of HIV/AIDS – namely, the
Global Fund to Fight AIDS, Tuberculosis and Malaria. This single PPP contains 88 participants,
larger than the number of a whole NTD network. However, HIV/AIDS had a relatively small
network of PPPs until the early 2000s. Figure 3-2 illustrates the number of PPPs and participants
in the three issue areas in 1999 (left figure) and as of today (right figure). There is no bar for
NCDs on the left figure because there was no PPP in this issue area back then. There were only
two PPPs and 20 participants in the area of HIV/AIDS back in the 90s, although there were
already 8 PPPs with 30 participants in the area of neglected tropical diseases. The Global Fund
was established in 2002 and thus it makes sense that there were a limited number of participants
in the HIV/AIDS network, but the number of PPPs in this issue area was also very small before
2000.
The general trend of creating transnational PPPs started in the late 1990s as we saw in
Chapter 1, and some people might assume that the HIV/AIDS did not have a high level of PPP
usage before 2000 because there were no PPPs back then. Although it is true that transnational
PPP was not a common governance modality until the late 1990s to early 2000s, there were
already more than a dozen of PPPs in the global health sector (Network Figure 5), and to iterate,
half of the PPPs in the area of NTDs were created by 2000. The PPP network of NTDs back in
1999 (Network Figure 6) looks much larger than that of HIV/AIDS (Network Figure 7). This
suggests that PPP was already accepted as an appropriate governance modality in the issue area
of NTDs back in the 90s, while there is a clear shift in the area of HIV/AIDS at around the turn
of the millennium. Chapter 6 explains this rapid change in the area of HIV/AIDS from the
success of social activism: the coalition of activists altered preferences of the business sector and
52
shifted the situation from scenario C (diverging preferences) to scenario B (overlapping
preferences).

Figure 3-2: Number of PPPs and Participants (left, before 2000; right, current)

0
8
2 0
30
20
0
5
10
15
20
25
30
35
NCDs NTDs HIV
PPPs Participants
3 16 11 9
86
154
0
20
40
60
80
100
120
140
160
180
NCDs NTDs HIV
PPPs Participants
53

Network Figure 5: All Issue before 2000
54

Network Figure 6: Neglected Tropical Diseases before 2000

55

Network Figure 7: HIV/AIDS before 2000

56
Compositions
The three issues have different compositions of the type of participants. The HIV/AIDS network
has been largely composed of public actors: As of today, half the participants of the HIV/AIDS
PPPs are governmental donors, and almost 60% of the participants were either governmental or
intergovernmental organizations in the 90s. The PPP network for neglected tropical diseases also
had more than half of the participants from the public sector before 2000, but it currently
contains more business participants than governments and IGOs combined. NTDs always has a
higher proportion of philanthropic foundation than HIV/AIDS or the all issue areas, showing a
strong interest of philanthropic foundations in this issue area. The issue area of non-
communicable diseases has a strong participation from intergovernmental organizations and a
relatively low proportion of governmental participations.

57

Figure 3-3: Composition of Participants by Type
(top, current; bottom, before 2000)

Table 3-3 below lists the actors who have the highest scores for degree centrality in each
network (meaning that these actors are participating many PPPs that contains large numbers of
partners). Because the NCDs network is quite small, all the participants rank in the top 4. NTDs
and HIV/AIDS show somewhat similar patterns, having the US and the Bill and Melinda Gates
Foundation as the two most central actors. However, while a pharmaceutical company (GSK,
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
All issues NCDs NTDs HIV
Donor government IGO Business Foundation Other
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
All issues NTDs HIV
Donor government IGO Business Foundation Other
58
GlaxoSmithKline) is ranked at the top 4 in NTD network, no business-sector actor is ranked in
top 5 for HIV/AIDS. This is consistent with the strong government participation in the
HIV/AIDS network, as we saw just above. It is rather surprising that the WHO appears as a
central actor only in the NTD network. World Bank is more central than the WHO in both NCDs
and HIV/AIDS networks. The NCD network is centered around two European participants (EU
and the EFPIA – a pharmaceutical industry association in Europe). Other two business
participants in this network belong to the pharmaceutical industry as well (IFPMA and Merck).
This shows that the business actors outside of the pharmaceutical industry, such as the food and
alcohol industries have not engaged with PPPs in this issue area. This is puzzling given that these
industries have expressed interests in creating PPPs to address the issue of NCDs (as we will see
in Chapter 4).

Table 3-3: Nodes with the Highest Degree Centrality

NCDs NTDs HIV
1 EFPIA, EU USA USA
2 USA BMGF BMGF
3 IFPMA, WB, WEF WHO WB
4 Merck GSK UK
5 UK Germany
Notes: orange = public actors, blue = business actors

Because the size of the networks varies across these issue areas, it is reasonable to think that
the number of central actors also differ across these areas. It is impossible to identify such
numbers a priori, but a core-periphery analysis provides a useful technique to identify all the
central (core) actors in each network, by dividing all the participants into either core or
periphery. Results of the core-periphery analysis is shown in Table 3-4. As we could expect, the
59
number of core actors corresponds to the size of the network, with the HIV/AIDS network
having the greatest number of core actors.
Among 20 core actors in the HIV/AIDS network, 11 are governmental entities and 6 are
intergovernmental organizations. Wealthy bilateral governments, such as the US, UK, Germany,
France and Japan are all identified as core actors in this network. Although it was not ranked in
top 5 in terms of the degree centrality, now the WHO is identified as core actor in the core-
periphery analysis, along with various other IGOs including the World Bank, UNAIDS, UNFPA,
and UNICEF. Novartis – a Swiss pharmaceutical company – is the only business actor identified
as a core in this network. In contrast, there are three pharmaceutical companies (GSK, J&J, and
Sanofi) identified as core actors in the NTD network, even though the network has a smaller
number of core actors than the HIV/AIDS network does. As in the area of HIV/AIDS, the US,
the UK, and Germany are identified as cores in the NTD network. Ireland and Switzerland are
core actors in NTDs but not in HIV/AIDS, suggesting that governments have different levels of
interest in joining PPPs across different health issue areas. In addition to the Bill and Melinda
Gates Foundation, another philanthropic foundation, the Wellcome Trust, joined the core in the
NTD network. The Gates Foundation is a core actor in both the NTDs and HIV/AIDS networks.
The only core actors identified for the NCD network are the EU and the EFPIA.
In these three networks, all the business actors identified as core actors are in the
pharmaceutical sector, and no other industry was located at the center or in a core in these PPP
networks. Indeed, most of the business participants in these networks are either from the
pharmaceutical or biotech industries (Figure 3-4). More than 70% of the business participants in
all the three networks are from the pharmaceutical industry, although the HIV/AIDS network
contains participants from a few other industries such as food and telecommunication.
60
Table 3-4: Variation in the Core-Periphery Analysis

NCDs NTDs HIV
EFPIA Australia Australia
EU BMGF BMGF

Germany Canada

GSK Denmark

Ireland EU

J&J France

Netherlands Germany

Sanofi Japan

Switzerland Netherlands

UK Norway

USA Novartis

WB Sweden

WellcomeTrust UK

WHO UNAIDS

UNF

UNFPA

UNICEF

USA

WB

WHO
61

Figure 3-4: Industry Compositions

QAP Correlations
The above assessment already indicates that PPP networks across these issue areas are different
in terms of size, participants, central and core actors. In addition to this, a technique known as
the Quadratic Assignment Procedure (QAP) can succinctly show how similar/differ these
networks are by calculating correlations among matrices of these networks (Valente 2010). For
instance, it is theoretically possible that the same sets of donors are always working together to
create PPPs regardless of issue areas, and in such a case, there should be high correlation among
PPP networks of these issue areas. The purpose here is to demonstrate the heterogeneity among
these PPP networks so that the puzzle this dissertation is trying to tackle – heterogeneity of the
formation of PPPs across different areas – could be better substantiated. I used the UCINET to
calculate the Pearson Correlations, and the results are shown in Table 3-5 below.

0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
All issues NCDs NTDs HIV
Pharmaceutical Biotech Healthcare Food
Oil, extractive Telecommunication Chemical Others
62
Table 3-5: QAP Correlations

HIV NCDs NTDs
HIV 1
NCDs 0.075 (0.001) 1
NTDs 0.104 (0.001) 0.101 (0.000) 1
Notes: p-values in parentheses

The results indicate that the correlations among the three PPP networks are fairly low,
indicating that these health issues have very distinctive PPP networks from one another in terms
of who connected whom within the network. We can see the highest correlation between the
NTD and HIV/AIDS networks, with a Pearson Correlation of 0.104. This is statistically highly
significant as the p-value of 0.001 indicates. This means that the correlation between the NTD
network and the HIV/AIDS network is less than 10.5%, a very weak associations between these
networks. In other words, the way actors link with each other in the NTD network is very
different from the way they do in the HIV/AIDS network. The correlation between NCDs and
NTDs, as well as the correlation between NCDs and HIV/AIDS are even lower – 0.101 and
0.075 – respectively. These are also statistically highly significant. These overall very low
correlations suggest that the PPP networks in these three issue areas show different patterns of
connections among the participants.

Summaries of the Network Comparison
This section demonstrated how the networks of PPPs differ across health issue areas. Among the
three issue areas selected for the examination, NTDs and HIV/AIDS have larger PPP networks
compared to NCDs. The QAP correlations also demonstrated that the correlations among the
three PPP networks are quite low. This means that nodes that are connected in one network are
not necessarily connected in other networks. Moreover, the participation patterns of
63
governmental and business donors vary across the issue areas. For instance, central nodes in the
NTD network (most notably the US) are not central in the NCD network. Pharmaceutical
companies are dominant among the business participants, but they are identified as core actors
mainly in the network of NTDs. The HIV/AIDS network is a predominantly “public” network.
Another important finding is that the issue area of NTDs have developed the PPP network
relatively steadily, while HIV/AIDS saw a rapid increase in the use of PPP after 2000.
These varying constellations of PPP networks altogether support the starting argument of this
dissertation: There are variations in the pattern of PPP creation across different health issue
areas. In other words, this assessment empirically reveals that there is a variation that needs to be
explained. Some authors have assumed that the increasing use of transnational PPPs are overall
trend, and such an assumption implies every single global issue has generated many PPPs. As far
as health issues are concerned, this is not the case. By revealing that there are quantifiable
variations in the level of PPP usage, this section establishes the empirical puzzle that the
dissertation tackles: there are some health issues that have generated a greater use of PPP than
others – what explains such variations? Answering this question warrants in-depth studies of
both cases that have and have not generated transnational PPPs. This is the task that the
following case-study chapters will work on.

3-3. Methodological Strategies for the Case Study

The following three chapters will substantiate my theoretical argument by closely looking at
three health issues that have and have not generated many transnational PPPs. For the cases with
64
many PPPs (neglected tropical diseases and HIV/AIDS), I will conduct a conventional
qualitative case study to understand how the issue has emerged in international arena, how
different types of actors have negotiated the creation of PPPs in the issue area, and who decided
to join the partnerships. It is inherently easier to examine the creation of PPPs than non-creation
of PPPs, because there is a clear focal point a researcher can investigate: We can take a look at
the “history” pages of the PPP websites, ask for interviews with actors participating the
partnerships, and read some documented negotiations among stakeholders that led to the creation
of these PPPs.
In comparison, it is much harder to investigate why something (in this context, PPP) does not
exist: We cannot be sure where to start – it is not clear who a researcher should talk to (who
would be potential partners if there were any PPPs in this issue area?), and it is harder to identify
relevant documents (which forums would potential partners use to discuss the creation of PPPs if
there were any interests in such an initiative?). In order to deal with this difficulty, for the case in
which not many PPPs have been created (non-communicable diseases), I employ qualitative and
computational text analysis of the UN multi-stakeholder negotiations and assess how CSOs and
the business sector expressed their preferences regarding policy interventions in this issue area.

65
Chapter 4. Non-Communicable Diseases:
Conflicting Interests between “Health-Harming Industries” and Civil Society

This chapter illustrates the case of non-communicable diseases (NCDs) as an example of
scenario A of conflicting preferences between the business sector and civil society. As the major
killer of the 21
st
century, NCDs have emerged as an important global health and international
development issue in the past two decades. However, despite the growing interests among both
various UN organizations and wealthy industries in this issue, NCDs have not generated many or
large-scale PPPs. This situation provides an intriguing puzzle considering the state of the
literature: What explains the low level of PPP usage in this issue area if not the lack of IGO
leadership and the economic stakes of powerful industries? In this chapter, I demonstrate that the
relatively low usage of PPPs in the area of NCDs is a result of the conflicting preferences
between civil society organizations and some involved industries, namely the tobacco, alcohol,
food and beverage industries. A broad network of civil society has pursued a legal approach to
control NCDs and their major risk factors. In particular, certain products such as tobacco, alcohol
and soda are clearly recognized as “health-harming” commodities, and civil society has
advocated for the regulation of these products as a priority intervention to address NCDs. Facing
this regulatory movements, the industries have fought back by promoting voluntary measures,
including the use of PPPs involving themselves. This starkly conflicting preferences between
civil society and the business sector have resulted in the lack of many or large-scale PPPs in this
issue area, along with the overall stagnated and insufficient progress of NCD governance at the
global level.
66
This chapter starts with reviewing the background information of this issue area, including the
working definition of “non-communicable diseases,” a recent development of global NCD
governance, and how these diseases are commonly framed by different types of advocates.
Second section then summarizes the making of the WHO Framework Convention on Tobacco
Control (FCTC) as an illustrative example of the hostile relationship between the business sector
and civil society networks in the governance of NCDs. The case of the FCTC also reveals how a
regulatory approach was initiated in relation to the control of NCDs at the global level. Based on
the historical understanding of the confrontational business-CSO relations, third section
examines whether the same or similar constellation of stakeholders can be seen in the
overarching governance of NCDs, beyond the specific area of tobacco control. This section
employs a combination of computational and qualitative text analysis to identify the major topics
discussed by various types of actors and policy preferences of these actors in global governance
of NCDs. Fourth section concludes this chapter by summarizing the major finding of the text
analysis, highlighting the conflicting policy preferences between civil society and the alcohol,
food and beverage industries, with the former pursuing the stricter regulation on health-harming
products while the latter advocating for voluntary initiatives including the use of PPPs.

4-1. Background

Definition
Communicable diseases are illness caused by an infectious agent that spreads from a person to
another person. Non-communicable diseases are basically the opposite of communicable
67
diseases, as the “non” in the label indicates (Skolnik 2016). According to the WHO, non-
communicable diseases (NCDs) are also considered as chronic diseases, which tend to be of long
duration and “are the result of a combination of genetic, physiological, environmental and
behaviours factors” (WHO 2018a). This explanation reveals that the term “non-communicable
diseases” lacks a consolidated definition, and it could be extended to encompass a wide spectrum
of health problems such as mental health issues, disabilities, trauma, neurological disorders,
musculoskeletal problems and dermatological conditions (Blundell and Hine 2019). Because of
this blurry definition and wide scope, Blundell and Hine (2019) argue that the all-encompassing
nature makes the term meaningless, and they suggest stopping defining them by what they are
not. It is also pointed out that the dichotomous connotation of the label “non-communicable
diseases” (as opposed to “communicable diseases”) is misleading. Some NCDs and associated
risk factors are actually infectious: For instance, 10% of human cancers can be attributed to viral
infection, and some crucial high-risk behaviors such as smoking might be “contagious” within a
community.
Despite these downsides, combining several diseases under a single label may help advocacy.
An aggregated burden of diseases makes these diseases look more important than being
presented separately, and this makes it easier to attract political attention. We could see the
similar strategy in the case of neglected tropical diseases (NTDs), combining several diseases
under a single label (Chapter 5). With that being said, the broad and blurry nature of the label
“NCDs” may hamper the advocacy efforts, and perhaps in order to deal with this issue, the WHO
and international NCD communities have used the term with a clear focus on four major diseases
- cardiovascular diseases, cancers, chronic respiratory diseases and diabetes. Four major NCDs
are collectively responsible for almost 70% of all deaths across the globe, and the WHO
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recognizes four risk factors – tobacco use, physical inactivity, harmful use of alcohol and
unhealthy diets – as the major driver of the rapid rise of NCDs. Cardiovascular diseases account
for most NCD deaths, killing 17.9 million people annually, followed by cancers (9.0 million),
respiratory diseases (3.9million), and diabetes (1.6 million) (WHO 2018a). Also, tobacco
accounts for over 7.2 million deaths every year (including from the effects of exposure to
second-hand smoke), and excess intake of salt/sodium accounts for 4.1 million annual deaths.
Insufficient physical activity contributes to 1.6 million deaths annually.
Following the WHO, this dissertation adopts the narrow definition of NCDs. Partnerships are
considered belonging to the issue area of NCDs if they aim to address either (or some) of the
major four diseases and four risk factors. Partnerships addressing other non-infectious health
issues, such as musculoskeletal health and road safety are not categorized as “NCD partnerships”
in this study.
12
The issue area of nutrition is closely associated with the four major diseases
(especially diabetes) and four risk factors (healthy diets, in particular). Yet, I consider nutrition
as an issue area separate from NCDs because of its somewhat independent trajectory of advocacy
and the historical focus on undernutrition (as opposed to overweight). Future research will
combine the issue area of nutrition to the analysis, but for the time being, this chapter focuses on
four major NCDs and four risk factors, excluding those partnerships that are specifically
addressing the issue of nutrition.

12
A partnership addressing road safety is categorized as “road safety,” and a partnership for
musculoskeletal health is labeled as “other non-infectious diseases” in my dataset.
69
Magnitude and Recent Evolution of NCDs as a Global Health Issue
The burden of NCDs has risen rapidly across the world, and it is greater than that of
communicable diseases in both low- and middle-income countries (LMICs) and high-income
countries. Only sub-Saharan Africa has the higher burden of diseases from communicable
diseases than from non-communicable diseases, yet the NCD burden is fast growing even in this
region: NCDs are estimated to overtake communicable, maternal, neonatal, and nutritional
diseases combined as the leading cause of mortality in sub-Saharan Africa by 2030 (Bigna and
Noubiap 2019). Figure below shows that the NCD death rates are indeed relatively high in Africa
and Asia, and 82% of the 16 million people who died prematurely of NCDs (before reaching 70
years of age) lived in LMICs, where universal health coverage or access to healthcare services
are often limited (WHO n.d.a). This contradicts a common assumption that these diseases are
important burden only for affluent countries. NCDs are rather disproportionately affecting
LMICs and thus becoming a “global” health issue. This high rate of “premature death” also
indicates that NCDs are an important health threat not only for the elder but for people at all
ages. In particular, two thirds of premature deaths in adults are associated with childhood
conditions and behaviors, and young people are at a greater risk of being exposed to the major
risk factors of NCDs. Over 150 million young people smoke, 81% of adolescents do not get
enough physical activity, and 41 million children under 5 years old are overweight or obese
(WHO n.d.a).

70

Figure 4-1: NCD Death Rate (per100000), 2016
Source: WHO “NCD death rate,” http://gamapserver.who.int/gho/interactive_charts/ncd/mortality/total/atlas.html

The developing parts of the world are facing the double burden of diseases from
communicable and non-communicable diseases, and the socioeconomic costs of these diseases
make the prevention and control of NCDs a major development imperative for the current
century (WHO n.d.b). A report by Harvard School of Public Health and the World Economic
Forum made the case that NCDs pose a substantial economic burden and that this burden will
evolve into a cumulative output loss of US$ 47 trillion over the next two decades (Bloom et al.
2011). This line of economic argument pushed the issue of NCDs up in the international
development agenda, and the UN SDGs incorporated the issue of NCDs, with target 3.4 designed
to “reduce by one third premature mortality from non-communicable diseases through
prevention and treatment and promote mental health and well-being” by 2030 (UN 2015).
Given the huge impact of NCDs worldwide and in low- and middle-income countries in
particular, there have been political movements towards a better control of NCDs. Since the
WHO presented the Global Strategy for the Prevention and Control of NCDs in 2000, many
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resolutions were adopted both at the World Health Assembly and the UN General Assembly
(Table 4-1). Most notably, three High-Level Meetings on NCDs were held at the UN General
Assembly in 2011, 2014, and 2018, making NCDs the second health issue discussed at this level
(the first was HIV/AIDS). The UN Interagency Task Force on NCDs was created, bringing
together over 40 UN agencies and development banks to catalyze the actions for NCDs. These
movements and the evolution of cooperation among public actors clearly show that this issue has
become an important agenda for IGOs and their member states.

Table 4-1: Timeline of the NCDs Governance

On the other hand, large multinational corporations including the alcohol and the food and
beverage industries have vocally supported the idea of public-private partnerships, admitting that
NCDs require cooperative actions by all relevant stakeholders. These industries have actively
Year Document/ Event
2000 The Global Strategy for the Prevention and Control of NCDs
2003 Framework Convention on Tobacco Control adopted
2004 Resolution on Global Strategy on Diet, Physical Activity and Heatlh (DPAS)
Resolution on Health Promotion and Heathy Lifestyle
2005 Resolution on Cancer prevention and control
2008 Global Strategy Action Plan 2008-2013
2009 Western Asia Ministerial Meeting on noncommunicable diseases and injuries
2010 Resolution on Strategy on the harmful use of alcohol
Resolution on Marketing of food and non-alcoholic beverages to children
2011 WHO Global Forum on NCDs
First Global Ministerial Conference on Healthy Lifestyles and NCDs Control
1st High-Level Meeting
2013 Global NCD Action Plan 2013-2020
2014 2nd High-Level Meeting
2015 SDGs adopted
2017 WHO Global Conference on NCDs in Montevideo
2018 Commission Report: Time to Deliver
3rd High-Level Meeting
72
participated in the UN multi-stakeholder discussions on the governance of NCDs, and many
companies have offered financial and technical assistance for international and national efforts to
address the burden of NCDs.
If, as the existing explanations have stated, PPPs can be created by entrepreneurship of IGOs
or powerful industries or the combination of these two factors, there should be a remarkable
usage of transnational PPPs in the area of NCDs. However, as we already saw in Chapter 3, there
have not been many PPPs generated in this issue area in comparison to other health issue areas,
such as women’s health, malaria, and even “neglected” tropical diseases. I argue that the lack of
PPP in this issue area derives from the fact that CSOs have strongly supported regulations
instead of a greater provision of specific goods.

Frames and Interventions
A broad range of factors, including unplanned urbanization, globalization of unhealthy foods and
lifestyle, and population aging are recognized as driving forces of a rapid increase in the global
burden of NCDs (WHO 2018a). Unlike viral diseases which have a clear “cause” of the diseases,
the pathology of NCDs are quite complicated, and two competing frames have been offered in
the debate over what (and who) should be responsible for the rise of NCD burden. On one hand,
so-called neoliberal or market-oriented framing of NCDs emphasizes the primacy of the
individual consumer over the responsibility of state or economic actors to incentivize healthier
consumption. As such, public health detriments are viewed as failures of individual choice-
making rather than as dereliction of governmental duty to ensure health-enabling environments
and the right to health by addressing externality-induced market failure. This framing is
generally advanced by institutions benefiting from market-oriented policies and challenged by
73
health and development advocates concerned about the social, economic and environmental
harms related to NCDs (Battams and Townsend 2019). On the other hand, health advocates,
represented by civil society actors usually frame the issue with an emphasis on responsibility of
government to regulate trade and marketing of products that are or may be harmful to public
health, such as tobacco, alcohol and unhealthy foods. For instance, Weishaar and her colleagues
(2016) identified two competing frames in the media coverage of NCDs; corporations attempt to
promote the “market justice frame” (which essentially reflects neoliberal assumptions), while
public health advocates endorse the “social justice frame” which emphasizes the social and
political determinants of health and the need for regulations.
As such, existing studies have already found that different types of actors have enforced two
competing frames of NCDs. Based on these different framing and understandings of the issue,
different set of policy interventions have been proposed in the area of NCDs, including public
education to encourage healthier lifestyle, empowerment of youth, and regulations of health-
harming products. Although acknowledging various interventions to address NCDs, overall NCD
communities and the WHO in particular have put strong emphasis on the prevention of NCDs
rather than treatment as a priority intervention. In contrast to costly treatment, some NCDs can
be prevented at relatively low cost. This gives a notion that prioritizing treatment (as in the case
of HIV/AIDS) is unrealistic, and thus major advocates for NCDs have strongly focused on
prevention in this issue area. Tobacco control in particular is at the center of the prevention
effort. Tobacco kills up to half of its users, contributing to nearly 6 million deaths each year. It is
estimated that the annual death toll could rise to more than 8 million by 2030. Nearly 80% of the
world’s 1 billion smokers live in LMICs, giving this issue a flavor of global inequality (WHO
n.d.c). In order to see how the prevention and the regulatory control of major risk factors become
74
the focus of global NCD governance, next section reviews the early development of NCD
governance with a special focus on the making of the WHO Framework Convention on Tobacco
Control (FCTC).

4-2. Vector of Diseases and the Historical Hostility
13

Tobacco Control and the Making of FCTC
As the first treaty negotiated under the auspices of WHO and the first collective response to
NCDs, the FCTC provides a critical case for understanding the constellation of preferences
among different types of stakeholders. The FCTC was unanimously adopted by the fifty-sixth
World Health Assembly on May 21, 2003, and it includes provisions for comprehensive ban on
tobacco advertising, promotion, and sponsorship, a ban on misleading descriptors that confuse
consumers that certain products are safer, and a mandate to place warning that cover at least 30%
of tobacco packaging (WHO 2003). By June 22, 2003, 168 member states signed the treaty and
the FCTC became one of the most widely embraced global treaties in history (Wipfli 2015).
The process of FCTC negotiation shows a stark conflict between the tobacco industry and
CSOs, with the former directly opposing the regulation of their products per se while the latter
advocating the most progressive form of regulation. Two global networks of NGOs – the
Framework Convention Alliance (FCA) and the Network for Accountability of Tobacco

13
Future revision will add two more sub-section in this section. One of them, Exporting Unhealthy Food through
Trade Liberalization, will argue more in detail how the liberalization of international trade has exacerbated the
burden of NCDs in LMICs through the importation of unhealthy foods and other commodities in these countries.
The other sub-section, Long Battle over Breastmilk Substitute, will discuss the historical hostility between civil
society actors in the area of nutrition and the food industry by introducing the episode of the marketing of breastmilk
substitutes.
75
Transnationals (NATT) – coordinated FCTC lobbying efforts worldwide. Representatives of
civil society were key actors throughout the negotiations, although they were not formal
participants in the FCTC negotiations. Official participation was limited to a small number of
NGOs which has formal relations with WHO, but the FCA published a daily Alliance Bulletin as
a mean to influence the positions of formal delegates, The Bulletin served as an important source
of information for state delegates and it also worked as a tool of “naming and shaming.” On the
back page of the Bulletin was the Orchid and Dirty Ashtray Awards for countries involved in the
treaty negotiation, and some governments took the award seriously. For instance, China
complained to the FCA when the country received the infamous award on the Bulletin. These
NGOs particularly targeted the US delegates. The advocates launched a demonstration in front of
the US Department of Health and Human Services and tried to reveal the double standard
between the government’s rhetoric about protecting the world from terrorism and its inaction in
controlling the deadly tobacco industry (Wipfli 2015).
The momentum to regulate tobacco started at the national level in some industrialized
countries. Some developed countries, such as the US and the UK, initiated an early effort to
control tobacco use in the 1960s. The Royal College Report in the UK in 1962 and the Surgeon
General’s Report in the US in 1964 both discussed the relationship between smoking and health,
and these countries started initiatives such as the health warnings on cigarette packages and
advertising restriction. Further measures to control tobacco started in the late 1980s with the rise
of new evidence that secondhand smoke caused death and disease in non-smokers. This finding
swiftly shifted the debate from the “right to smoke” to the “right to clean air.” Initially, actions
were taken to separate smokers and non-smokers within the same space, followed by the creation
of separate smoking spaces, and then complete bans on indoor smoking. The movement toward
76
complete bans was largely motivated by evidence that ventilation and air cleaning could not
remove cigarette smoke toxins from the air. Meanwhile, the tobacco industry had been denying
the relationship between cigarette smoking and diseases for decades, but a litigation with the
attorney general of Minnesota in 1998 forced the tobacco industry to reveal confidential
documents. This revealed that the industry was aware of the harmful effects of smoking since the
mid-1950s and had implemented a strategy to hide this information. This hugely undermined the
credibility of the industry, and in the early 2000s, many states in the US introduced the
regulations to be completely smoke free in public places and working places. Other
industrialized countries such as Canada, Ireland, Norway and New Zealand enacted
comprehensive smoke-free indoor air laws around the same time.
Internationally, the first World Conference on Tobacco or Health took place in 1967, and the
WHO adopted its first resolution on tobacco in 1970. Back then, however, tobacco control was
largely regarded as a concern exclusively to high-income countries, and regulations at the
national level were pursued separately instead of international regulations. The situation changed
by the early 1990s. With the major changes in international market, such as the opening of the
former Soviet Union markets and the expansion of free trade in East Asia and Latin America,
the tobacco industry expanded globally during the 70s and 80s. As a result, smoking rate and the
burden of diseases related to tobacco use rapidly increased regardless of income level of the
countries. At the same time, by the late 1990s, globalization of the tobacco industry had been
undermining national tobacco control efforts. Cross-border advertising was reducing the
effectiveness of nationally enforced advertising bans, and the industry was lobbying to resist
regulation of its products in many LMICs. This situation gradually revealed the necessity of
regulation at the international level.
77
Two scholars, Ruth Roemer and Allyn Taylor, promoted the idea of making binding
regulation under the auspices of WHO. In 1994, they successfully drafted and passed a resolution
calling on national governments and WHO to initiate “action to prepare and achieve an
International Convention on Tobacco Control to be adopted by the United Nations.” However, it
was not until the election of Gro Harlem Brundtland as WHO Director General in 1998 that
WHO became serious in its intentions to make the FCTC reality. Brundtland had had a long
political career as former prime minister of Norway and had experience negotiating treaties as
the former commissioner of the Sustainable Development Commission for the UN in the 1980s.
Soon after assuming the office, Brundtland established the Tobacco Free Initiative (TFI) as a
special cabinet project. The TFI launched media and advocacy campaigns to inform governments
and civil society of the urgent need for a coordinated international effort to control tobacco.
WHO also awarded the British-based Action on Smoking and Health (ASH) a grant to identify
how to involve civil society in the FCTC negotiations, and ASH successfully mobilized a loose
network of NGOs around the world, which evolved into the Framework Convention Alliance
(FCA). The TFI also facilitates collaboration across international organizations, involving
UNICEF and the World Bank, among others. The Interagency Task Force on Tobacco Control
was created in 1999, and fifteen UN organizations and three Bretton Woods Institutions
participated in the task force. The World Bank’s 1999 report, “Curbing the Epidemic” identified
cost-effective interventions to enhance revenues and promote health, such as tax increases,
promotion bans, warning labels, restriction on public smoking, and access to cessation therapies.
This report provided a credible evidence for global tobacco regulation and helped fuel
momentum towards the negotiation of the FCTC.
78
In May 1999, the World Health Assembly adopted a resolution (WHA 52.18) to establish a
technical working group and an Intergovernmental Negotiating Body (INB) to prepare a draft
and negotiate the proposed convention on tobacco control. Before the first INB session, WHO
convened a public hearing on issues related to the proposed framework convention, and both
civil society actors and tobacco companies provided written and oral testimonies. The
testimonies reveal that civil society passionately spoke about the major health concerns linked to
passive smoking. CSOs argued that the FCTC must include obligations to reduce exposure to
tobacco smoke. In contrast, multinational tobacco companies, such as British American Tobacco
(BAT) and Japan Tobacco International (JTI) argued that governments should be free to decide
the nature of tobacco control regulations in their own context and should not be forced to
implement one set of standards such as those embodied in the FCTC. This hearing was the only
official FCTC-related event in which the tobacco industry was allowed to participate, but the
industry largely sustained and expressed the positions throughout the negotiation process.
The tobacco industry did not give up on affecting the FCTC negotiation even though the
companies are not allowed to formally participate in the discussion. The industry successfully
influenced the composition of national delegations, and for instance, Japan’s delegations shifted
from the one composed mostly of representatives from the Ministry of Health, Welfare, and
Labor to the one comprised of more officials form the Ministry of Finance. The industry also
attempted to divert attention away from the FCTC by making voluntary programs such as youth
smoking prevention programs. Some governmental delegates, namely the US, Germany, Japan
and China, tried to reflect the interests of their tobacco companies on the negotiation process.
“The early negotiations were tedious, contentious, and often confusing,” and “[T]he negotiations
79
were marked by intense disagreement between countries on a number of key issues” (Wifli 2015:
43).
To be fair, NGOs did not achieve all of the provisions on their wish list, and most
importantly, they were not able to include the language that clarifies the importance of health
over trade. But still, the FCTC secured the bottom line of not allowing a reservation clause which
would have enabled countries to be bound only by specific provisions of their choosing.
Considering that there are no other binding regulations under the auspices of the WHO, the
FCTC provides one of the most successful stories in the control of NCDs and a major risk factor.
To date, however, there has not been successful effort to replicate the FCTC in other areas of
global health. It is mentioned to be illustrative of the international community’s shift away from
the use of international legal measures towards non-binding public-private partnerships during
the past few decades (Wipfli 2015). This is probably right, and the overall trend in global
governance towards a more voluntary modality has made it increasingly difficult to push a
binding regulation of NCD risk factors such as alcohol and soda. However, the issue area of
NCDs have not generated as many PPPs as other health issue areas either. The story of global
NCD governance, thus, is not just a shift from regulation to PPPs: There are some factors
resisting the strong trend towards the creation of PPPs in this issue area. Would policy
preferences of civil society explain this situation, hampering the making of PPPs in this issue
area so that they can still pursue the making of binding regulations of other NCD risk factors? By
employing computational and qualitative text analysis, next section assesses policy preferences
of civil society as well as the business sector and empirically examines a plausibility of my
theoretical scenario of conflicting preferences between the business sector and CSOs.

80

4-3. Are Conflicting Views Blocking the Creation of PPPs?

Methodological Strategies and Data
This chapter employs both computational text analysis (topic modeling) and qualitative narrative
analysis to examine what policy interventions the business sector and CSOs have pursued in the
governance of NCDs. First, I analyze what topics are discussed by various stakeholders
(including CSOs, business sector, IGOs and the UN member states) during the key UN multi-
stakeholder negotiations in the field of NCDs by using computational topic modeling. A purpose
here is to identify major topics these stakeholders brought about during the policy-making
discussions and to examine whether any policy interventions (international laws, national
regulations, or voluntary initiatives such as PPPs) are raised as a key topic in the negotiations.
Another reason to combine the computational topic modeling with the qualitative narrative
analysis is to avoid a human bias to focusing on documents and themes that are related to and
supportive of my own theoretical explanation.
After grasping the major topics, I qualitatively analyze how each stakeholder narrates these
topics. Key questions asked in the process of qualitative analysis include the followings: How do
central actors in civil society talk about the role of industries in the governance of NCDs? Do
CSOs support regulatory measures such as taxation or mandatory contribution to international
funds, or are they willing to cooperate with the industries on a voluntary basis to expand the
provision of certain goods and services? Do the industries mention about the threats of public
regulations, and do they show a will to contribute to addressing the issue? Does any industry
show economic interests in expanding a provision of their certain products?
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In order to compile the data on what and how stakeholders discuss the issue of NCDs, I
collect the statements submitted during the preparation process of the Third High-level Meeting
on NCDs, which was held on September 2018 at the UN General Assembly in New York. There
were four forums in which various stakeholders could submit their comments as to how NCDs
should be governed at the global level. The four forums are the followings:
1. Montevideo: Web-based consultation for the development of outcome document for the
WHO Global Conference on NCDs in Montevideo, hosted by WHO during 10-25 August
2017
14

2. Commission: Web-based consultation on a preliminary draft report of the WHO High-
level Commission on NCDs, hosted by WHO during 10-16 May 2018
15

3. IH: The UN interactive hearing on NCDs, hosted by the President of the UN General
Assembly, with the support of WHO, on 5 July 2018
16

4. HLM: The Third UN General Assembly High-level Meeting on the Prevention and
Control of NCDs, on 27 September 2018
17

As Table 4-2 below shows, my data for topic modeling contains a total of 421 documents
18

from four types of stakeholders: CSOs (not-for-profit entities, including academic institutions),
business sector (for-profit entities, including business associations), the UN member states, and

14
Data available at https://www.who.int/ncds/governance/outcome-document-global-conference/en/
15
Data available at https://www.who.int/ncds/governance/high-level-commission/web-based-
consultation-may2018/en/
16
Data available at https://www.who.int/ncds/governance/third-un-meeting/interactive-hearing/en/
17
Data available at https://www.who.int/ncds/governance/third-un-meeting/meeting-statements/en/ and
https://www.who.int/ncds/governance/third-un-meeting/multi-stakeholder-panels/en/
18
There are some statements written in Spanish and French. These documents are translated by using
Google Translate before being included in the dataset. For the accuracy of Google Translate’s translation
ability in these languages, see de Vries, Schoonvelde and Schumacher (2018).
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IGOs. A number of statements submitted by CSOs is the largest among the four types of actors,
followed by the business sector, member states and IGOs.
19

Table 4-2: Number of Documents Submitted by Each Type of Actors

Montevideo Commission IH HLM Total
Civil society 60 150 59 38 307
Business sector 17 43 6 3 69
Member state 10 6 0 10 26
IGO 2 3 5 9 19
Total 89 202 70 60 421

The results of the topic modeling and a qualitative narrative analysis indicate that the politics of
making (or more precisely, not making) PPPs in the issue area of NCDs is quite illustrative of the
hypothetical scenario A discussed above in the theory section. A preliminary topic modeling
reveals that the control of health-harming commodities such as tobacco, alcohol, and unhealthy
food and beverage has been the major topic in the multi-stakeholder negotiations in the NCDs
governance and that the industry engagement in the governance of NCDs has been debated. A
qualitative narrative analysis finds that CSOs are pursuing regulations of the health-harming
products. The CSOs are indeed vocally and explicitly opposing the idea of cooperating with the
business sector, being aware of the possibility that such cooperation would hamper the effective
control of NCDs through regulations. Facing such hostility, the alcohol and the food and
beverage industries are promoting narratives that the industries can help. The industries’
proposal to work together, however, has not been widely accepted by CSOs, and IGOs kept an
ambiguous position regarding the creation of PPPs.

19
With these documents, I create a corpus and a document-feature matrix to conduct topic modeling. In
all the document-term matrix, I stemmed the terms, lowered all the letters, and removed URLs, numbers,
punctuations and stop words for English language.
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Topic Modeling: Identifying Key Topics in the Negotiations in the NCDs Governance
Topic modeling found that the major topics discussed in the negotiation forums are mostly
related to the control of health-harming products, such as alcohol, tobacco, and food and
beverage high in sugar. Table 4-3 summarizes fifteen topics produced by the corpus, with hand-
applied labels and fifteen top stemmed words in each topic. Topics 1 (alcohol), 3 (unhealthy
food), 13 (tobacco), and 15 (alcohol) all seem to be closely associated with the control of these
health-harming products. In particular, topic 3 on unhealthy foods include the term “tax,”
suggesting that the stakeholders were discussing a regulatory measure to control unhealthy
foods.

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Table 4-3: Fifteen Topics in the NCDs Governance

In the context of this study, topic 8 (industry engagement) is of particular importance. The top
four words “sector”, “privat”, “recommend”, “engag” imply that this topic is about the
engagement of private sector in the NCDs governance, possibly including public-private
partnerships. We cannot be sure, at this stage, whether PPPs and the private sector engagement in
the area of NCDs are overall perceived negatively or positively by the stakeholders, but the result
Labels Top 15 terms
1 Alcoohol as a risk factor
health, ncds, prevent, alcohol, new, point, follow, polici, factor, develop,
risk, intern, intervent, measur, global
2 More funding and action
ncds, countri, commiss, recommend, health, ncd, mental, action,
implement, intervent, develop, report, invest, progress, fund
3 Unhealthy-food industries and tax
food, tax, product, beverag, nutrit, industri, consum, sugar, diet, healthi,
associ, polici, reduc, consumpt, inform
4 Civil society
diabet, peopl, ncds, meet, nation, govern, need, societi, live, declar,
access, un, civil, polit, us
5 Access to healthcare
care, health, palliat, treatment, cancer, univers, patient, diseas, global,
prevent, world, intern, control, document, medicin
6 Healthy lifestyle
health, promot, activ, action, physic, global, support, sustain, plan,
noncommunic, implement, develop, public, increas, educ
7 Health workers
health, nurs, ncds, report, manag, prevent, care, work, healthcar, support,
practic, role, servic, profession, provid
8 Indusry engagement
sector, privat, recommend, engag, paragraph, govern, support, report,
draft, ncds, comment, approach, member, encourag, respons
9 Public role to protect human rights
right, human, state, public, effect, can, mani, interest, industri, must,
involv, protect, without, polici, work
10 Encouraging action
obes, health, ncds, polici, recommend, includ, address, report, action, high-
level, prevent, within, opportun, determin, diseas
11 Burden of diseases
diseas, prevent, risk, death, countri, burden, global, million, can, caus,
cost, heart, pollut, diabet, cardiovascular
12 Encouraging action (2)
ncds, health, develop, prevent, polici, control, nation, includ, ncd, achiev,
address, sector, implement, global, risk
13 Tobacco control
tobacco, smoke, product, health, use, harm, reduct, public, risk, reduc,
cigarett, control, innov, e-cigarett, new
14 Lifecourse approach
ncds, peopl, age, children, popul, health, women, life, approach, need,
live, ncd, young, includ, older
15 Alcohol control
alcohol, harm, use, reduc, polici, drink, health, consumpt, increas, global,
report, price, draft, includ, research
85
of the topic modeling at least suggests the possibility that the role of private sector is one of the
important (and probably controversial) topics in the negotiation process.
When conducting topic modeling on the documents submitted by CSOs and the business
sector separately, we can actually see that the role of private sector is discussed with different
sets of words by CSOs and the industries. The private sector talks about themselves by using
very positive words, such as support, commit, action, contribute, achieve, and progress. These
terms possibly indicate the business sector’s support for PPPs. In contrast, CSOs mention
industries with a more dubious tone, combining terms such as tax, interest, public and control.
Another interesting point is that the business sector intensively talks about food policies, using
terms such as “inform”, “label”, and “advertise” but not “tax” or “regulations.” It possibly
suggests that the industries are advocating for the use of voluntary measures instead of regulatory
measures, such as tax on unhealthy foods.

Qualitative Narrative Analysis: Policy Preferences of CSOs and the Business Sector
In order to more accurately examine how CSOs and the business sector were expressing their
preferred policy interventions, I conduct qualitative narrative analysis of the same sets of
documents that are used for the topic modeling.
20
The qualitative analysis found that CSOs have
advocated for the regulations, taxation in particular, on health-harming commodities including
tobacco, alcohol and unhealthy food and beverage. Some CSOs are rather vocally arguing
against cooperating with the industries (especially with alcohol companies), stating that
participation of these companies would compromise the governance of NCDs. In contrast, the

20
Data sources are indicated above in the topic modeling section. The qualitative content analysis also
refers to other materials such as press releases of the key stakeholders.
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business sector has openly supported creating PPPs to control NCDs, depicting itself as a reliable
ally instead of a problematic producer of unhealthy commodities.
These findings are quite close to scenario A: When CSOs are pursuing regulations on
activities of industries, the business sector has incentives to advocate for the creation of PPPs to
forestall the momentum towards regulations. Yet, PPPs cannot be established under such a
condition because the preferences of the two stakeholders are conflicting with one another and
there is no overlap between them.

Civil Society, Pursuing Regulations on Health-Harming Products: As we saw in the topic
modeling section, CSOs have formally engaged with the negotiation process in the NCDs
governance. The UN General Assembly set up the Civil Society Task Force ahead of the first
High-Level Meeting in 2011, and the Director-General of WHO established the Civil Society
Working Group in the preparatory process for the third High-Level Meeting. Given the
aggregated nature of NCDs, a wide range of CSOs are involved in the discussion, but the most
prominent one is the NCD Alliance which was formed in 2009 as a coalition of three
organizations (the International Diabetes Federation, the World Heart Federation, and the Union
for International Cancer Control). Since then, the NCD Alliance has expanded its membership
and now contains 2000 organizations operating in more than 170 countries. Katie Dain, a CEO
of the NCD Alliance, served as a co-chair of the 2018 Civil Society Working Group.
Dain (2018) explains that the NCD Alliance has formulated a frame of NCDs that emphasizes
four aspects: 1) Definition of NCDs as four major diseases and four major risk factors (4 by 4
definition), 2) NCDs as a human development priority, 3) Economic arguments that it is too
costly to neglect NCDs, and 4) Cost-effective solutions. Messages and narratives of the Civil
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Society Working Group mostly correspond with this framing (which is not surprising given that
Dain served as the co-chair), but these narratives further articulate specific interventions that
civil society collectively prefers. The main messages include the following (emphasis added):
21

• Prevention is an investment in health, development and economy.
• There is a clear investment case for scaling up action on NCDs. The solutions exist – a set
of Best Buys backed by evidence – and have a high return on investment.
• Demonstrate that real increases in excise taxes and prices for tobacco products,
alcoholic beverages, and sugar-sweetened beverages is part of a comprehensive
approach to NCD prevention and control that both reduces consumption and provides a
source of domestic revenue.
• Call on governments to take a step further at the 2018 High-Level Meeting and adopt a
more comprehensive approach to taxation – including of sugar, tobacco and alcohol.

It is apparent in these messages that the advocacy network considers that NCDs should be
controlled by regulations on health-harming products, such as tobacco, alcohol and ultra-
processed foods and beverages. As is well known, the WHO member states adopted the
Framework Convention on Tobacco Control in 2003, but there are no such regulations on other
health-harming commodities. Supported by CSOs and low- and middle-income countries, the
WHO has advocated for so-called “best buy” interventions for NCDs which mostly promote
taxation and other regulatory measures on health-harming products (WHO 2017a). In this
context, the industries are largely recognized by CSOs as enemies and the subject of regulations
instead of potential allies, leaving little possibility for public-private cooperation.

21
Full description available at https://www.who.int/ncds/governance/high-level-meetings/Workstream_1-
Key_Messages_and_narrative.pdf?ua=1
88
CSOs are in general cautious about collaborating with the private sector, and some
organizations harshly argue against PPPs as the following statements clearly demonstrate:

We strongly believe that this proposed 'partnership'-approach is entirely the wrong
strategy. There are numerous examples of the powerful sway that the tobacco, alcohol,
and food industries have over international governments and how this impedes effective
health policy. Evidence suggests that these corporate social responsibility strategies are
intended to facilitate access to government, co-opt nongovernmental organizations to
corporate agendas, build trust among the public and political elite and promote untested,
voluntary solutions over binding regulation. While the tobacco industry is not allowed at
the negotiation table because of an "intrinsic conflict of interest", the Global Alcohol
Producers Group (GAP-G) was a civil-society representative at the (first) UN HLM.
Predictably, given existing evidence on efforts by the alcohol industry to prevent effective
public health policies, they pushed for voluntary rather than regulatory approaches.
Global Health Watch (2011) “PHM analysis of the international response to NCDs”
22

To protect the right to health, measures must be taken to avoid the interference of the
tobacco, food, sugar-sweetened beverages and alcohol industries when establishing and
implementing public health policies.
Healthy Latin American Coalition and Interamerican Heart Foundation Argentina (2018)
Statement submitted to the Interactive Hearing

22
Full text available at https://www.ghwatch.org/who-watch/topics/ncd
89
For our work today and for future generations, we respectfully share that we have deep
concerns over the alcohol industry’s inclusion in this process. They should no more be
considered as a part of the whole of society than a cancer should be included as a part of
the whole of the body. They should no more be included here than it was determined the
tobacco industry should not be included in the Framework Convention on Tobacco
Control. Their inclusion would not merely be an act of involving the private sector; this is
the alcohol industry, the segment that has a vested commercial interest in the sale and
consumption of this harmful product.
U.S. Alcohol Policy Alliance (2018)
Statement submitted to the Roundtable at the third High-Level Meeting

Industries, Supporting Partnerships under the Threats of Regulations: The tobacco industry
is not allowed to join the discussion with the UN agencies, but other industries including the
pharmaceutical, alcohol, and food and non-alcoholic beverage industries have engaged in the
negotiation. In their Lancet article, Geneau and his co-authors (2000) identify three frames of
NCDs that hinder political actions. Three such frames are 1) NCDs as a disease of individual
choice; 2) NCDs as a disease of ageing, which leads to the logic that there is nothing that policy
can do, and; 3) NCDs as a disease of the affluent, which suggest that the prevalence of NCDs
prove the maturity of society and hence there is no need for global assistance. The narratives
produced by the industries mirror these frames, but starkly contrast with the messages from
CSOs.
The industries’ favorite argument is that NCDs are a consequence of individual choice, which
leads to victim-blaming sentiments instead of support for public policies such as regulations.
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Indeed, the business sector has explicitly stated that regulation is not effective, despite scientific
evidence as to taxation’s effectiveness for addressing NCDs (Tangcharoensathien et al. 2019).

There is a wrong perception that food and beverage taxes constitute a success story of
policy intervention to fight obesity.
Alliance of Food and Beverage Associations in Latin America (2018)
Statement submitted to the Interactive Hearing

The industries also try to convince others that they are effective partners rather than an enemy
in the governance of NCDs, and they suggest that voluntary multi-stakeholder cooperation is a
more appropriate measure to address the issue.

Private sector actors from the food, drink, beer, wine, and spirits sectors are effective
partners in accelerating progress towards the SDGs. Responsible businesses from all
sectors can learn from each other’s successes and have positive impacts in many areas,
including co-regulation, production, packaging, and marketing.
The International Alliance for Responsible Drinking (2018)
Statement submitted to the Interactive Hearing

Private sector action is indispensable if we want to achieve the SDG 3.4. … If we want to
achieve SDG 3.4, we need to overcome our “simplified enemy narratives”
Food Drink Europe (2018)
Statement submitted to the Interactive Hearing
91

It is not surprising that these statements came from the producers of health-harming products.
As the CSOs pursue regulations on their products, the alcohol and the food and beverage
industries are facing “legal threats.” This situation gives the industries a stake to promote the
creation of PPPs as an alternative to regulations. It explains why the industries clearly support
voluntary cooperation while arguing against taxation. To be clear, there should be PPPs in this
issue area if the corporate takeover explanation is correct. The corporations express clear
interests in creating partnerships. Yet, no remarkable transnational PPP has been generated in
this issue area. This suggests that the creation and non-creation of PPPs cannot be explained by
corporate strategies alone.
For the pharmaceutical industry, the storyline is a bit different. The industry is not facing
legal threats unlike its counterparts in health-harming industries. It thus makes sense that the
pharmaceutical industry does not aggressively support PPPs. The pharmaceutical industry shows
(at least rhetorical) support for PPPs, but the emphasis in its narrative is on rejecting the
argument that high price is the obstacle for access to medicines. The first thing addressed in the
industry’s statement is that pharmaceutical companies should not be blamed for the lack of
access to NCDs treatments.

Before talking about the industry’s commitment to SDG3.4 and SDG17 I wanted to
address an issue which has been raised several times this morning: that high prices of
insulin are the main reason that many diabetes patients in LMICs don’t have access to
treatment. If it only were that simple! Fact is that in spite of companies’ tiered pricing
92
policies and partnership efforts access to insulin still remains a challenge, in particular
in low-income settings.
International Federation of Pharmaceutical Manufactures and Associations (IFPMA)
(2018)
Statement submitted to the Interactive Hearing

This statement illustrates the industry’s reluctance to further facilitate a better provision of
NCDs medicines, and the situation here rather exemplifies scenario C: Even though CSOs call
for a greater provision of insulin in resource-poor countries, the industry does not see economic
benefits in cooperating on this front and thus is unwilling to launch partnerships. Unlike the
situation surrounding the health-harming industries, partnerships with the pharmaceutical
industry in the NCDs area might emerge in the future if CSOs stimulate economic incentives of
the industry (enforcement of the economic license) and shift the scenario from C to B. So far,
NCDs require such diverse treatments that the pharmaceutical industry might consider it too
costly to provide all the lucrative medicines. As the advocacy networks of HIV/AIDS did (see
Chapter 6), if the NCDs advocates focus on a very specific therapeutic area, this might positively
affect the economic calculations of the pharmaceutical companies.

4-4. The Consequence of Starkly Conflicting Preferences

In order to investigate the reason behind non-creation of PPPs, this chapter looked at the case of
non-communicable diseases. As being articulated in the theoretical scenario A of conflicting
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preferences, the CSOs in the field of NCDs have been strongly advocated for the use of
regulation as a priority intervention to control NCDs and their major risk factors. This pursuant
of regulatory measures started with the making of the WHO FCTC, where CSOs argued for the
strict control of tobacco while the tobacco industry opposed the necessity of such regulation.
Critically, the tobacco industry proposed voluntary initiatives such as youth programs as an
alternative to the international regulation. A very similar constellation of preferences can be seen
in the extended debate over NCDs and other major risk factors. Networks of CSOs pursue
regulations, such as taxation on alcohol and soda, while the producers of these products vocally
support the use of voluntary initiatives including the formation of PPPs. This starkly conflicting
preferences between civil society and the business sector have resulted in the lack of many or
large-scale PPPs in this issue area, along with the overall stagnated and insufficient progress of
NCD governance at the global level.
WHO – a major IGO operating in this issue are – is so far not bold enough to take a clear side
of CSOs and pursue another international regulation with the aim of controlling NCDs, but it
cannot collude with the health-harming industries either. Ignoring the voice of CSOs and
launching transnational PPPs in the face of criticism would tarnish the credibility and moral
authority of the health organization. A recent WHO decision not to engage with the alcohol
industry when developing alcohol policy might be a sign that the preference of CSOs is winning
over the interests of the business sector, but the realization of regulatory controls of the NCD risk
factors requires another (or probably many more) steps (Torjesen 2019). What the development
of NCD governance so far indicates is that it is hard to create transnational PPPs under the vocal
opposition from CSOs in the issue area, even if the powerful industries like Big Alcohol and Big
Food prefer taking that rout instead of the regulatory one. Future direction of global NCD
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governance remains to be seen, but I suppose it is unlikely that large-scale PPPs be created in
this issue area unless the business sector successfully propitiates or subjugates a crucial segment
of CSOs and breaks the “conflicting preferences” between the two.

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Chapter 5. Neglected Tropical Diseases:
Welcoming “Profitable Gifts” from Pharmaceutical Companies

The case of neglected tropical diseases (NTDs) illustrates the scenario B of overlapping
preferences discussed earlier in the theory chapter. In fact, NTDs is the issue area which has
enjoyed the longest and the most successful partnerships among industry, NGOs, and
governmental and intergovernmental actors. Most of the largest pharmaceutical companies are
joining one or more partnerships to address NTDs, and the role of the companies is widely
accepted and even praised in this issue area. This chapter analyzes how this situation came about.
I argue that the pharmaceutical industry won the status as an indispensable and trustworthy
partner through an early engagement with the control of NTDs. Even before NTDs were
recognized as an important global health issue, pharmaceutical companies started working with
various actors including the WHO and numerous NGOs, by launching generous drug donation
partnerships. The WHO and not-for-profit organizations did not fully trust the industry at the
beginning, but they decided to create a drug donation PPP anyway because there was no other
effective way to control NTDs. The success of the drug donation partnerships and the long
history of collaboration have further built a trust among these actors, which since early 2000s has
enabled the creation of another type of PPP – product development partnerships.
This chapter starts by summarizing some background information of this issue area, including
the definition of “neglected tropical diseases,” the magnitude of the disease burden, and how
these diseases have been framed by the advocates of this issue. The second section then reviews
the creation of drug donation PPPs by paying special attention to the case of the Mectizan
Donation Program – the oldest partnership of this kind. The third section moves on to the review
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of a more recent development of product development PPPs, which happened in tandem with the
rise of NTDs as one of the priorities in international development agenda. The case of the Drugs
for Neglected Diseases initiative (DNDi) provides an illustrative story as to how NGOs and the
pharmaceutical industry could find the place where their preferences overlap. The fourth section
concludes this chapter by summarizing the key factors that made the issue area of NTDs one of
the most popular destinations of PPPs.

5-1. Background

Definition
Unlike newly emergent viral diseases such as SARS and AIDS, the diseases that are categorized
as neglected tropical diseases have been present for the most part of human history. The term
“neglected tropical diseases,” however, emerged relatively recently. A similar term “great
neglected diseases” was first used by the Head of the Rockefeller Health Department, Dr. Ken
Warren, in the 1980s (Molyneux 2012). Later in 2003 at the International Workshop on
Intensified Control of Neglected Diseases in Berlin, the WHO coined the term “neglected
tropical diseases” to describe a “set of diseases that are ancient, worsen poverty, and typically
impair health and productivity while carrying low death rates” (Salaam-Blyther 2014). Since
then, there has been an increasing recognition of NTDs among the international health
community, and global efforts to address these diseases have accelerated (Salaam-Blyther 2014).
Even with this growing recognition, however, the definition of the term is somewhat blurry.
Liese et al. (2010) point out that there is no standard global definition of neglected tropical
97
diseases, and there have been two different understandings of the term. The first understanding
of the term emphasizes “neglect” as the defining characteristic, while the second understanding
focuses more on the shared features of the diseases and their effects on poverty and development.
Another interpretation predominantly used by civil society actors focuses on “population”
instead of “diseases” that are neglected. For instance, criticizing the lack of research and
development on NTD medicines, Don and Chatelain (2009) argue that “[T]hose diseases which
predominantly affect inhabitants or poorer nations, are of no military or strategic interest to
wealthy countries and are not supported by markets or patients organizations capable of
attracting the attention of politicians, have fallen below the radar of modern drug discovery.
Moreover, those afflicted are unable to bear the cost of development. These diseases have
therefore been forgotten and often labeled as neglected diseases or, perhaps more appropriately,
‘diseases of the neglected’” (pp. 33-34).
The definitions used by different organizations in different places illustrate the various
understandings of the term. For instance, back in 2007, the WHO mentioned that neglected
tropical diseases are “chronically endemic and epidemic-prone tropical diseases, which have a
very significant negative impact on the lives of poor populations [and] remain critically
neglected in the global public health agenda.” The WHO raised 14 specific diseases to be
focused on by the organization (WHO 2007a). More recently in 2017, the WHO added some
diseases to its list of “neglected tropical diseases,” putting a total of 20 diseases under the
umbrella category (WHO n.d.g). On the other hand, the Neglected Tropical Disease Program at
the United States Agency for International Development (USAID) described the term as diseases
that “disproportionately impact the poor and rural populations, who lack access to safe water,
sanitation, and essential medicines. They cause sickness and disability, compromise children’s
98
mental and physical development, and result in blindness and severe disfigurement” (USAID
n.d.). The USAID focuses on five specific diseases as their target diseases.
Acknowledging the multiple composing elements, varying understanding, and evolving
nature of the concept of neglected tropical diseases, I follow a relatively broad understanding of
the diseases by the WHO. As of 2020, the WHO states that “[N]eglected tropical diseases
(NTDs) are a diverse set of 20 disease groups with a singular commonality: their impact on
impoverished communities” (WHO 2020a). Accordingly, this dissertation considers the
following group of diseases as neglected tropical diseases:
23

• Buruli ulcer
• Chagas disease
• Dengue and Chikungunya
• Dracunculiasis (guinea-worm disease)
• Echinococcosis
• Foodborne trematodiases
• Human African trypanosomiasis (sleeping sickness)
• Leishmaniasis
• Leprosy (Hansen's disease)
• Lymphatic filariasis (elephantiasis)
• Mycetoma, chromoblastomycosis and other deep mycoses
• Onchocerciasis (river blindness)
• Rabies
• Scabies and other ectoparasites

23
A summary and explanation for these diseases can be found at WHO (n.d.g).
99
• Schistosomiasis (snail fever)
• Soil-transmitted helminthiases
• Snakebite envenoming
• Taeniasis/Cysticercosis
• Trachoma
• Yaws (Endemic treponematoses)

Among these diseases, special attention will be paid to soil-transmitted helminths,
schistosomiasis, lymphatic filariasis, trachoma, and onchocerciasis because they account for
approximately 90% of the global NTD burden and many of NTD partnerships have developed to
address these specific diseases (Salaam-Blyther 2014).

Magnitude
Many people outside the health sector might have never heard of the names of these diseases.
Indeed, these diseases are not as famous as the so-called Big Three infectious diseases
(HIV/AIDS, malaria and tuberculosis) among the general public and they are “neglected” in this
sense. However, these diseases collectively generate a great disease burden, especially on those
who reside in tropical and subtropical areas (figures below). According to the WHO, NTDs are
currently prevalent in 149 countries and more than one billion people are affected. NTDs cause
an estimated 35,000 deaths per day worldwide, and the lack of timely access to treatment makes
hundreds of millions of people “severely disabled, disfigured or debilitated, often resulting in
social exclusion, stigmatization and discrimination” (WHO 2020a). Payne and Fitchett (2010)
estimate another 2.7 billion people living on less than US$2 are at risk. Although the mortality
100
rate for these diseases is relatively low, NTDs have a higher health burden than malaria and
tuberculosis in terms of the disability-adjusted life year (DALY) because the diseases cause life-
long disability (MacKey et al 2014; Liese et al. 2010). NTDs significantly impact economic
capability and quality of life due to their disabling nature, and many authors have suggested that
the control of NTDs is an efficient way to fight poverty. The WHO points out that NTDs cost
developing communities billions of dollars every year in the form of direct health costs, loss of
productivity and reduced socioeconomic and educational attainment (WHO 2020a).

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Figure 5-1: Geographic Distribution of Lymphatic Filariasis and Onchocerciasis
Source: WHO http://gamapserver.who.int/mapLibrary/Files/Maps/LF_2016.png, and WHO
http://gamapserver.who.int/mapLibrary/Files/Maps/Onchocerciasis_2017.png For more details, see
http://gamapserver.who.int/mapLibrary/app/searchResults.aspx
102

As the figures above show, the vast majority of people affected by NTDs reside in tropical
and subtropical areas of the world. In other words, NTDs are predominantly a “developing
countries’ issue.” A popular narrative surrounding NTDs reflects this connection between the
diseases, poverty, and development. NTDs are frequently labeled “diseases of poverty” or
“disease of the poor” (Liese et al. 2010; Molyneux 2014). This makes a clear contrast between
the prevalent understanding of non-communicable diseases, as we saw in Chapter 4. Despite the
disproportionate impacts of non-communicable diseases on low- and middle-income countries,
non-communicable diseases have been widely assumed to be a “disease of the rich” (Geneau et
al. 2000). In contrast, no one doubts the idea that neglected tropical diseases are strongly
associated with poverty in the Global South, as the name itself contains that term “tropical” and
can be easily connected to historical poverty in tropical regions.

Frames and Interventions
Indeed, one of the two framing elements that NTD advocates almost always emphasize is the
strong link between NTDs and poverty. Recognizing NTDs both as a cause and the effect of
poverty, Payne and Fitchett (2010) argue that NTD treatment and control is essential in
improving the lives of the “bottom billion.” The impact of NTDs on maternal and child health is
also well recognized, as more than one third of pregnant women in sub-Sahara African countries
are estimated to be infected with at least one NTD agent, and the diseases can have a negative
impact on maternal and child health if they are not detected and treated appropriately (Mackey et
al. 2014: 956). Beyond maternal and child health, advocates usually argue that NTDs are deeply
connected to other health issues including mental health (Bailey et al. 2018), women’s health, the
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big three infectious diseases, and non-communicable diseases (Hotez 2013). An explicit link has
been made with the concept of universal health coverage (UHC) in recent years, as the UHC won
the high profile in the current WHO agenda (Furst et al. 2019; Molyneux 2018). These
connections with NTDs and various other issues are intentionally advanced by NTD advocates,
reflecting their belief that addressing NTDs would contribute to improving almost any other
health and development issues.
It is interesting, however, that the diseases are not often framed as a human rights issue (Liese
et al. 2010). This makes contrasts sharply with the framing strategy of AIDS activists. In the
issue area of HIV/AIDS where access to life-saving medicines is framed as human rights, any
efforts made by pharmaceutical companies tend to be considered as an act of responsibility that
the companies are obliged to fulfil; otherwise, the companies infringe on people’s right to health.
In contrast, drug donations in the area of NTDs are overall regarded as a benevolent gift from the
generous industry, hence giving a positive reputation to the companies as an example of good
corporate citizenship.
Another important framing element of NTDs is the cost-effectiveness of the interventions and
the feasibility of eradicating these diseases. This narrative is fundamentally related to the role of
pharmaceutical companies in the history of NTD governance. As the case of the Mectizan
Donation Program in the next section reveals, large pharmaceutical companies started engaging
with the control of NTDs even before the term “neglected tropical diseases” was coined.
Moreover, we could even consider that it was these companies’ drug donation strategies that set
the narratives and understanding of how the issue of NTDs should be addressed.

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5-2. Building Trust through an Early Engagement in Drug Donation PPPs

Development of Drug Donation Partnerships
The early development of NTD programs can be characterized as an expansion of drug donation
programs. NTDs have received more drug donations from pharmaceutical companies than have
any other public health initiatives, and Liese et al. (2010) succinctly say “cooperation between
the [pharmaceutical] industry and programmes for neglected tropical diseases is a good example
of a public-private partnership” (p. 71). Indeed, PPPs in this issue area are widely appraised as
good and successful.
Many of the world’s largest pharmaceutical companies have drug donation programs in the
area of NTDs. The oldest program among them is the well-known Mectizan Donation Program
created by Merck, through which the pharmaceutical firm has donated ivermectin (brand name,
Mectizan) to help eradicate onchocerciasis. This program started in 1987, well before the term
“neglected tropical diseases” emerged in 2003. Following the 1998 pledge made by
GlaxoSmithKline to donate albendazole in order to help eradicate lymphatic filariasis, the
Mectizan Donation Program was also expanded to donate Mectizan to treat lymphatic filariasis
wherever this disease and onchocerciasis are co-endemic. In the same year, Pfizer also launched
a program known as the International Trachoma Initiative,
24
donating azithromycin to treat
trachoma in 58 endemic countries. A Swiss pharmaceutical company, Novartis,
25
also started
donating multidrug therapy (rifampicin, clofazimine, and dapsone) to treat leprosy in 2001,

24
Pfizer “International Trachoma Initiative,”
https://www.pfizer.com/responsibility/global_health/international_trachoma_initiative (accessed
November 4, 2020)
25
For Novartis CSR in the infectious disease, see https://www.csrwire.com/press_releases/33691-
Novartis-Extends-Commitment-to-Help-Achieve-Final-Elimination-of-Leprosy (accessed November 4,
2020)
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collaborating with a range of organizations including the WHO. More recently in 2006, Johnson
& Johnson launched a PPP named Children without Worms. This partnership aims to eliminate
intestinal worms by donating the medicine mebendazole. In 2007, Merck KGaA (German
Merck) started collaborating with the WHO to combat schistosomiasis, and the company donates
praziquantel for the purpose.
This is just a short list of the most famous projects launched by pharmaceutical companies,
and there are many other initiatives trying to address one or more neglected tropical diseases (for
more detail, see Cohen et al. 2016). In the context of my study, an important aspect of these drug
donation programs is that these programs are mostly co-operated by the pharmaceutical
companies and public entities, such as the WHO, and therefore fall under the category of PPPs in
my definition. In this sense, these drug-donation PPPs are different from a more traditional way
of donation where pharmaceutical companies just give a bunch of medicines without clear goals
or procedures (Lucas 2002; Dull and Meredith 1998; Fettig 1998; Foege 1998). This “new type
of giving” (Lucas 2002) is more institutionalized than traditional ad-hoc drug donations, and the
role of pharmaceutical companies does not end when they give drugs to another entity – they
have more control in decision making regarding program operations.
The earliest examples of such drug-donation PPPs started well before these several diseases
were even recognized under a single label of neglected tropical diseases, and it was also before
the general trends towards the use of PPPs emerged in the late 1990s / early 2000 (see chapter 1).
As far as the partnerships with the pharmaceutical industry are concerned, this is probably where
support for PPPs began to sprout. The Mectizan Donation Program, in particular, established a
model of drug-donation PPPs and created a trajectory for smooth cooperation between the
pharmaceutical industry and other types of actors that many programs later followed. In the
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following paragraphs, I illustrate how pharmaceutical companies came to engage with the
governance of NTDs and, more importantly, how the industry gained the image as a legitimate
and trustworthy partner in this issue area by looking at the case of the Mectizan Donation
Program.

Mectizan Donation Program
The Mectizan Donation Program was launched in 1987 when Merck & Co., Inc., a leading
pharmaceutical company located in New Jersey USA, decided to donate Mectizan (ivermectin)
“as much as needed, for as long as needed” to help eliminate onchocerciasis (Merck 2019;
Gustavsen, Colatrella and McCoy 2018). This program had a significant impact on the direction
of NTD governance, since it initiated mass drug administration (MDA) as a priority intervention
to control and eliminate onchocerciasis and other major NTDs (Lawrence et al. 2015: 5).
Onchocerciasis is a tropical parasitic disease spread by the bite of a black fly – a disease
vector that breeds in rivers. Symptoms includes pain and itching of the skin, vision loss and
eventual blindness, and thus this disease is also known as “river blindness” (Gustavsen,
Colatrella and McCoy 2018). The disease has detrimental effects on the quality of life of infected
people and communities. The disease even forced villages to relocate from rivers to less fertile
land, devastating the lives of agricultural communities (Collins 2004). Before ivermectin was
developed, vector control (instead of mass drug administration) was the major intervention to
deal with the disease. In 1974, the WHO launched its first initiative on NTDs, the Onchocerciasis
Control Programme, with collaboration with the World Bank, UNDP, and FAO. The
Onchocerciasis Control Programme initially employed vector control and sprayed insecticides
from helicopters and aircrafts over the breading sites of the black flies in order to kill their larvae
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(WHO n.d.d). This intervention was not ideal because the insecticides could be toxic for human
health. There were medicines for onchocerciasis (diethylcarbamazine and suramin), but they
were not good options either because of their strong side-effects (Collins 2004). In contrast,
ivermectin could be easily taken orally as tablets and did not show any strong side-effects.
26
The
medicine gradually kills the larval Onchocerca volvulus worms – microfilariae – that live in the
subcutaneous tissue of an infected person, and treatment with ivermectin halts the progression
towards blindness. Ivermectin does not kill the adult worms but suppresses the production of
microfilariae by adult female worms, thus reducing transmission. WHO explains that taking one
dose of ivermectin once a year for 16-18 years could break the cycle of transmission of this
disease (WHO n.d.e).
The efficacy of this medicine offered a potential to change the landscape of onchocerciasis
control, but what was truly game-changing was Merck’s decision to donate Mectizan because it
made mass drug distribution a “cost-effective” intervention. In other words, this intervention is
not cheap or cost-effective if the medicine is not donated for free. Many of my interviewees
emphasized that the international NTD community decided to move towards the direction of
mass drug administration because drugs are donated. Otherwise, other interventions such as
improving access to clean water might be more cost-effective. In this sense, it was a
pharmaceutical company that determined the way this disease should be addressed. The decision
to donate ivermectin made mass drug distribution affordable, and it was after this decision that
the elimination of onchocerciasis turned to be a realistic goal for low- and middle-income
countries (Lawrence et al. 2015: 5).

26
Ivermectin provided a safer choice for the treatment of onchocerciasis, but a risk remains for a Loa loa
co-endemic areas. Mectizan Donation Program, APOC, Merck, BMGF, and other partners have worked to
find a solution for this issue.
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Merck’s donation of Mectizan first directed the strategy of the WHO Onchocerciasis Control
Programme towards mass drug administration from vector control (Liese et al. 2010; WHO).
Until today, mass drug administration remains a major intervention to control onchocerciasis and
seven other NTDs. Almost every paper discussing the control of NTDs mentions mass drug
administration as a major intervention (Furst et al. 2017; Salaam-Blyther 2014; Molyneux 2014;
Molyneux, Savioli, and Engels 2017; Molyneux et al. 2018; MacKey et al. 2014; Payne and
Fitchett 2010), and they also point out its cost-effectiveness. For instance, MacKey et al. (2014)
mention that providing NTD drugs in Africa costs only $0.40 per person per year. Another
estimate gives a similar number: Kaiser Family Foundation (2019) explains that mass drug
administration is a major intervention in the control of NTDs because a combination of four
drugs used for 7 most prevalent NTDs costs only $0.10-$0.50 per person per year.
Merck’s decision to donate ivermectin has thus been highly praised as the longest and most
successful philanthropy in the field of public health. However, it was not the company’s
intention to develop and donate a life-changing medicine for the world’s poor. Ivermectin was
originally developed as a for-profit veterinary drug to treat parasitic infections in livestock
(Collins 2004). The animal medicine, named Ivomec, was introduced to the markets in several
countries in 1981 as an injection formulation for cattle, and by 1987, Merck had expended the
lineup of ivermectin to be used for pigs, sheep, horses, and dogs. By the end of the 1980s, it
became the world’s most profitable veterinary drug and the company’s second largest selling
product (Collins 2004: 103).
Already in 1978, William Campbell, a parasitologist working for the company, found that the
medicine might also work on onchocerciasis, a disease that burdened many people in tropical
regions. He passed responsibility for the drug development on to a Merck’s physician
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Mohammed Aziz, and Aziz began clinical trials in Senegal in 1981 under the collaboration with
the WHO’s TDR. The trial demonstrated the efficacy and safety of the drug, and ivermectin
provided a better option to tackle onchocerciasis compared to other existing medicines that had
serious side-effects. Soon after the marketing team of the company calculated the pricing,
however, Merck realized that they could not make any profit out of this medicine because there
was no way the affected populations of onchocerciasis could pay about $3 per dose, the usual
price set for an anti-parasitic drug (Collins 2004).
At the beginning, the company was reluctant to donate the product. There were three options
Merck considered (Frost et al. 2002). The first option was to sell the medicine to the WHO at a
compromise price of $1. The WHO did not agree with this idea, saying it was still too expensive
and should be less than $0.50. The second option was to sell the medicine at $0.50 and receive
compensation from a third party, such as bilateral donors. The head of the Merck Research
Laboratories talked to USAID, the US Department of State, European governments, African
governments, and private foundations, but no entity showed willingness to support the effort.
Senators Bill Bradley, Edward Kennedy, Frank Lautenberg, and Richard Lugar sought
Congressional action to support the worldwide distribution of ivermectin, but their effort was
also unsuccessful (Collins 2004). Third, and the least-preferred option was to donate the
medicine. This idea appeared problematic for both the company and the WHO. For the WHO,
there was a concern that patients would doubt the quality and effectiveness of the medicine if it
was free. On the other hand, Merck was under pressure from other pharmaceutical companies not
to make donations. Pharmaceutical companies were worried that the donation of ivermectin
would set a precedent that the industry had to donate NTD medicines, and such an expectation
would reduce commercial incentives to invest in the development of NTD drugs.
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Facing this difficult situation, Merck also considered the possibility of abandoning the human
use of ivermectin, but the company decided otherwise for several reasons. The biggest concern
was about their public image. Abandoning a medicine, knowing that it would dramatically
improve the lives of millions of the world’s poor, would significantly tarnish the company’s
public image (Frost et al. 2002). They were also concerned about the morale among employees,
especially among scientists who devoted their passion to the research and development of this
medicine. Some employees began to use the “Merck philosophy,” an ethical framework the
company had been using, to their arguments favoring the donation of the drug (Collins 2004).
Merck actually had experience at establishing a strong position in the market where it donated its
life-saving medicines. After World War 2, the company donated a large supply of streptomycin
to Japan, where tuberculosis had a high prevalence rate. Merck later became the largest
American pharmaceutical company in the Japanese market, and this experience gave the
impression that donations could actually lead to business gains (Collins 2004). Business
performance of the company at that time was good, and senior management felt it was affordable
to donate this single medicine to resource-limited communities. The donation would be tax
deductible under the US tax code, and it would not cost too much for the company anyway.
On top of these favorable conditions, the various ivermectin-based veterinary drugs were
already quite successful: ivermectin for animal use was earning more than $300 million annually,
with a 15 % growth in sales per year. It was thus likely that the profits would exceed the costs for
production and distribution even if Mectizan was donated for human use. Wehrwein (1999)
indeed mentions that the donation of Mectizan was a minimal price to pay for the benefits of
good publicity, improved employee morale, and tax write-offs. After three years of debate,
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Merck decided to donate the drug, and the company and the WHO jointly announced the
establishment of the Mectizan Donation Program on Oct 21, 1987.
In this process leading up to the decision to donate Mectizan, Merck figured out that it
needed to create an institution outside of its body in order to carry out the donation projects.
Merck had two major concerns regarding a distribution mechanism (Frost et al. 2002).
Considering the huge success of ivermectin in the veterinary drug market, the company was
reasonably worried about drug diversion to a black market. Merck also needed to monitor the
safety of the medicine, because there was a possibility of unknown side-effect that might
negatively affect the sales of ivermectin in veterinary market. In order to deal with these
concerns, the company first turned to the WHO in 1985. However, despite repeated attempts to
urge WHO to take active leadership in building a distribution mechanism, the company did not
receive a clear response from the WHO (Frost et al. 2002). WHO had its own concerns. In
particular, the organization was cautious about its legal status as an intergovernmental
organization and trying to avoid jointly running a program with a private for-profit firm.
Merck also needed a partnership with NGOs. Mectizan had to be delivered to millions of
people living in remote areas of Africa and Latin America where basic infrastructure did not
exist. Under such circumstances, it is necessary to cooperate with organizations that knew local
settings better. In addition to this physical barrier, there were cultural barriers to be taken care of.
Many people in endemic communities experienced terrible side-effects of previous medications
for onchocerciasis during the 1970s and 1980s, hence they distrusted Western medicines. Merck
thought these barriers could be overcome by cooperating with organizations already working in
the communities. In the end, the company decided to collaborate with the Task Force for Child
Survival (a nonprofit public health organization, now the Task Force for Global Health)
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(Gustavsen et al. 2018; Collins 2004). When Merck approached William Foege at the Task
Force, many warned him that pharmaceutical companies could not be trusted and discouraged
him from getting involved. Foege decided to help Merck’s effort regardless, and here, the wall of
distrust was experimentally fallen between the industry and nonprofit organizations.
With the help of Task Force, Merck created an independent expert committee to review and
approve drug requests. The independent expert committee, the Mectizan Expert Committee
(MEC), is made up of individuals with expertise in global health, tropical diseases, entomology,
parasitology, and disease control and includes participation by WHO Headquarters, WHO
AFRO, the African Program for Onchocerciasis (APOC), the Onchocerciasis Elimination
Program for the Americas (OPEA), the World Bank, and the Centers for Disease Control and
Prevention (CDC) of the United States (Lawrence et al. 2015). This Mectizan Expert Committee
– with the Mectizan Secretariat offices locaded in Atlanta, Washington DC, and France – is the
major body of the Mectizan Donation Program (Peters and Phillips 2004).
This is how the program became a drug-donation PPP instead of a more traditional drug
donation initiative that resides within a company’s CSR office. By taking this institutional
structure, the Mectizan Expert Committee could maintain the independence from Merck and gain
administrative support from the Task Force. Merck could focus on producing medicine and
paying for committee expenses and honoraria (Frost et al. 2002). This division-of-labor through
partnership seems to be contributing to high satisfactory evaluations from participating
organizations, as the survey by Peters and Phillips (2004) reveals.
The inclusion of various sets of actors surely helped the operation of the Program. In
particular, the Mectizan Donation Program came to cooperate with NGOs, such as Sight Savers
and the International Eye Foundation, that had been working on onchocerciasis in African and
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Latin America since the 1950s and 1960s (Collins 2004). NGOs acted as intermediary bodies in
the distribution of ivermectin: They employed people from both the US and the endemic
communities where ivermectin needed to be distributed, and therefore NGOs could understand
the ways to deal with both sides of the distribution process. This way, NGOs played a major role
in the implementation fields of the Program and contributed to inventing the distribution
strategies that were modeled after by other drug-donation PPPs.
The most important among such strategies is so-called Community Directed Treatment with
ivermectin (CDTi) strategy (Gustavsen et al. 2018). It was useful to overcome distrust for
Western medicines among local people in onchocerciasis-endemic communities. At the
beginning, the Program was implemented through a mobile-team model which was composed of
health workers from the Onchocerciasis Control Programme of the WHO, national governments,
and NGOs. The team visited the communities to educate local peoples on the disease and the
medicine, but some community members remained skeptical and refused to take ivermectin. In
order to overcome the distrust, the Program shifted to the community-based approach in which
organization members worked with local ministries to train health volunteers who then
distributed the drug in their communities (Collins 2004; Nyiama 1988). Under this model, the
distribution of ivermectin became integrated into the traditional patterns of community life and it
also gave a sense of local ownership. After this shift from a mobile-team model to the CDTi, the
Program became more successful in the project implementation (Collins 2004).
The Program also developed a simple dose pole marked by height and the corresponding
number of tablets, and this dose pole is still used today for mass drug administration for NTD
medicines. A number of tablets to be taken by each individual was usually determined based on
his/her weight, but a scale to measure weights did not work well on uneven and dusty surface.
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This height-based dose pole solved this problem and made it easier to distribute the medicine in
the local setting (Lawrence et al. 2015). Packaging of the medicine was also improved based on
NGOs’ local experience. The drug was previously packaged in foil strip of six tablets each and it
was cumbersome to open them to distribute to hundreds of people in a community. NGOs bought
up the problem to Merck and the company reformulated the drug into a bottle of 500 tablets, so
that the actual process of distribution would be much easier. These improvements could not be
made without the insights of NGOs operating in local fields of implementation, and it was
probably impossible for the program to succeed without a commitment by NGOs (Lawrence et
al. 2015).
Through a series of learning and improvements, the Mectizan Donation Program came to be
widely considered successful. In 2013, Colombia became the first country to eliminate
onchocerciasis, followed by Ecuador, Mexico, and Guatemala (Merck 2019). Merck proudly
mentions that the Mectiazn Donation Program “reaches more than 300 million people in the
affected areas annually, with more than 3.4 billion treatments donated in 29 countries in Africa,
six countries in Latin America, and in Yemen since 1987” (Merck 2019). The success of mass
drug administration with ivermectin led to the idea that drugs for other neglected tropical
diseases could be distributed using the same strategy (Lawrence et al. 2015), and numerous drug-
donation programs were established by other pharmaceutical companies. Many of the companies
have donated one or more NTD drugs through WHO, with help of NGOs in local operations
(Lawrence et al. 2015).
The Mectizan Donation Program itself has expanded over time, and the process of expansion
indicates that pharmaceutical companies can cooperate with one another in actual operations of
the programs. This image that “companies cooperating for the sake of public health” probably
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helped even boost up the reputation of the industry as a whole. In 1998, Merck began partnership
with another pharmaceutical giant, GlaxoSmithKline, to expand the scope of the Mectizan
Donation Program to include the elimination of lymphatic filariasis (also known as elephantiasis)
(Merck 2019). Following the decision made by GlaxoSmithKline to donate unlimited supplies of
albendazole to eliminate elephantiasis globally, Merck decided to donate ivermectin to fight
against this disease as well. Studies indicate that 5-7 years of treatment using ivermectin and
albendazole could break the cycle of disease transmission within communities and thereby
eliminate the diseases. This required increased coordination between two donation programs, so
the Mectizan Expert Committee was expanded to the “Mectizan Expert Committee/Albendazole
Coordination” to ensure proper coordination with GlaxoSmithKline. This example shows that,
by launching drug donation programs, pharmaceutical companies might be competing with each
other for good reputation. But, at the same time, the companies also showed that they can
cooperate under a single goal of achieving the elimination of NTDs.
Even though Merck initially did not prefer donations of ivermectin, with hindsight, it seems
that the company made a right decision. With the success of the drug donation programs, the
pharmaceutical industry won the reputation as trustworthy and indispensable partners in the
governance of NTDs. In this issue area, unlike others such as non-communicable diseases and
nutrition, there is a general sense of trust among NGOs towards the industry. Friendly
relationship is reflected on a robust financial tie between the industry and NGOs. For instance, in
April 2017, Merck announced a US$300,000 grant to support NGOs working with local
communities to help make progress towards onchocerciasis and elephantiasis elimination.
Moreover, pharmaceutical companies secure a seat in governing body of many NTD-related
initiatives. For instance, in 2015, Merck provided $250,000 to a new PPP called Expanded
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Special Project for Elimination of Neglected Tropical Diseases (ESPEN), and a company
representative sits on the ESPEN Steering Committee as a private sector delegate to provide
guidance on efforts to eliminate NTDs in Africa (Gustavsen et al. 2018). This indicates a big and
accepted presence of the pharmaceutical industry in the governance of NTDs beyond the drug
donation programs.
This brief review of the development of drug donation PPPs reveals that the pharmaceutical
industry has entrenched its status as important partners in the governance of NTDs. However, I
need to clarify that my argument is not that this strong position of the pharmaceutical industry in
global NTD governance was all planned by the industry. As Merck’s initial reluctance for
ivermectin donation indicates, probably the industry has gained this reputation by chance. Yet, at
the end of the day, what matters here is that the industry built such a good image and standpoint
in the governance structure of NTDs. The friendly relationship between the industry and other
types of actors (NGOs in particular) is reflected in the recent movements to turn NTDs into one
of the priority issues in global health. Pharmaceutical companies were invited to the key events
throughout the course, and during this process, pharmaceutical companies even strongly
established their position not only as donors of existing drugs but as partners in product
development partnerships.

Recent Evolution of NTDs as a Global Health Issue
Despite the availability of cost-effective interventions, NTDs did not attract much attention when
the world made the development priorities at around the turn of the millennium. The UN
Millennium Development Goal 6 stated to “[C]ombat HIV, malaria, and other diseases” (UN
2000b, emphasis added) – here, NTDs were clearly overshadowed by more high-profile
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infectious diseases. Many advocates of NTDs show grievances against the treatment of NTDs as
“other diseases,” and one of the leading advocates in the field, David Molyneux, argued in 2014
that NTDs should become more than just “other diseases” in the post-2015 agenda (Molyneux
2014).
Probably driven by this frustration, the advocacy to push up NTDs in global health agenda
accelerated during the 2000s, and global commitments for NTDs has dramatically expanded in
the process leading up to the creation of SDGs. Two workshops were co-hosted by the WHO and
German development agency GTZ in Berlin in 2003 and 2005, and the first of these two
International Workshops on Intensified Control of Neglected Diseases coined the term
“neglected tropical diseases” to unify the various diseases under a single category. WHO created
the department dedicated to NTDs in 2005, and a couple of years later in 2007, it finalized the
first Global Plan to Combat Neglected Tropical Diseases which outlines several goals and
targets to reach by 2015 for global control, elimination, and eradication of NTDs (WHO 2007a).
In the same year, a scientific journal PLOS Neglected Tropical Diseases published its first issue
dedicated to NTDs. By this time, the area of NTDs came to face the fragmentation of numerous
different NTD programs. The fragmented structure of NTD governance is at least partly because
the major focus of the NTD advocates has been less on coordination than on advocacy to
establish NTDs as a global health priority and to attract more financial resources (Liese et al.
2010). Under this situation, WHO tried to play a role of coordinator. In order to harmonize
activities of the multiple partners globally, WHO called a first Global Partners’ Meeting on
NTDs in 2007. Pharmaceutical companies such as Merck, GlaxoSmithKline, and Johnson &
Johnson were all invited to this meeting as “partners” (WHO 2007b).
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Echoing the development of international efforts, the USAID launched its first project
focusing on NTDs in 2006, and the UK also committed funding to the control of NTDs in 2007.
These two governmental donors have loomed their presence in global NTD governance since
then. In 2013, the US and the UK provided 50% of international NTD support (Molyneux 2014).
The recent development of the US NTD Program is remarkable. Prior to the first US program
launched in 2006, most of the donors and implementing partners focused on a single NTD. The
US program attempted to change the situation to improve efficacy of NTD control, integrating
treatment for several NTDs. Congressional appropriations for NTDs have grown from $15
million in 2006 to $100 million in 2014, and the House Malaria Caucus expanded its purview to
include NTDs in October 2009, followed by the Senate Malaria Caucus in September 2012
(Salaam-Blyther 2014:1).
This momentum continued in the following decade. In 2010, WHO published its first Report
on NTDs, which further advanced the efforts to provide an integrated framework to control
NTDs (WHO 2010). Lancet, one of the most influential medical journals in the world, published
a special issue on NTDs on the same year. Two outstanding events took place in 2012. The first
is the launch of the first WHO Roadmap for NTDs, Accelerating Work to Overcome the Global
Impact of Neglected Tropical Diseases, which presents the “next step forward in relieving and, in
many cases, finally ending the vast misery caused by these ancient diseases of poverty” (WHO
2012). Inspired by the Roadmap, the Bill and Melinda Gates Foundation hosted a meeting where
various key stakeholders, including donor governments like the US and the UK, WHO, the
World Bank, and 13 pharmaceutical companies, endorsed the London Declaration on NTDs with
an aim to control or eliminate at least 10 NTDs by 2020 (MacKey et al. 2014). The UK DFID, in
collaboration with the Bill and Melinda Gates Foundation, UAE, and Children’s Investment
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Fund Foundation announced a five-fold increase in funding for Guinea Worm Eradication
(Molyneux 2012). The pharmaceutical companies pledged billions of drug donations.
27
This
made the largest coordinated action to address NTDs to date. The London Declaration led to the
creation of the Uniting to Combat NTDs, a partnership institution which is in charge of
monitoring the progress pledged by the Declaration. The Uniting to Combat later received a new
world record by the Guinness Book of World Records in 2017, for the most medicines donated
in a 24 hour-period (Gustavsen et al. 2018).
After the series of events, reports, and pledges, the wish to include NTDs in the global
development agenda was achieved. In the Sustainable Development Goals (SDGs), target 3-3
clearly mentions: “By 2030, end the epidemics of AIDS, tuberculosis, malaria and neglected
tropical diseases and combat hepatitis, water-borne diseases and other communicable diseases”
(UN 2015, emphasis added). The global efforts are still expanding, with G7 recognizing NTDs
as a major challenge in 2015 (Molyneux 2017 Lancet), and the NTD Summit was held in 2017 to
reaffirm the commitments made by the London Declaration.
The summaries of recent evolution of NTDs as a global health priority reveals that it was only
recently that NTDs established its “brand” (Molyneux 2012) as a justifiable cause for investment
at the global level and in a broader development community. The important feature of this recent
development is that the pharmaceutical industry was already sitting at the table in these events as
an important “partner,” and it was not even discussed whether international NTD community
should work with the business sector or not – pharmaceutical companies are the major
component of international NTD community by this time. It was in this context that the

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A full list of commitments is available here:
https://www.who.int/neglected_diseases/NTD_London_Event_Table_Commitments.pdf (accessed
November 4, 2020)
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pharmaceutical industry started engaging with another type of PPP: so-called product
development partnerships. This type of PPPs usually requires a deeper level of collaboration
among participants than the case of drug donation programs, since it engages with the core
activity of the industry: research and development is the core element of the R&D based
pharmaceutical companies, which makes them distinctive from generic pharmaceutical
companies. Next section argues that such a deeper level of engagement between the industry and
other types of actors was enabled by two factors: strong focus of NGOs on the provision of (and
access to) NTD treatments as a priority intervention in the control of NTDs, and economic
calculation of the pharmaceutical industry indicating that the partnership might benefit the
industry and would not harm their bottom line in any case.

5-3. Engaging at the Even Deeper Level through Product Development Partnerships

Even though mass drug administration has been emphasized as the major intervention in the
control of NTDs, it is important to recognize that this method alone cannot eliminate all NTDs.
Of the 20 diseases categorized as NTDs, only 8 can be treated with mass drug administration
(Salaam-Blyther 2014). Because 7 most common NTDs could be controlled by this intervention,
it might make sense for many donor organizations to prioritize mass drug administration in order
to make as much impact as possible in a limited timeframe. However, there was a growing
concern about the lack of research and development of drugs, diagnostics, and vaccines for
NTDs (Payne and Fitchett 2010; Molyneux et al. 2018). Some NTDs have no effective
treatment, and an excessive focus on mass drug administration posed challenges for the
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management of diseases such as trypanosomiases, Buruli ulcer, leprosy and the leishmaniases
which require intensive disease management (Molyneux et al. 2018; Salaam-Blyther 2014).
Dengue has become more prevalent over time and thus is posing a need for better control:
Compared to 1970 when the disease was found only in 9 countries, Dengue is recently endemic
in more than 100 countries. Moreover, even diseases that could be addressed by mass drug
administration have shown the necessity of new medicines. There is an emerging evidence that
one of soil-transmitted helminthiases (hookworm) is developing resistance to existing
medication, and importantly, soil-transmitted helminthiases comprise almost 80% of all NTD
cases (Salaam-Blyther 2014).
The development of new treatments and vaccines for NTDs cannot be incentivized through
the usual system of the protection of intellectual property rights (IPR). Under the WTO’s TRIPS
Agreement, the IPR system grants monopoly to pharmaceutical companies for a maximum of 20
years, and this is how pharmaceutical companies recoup the costs of R&D investments: the
monopoly allows companies to set a market price well above the marginal cost of production.
However, a vast majority (if not all) of the populations affected by NTDs lives in low- and
middle-income countries, where people have very low purchasing power and health insurance
systems are also limited. Because of this risk of uncertain return on investment, pharmaceutical
companies are reluctant to invest in R&D for diseases that predominantly affect low and middle-
income countries. We saw this kind of reluctance in the case of the Mectizan Donation Program:
Merck considered abandoning the development of ivermectin for human use, because the
affected population could not afford a targeted price of $3 for ivermectin. In addition, there are a
number of obstacles of the delivery of medicines in LMICs, including poor local infrastructure,
lack of political commitment and bad governance, weak legal frameworks, and there can be no
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guarantee that a developed product will reach the population in need without any problem. This
also discourages pharmaceutical companies from investing in R&D for NTDs (Aerts et al. 2017).
The lack of incentives is reflected in the following numbers. A seminal paper published in
2001 showed that only 1.1% of new drugs approved between 1974 and 1999 were treatments for
NTDs, even though these diseases represented 12% of the global disease burden (Trouiller et al.
2001; DNDi 2014). Trouiller et al. (2002) also found that less than $100 million was invested in
the development of NTD medicines in 1999. In its advocacy publication, Médecins Sans
Frontières (MSF) coined the term “fatal imbalance” to emphasize this gap between the high
disease burden and the low investment in R&D in the issue area of NTDs (MSF 2001a). Indeed,
most of the drugs used to treat NTDs were the products of colonial era, and these medicines were
often not perfectly effective and difficult to administer in resource-limited settings. Several of the
medicines were becoming ineffective because of increasing parasite resistance (Pécoul 2004;
Croft 2005).
In order to deal with this situation, several mechanisms were proposed. These proposals are
usually classified into so-called push and pull schemes. Push mechanisms attempt to reduce
upfront costs inherent to R&D activities by giving grants and subsidies before a product is
discovered. Research grants from governments and philanthropic foundations are an example of
push mechanism (Aerts et al. 2017). Pull schemes, on the other hand, purpose to encourage R&D
investments by offering rewards for successful discovery of a product. For instance, priority
review voucher (PRV) can work as a pull mechanism by offering a successful developer a
priority to be reviewed for the product. Another example of pull mechanism is an advance
market commitment (AMC), where a donor makes a legally binding commitment to purchase a
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certain amount of a vaccine or drug if the product is successfully developed (McGoey 2014).
Push and pull schemes do not need to be zero-sum and they can be combined as mixed schemes.
Motivated by the lack of safe and effective treatments and the ideas of push and pull
mechanisms to provide R&D incentives that could possibly be alternative to the traditional IPR
system, many product-development PPPs have been created since early 2000s. The Foundation
for Innovative New Diagnostics (FIND) was launched in May 2003 at the World Health
Assembly in Geneva, aiming to develop new diagnostic tests for neglected diseases. FIND is
funded by various bilateral, multilateral, and private donors including the WHO, the UK’s DFID,
and the Gates Foundation (WHO n.d.f). In 2005, the Integrated Vector Control Consortium
(IVCC) was launched with a grant from the Gates Foundation to the Liverpool School of
Tropical Medicine, involving several governmental and business partners such as the USAID,
Australian Aid, the Swiss Agency for Development and Cooperation, Bayer, and Sumitomo
Chemical (IVCC n.d.). Another partnership, the Anti-Wolbachia Consortium (A WOL), was
created in 2009 as a global consortium of academic and industrial partners when the Gates
Foundation awarded a $23 million grant to the Liverpool School of Tropical Medicine (Science
Business 2009). The aim of this consortium is to develop new drugs against onchocerciasis (river
blindness) and lymphatic filariasis (elephantiasis), as evidence is emerging that the vector of
onchocerciasis is developing resistance to ivermectin.
As these examples indicate, product-development PPPs have so far mainly employed push
schemes, with governmental or philanthropic organizations providing upfront financing for
research and development (Aerts et al. 2017). Caffrey and Steverding (2008) mention that PPPs
usually receive “capital from the public sector and/or philanthropic organizations and these funds
are then distributed on a competitive basis to collaborative academic and industrial institutions
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where the actual research is performed.” In 2011, half of the 34 new formulations for NTDs in
clinical development were sponsored by PPPs, charities, or philanthropic institutions (Aerts et al.
2017). Some prefers pull mechanisms to push schemes because the former is contingent on a
successful discovery of product and thus no money would be wasted for unsuccessful efforts to
find a treatment or vaccine. With this caveat in mind, the development of product-development
PPPs has helped put more money on the table: Since large donors such as the Bill and Melinda
Gates Foundation started investing a large amount of money through PPPs, the pharmaceutical
industry has also been motivated to allocate more resources for NTD R&D. By 2016, a total of
$3 billion came to be spent annually on R&D for NTDs (Cohen et al. 2016). Although this is still
a relatively small amount compared to R&D for other (more profitable) disease areas, increased
funding has resulted in new products to treat NTDs. In 2005, Moran found that three-quarters of
all identified R&D (47 projects) was conducted by drug development PPPs, often working with
large and small pharmaceutical companies (Moran 2005). Between 2000 and 2013, 43 new
products were approved for NTDs (Cohen et al. 2016 p.1194).
In tandem with the development of product-development PPPs in this issue area, the term
“neglected tropical diseases” itself has built the status as one of the important global health
issues, and an increasing number of public and private actors has engaged in the governance of
NTDs. How did this new type of PPPs come to be created? A closer look at one of such PPPs
would illustrate the role of NGOs and motivations of the business sector in building product-
development PPPs. The following subsection will look at the case of the Drugs for Neglected
Disease initiative (DNDi).

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Drugs for Neglected Diseases initiative (DNDi)
The Drugs for Neglected Diseases initiative (DNDi) was established in July 2003 by seven
organizations with an aim to address the lack of R&D for NTD treatment. The founding
members include Médecins sans Frontières (MSF), the Special Programme for Research and
Training in Tropical Diseases (TDR, created by the WHO, UNDP, and the World Bank),
France’s Pasteur Institute, and four public sector institutions based in Global South – the
Oswaldo Cruz Foundation from Brazil, the Indian Council for Medical Research, the Kenya
Medical Research Institute, and the Ministry of Health of Malaysia. Strictly speaking, DNDi
does not fit in my definition of PPPs because it does not have a business-sector actor directly
composing a “partner” of this institution. However, DNDi does work quite closely with for-profit
pharmaceutical companies, both large multinational companies and smaller scale firms (indeed,
the initiative calls these companies “partners”), and considering its relatively early establishment
and the prominence in the field, the case of DNDi offers an illustrative story to understand the
role of NGOs in the development of this type of partnerships.
To put it bluntly, DNDi is widely considered as a brainchild of MSF – a very influential NGO
in the field of global health – because this initiative was created following the strong advocacy
by MSF, and the NGO is one of the founding members. Apparently, civil society thought that the
promotion of R&D for NTDs, and ultimately a better provision of effective medicines, is the
priority and necessary intervention to address the issue of NTDs. As we saw above, the major
and priority intervention for the control of NTDs has been mass drug administration with
existing medicines. Since late 1990s, R&D for more effective and safer medicines is added to the
list of priority intervention. A crucial point here is that both mass drug administration and R&D
for NTD medicines can neatly fit under my intervention category of “greater provision of certain
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products.” At this moment, NGOs were not pursuing regulatory measures to restrict industrial
activities, and many civil society actors were rather eager to attract attentions from the
pharmaceutical industry in order to achieve their goal of a better provision of NTD treatments.
In 1999, recognizing the lack of effective drugs to address the diseases of neglected
populations of the world, MSF brought together a team of international experts – Drugs for
Neglected Disease working group – to study this issue. The working group analyzed the causes
of the crisis and recommended the creation of a new initiative that can pursue innovative
strategies to ensure the development of new and affordable medicines for NTDs, particularly the
most neglected diseases such as leishmaniases, Chagas’ disease and human African
trypanosomiasis (DNDi n.d.a). The result was the creation of DNDi as a partner institution
between MSF, TDR, and five publicly-funded research organizations (DNDi 2014; Caffrey and
Steverding 2008).
DNDi provides a new model of product development for disease areas where a conventional
IPR system cannot give incentives. Several features characterize such DNDi model, including “a
concretely patient-centred, needs-driven approach; a commitment to both equitable access to
treatment for patients and open access to knowledge; financial and scientific independence; and
the leveraging of existing knowledge and expertise by building solid alliances with public and
private partners” (DNDi 2014:3). These are all novel features that characterize the DNDi model,
but two “partnering” features are especially indispensable for the operation and success of this
initiative.
First is the strong involvement of partners based in disease endemic countries (DNDi 2014:5).
Having core partners coming from the affected regions helps the initiative define priorities and
facilitate implementation of new tools. It also gives legitimacy for this initiative as something
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representing the actual needs of the affected people. Hence, it was an intentional decision to
include organizations from four endemic countries – Brazil, India, Kenya and Malaysia – as
founding partners. This seems to be a wider trend in drug-development PPPs in the area of
NTDs: nearly one-quarter of PPP projects involve developing country pharmaceutical firms as
the manufacturing or development partner (Moran 2005).
Another, more important feature in the context of this dissertation, is the close alliances with
pharmaceutical and biotechnology companies through innovative IPR licensing. Because DNDi
does not have its own laboratories or manufacturing facilities, it cannot function without the
engagement of partners who have actual R&D capacities. In order to identify potential new
compounds and ultimately develop medicines for NTDs, it is unavoidable to work with
pharmaceutical companies that have compound libraries (DNDi 2014; Chatelain and Ioset 2011).
The director of DNDi since its creation, Dr Bernard Pécoul, explicitly points out the significance
of working with the pharmaceutical industry: “Pharmaceutical companies have a particularly
important role to play: they possess vast repositories of molecules, the means to move from
development to industrial production, and highly specialised teams of researchers. Their
contribution will be crucial to the success of DNDi” (Pécoul 2004).
Indeed, many of the medicines came out from the DNDi projects were developed through
collaboration with the pharmaceutical industry. For instance, the first product DNDi registered in
2007 is the antimalarial artesunate-amodiaquine fixed-dose combination (ASAQ) that was
developed through a partnership with a French pharmaceutical company Sanofi Aventis (now
Sanofi). The development of this medicine started in 2002, first as a collaboration involving a
number of universities, MSF and TDR. Later in 2005, a collaboration agreement was signed
between DNDi and Sanofi Aventis, which put the company in charge of industrial development
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and implementation of this first once-a-day ACT against uncomplicated malaria for adolescents
and children (DNDi 2014; Caffrey and Steverding 2008). Sanofi Aventis agreed to make this
product non-exclusive, meaning that this medicine would not be patented, and the company also
agreed to sell the product at cost (less than $1 for adults and $0.5 for children in the public
sector) (DNDi 2014).
DNDi so far has developed 8 treatments, and 7 among them were developed from existing
molecules and recombining drugs to bring better treatments to patients (DNDi n.d.b). For a
longer term, the initiative aims to bring more innovative changes by developing treatments from
new chemical entities, and for this sake, DNDi has been expanding the compound-mining
activities through collaborations with various partners, particularly with pharmaceutical
companies (DNDi 2014). For instance, DNDi works with Sanofi to re-assess a collection of 300
marketed drugs and clinical candidates. GlaxoSmithKline is another partner who allows DNDi to
access to its collections of marketed drug sets. The initiative also collaborates with a Japanese
pharmaceutical company, Eisai, to develop a treatment for Chagas’ disease. In 2009, the two
parties signed a collaboration agreement. Under this partnership agreement, DNDi is responsible
for the clinical development of the potential medicine within endemic countries, and Eisai
supplies the drug at no cost (DNDi 2014: 15).
These examples of product development suggest that there are overlapping interests between
civil society and the pharmaceutical industry, providing a win-win situation for these two
different types of stakeholders. From the perspective of the industry, the cost to engage in this
kind of partnerships are relatively low because the pharmaceutical companies already have
molecule repositories and no additional action is required. Granting DNDi an access to the
repositories does not pose additional costs to the companies. Many molecule compounds are just
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sitting in shelves unless other entities – like DNDi – are willingly make efforts to screen them. If
a partner (in this case, DNDi) found a medical use of their compound, it would be beneficial for
the companies. The compound might be successfully developed as a treatment, and even if the
company cannot make any profit out of NTD medicine, it would still help improve their
publicity. If they are lucky, the medicine may find a market in more developed parts of the
world. Even if the partner (DNDi) does not find any medical use of their compound, it does not
harm the business either. Thus, in terms of economic calculations, engaging with product-
development PPPs in the area of NTDs does not really cost anything for the business, and
pharmaceutical companies have no reason to oppose such cooperation.
In her review of product-development PPPs, Moran (2005) found that multinational drug
companies were conducting half of new NTD drug development (32 project) and in all cases,
these companies agreed to provide the final products to poor patients in developing countries at
not-for-profit prices. Most of these projects were carried out by four companies that have formal
neglected-disease division: GlaxoSmithKline, Novartis, AstraZeneca, and Sanofi Aventis. Moran
raised three factors that possibly motivated these companies to join the product-development
partnerships: minimizing the risk to their reputation by wiping off the image that these
companies have failed to address developing country needs; corporate social responsibility; and
long-term strategies to position themselves in emerging markets or to build access to low-cost
developing country researchers (Moran 2005). This analysis suggests that pharmaceutical
companies can benefit in a long run, even if they cannot profit right away from the NTD
medicines per se.
A clear commitment by the Bill and Melinda Gates Foundation in R&D for NTDs probably
worked as an additional push factor for the companies. The Gates Foundation has been the
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principal funder of product-development PPPs, providing about 50% of annual income of this
type of PPPs (Payne and Fitchett 2010). For the investors (or donors) like Bill Gates, the
possibility of “eradication” gives a great appeal for the issue area of NTDs. “Eradication” is a
magical term which motivates donors, because these actors need to justify their commitments by
advertising how much impact their efforts have made. In comparison to other measurable
outcomes, such as a number of vaccines distributed and a percentage of reduction in disease
prevalence, eradicating a certain disease gives a strong impression and gives a sense of achieving
ultimate goal. Indeed, many of my interviewees pointed out that one possible reason why the
Gates Foundation strongly commits to the control of NTDs is because eradication of these
diseases is withing the reach of a current state of science. If a giant organization like the Gates
Foundation is committed to the task of R&D for NTDs, it probably encourages other
organizations – including pharmaceutical companies – piggybacking the eye-catching efforts to
earn great publicity, especially if there are not much financial costs incurred.
For civil society actors such as MSF and also DNDi (if we consider this initiative as an
example of partnerships between NGOs and global south), concessions made by the industry
show that civil society does not compromise the ideal of equitable access even when they
“partner” with the industry. As already mentioned, “a commitment to both equitable access to
treatment for patients and open access to knowledge” is one of the characteristics that makes
product-development PPPs such as DNDi unique. DNDi states that it “adopted an intellectual
property (IP) policy based on two critical guiding principles: the need to ensure that drugs are
affordable and accessible in an equitable manner to patients who need them; and the desire to
develop drugs as public goods wherever and whenever possible. These principles have been the
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basis of contract negotiations undertaken by DNDi from the outset, particularly with a view to
obtaining the best possible conditions to facilitate access to treatments” (DNDi 2014).
In reality, it seems that the IP policy of DNDi is rather flexible compared to a very firm stance
retained by civil society organizations such as MSF. Don and Chatelain (2009) mention that
negotiation of terms of access to intellectual property with pharmaceutical companies is done on
a case-by-case basis, and even though it is DNDi’s policy to disseminate intellectual property
associated with neglected diseases research as widely as possible, “DNDi remains pragmatic
while negotiating and respects more stringent restrictions in return to access to new compounds
which may lead to new therapies for treatment of neglected diseases, keeping in mind patient’s
interests” (Don and Chatelain 2009: 41). This softer attitude might make it easier for
pharmaceutical companies to consider working with the initiative.
In any case, what matters here is that DNDi is quite satisfied with the fact that pharmaceutical
companies are not aggressive in protecting IPR in the area of NTDs. In an interview, the director
of DNDi mentioned that “[T]he fact we have signed a partnership with a large company like
Sanofi Aventis, for instance, and that they accepted nonexclusivity, is a breakthrough, and
should, I believe, be used for all products for neglected diseases. This experience will help us a
great deal in negotiating new contracts with other companies, as we can use our experiences with
Sanofi Aventis as a model for future discussions” (Pécoul 2009). The director, Dr Pécoul, has a
long career in civil society organization. He worked at the Access to Essential Medicines
Campaign of MSF, and prior to that, he was Executive Director of MSF-France. He also worked
as a MSF field physician across Africa, Latin America and Asia. Therefore, the sentiment
expressed by Dr Pécoul, I would imagine, is closer to many NGOs in the field of NTDs, and this
indicates that NGOs have no problem with working with the pharmaceutical industry as long as
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they can achieve their goal of improving the provision of (and access to) effective medicines for
NTD.
More recently, there was actually a movement to create a legally binding convention on R&D
under the auspices of WHO. The aim was to make R&D investments for neglected diseases
mandatory for member states depending on their ability to pay (Moon et al. 2012; Dentico and
Ford 2005). However, the idea was not promoted as an alternative for product-development
PPPs, and the discussion faded away once a large PPP called the Coalition for Epidemic
Preparedness Innovations (CEPI) was created after the outbreak of the Ebola disease in 2014.
The movement towards the creation of such a R&D convention probably gave incentives for
pharmaceutical companies to accelerate their “voluntary” efforts to develop NTD medicines. For
instance, the Global Health Innovative Technology Fund (GHIT) is a product-development PPP
more recently established in 2013 by Japanese government and Japanese pharmaceutical
companies, with collaboration with UNDP and the Gates Foundation. Many Japanese
pharmaceutical companies swiftly decided to engage with this PPPs when the idea of this
partnership came up. More detailed assessment is warranted, but one feasible explanation for this
commitment is that the companies (and also many donor countries) did not want to see a
stringent measure like R&D convention in the issue area of NTDs.

5-4. How Could It Be Possible? Overlapping Preferences of the Stakeholders

This chapter reviewed the development of two different types of PPPs in the area of NTDs. As
one estimate indicates, the issue area of NTDs has experienced a proliferation of partnerships
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involving numerous actors: There are over 2609 projects in 113 countries involving 73 different
partners in the field of NTDs (Molyneux 2018). There are many different ways of counting
partnerships and partners, but regardless of how we measure, what is outstanding in this issue
area is the friendly relationship between the pharmaceutical industry and other types of actors
including NGOs. How could it be possible?

One of the key factors that facilitated the favorable environment for PPPs is the early entrance of
large pharmaceutical companies in the control of the major NTDs, such as onchocerciasis. When
there was no effective intervention to control NTDs, a pharmaceutical company found an
effective medicine to break the transmission cycle of onchocerciasis – one of the major diseases
now categorized as neglected tropical diseases. Merck decided to donate the medicine because
several factors, including the good business performance at that time and the concern for public
image allowed the company to make such a decision. NGOs were not in a position to oppose this
proposal – if there was no other way to effectively control the disease, why would they refuse to
work with the company to deliver a life-changing medicine?
Even before ivermectin was invented, there were some NGOs working in the area of NTDs.
However, it was actually the donation of Mectizan that truly triggered NGO activities in this
field. One of the most well-known activists in the field of NTDs, Simon Bush, states that “[T]he
current role of NGDOs [nongovernmental development organizations] in NTD control has
undoubtedly been built on the experience with onchocerciasis control beginning in the early
1990s, which was stimulated by the donation of Mectizan. From then on NGDOs began to work
with governments and the affected communities to distribute Mectizan” (Bush and Hopkins
2011). Many authors have pointed out that the major role of NGOs has been the implementation
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of drug distribution projects (Elhassan et al 2018; Rotondo et al. 2016; Molyneux 2012,
Molyneux et al. 2018). And, given their role as implementors of the projects, NGOs have been
supportive of the industry’s decisions to build drug donation partnerships – without the donations
of drugs, there was not task for these NGOs to implement. In fact, the coordination of NGO
activities has developed surrounding the theme of drug distribution. At the meeting held by
WHO in 1991, seven NGOs got together to discuss collaboration among them, and this led to the
setup of the NGDO coordination group for Onchocerciasis control in 1992 to “help promote
worldwide interest and support for the use of Mectizan against onchocerciasis in endemic
countries” (Bush and Hopkins 2011). This clearly indicates that NGOs were not opposing, but
rather promoting the partnerships with the pharmaceutical industry for the sake of greater
provision of effective medicines. More recently in 2007 and 2008, NGOs got together to further
facilitate the coordination in the drug distribution in endemic countries, and in September 2009,
these NGOs agreed to form the NTD NGDO Network (NNN).
The history of drug-donation PPPs thus reveals that the early move made by the industry, the
lack of other available and effective interventions, and the NGOs’ focus on project
implementation rather than advocacy all worked in favor of the creation of the partnerships
between pharmaceutical companies and other types of actors, including NGOs and
intergovernmental organizations such as WHO. The success of these drug-donation PPPs and
good experience of working with the industry have nurtured a sense of trust among international
NTD community. This later enabled the creation of product-development PPPs. By this time, the
pharmaceutical industry has learned not to aggressively pursue profits from the NTD medicines
per se. Working as a partner in this issue area is not very costly for the companies, and it brings
great reputation and long-term benefits to them. On the other hand, NGOs started advocating for
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increased R&D for more effective NTD treatments, and they are aware of the fact that this goal
cannot be achieved without the participation from large pharmaceutical companies that have
molecule repositories. Each of these stakeholders know where to compromise, and they found
out that they can actually pursue their goals through product-development partnerships, without
making too much concession. NGOs can pursue their preferred intervention (a greater provision
of treatments by developing better medicines), and the pharmaceutical industry can improve their
publicity and possibly benefit financially as well, in case the process of drug development finds
out a use of the medicine in developed country-markets. This is where the preferences of two
stakeholders came to overlap.
Reflecting this amicable relationship between two types of stakeholders, WHO – the key
intergovernmental organization operating in this field – openly welcome the industry as crucial
partners, and no one argues against it. For instance, WHO recently hosted the multi-stakeholder
consultation in order to develop a new Roadmap on NTDs, and the outcome document includes
paragraphs stating that “[T]he [WHO] Secretariat will continue to engage with the
pharmaceutical industry to secure donated medicines and products, and to advocate for increased
commitments from partners, donors and academic institutions” (WHO 2020a, paragraph 17).
This clear commitment of the WHO to PPPs is rather exceptional, considering that there is
increasing concerns among WHO and broader international health communities regarding
conflicts of interest in partnering with private-sector actors. Because of the COVID-19
pandemic, the new Roadmap was not launched at the World Health Assembly in 2020 as it was
originally planned. But it is almost certain that the Roadmap will be official launched at the end
of this year (2020), and it is very likely that the open and clear support for PPPs with the
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pharmaceutical industry will continue in the foreseeable future in this issue area of NTDs (WHO
2020b).
Before concluding the chapter, it is worth noting that the proliferation of PPPs does not
immediately or necessarily mean the success of the global NTD governance. There are some
concerns regarding the way these PPPs operate. In their recent review of the PPPs literature,
Aerts et al. (2017) raise some problems with product-development PPPs, including their lack of
transparency, accountability, clear government structure, and alignment with country priorities
and systems; their tendency to alter existing medicines rather than creating new ones; and the
lack of coordination between sectors and partners resulting in duplicated efforts. The lack of
transparency and evaluation is particularly a serious problem. Most of the studies regarding
product-development PPPs are descriptive, and the review found only one study empirically
assessing the effectiveness of PPPs. This empirical study revealed that the product-development
PPP is not the most cost-effective approach if it employs a push mechanism through R&D grants
(Aerts et al. 2017).
Another concern is that the control of NTDs has become overly “biomedical” because of the
proliferation of drug-donation PPPs and more recently through the development of product-
development PPPs. For instance, there is a debate among scholars whether excessive focus on
mass drug administration has led to the underestimation of hygiene improvement and other
“public health” measures to address neglected tropical diseases. In the PLOS Medicine debate
paper (Spiegel et al. 2010), Hotez, Hansen and Bundy support the cost-effectiveness of mass
drug administration and PPP initiatives based on drug donation, while Singer criticizes that the
NTD initiatives have been “over-medicalized” during the past decade. Singer emphasizes the
importance of prevention, for instance, by improving access to safe water and good sanitation.
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He argues that such preventive measures can tackle multiple NTDs simultaneously compared to
medical approach that tends to focus on specific diseases. Still other scholars emphasize the
importance of social determinants of NTDs. Spiegel, Dharamsi, Wasan, and Yassi mention that
the excessive focus on developing new drugs has diverted attention and funding away from other
manifestations of neglect, such as the weak health systems and poor socio-environmental
conditions that cause and perpetuate NTDs. These authors therefore suggest using a proportion
of R&D funding to address underlying weakness of health system (Spiegel et al. 2010).
As already mentioned, mass drug administration alone cannot eliminate NTDs. Despite the
limitation of this intervention, the US NTD Program has focused almost exclusively on mass
drug administration (Salaam-Blyther 2014). Administration officials recognize the importance of
a comprehensive approach, but a Senior Operations Advisor of the USAID NTD Program argued
that “the directive from Congress was to focus on mass drug administration. Given the limited
resources, mass drug administration is the most efficient and cost-effective way to control [and]
eliminate these diseases” (Emily Wanwright, cited in Salaam-Blyther 2014). Even though
international NTD community generally accepts mass drug administration and drug donation
from pharmaceutical companies as a right thing, a close cooperation between the pharmaceutical
industry and the USAID NTD Program might raise a concern for conflicts of interest if the
Program employs only mass drug administration to address NTDs. The pharmaceutical industry
has donated several NTD drugs to many of the countries that also receive support from the
USAID, and there is seemingly a close alignment between the operation of USAID and the
targeting of pharmaceutical donations by the companies (Kaiser Family Foundation 2019;
Gustavsen and Hanson 2009).
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Although this dissertation focuses on the creation of PPPs, it is important to clarify once again
that this does not mean this study supports the efficacy or normative values of these PPPs: PPPs
may contribute to addressing health issues; they may be rather detrimental if these partnerships
distract policy attentions and resources from a more comprehensive and effective approach to
resolve the health issues. What I demonstrated in this chapter is that there has been a
development and proliferation of two types of PPPs – drug donation PPPs and product-
development PPPs – in the issue area of NTDs, and my argument is that these PPPs are the
products of overlapping preferences of two different types of stakeholders – multinational
pharmaceutical companies and NGOs operating in the field.

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Chapter 6: HIV/AIDS:
Affecting the Calculations of Big Pharma to Gain Life-Saving Medicines

This chapter uses the case of HIV/AIDS to illustrate how the two kinds of “licenses to operate” –
economic incentive and legal threat – work to change the business sector’s preferences regarding
the creation of PPPs. The development of HIV/AIDS movements essentially describes the shift
from scenario C (diverging preferences between CSOs and the business sector) to scenario B
(overlapping preferences between these two types of actors). In the early 2000s, HIV/AIDS
became the major issue in global health and more broadly in international development agenda.
Since then, large-scale PPPs have been created to address this issue, and as of today, HIV/AIDS
is one of the most popular destinations for PPP initiatives. However, it was not the case until
AIDS activists around the world worked in a coalition and successfully convinced governmental
donors and the private sector to make an effort to address this health issue. Without such
advocacy, pharmaceutical companies manufacturing antiretroviral drugs could not see any
economic stakes in engaging with the movements towards universal access to antiretroviral
medicines. A group of multinational pharmaceutical companies even filed a lawsuit against the
government of South Africa when the country tried to make a law that allows importation of
generic drugs. The argument made by the pharmaceutical industry was quite simple, revealing
economic basis of their unwillingness to help a greater provision of AIDS medicines: the
companies had to protect their profits in order to recoup the costs of investments for these life-
saving drugs, and it was not their responsibility to assure access to medicines in developing
countries.
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This chapter shows how such a stance of the pharmaceutical industry changed over the course
of HIV/AIDS movements, and how civil society activists effectively used various strategies to
affect the business calculations so that the companies would be willing to join the international
efforts to promote access to antiretroviral medicines. The chapter proceeds as follows.
First section summarizes the background information of this issue area – how the disease
emerged as a serious threat to public health in the 1980s, how much impact this disease has made
on human health and economic development worldwide, and how the issue came to be framed
and what interventions were chosen to fight against HIV/AIDS. Second section then describes
the development of AIDS activism first in the US then in developing countries, most notably in
South Africa. This section also illustrates the clear opposition of the pharmaceutical industry to
engaging with the initiatives promoting access to their lucrative antiretroviral medicines. The
lawsuit made by the industry against the government of South Africa is a symbolic gesture
reflecting the companies’ unwillingness to work with governmental bodies to expand the
provision of treatment.
Third section analyzes what changed such uncooperative stance of the industry. Several
factors could be raised, including the strong framing of the issue through the lens of human
rights and the characteristic of the advocacy coalition which involved some prominent high-rank
figures such as WHO’s Johnathan Mann, Peter Piot, and Nelson Mandela. Yet, particular
emphasis of this section will be on how advocacy strategies affected economic calculations of
the pharmaceutical industry. I demonstrate that the strong promotion of access to treatment as a
“single defining prescription,” entrance of generic pharmaceutical industry in the market, and the
increasing commitment on this issue by industrialized countries all worked in favor of creating
partnerships between public and private actors. Fourth section reviews major findings of this
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chapter, summarizing what the case of HIV/AIDS tells about the function of “economic and
legal licenses to operate” when the business sector decides whether it wants to create PPPs or
not.

6-1: Background

Definition and Magnitude
HIV/AIDS is a disease that has spread across the globe and probably one of the most “famous”
or “popular” issues in global health. Human immunodeficiency virus (HIV) attacks immune
system of human body, specifically the white blood cells called CD4 cells. By destroying these
CD4 cells, HIV weakens a person’s immunity against infections such as tuberculosis and
cancers. Acquired immunodeficiency syndrome (AIDS) is a term that applies to the most
advanced stages of HIV infection. When the count of CD4 cell falls below 200, the person’s
immunity is severely compromised and any of so-called “opportunistic infections,” such as
tuberculosis, cryptococcal meningitis, and bacterial infections are likely to occur. HIV can be
transmitted by unprotected sex; blood transfusion of contaminated blood; sharing of needles,
syringes, other injecting equipment, surgical equipment or other sharp instruments; and from a
mother living with HIV to her infant during pregnancy, childbirth or breastfeeding. There is no
cure for the disease yet, but HIV infection can be contained and managed as a chronic health
condition with continued adherence to treatment. Without treatment, HIV can develop into AIDS
within 10 to 15 years and eventually lead to death (WHO 2017b).
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Because of the disease characteristics, HIV/AIDS has affected various aspects of international
development and security. The virus is sexually transmittable and hence young populations
usually have a high HIV prevalence rate. This leads to a low labor productivity, which ultimately
contributes to low economic growth. Children orphaned by AIDS are at a greater risk of being
malnourished, and they are first to be denied education either because of stigma or the limited
resources available at their extended families. Already in 1999, the UNICEF estimated that a
total of 13 million children would lose their mother or both parents by the end of the next year,
and the large scale of AIDS orphanage was considered a crucial contributor to the enduring
poverty in Africa (UNICEF 1999). The link between HIV and security is well recognized as
well. Civil and international conflicts help spread HIV as populations, refugees, and armies move
across territories. In regions where HIV/AIDS has reached epidemic proportions, the disease
destabilizes or destroys the basic infrastructures that offer security and protection, including
military and police forces (UNAIDS 2003).
The magnitude of HIV/AIDS is appalling: Since the beginning of the epidemic, 76 million
people have been infected and about 33 million people have died of HIV/AIDS (WHO 2019).
The number of deaths caused by HIV/AIDS is greater than the military and civilian deaths
combined in World War 1, and it is almost equivalent to the magnitude of the Black Death in
Europe back in the 14
th
century. It is estimated that approximately 38 million people are still
living with HIV/AIDS. Africa is most severely affected, with almost 68% of the people living
with HIV (25.7 million) reside in the WHO African region. South Africa has the highest number
of people living with HIV/AIDS (7.5 million), and Eswatini (formerly known as Swaziland) has
the highest HIV prevalence rate (27% among adults).

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Figure 6-1: People Living with HIV, 2019 (top) and 1990 (bottom)
Source: UNAIDS https://aidsinfo.unaids.org
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Considering these overarching effects and the striking magnitude, HIV/AIDS has come to be
recognized as one of the major global issues our world faces. The disease was singled out in the
UN Millennium Development Goals (UN 2000b), and the UN Security Council also adopted a
resolution in 2000, highlighting the potential threat the epidemic poses for international security,
particularly in conflict and peacekeeping settings (UN 2000c). According to an international poll
conducted by UNAIDS, 92.1% of the respondents answered that AIDS pandemic is a crucial task
that international communities should tackle (UNAIDS 2010). This issue area saw the creation of
giant PPPs since the early 2000s, such as the Global Fund to Fight AIDS, Tuberculosis, and
Malaria. From the humanitarian perspective, it is no surprise that the disease has gathered a great
political attention and huge financial resources. Rather, what is puzzling is that it took so long
(almost 20 years since its initial epidemic) to get to this level of international efforts. Even
though PPP was not a common governance modality before the 90s, some issue areas such as
neglected tropical diseases had already generated some noteworthy PPPs by the time that PPP
won a recognition as a popular governance modality (as we saw in Chapter 5). Why, then, the
issue area of HIV/AIDS did not produce much use of PPPs for a while? This chapter will shed
light on economic calculations of the business sector as a factor that affects the creation and non-
creation of transnational PPPs.

Frames and Interventions
Even though the AIDS epidemic started in the US (as described in the next sub-section), the
current geographical distribution of the HIV incidence suggests that there is a strong tie between
the disease and poverty. Many authors pointed out that poverty, colonial history, and neoliberal
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economic and trade policies have exacerbated the AIDS crises in Africa (Irwin, Millen and
Fallows 2003).
The history of colonization has caused social and political turmoil in the continent and has
spread malnutrition, maternal and child illnesses and infectious diseases widely in Africa. All of
these public health conditions have facilitated the spread of AIDS. Even after independence,
many African countries economically depended on former colonial powers and accumulated
huge debts to foreign capital. These countries eventually had to follow the policies imposed by
international financial institutions, most notably the “structural adjustment programs” promoted
by the IMF and the World Bank. It is well known that the structural adjustment programs are
characterized by privatization of basic services including healthcare, and the budget cuts in the
public sector directly affected the spread of HIV/AIDS because many people could not afford
healthcare from private hospitals. Ironically, the World Bank published a report which
articulated the basis of the structural adjustment program in Africa in 1981, the year HIV was
first announced in the United States. At the very time the virus was spreading across the globe,
many African countries were forced to reduce the budget for healthcare services. Peter Piot, the
first director of the UNAIDS, pointed out that 32 African countries were spending $15 billion for
debt repayment, four times more than the amount they paid for healthcare and education (Picard
2000 a; Swarns and Altman 2000; Tan 2000).
The prevalent image of this health issue is similar to that of neglected tropical diseases
(NTDs) which I assessed in Chapter 5, in a way that the issue is strongly associated with poverty.
However, while no actor was clearly identified or targeted as “enemy” in the international efforts
to control NTDs, the situation surrounding the international AIDS governance has been more
contested, with civil society activists vocally protesting against ineffective AIDS policies and
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greedy manufacturers of life-saving medicines. The issue of HIV/AIDS has been framed as a
human right issue, first in the context of prevention that people have a right to protect themselves
from forced testing and quarantine. After effective treatment – highly active antiretroviral
therapy (HAART) – was introduced in 1996, a greater access to (and provision of) the treatment
became the focus of the HIV/AIDS control, and this policy preference has also been advocated
with the human rights framing.
Civil society organizations have played a major role in this process, and although the
importance of comprehensive AIDS policy beyond the distribution of treatment is recognized,
the access to AIDS medicines has been at the center of global HIV/AIDS governance (as
discussed in 6-2). In fact, the advocacy for HIV prevention has largely failed because the
prevention was highly politicized in the religious context, especially in the US. As a result, a
large proportion of international HIV/AIDS commitments has been specifically allocated for
treatment (Kapstein and Busby 2010). For instance, the US PEPFAR, the largest bilateral donor
in the issue area, has allocated more than 50% of its budget to treatment.
In the context of my theoretical framework, this indicates that CSOs prefer a greater provision
of goods (antiretroviral medicines) rather than regulating certain industrial activities as a priority
intervention in this issue area. This leads to the proposition 1-b: CSOs would support the
creation of PPPs in an area where they are pursuing a greater provision of specific goods.
However, the case of HIV/AIDS illustrates that the CSOs preference alone cannot activate the
creation of PPPs, as the scenario C of my theoretical framework argues: PPP is less likely to be
created in an issue area where the business sector does not economically benefit through a
greater provision of the goods or the industry does not anticipate financial damages from the
lack of the provision. This would be the case even if CSOs in the issue area are pursuing a
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greater provision of the goods and advocating for the creation of PPPs. Economic calculations
of the business sector play a role here, and in the issue area of HIV/AIDS, civil society activists
indeed needed to alter the business preferences in order to accelerate the access to treatment and
the creation of PPPs. Since the disease was first recognized as a public health issue in the US,
AIDS activists have accumulated experience and moral authority in the politics of AIDS, and
they have changed preferences and behaviors of governmental entities and the pharmaceutical
industry over the course of time.

How It Started: Discovery of HIV/AIDS in the US
Although HIV/AIDS as of today is strongly associated with poverty and disproportionately
affects Africa, the disease was actually first identified as a public health concern in the US.
In June 1981, the US Centers for Disease Control and Prevention (CDC) issued a report
describing a few severe pneumonia cases observed in Los Angeles between October 1980 and
May 1981. Even though the cause of these cases were yet to be identified, this announcement
made the first official record of the disease now identified as HIV/AIDS. The patients were
young gay men, and several similar cases were found in New York as well (Grmek 1990). The
New York Times reported that a rare disease was found among gay men, and because there was
no scientific name for the disease, it was called by very stigmatized labels such as “gay cancer,”
“gay pneumonia,” and “gay plague.” As it is widely known, HIV/AIDS was considered a gay
epidemic when it first appeared in the US.
AIDS has spread rapidly since 1982, and it came to affect wider populations beyond gay
people, most notably heroin addicts, Haitian, and hemophiliacs (these groups were labeled as
“4H” high-risk groups). Still, the majority of victims were out of the mainstream of the society,
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and this epidemiological pattern at least partly caused the delay in the development of AIDS
policy in the US. The US government – from Raegan to Clinton administration – did not take
adequate measures against HIV/AIDS, and this provided a basis of the rise of AIDS activism,
centered around the gay communities.
It was not only the US government that was slow in taking action against the epidemic.
International efforts to fight against HIV/AIDS did not grow for several years, partly due to the
lack of WHO leadership and the organization’s assumption that industrialized countries could
deal with the issue on their own. The initial scientific progress was mainly driven by the US
CDC, the National Institute of Health (NIH), and the Pasteur Institute in France (Grmek 1990).
The evidence of a viral cause of the disease was obtained in the summer of 1982, but it took
whole six years until the world saw the first AIDS medicine called AZT (azidothymidine). The
WHO convened the first official meeting on AIDS in November 1983, two years after the
disease was discovered in the US. HIV/AIDS was slowly recognized as an international threat,
and in May 1986, the World Health Assembly approved the creation of the Special Programme
on AIDS (SPA, later renamed the Global Programme on AIDS (GPA)) as the architect of the
global AIDS plan (Mann 1987).
The WHO’s Programme on AIDS played a catalytic role in connecting the issue of
HIV/AIDS with the human rights frame, but the Programme overall did not function well and it
ultimately resulted in the fragmentation of HIV initiatives and the marginalized role of the WHO
in global AIDS governance. Because there was no treatment back then, the focus of international
efforts was on prevention. The WHO initially adopted a traditional method of quarantine to stop
the spread of this infectious disease. The director of the SPA, Johnathan Mann, had a different
view. Mann believed that protecting the rights of people living with HIV was essential and
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argued that measures such as quarantine or mandatory testing would drive infected people into
hiding. The politics of AIDS is strongly associated with the use of human rights framing,
especially in the context of access to medicine, but the human rights frame was first employed to
advance appropriate measures for HIV prevention.
Unfortunately, many WHO officials were so used to the traditional quarantine measure that
they could not accept the human rights approach advocated by Mann, and the internal conflict in
the WHO intensified. When Hiroshi Nakajima took an office of the Director-General of the
WHO, the tension within the health organization reached the highest point. Nakajima supported
conservative and traditional preventive measures, and the views of Namajima and Mann starkly
conflicted with one another. Nakajima cut the budgets of the AIDS Programme and even
disturbed the collaboration between the Programme and other UN bodies. As a result, Mann left
the office in 1990. His successor, Michael Merson, adopted traditional quarantine approach as a
priority measure to contain the epidemic, but many member states had already lost faith in the
WHO and the Programme never regained a central role in the international fight against
HIV/AIDS.
The Global Programme on AIDS was dissolved in December 1995, and the newly established
Joint United Nations Programme on HIV/AIDS (UNAIDS) replaced the position in 1996. The
UNAIDS is a joint institution hosted by 11 UN bodies, including the UNICEF, UNDP, UN
Women, WHO, and the World Bank. The fact that the new body was created outside the WHO is
noteworthy, since it indicates the lack of WHO leadership in this issue area and also the
complexity and multidimensionality of the issue of HIV/AIDS.

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6-2. Diverging Preferences over the Access to AIDS Treatment

“Release Those Drugs!”: The Rise of AIDS Activism
While the WHO was losing credibility in the governance of AIDS, civil society activists were
gaining momentum in the US over the approval of, and access to, the first AIDS medicine. The
initial target of protests was the US Food and Drug Administration (FDA), because the process
of clinical trial was not fast enough from the perspective of people living with HIV/AIDS.
However, it did not take too long for activists to recognize that the key stakeholder in the game
was actually the pharmaceutical industry. AZT was originally developed as an anti-cancer drug,
but it was not very successful as a cancer treatment. The medicine was thus forgotten until the
US National Cancer Institute contacted major pharmaceutical companies in 1984, asking them to
send any substances that might inhibit the activities of retrovirus (a kind of virus that HIV
belongs to). In responding to this notification, Burroughs Welcome, a subsidiary of British
pharmaceutical company Welcome (now GlaxoSmithKline), reported AZT to the National
Cancer Institute. Researchers at the Institute soon found the potential effect of AZT on HIV, and
phase 1 of the clinical trial was immediately launched in 1985. Promising findings from the trial
accelerated the process of phase 2, and the medicine was approved in March 1987 without going
through phase 3. Behind this rapid approval was the vocal protests by AIDS activists (Collins
and Pinch 2001).
Once the medicine was approved, however, a crucial barrier for access emerged: the price
of the medicine. Welcome set the price at $ 8,000 to $ 10,000 per person per year, and even
those who lived in wealthier countries like the US could not get access to the treatment with such
a high price. The activists quickly mobilized to protest against the company. The AIDS Coalition
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to Unleash Power (ACT UP) is one of the most prominent activist groups in the history of AIDS
politics, and the coalition’s first and ongoing target was the pharmaceutical industry, which they
considered profiteering from the AIDS crisis by selling drugs that most people living with
HIV/AIDS could not afford. The first protest was launched on the Wall Street in New York in
March 1987, and the protestors chanted “Silence = Death,” “No more business as usual,” and
“Release those drugs” (NYC LGBT Historic Sites Project n.d.). Echoing the protest, major
media outlets also criticized the pricing of the pharmaceutical company. Right before the
medicine was approved by the FDA, the New York Times mentioned that “Members of
Congress were told today that by the end of the year numerous AIDS patients would be eligible
to receive a new drug that could extend their lives but that a substantial number might not be able
to afford it” (Weinraub 1987). Washington Post pointed out that “[S]ince many AIDS victims
lose their jobs – and their health insurance – or have health insurance plans that do not cover
prescription drugs, the concern is that many patients will not be able to afford the drug even if it
is available. This is a question that will apply not only to the United States but to a larger area of
the world as well” (Squires 1987). Even the Wall Street Journal noted that there was a “mounting
concern over just how many patients can afford treatment and who will pay for it” (Chase 1987).
The concerns about the pricing of the treatment crossed the national borders pretty fast.
Australia, for instance, was facing a difficult situation with the payment for the expensive
medicine, and the State Government of New South Wales sent a letter to Welcome Australia,
asking to lower the price so that the government could sustain the distribution of the medicine to
those living with HIV/AIDS (Margo 1987). In contrast, the company’s pricing policy was
welcome by investors. The stock of the company reached a record high after the announcement
of the drug approval, and the Times quoted a comment by a pharmaceutical analysist: “AIDS is
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here to stay for several years and unless the Wellcome drug is shown to be no good, its shares
will always have a premium rating” (Clark and Leonard 1987).
The episode of AZT indicates that the pricing policy of the pharmaceutical industry was
controversial in the area of HIV/AIDS from the very beginning. Since then, numerous protests
were mobilized in the US and other industrialized countries to criticize the greed of
pharmaceutical companies. At the 5th International AIDS Conference in Montreal in 1989,
protesters accused Big Pharma of prioritizing profits over human lives, and activists across the
US got together in April 1993 and surrounded the headquarters of the Pharmaceutical
Manufacturers Association (ACTUP n.d.a; Collins and Pinch 2001).
An important point here, however, is that these Western protesters demanded a better access
to AIDS medicines in their own countries, such as the US and Australia. The access situation
needed to be improved in these places first, and until then, the movement for “universal access”
to treatment, including in developing countries, did not gain momentum. The first attempt to
expand the scope of activism was made in 1996, but many activists based in global north did not
take it seriously because they considered an improvement of access in their own countries should
be prioritized at the moment. Eric Sawyer, a prominent ACT UP activist, commented that he
faced huge negative reaction from the treatment activist community when he proposed universal
access to AIDS medicines: “Look, we can’t meet the needs of clients in Manhattan, let alone
Brooklyn or the Bronx. There is no way we are prepared to take on AIDS in the developing
world or AIDS in Africa, especially since they don’t have clean water or food in Africa. Until we
get everyone who needs treatment in the Bronx or until they get clean water in Africa, don’t talk
to us about AIDS in Africa” (Sawyer, quoted in Behrman 2004:123). Peter Piot also made the
similar comment. When he advocated for universal access to treatment at the global level in his
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speech, no one paid attention to it “because the agenda was ‘Let’s get as many people as possible
on treatment in the developed world.’ AIDS activists hadn’t shown the slightest interest in AIDS
in Africa, in developing world. That was coming later, when treatment was accessible [to them]”
(Piot 2006).
Two years later, the situation changed when the effect of HAART in developed countries was
proven at the12th International AIDS Conference held in Geneva. Both the numbers of deaths
and new infection suddenly dropped in the US after HAART was introduced in 1996. HIV/AIDS
was the top 8th cause of death in the US in 1995, but it was not even ranked in top 15 in 1998
(Behrman 2004). After this dramatic improvement of the situation in developed countries, the
activists were ready to fight for a greater access to treatment in developing parts of the world. At
the end of this conference in 1998, the Health GAP was created as a broad coalition of activists
to address the access to AIDS treatment in developing countries. Health GAP moved fast,
building network with other activist groups such as ACT UP and the Consumer Project on
Technology (CP Tech). These activist networks later played a crucial role in changing economic
calculations of pharmaceutical industry in global governance of HIV/AIDS.
One aspect of the early AIDS activism worth mentioning is that the pharmaceutical patent
was yet to be identified as a barrier for access to medicine when the focus was on the access to
treatment in the US and other developed countries. The pricing policy of pharmaceutical
companies was the direct target of the criticism, and the patent system itself was not raised as an
issue in the access to AIDS medicines. A robust international regulation on intellectual property
rights did not exist at the moment, and it was actually around this time that the governments and
the business from the US, Europe and Japan were trying to establish the TRIPS Agreement as a
part of the new trade regime.
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The Agreement on Trade-Related Aspects of Intellectual Property Rights (TRIPS Agreement)
was established as part of the World Trade Organization in 1995. Many activists claimed that
TRIPS has been an obstacle to drug access because it enforces all WTO member states to grant
product patents on pharmaceutical substances regardless of their stage of development. Prior to
TRIPS, there was no internationally binding regulation on the protection of pharmaceutical
patents, and each country could decide whether giving patent on pharmaceuticals or not. James
Love of the CP Tech later contributed to the protests against the intellectual property system, but
he mentioned that no CSOs were aware of the importance of trade agreement at this stage of
activism (Love, cited in Devereaux et al. 2006).

It Is Not Our Responsibility: Economic Rationale of Big Pharma’s Noncooperation
As the early history of AIDS activism illustrates, civil society has long targeted the
pharmaceutical industry in order to improve access to treatment. The industry, however,
remained insensitive to the public outcry and kept the logic of the market in order to push back
the social movements. A group of large pharmaceutical companies even filed a legal case against
the government of South Africa amid the AIDS crisis – a symbolic gesture showing that the
business sector was not willing to contribute to a better access to AIDS treatment.
In the late 1990s, after the long struggle against Apartheid, South Africa was facing the health
emergency from HIV/AIDS. The country had the largest number of HIV/AIDS cases in the
world, and the HIV prevalence rate was an overwhelming 25% among expectant mothers (South
Africa Department of Health 2003). The government of South Africa tried to cope with the AIDS
crisis by amending the national patent law (the Medicines and Related Substances Control
Amendment Act, No. 90 of 1997). This amendment included the provision that allowed the
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Minister of Health to override drug patents in a state of emergency, so that they could afford
essential medicines for their population by manufacturing or importing cheaper generic versions
of medicines.
Civil society welcome the law, especially because the AIDS policy in South Africa had been
half-hearted and unsuccessful up to this point. The newly established government of the African
National Congress prioritized the transition to democratic systems, and the control of HIV/AIDS
did not attract much attention for a while (Van der Vliet 2001). It is also said that the government
was hesitant to send the same message, such as the use of condoms, that was once promoted
under the apartheid administration to control the population of Black people. In fact, the AIDS
policy under the Mandela administration was ineffective and scandalous. In 1997, for instance, a
chemical called Virodene was announced to be effective in treating AIDS, but it turned out to be
not only ineffective but toxic. On the other hand, the government did not trust Western medicine
and was reluctant to distribute antiretroviral drugs such as AZT. The government also claimed
that there was not enough resource to buy expensive AIDS treatment because the health budget
was cut after the structural adjustment program (Bond 1999). This policy led to intense criticism
from home and abroad, and the government of South Africa eventually decided to amend the
patent law to import generic versions of antiretroviral drugs.
Up until the law was signed by Nelson Mandela, pharmaceutical companies vigorously tried
to prevent this legislative process. The pharmaceutical industry worked on the US government to
put pressure on South Africa not to amend the patent law. In May 1997, Aldridge Cooper from
Johnson & Johnson and Harvey Bale from the Pharmaceutical Research and Manufacturers of
America (PhRMA) sent a letter to the US Secretary of Commerce, expressing their concerns
about the South African amendment law. Other pharmaceutical companies echoed this concern,
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and 47 companies signed a letter to Charlene Barshefsky, the United States Trade
Representative, asking her to “pursue all appropriate action” against the amendment law
(Devereaux et al. 2006: 79). Before passing the amendment law, in 1996, South Africa actually
requested the US to offer medicines at discounted prices so that the country can effectively fight
against the HIV/AIDS crisis without changing the patent law. Under such a clear and strong
opposition from the pharmaceutical industry, however, the US did not give a favorable response
to South Africa, and the amendment law was passed in October 1997.
Having lost the legislature process, some 40 pharmaceutical companies (later 39 companies
due to a merger) decided to sue the government of South Africa, insisting that the law would
infringe their patent rights on AIDS drugs. More specifically, the pharmaceutical industry argued
that the law would violate the Article 2 of the South African Constitution on property rights and
it would also violate the TRIPS Agreement, an international agreement on the protection of
intellectual property rights established in 1995 (Johnson 2006; Bond 1999). The lawsuit (case no.
4183/98) was filed in 1998.
With this lawsuit, the pharmaceutical industry was trying to protect long-term profits rather
than immediate benefits from the sales in South Africa. South Africa was potentially important
market in Africa given its relatively large economy and population, but African market generated
only 1% of the pharmaceutical sales at the time of the lawsuit. The amendment law was not
exceptionally radical either, as other countries such as the Philippines and Brazil also adopted
laws which allowed parallel imports and the compulsory licensing of AIDS medicines (TAC
2001). The industry was nevertheless afraid of the possibility that other countries, especially
high-income countries, would follow the trends toward the softening of intellectual property
rights. The companies were also worried that generic versions of their drugs may be brought
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back from Africa to developed markets where the majority of profits were generated (Barnard
2002). AIDS activism in South Africa looked relatively moderate at that time, and the industry
anticipated a low level of pushback to the lawsuit (Berger 2008). By punishing South Africa for
making such an amendment law, pharmaceutical companies thought that they could easily warn
the world that their intellectual property rights should be protected anywhere under any
circumstances.
Based on the logic of the market, the industry clearly communicated their rationale of
opposing the law. The industry warned that the infringement of their intellectual property rights
would undermine research and development of medicines. Alan Holmer, the president of
PhRMA mentioned “[W]e recognize that AIDS is a major problem, but weakening intellectual
property rights is not the solution” (Holmer, cited in Devereaux et al. 2006: 90). The companies
also argued that they were being made scapegoats for South African government’s inaction on
the disease: “in a world where billions do not have access to clean water or adequate food, low-
cost drugs are not a panacea.” The head of the Pharmaceutical Manufactures’ Association
(PMA), Mirryena Deeb, commented that “[W]hen people are angry and dying out there, the
government mustn’t accuse us of delaying their treatment” (Deeb, cited in Picard 2001). From
these comments, it is clear the industry assumed that government should be responsible to
protect public health and that it was not the duty of the industry to assure a better provision of
AIDS treatment. Their argument largely depended on the notion that the business sector is of
course allowed to pursue profits because without such profits, there is no incentive for them to
invest in expensive pharmaceutical research and development.
However, this clear stance of the industry backfired: It was the first case that the business
sector explicitly and publicly weighed the importance of the economic incentives (based on
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intellectual property rights) against public health (Olsen 2006). This argument clearly juxtaposed
two distinctive rights – property rights of the wealthy industry on one hand, and human rights
(right for health) of the world’s poor on the other hand. As we saw in the previous section, there
was a growing awareness about the global inequality in access to AIDS treatment around that
time, and the lawsuit provided a coalition of civil society with a great opportunity to criticize
pharmaceutical industry’s pricing and patent policies. Southern Africa director for Oxfam,
Belinda Coote, said “I think we all know here today that this is not about South Africa. This is
the pharmaceutical companies belligerently and aggressively defending their monopolies around
the world” (cited in Cauvin 2001).
People in South Africa was also ready to stand up against the industry. In 1998, the Treatment
Action Campaign (TAC) was created, which later became one of the most influential civil
society organizations in South Africa. Based upon their experience with Apartheid resistance,
members of TAC efficiently exploited the power of human rights norms and took advantage of
the clear juxtaposition between human rights and intellectual property rights. TAC initially did
not have adequate knowledge of international laws and intellectual property rights, but the
growing coalition of civil society from across the globe helped combining human rights norms
with the knowledge of intellectual property rights (Mbali 2005; Grebe 2011).
Therefore, contrary to the industry’s expectations to showcase that their intellectual property
rights should be protected even in poorer countries, this lawsuit helped gather worldwide
attention to the AIDS crisis in Africa and the perceived greed of pharmaceutical companies.
Pharmaceutical companies did not easily give up their economic argument even in the growing
criticism from the public. However, when the coalition of civil society targeted the US
government in the protests and successfully changed the US policy, the industry lost a great
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supporter in the pursuant of putting intellectual property rights above anything else. Civil society
also coalesced with generic pharmaceutical manufacturers such as Cipla from India and modified
the market situation of AIDS treatment. These two factors affected long- and short-terms
economic calculations of the pharmaceutical industry and ultimately shifted the climate of global
HIV/AIDS governance – from scenario C of diverging preferences to scenario B of overlapping
preferences.

6-3. From Diverging to Overlapping Preferences: The Power of CSO Activism

Convincing Governments
The US government was the best ally of the pharmaceutical industry in the advent to pursue
profits by strictly protecting pharmaceutical patents around the world. When the industry learned
about the plan of South Africa to amend the patent law, it did not hesitate to contact various
bodies of the US government in order to put pressure on the African government. Even after the
passage of the law, the US government did not back off. Rather, as Bond (1999: 769) illustrates,
the US governmental entities including the Embassy in Pretoria, the Department of State, the
Department of Commerce, the USTR, and the Vice President Al Gore engaged in a “full court
press” to protect profits of the pharmaceutical industry.
In early 1998, the US ambassador in South Africa and the USTR officials repeatedly urged
South Africa to reconsider the implementation of the amended law. The US ambassador
approached to the ambassadors of some European countries as well, trying to convince them that
European pharmaceutical companies were also negatively affected by the South African law.
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Although it was not as obvious as the US government, some prominent political figures from
Switzerland, Germany, and France, including President Jacques Chirac of France, expressed
their concerns about the law to the Deputy President Thabo Mbeki of South Africa. In April
1998, the USTR put South Africa on its Special 301 Watch List, and the following July, the
White House announced a decision to withhold preferential tariff treatment from certain South
African exports until “adequate progress” was made on the protection of intellectual property
rights in South Africa (Bond 1999: 771). Representative Rodney Frelinghuysen from the state of
New Jersey, where the headquarters of several large pharmaceutical companies were located,
inserted a provision to a congressional appropriations bill that cut aid to the government of South
Africa. The provision was approved in October 1998 (Devereaux et al. 2006).
In this American “full court press” in the legal case against South Africa, the Vice President
Gore played a particularly important role. In February 1999 at the binational commission
meeting between the US and South Africa, Gore warned Mbeki: “I want to make you aware of
the strong and growing domestic pressure being brought to bear in Washington. I’m concerned
that, without significant progress toward a resolution, a single trade issue could overshadow our
bilateral relationship” (cited in Devereaux et al. 2006: 83). Around the same time, PhRMA
recommended that the USTR move South Africa to its Priority Watch List, a step closer to
formal sanctions compared to Special 301 Watch List. In April 1999, the USTR once again
placed South Africa on the 301 Watch List during the annual review of IPR violators.
All these episodes demonstrate that the pharmaceutical industry was gaining a huge assist
from the US government in their fight against South African patent law. The industry was clear
that the amendment law was detrimental to the long-term profits of the industry and hence it
would ultimately harm the economy of the US. However, it became hard to hold this strong
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stance when Vice President Gore announced that he would run for the next presidential election
and when American civil society decided to target Gore in their protests.
Eric Sawyer of the ACT UP mentioned that the activists were certain that Gore was playing
an active role in sustaining the public health crisis in Africa. The activists obtained what they
called “smoking gun memo” – a note sent from a State Department staff to a representative of
New Jersey, confirming that the Clinton/Gore administration was doing everything in its power
to support the interests of several large international pharmaceutical firms in the state in their
battle to prevent the South African government producing generic versions of AIDS medicines.
The memo also listed courses of action, including the use of the 301 Watch List and the
withholding of foreign aid (Sawyer 2002). The pharmaceutical industry was making large
political contributions to the US government in general, and Gore was also personally well-
connected to the industry. In fact, many of his close associates and advisors were lobbyists from
the pharmaceutical industry. The list includes Gore’s domestic policy advisor David Beier (a
former head lobbyist for Genetech), a top advisor Tony Podesta (a contracted lobbyist for
PhRMA), a close associate Tom Downey (a lobbyist for a pharmaceutical giant, Merck), and a
fundraiser Peter Knight (former lobbyist for Schering-Plough). Furthermore, Gore received
financial contributions from many of the largest pharmaceutical companies: From 1983 to 1990,
he received at least $18,650 in contributions from pharmaceutical companies; the Clinton-Gore
campaigns of 1992 and 1996 brought in $582,945 from Squibb, Glaxo-Wellcome, Pfizer and the
PhRMA; another $250,000 was contributed for Clinton-Gore’s 1993 Inauguration; for his 2000
campaign, Gore received additional $51,000 from pharmaceutical industry in 1997-98, and the
group of pharmaceutical companies (Squibb, Glaxo-Wellcome, Pfizer and the PhRMA) gave
another $276,850 in soft and hard money to Democratic party committees (ACT UP n.d.b).
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Activists argued that the close tie between Gore and the pharmaceutical industry gave enough
reason to believe that the presidential candidate is working to benefit the industry at the cost of
public health in South Africa. American activists chased after Gore’s election campaigns,
interfering his speech by shouting “Gore’s greed kills: Africa needs AIDS drugs.” These protests
attracted media attention, and major news sources such as Guardian and Washington Post
reported the argument of the protesters (Borger 1999; Babcock and Connolly 1999).
Facing this public embarrassment, Gore swiftly changed his position. He persuaded the
administration to relieve pressure on South Africa and urged to seek global funding for
AIDS (Sawyer 2002). The US government excluded South Africa from the Special 301 Watch
List in December 1999 (Olesen 2006). At the Seattle WTO Ministerial Conference, President
Clinton declared a change in the US policy on intellectual property rights and access to
medicines. He promised that the USTR and the Department of Health and Human Services
would work together so that the US trade policy could stay in line with public health policy of
developing countries. The USTR announced the updated Watch List in March 2000, and the list
removed most of the countries which were on the list because of their pharmaceutical patent
policy. In May 2000, President Clinton issued the executive order on access to HIV/AIDS
pharmaceuticals and medical technologies, explicitly signaling the country’s support for
compulsory licensing of AIDS medicines (‘T Hoen 2003). This drastic change of the US foreign
policy isolated the pharmaceutical industry in the debate over intellectual property rights vs.
access to medicines (Olesen 2006).
By the time when the legal case was actually brought into the court in May 2000, the
pharmaceutical industry could not rely on support from the US government or any other
governments of industrialized countries. Prior to the ministerial conference in Seattle, the Dutch
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minister of international development made it clear that his country supported manufacturing of
affordable generic medicines in developing countries (MSF 1999). In March 2001, EU trade
commissioner Pascal Lamy responded to an open letter from the prominent civil society group,
MSF, supporting countries’ right to override patent rights under certain conditions. The
European Parliament later issued a resolution which directly called on the pharmaceutical
companies to withdraw from the case (Olsen 2006). With the support of OXFAM, Glenys
Kinnock, a member of the European Parliament from the UK, travelled to South Africa to follow
the court case. Kinnock pressured Lamy to ask the companies to withdraw the case, warning him
that doing otherwise might create problems with developing countries in the next round of WTO
talks. The German minister of development, Heidemarie Wieczorek-Zeul, and other European
politicians also echoed the idea of Kinnock. Olsen (2006) explains that the governments of
industrialized countries changed their position because of two reasons: active campaign
organized by prominent international NGOs, such as OXFAM and MSF; and the worldwide
media and public attention on this case.
In early 2001, Bush became a new president and the Republicans replaced Democrats as the
ruling party, but the new administration kept the policy made by Clinton (Barnard 2002).
International organizations such as the United Nations and the WHO had been signaling their
support for South Africa even before the case was officially convened. Therefore, after the US
and other industrialized governments flipped their policies, the pharmaceutical industry was
completely isolated and became the single target of the criticism. Without the support from the
US government, pharmaceutical companies could no longer argue that the benefit of the industry
is the benefit of the US as a whole. The economic argument advanced by the industry lost appeal
once the issue of access to medicines was framed in light of human rights. Unlike other issue
164
areas such as maternal health, where several different policy prescriptions were advocated, the
access to treatment was the single defining prescription in the issue area of HIV/AIDS. Under
this circumstance, it was obvious who should be blamed for the inadequate control of
HIV/AIDS, and the industry had to face the growing reputational cost all alone.

Human Rights Responsibility of the Industry?
With the evolution of human rights norms in the context of access to AIDS medicines,
intellectual property rights (pharmaceutical patents) came to be considered an obstacle to the
realization of the right to health, and many activists started considering responsibilities of
pharmaceutical companies. However, while a human rights approach might be generally
effective vis-a-vis governments, its power against the business sector is not clear because many
human rights laws put responsibility to protect human rights on government, not on non-state
actors such as the business sector (Johnson 2006; Kapstein and Busby 2013).
The aforementioned South African civil society group, TAC, was well aware of this
inevitable association between human rights framing and the primary role of the government.
TAC often referred to the South African Constitution as the basis of its claim that access to
AIDS medicines is a human rights issue (Mbali 2005; TAC 2010). After experiencing a long
dark era of apartheid, the country made a Constitution that incorporates an internationally high
standard of human rights provisions. It declares the government’s responsibility to protect not
only civil and political rights but also socio-economic rights, thereby the content of human rights
is interpreted broadly than a conventional understanding which focuses only on the former forms
of human rights (Jones 2005). This makes a clear contrast between the activists in South Africa
and prominent international human rights NGOs, such as Amnesty International and the Human
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Rights Watch. These human rights NGOs started engaging with the access to medicines
campaign after 2001, but they had been taking distance from the issue for a long time. Some
authors argue that it was because these NGOs were reluctant to go beyond their traditional focus
on civil and political rights (Youde 2010). Unlike these human rights NGOs, TAC explicitly
argued that socioeconomic rights compose an important part of human rights and that access to
life-saving medicines should be understood in this context.
This logic and reference to the Constitution inevitably underscored the responsibility of the
government. However, TAC cautiously avoided being considered as a critique of the
democratically elected government. The ANC government was widely supported by the people
after the long fight against apartheid, and it was impossible to win overarching support from the
population if TAC undermined the legitimacy of the ANC government. TAC therefore clarified
that the target of their protests was actually the pharmaceutical companies. Here, it is important
to note that TAC was not claiming that the industry had a responsibility to protect human rights
of South African people. There was no legal basis for such a claim – the business sector had no
clear obligation in relation to human rights. The activists thus claimed that the industry was
trying to disturb the effort of government trying to fulfil its responsibility to protect the right for
health. The industry might not have any obligation to directly protect human rights, but it was
not allowed to disturb the government from fulfilling its human rights responsibility either.
28
One
of the leaders of TAC, Mark Heywood, referred to Section 27 of the Constitution and argued that
the government of South Africa had an obligation to assure the access to healthcare among the
poor, and he further mentioned that “[I]n South Africa today non-state actors, such as privately

28
So-called principle of “do no harm”
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owned monopolies, are emerging as concurrent violators of human rights” (Heywood 2001:
134).
This strategic interpretation of human rights responsibilities helped strengthen the moral
cause of civil society’s argument on one hand and illegitimatized the economic argument of the
pharmaceutical industry on the other hand. This claim was widely supported by civil society
around the world. In collaboration with MSF, Oxfam, Health GAP and other organizations, TAC
mobilized a global demonstration on March 15, 2000 – the day the court was officially opened.
More than 5000 people marched around the Pretoria High Court, and the protests took place in
30 cities across the globe, including in Brazil, the Philippines, the US, the UK, Kenya, Thailand,
France, Italy, Denmark, Australia, and Germany. On the following day, MSF launched the global
“Drop the Case” petition and successfully gathered signatures from 260,000 people and 140
organizations from 130 countries (MSF 2001b).
In July of the same year, the International AIDS Conference was held in Durban, South
Africa. It was the first AIDS-related conference held in the global South, and more people from
the South attended the conference than ever before (IAS 2013). TAC mobilized a “global march
for HIV/AIDS treatment,” and 258 organizations from around the world join the march. On the
website prepared to organize the global march, Health GAP coalition harshly criticized the
pharmaceutical industry, arguing that “[D]enying people with HIV/AIDS access to affordable
medicines in order to protect profits or intellectual property rights, is tantamount to genocide”
(Health GAP Coalition n.d.). The global march grabbed attention from the mass media and was
covered by widely known newspapers such as New York Times and Washington Post (Swarns
and Altman 2000; Jeter and Brown 2000).
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In addition to mobilizing the protests, TAC also directly participated in the legal case as an
amicus curiae – an actor who is not directly involved in the case but would be seriously affected
by the result of the case. In order to justify the argument that the industry should not disturb the
government to realize the right to health in South Africa, the civil society group referred to
international human rights laws, such as International Covenant on Economic, Social and
Cultural Rights (CESCR), Convention on the Elimination of all forms of Discrimination Against
Women (CEDAW), and Convention on the Rights of a Child (CRC), in addition to the
Constitution of South Africa. Here, again, the TAC’s interpretation is clear that socio-economic
rights are part of fundamental human rights and that the government should protect these rights
of the population. If the pharmaceutical industry tries to disturb the governmental effort to fulfil
this human rights obligation, such an act is equivalent to violating human rights, the civil society
argued. In the words of Richard Elliot of the Canadian HIV/AIDS Legal Network, the campaign
started a spiral of negative publicity in which the pharmaceutical companies “faced mounting
global criticism and were stuck in the role of greedy global villains standing in the way of a
developing country government trying to get medicines to millions of poor Africans needing
medicines” (Elliot, cited in Olesen 2006).
In the end, the pharmaceutical companies withdrew the case on April 19, 2001. Many authors
have pointed out that the deteriorating public image was one of the factors that made the
companies decide withdrawing the case (Olesen 2006). Some comments from the pharmaceutical
industry support this inference: “We don’t exist in a vacuum, [w]e’re a very major corporation.
We’re not insensitive to public opinion. That is a factor in our decision-making,” said the CEO
of GlaxoSmithKline, J. P. Garnier, a day after the withdrawal (Swarns 2001; Olsen 2006). After
the governments of industrialized countries flipped their policies and the industry was singled
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out as a “human rights violator,” the concerns about publicity was probably heightening among
corporate executives. In combination of this reputational crisis and the long-term economic
damage the companies anticipated, more direct and immediate changes in the market situation
affected the preferences of pharmaceutical companies regarding the greater provision of AIDS
treatment.

Changing the Market Situation: The Risk of Compulsory Licensing and the Entrance of
Generic Medicines
Another critical change in the landscape of global AIDS governance is the entrance of generic
treatment in the market of AIDS medicines. During the early 2000s, generic manufacturers
started actively participating in the access to medicines campaign. Some developing countries
such as India and Brazil were already distributing generic versions of AIDS medicines, and there
was a growing momentum to replace the brand-name versions of expensive AIDS treatment with
the affordable generic versions globally. This gave a direct and immediate economic threat to
large pharmaceutical companies: If the companies did not change the stance regarding
intellectual property rights and access to medicines, they might lose the whole market of
HIV/AIDS medicines.
In order to appease the angry activists, major pharmaceutical companies first launched a joint
discount initiative. The Accelerating Access Initiative (AAI) was started in May 2000 as a
public-private partnership between five UN organizations (the United Nations Population Fund
(UNFPA), United Nations Children’s Fund (UNICEF), the WHO, World Bank and UNAIDS
Secretariat) and five pharmaceutical companies (Boehringer Ingelheim, Bristol-Myers Squibb,
GlaxoSmithKline, Merck, Hoffmann-La Roche, and later joined by Abbott Laboratories) to
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address the lack of affordability of HIV medicines and to increase access to AIDS treatment in
developing countries (WHO 2002). Interestingly, it is said that the UNAIDS proposed this
initiative as an alternative to amending the trade agreement on intellectual property rights.
UNAIDS considered it impossible to use exemptions of the TRIPS Agreement even in public
health emergency, and the organization attempted to encourage price negotiations between the
major pharmaceutical companies and the governments of AIDS-endemic countries (Brousselle
and Champagne 2004).
This approach did not satisfy the AIDS activists. Unlike the international organization,
activists believed that the use of trade agreement exemptions and expanding the use of cheaper
generic medicines were the best way to improve the situation. MSF argued in its press release
that the Accelerating Access Initiative lacked transparency and the speed of delivery, and the
NGO mentioned that Senegal was paying almost three times more of generic versions of
medicine in order to buy brand-name treatment under the initiative (MSF 2001b). In this
initiative, the UNAIDS and the WHO helped countries negotiate discounted prices with the
pharmaceutical companies one-by-one, and MSF criticized that this system could not provide
negotiation power to the governments; it rather gave companies a freedom to set the rules (MSF
2002). Another assessment of the Accelerating Access Initiative also raises similar problems
inherent in this initiative: the need for multiple contracts with multiple companies, complex
importation procedures, taxes levied on antiretrovirals, lack of support from pharmaceutical
companies in importation and transportation, slow delivery of the drugs, and lack of institutional
memory in pharmaceutical companies (Van der Borght et al. 2009).
29

29
By November 2002, even the UNAIDS and the WHO – the hosts of partnership – started encouraging the
involvement of generic companies.
170
Having failed to appease the activists and to derail the momentum towards the use of generic
medicines, pharmaceutical companies made further efforts. Pfizer offered South Africa a
donation of fluconazoke to treatment opportunistic infections of AIDS patients, and Boehringer
Ingelheim proposed a donation of nevirapine free of charge for the prevention of mother-to-child
infection. A series of discount and donation drastically lowered the marketing price of the triple
cocktail treatment from $3000 to $1000 per person per year (Barnard 2002). However, even this
reduced price was way more expensive than generic version of the same combination of
medicines. On February 7, 2001, MSF welcome an Indian generic pharmaceutical manufacturer
Cipla’s offer to provide the triple-combination therapy at $350 per person per year (MSF 2001b).
On March 8
th
, 2001, Cipla further encouraged the government of South Africa to issue a
compulsory license so that the country can legally import the generic versions of AIDS treatment
(Swarns 2001; Boseley 2001).
The real threat of the use of trade agreement exemptions, such as compulsory licensing, gave
additional pressure to the Western pharmaceutical companies. On the same day, Merck
announced that it would discount two AIDS medicines in South Africa and some other
developing countries – Crixivan for $600 and Stocrin for $500 per person per year. The company
sworn that the price was set at the cost of manufacturing.
30
On March 12, Bristol-Myers Squibb
and GlaxoSmithKline joined Merck and announced a major discount of AIDS treatment in Cote
d'Ivoire. GlaxoSmithKline also launched two initiatives to address malaria in Africa, and
Merck’s executive director for public affairs in Africa commented that “I certainly feel that
compulsory licences are unnecessary in this case. We are making these drugs available. We're
willing to work with the government in South Africa” (Sturchio, cited in Boseley 2001).

30
In the US, Crixivan cost more than $6000 around that time.
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Cipla actually first proposed the offer of affordable generic medicines in September 2000, but
it took half a year to make the brand-name companies decide to give huge discounts on AIDS
medicines. It was because the industry believed that generic medicines cannot be legally
distributed in countries like South Africa, where the companies obtained patents on most of the
important AIDS medicines. However, by March 2001, the possibility of South African
government issuing compulsory license was becoming realistic due to the growing support for
the access to treatment campaign. It was probably this threat – making a precedence of using
compulsory licensing for AIDS medicines – that moved the wealthy pharmaceutical industry
towards huge concession. To allow overriding pharmaceutical patent is an issue that may impact
a whole system of pharmaceutical research and development. Once the companies figured out it
was impossible to completely ignore the social demand for a greater access to AIDS treatment,
they decided to change their position from “enemy” to “partner” so that they can make
HIV/AIDS an exception in the overall trend towards the softening of the protection of
pharmaceutical patents. To put it differently, the industry decided to lose the battle (the issue
area of HIV/AIDS) and win the war (a whole system of intellectual property rights and the
pharmaceutical patents in other therapeutic areas).
It was only one month later that the group of pharmaceutical companies dropped the legal
case against South African government. From then on, the pharmaceutical industry rather
actively engaged in the international efforts to address the issue of HIV/AIDS in general and the
access to AIDS treatment in particular. The most prominent PPP in this issue area is the Global
Fund to Fight AIDS, Tuberculosis and Malaria. In 2001, the UN Secretary-General Kofi Annan
called for a global fund to combat HIV/AIDS that would require $7-10 billion annually. Prior to
this, only less than $ 200 million was allocated to HIV/AIDS. In 2002, advanced industrialized
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countries pledged their support for the Global Fund to Fight AIDS, Tuberculosis, and Malaria
(GFATM) as the centerpiece of the multilateral response. The private sector, including the
pharmaceutical industry has engaged with the Fund, and the private sector collectively hold two
seats of voting members on the Board of the Global Fund. One of the two seats is currently
occupied by a representative of Merck (Global Fund n.d.). With no one arguing against the
collective responsibility of international community to expand access to AIDS treatment, the UN
General Assembly Special Session in 2006 adopted the Political Declaration on HIV/AIDS,
declaring to “[C]ommit ourselves to pursuing all necessary efforts to scale up nationally driven,
sustainable and comprehensive responses to achieve broad multisectoral coverage for prevention,
treatment, care and support, with full and active participation of people living with HIV,
vulnerable groups, most affected communities, civil society and the private sector, towards the
goal of universal access to comprehensive prevention programmes, treatment, care and support”
(emphasis added, UN 2006: 3).
After the industry backed off in the legal case, the legal interpretation was also clarified
regarding the limitation of intellectual property rights protection. In November 2001, WTO
member states adopted a special Ministerial Declaration (so-called Doha Declaration) at the
WTO Ministerial Conference in Doha. The Doha Declaration affirms that “the TRIPS
Agreement does not and should not prevent Members from taking measures to protect public
health” (WTO 2001).
31
Civil society celebrated the victory, stating that “governments are free to
take all necessary measures to protect public health. Now, if drug companies price drugs beyond
the reach of people who need them, governments can override patents without the threat of
retribution” (MSF 2001b).

31
For the summaries of Doha Declaration in relation to public health implications, see WHO at
https://www.who.int/medicines/areas/policy/doha_declaration/en/ (accessed November 4, 2020)
173
However, although the Declaration does not limit the use of TRIPS flexibilities to certain
diseases, the pharmaceutical industry has been clearly trying to make HIV/AIDS an exception,
pursuing a stricter protection of pharmaceutical patent in other therapeutic areas. When India
decided not to approve the patent on a cancer drug named Glivec filed by Novartis, the Swiss
pharmaceutical company filed a lawsuit. After six years of the legal battle, the Indian supreme
court decline the appeal of the company, enabling Indian people to have access to the life-saving
cancer treatment which cost more than £1,700 a month in a country where the drug is patented.
Novartis expressed grievance, commenting that the decision of the Indian court “discourages
future innovation in India.” Ranjit Shahani, the firm’s vice-chairman and managing director in
India, said his company would be cautious about investing in India and continue to refrain from
research and development activities in the country (Boseley 2013). The case of Glivec indicates
that pharmaceutical companies did not whole-heartedly change its preference regarding the
pharmaceutical patent and access to medicines; rather, they were trying to save their reputation
and long- and short-term economic benefits by ruling out AIDS as an exceptionally important
health issue where access to treatment should be prioritized. This was the change made by the
well-mobilized AIDS activist, but it also indicates the limit of the access to medicine campaign –
the industry’s preference varies across health issue areas, and the activists need to fight and
modify the business preferences in each issue area.

Another Economic Factor: The Risk of Losing Partners in the Pharmaceutical Research
Another factor that worked as an additional economic threat to the industry is the possibility of
losing valuable partners in the field of pharmaceutical research. Through university-industry
collaboration in pharmaceutical research, some prominent research universities co-invented and
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held patents on crucial AIDS medicines. Hence, the universities were also under the growing
reputational pressure once the access to treatment campaign found out this fact. Unlike the
pharmaceutical industry whose widely accepted raison d'être is the maximization of profits,
universities were relying on a good image as a guardian of liberal values and thus were much
more vulnerable to publicity. Being targeted by AIDS activists and criticized in the light of
human rights, famous universities had no choice but to convince their research partners – the
pharmaceutical industry – to accommodate with the demand from the people living with
HIV/AIDS; Or else, universities might need to cut a tie with the “human rights violators” to
dissociate themselves from the evil act of their collaborators. The case of Yale University and
Bristol-Myers Squibb illustrates the point. The coalition of civil society demanded the university
and the company to allow the use of generic version of their AIDS medicine, d4T, in South
Africa. At that time, discount or donation were already so commonplace in the context of AIDS
treatment, but Yale and its partner went beyond that; they gave up a patent of a blockbuster
AIDS medicine.
The medicine was discovered by a Yale researcher, William Prusoff, under the US
governmental research funding. Yale University filed a patent in 1986 and licensed it exclusively
to Bristol-Myers Squibb in 1988. The patent was granted in 1990. Bristol-Myers Squibb
sponsored the clinical trial of the medicine, but it is said that the trial cost only $15 million and
the company recouped this cost immediately (Demenet 2002). When MSF asked Bristol-Myers
Squibb to allow them using generic version in South Africa, the company replied that the NGO
should ask Yale. However, when MSF did so in February 2001, the university said it had no right
to allow the usage of generic version because the university had licensed the patent to the
company.
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Yale had several reasons to act in this manner. With $40 million in annual revenue, the patent
on d4T was a cash cow for Yale, representing 90% of Yale’s entire royalty income. In addition,
Yale got a $250,000 grant from Bristol-Myers Squibb in 1999, have conducted cooperative
research with the company on diseases such as cancer, Alzheimers, and HIV/AIDS, and have
held symposia to encourage graduate students to meet their future employer (McNeil Jr. 2001;
Lindsey 2001; Demenet 2002). The huge amount of royalty income may have contributed to
Yale’s hesitation to release the patent, but it seems that maintaining a cozy relationship with the
critical business partner was more important to Yale than just keeping the paychecks coming.
The South African market was not so large that even if they released the patent there, the loss of
royalty income would not cause serious damage to fiscal condition of Yale. Rather, the problem
was the strong tie between two parties. The university first thought that the company would not
agree to give up on the right of manufacturing the medicine and thus tried to avoid getting
involved in the AIDS campaign.
However, Yale students did not let it happen. Some students contacted MSF and mobilized
the protests, demanding the university to give up on the pharmaceutical patent to protect the right
to health of the people in South Africa. Even Dr. Prusoff, the researcher who found the
effectiveness of the medicine, supported the protests, and because the research was supported by
governmental funding, the university was portrayed as making profits from the research funded
by public money. This was a real embarrassment for a “university that claims a 300-year-old
liberal tradition” (Remes 2001). As the protests gathered attention from mass media, Yale was
forced to persuade the company to release the patent of the drug.
Just like Yale did not want to harm its relationship with the giant pharmaceutical company,
the same logic seemed to work on the side of Bristol-Myers Squibb: The company had an
176
incentive to sustain a good research relationship with prominent research universities. Besides
d4T, Yale and Bristol-Myers Squibb were conducting collaborative research in various disease
areas. Complicating the relationship with Yale thus could have led economic loss for the
company. Because of the tie in pharmaceutical research, the company’s calculation of loss and
gain changed when Yale yielded human rights pressures. On March 14, 2001, before the
pharmaceutical industry withdrew the legal case in South Africa, Bristol-Myers Squibb
announced that it would release the patent of d4T in sub-Saharan Africa to allow other
companies to sell a generic version of the medicine (Adrangi 2001; Clark and Borger 2001).
As this case of university-industry collaboration demonstrates, when the coalition of civil
society seriously pursued the greater access to AIDS treatment, the pharmaceutical industry lost
its allies one after another – the US government, other industrialized countries, and important
research partners. With the growing reputational costs and the deteriorating market situation with
the entrance of generic manufacturers, the pharmaceutical industry recalculated their long- and
short-term economic costs and decided that becoming a partner would be more beneficial than
staying as a “human rights violator” in the issue area of HIV/AIDS.

6-4. What It Tells about Economic and Legal Licenses to Operate

This chapter reviewed that social movements demonstrated by AIDS activists shifted the
scenario from “diverging preferences between civil society and the business sector” to
“overlapping preferences” in the issue area of HIV/AIDS. Because the magnitude of HIV/AIDS
is currently well recognized, it might seem that some very large-scale PPPs, such as the Global
177
Fund to Fight AIDS, Tuberculosis, and Malaria naturally emerged in the issue area of
HIV/AIDS. However, the severity of health issue did not automatically activate the creation of
PPPs; In fact, it required mobilized efforts of civil society to transform the preference of the
business sector so that the pharmaceutical industry had no choice but to join the international
efforts to expand access to AIDS treatment – a priority intervention that AIDS activists have
advocated for in the governance of HIV/AIDS.
The story of HIV/AIDS governance highlights the importance of proposition 2 articulated in
the theory chapter. Proposition 2 states that the business sector would support the creation of
PPPs in an issue area where the industry can benefit economically through the provision of the
goods or alternatively the industry cannot avoid financial damages from inaction. While the case
of neglected tropical disease (Chapter 5) reveals the first half of the proposition – the
pharmaceutical industry thought the drug-donation programs would be beneficial for their
reputation and long-term profits –, the case of HIV/AIDS illustrates the second half of the
proposition. When the pharmaceutical industry faced the mounting public outcry and recognized
that they could no longer sustain the monopoly in the market of AIDS treatment, they also
understood that they could not avoid financial damages from inaction. If the pharmaceutical
companies did not change their stance on pharmaceutical patent in the issue area of HIV/AIDS,
they could have lost the very fundamental mechanism of intellectual property rights protection
on every therapeutic area. By reframing their position as a partner in access to AIDS treatment,
they tried to make HIV/AIDS as an exception in the protection of intellectual property rights, and
by doing so, the companies wanted to save economic benefits in other health issue areas.
The fact that PPPs were not created until the early 2000s, until the landscape of global AIDS
governance had changed by vocal social movements, suggests that CSOs willingness alone does
178
not facilitate the creation of PPPs. Civil society actors have been advocating for a greater access
to AIDS medicines from the very beginning, but there is a large time gap between the emergence
of such advocacy and the creation of PPPs in the issue area of HIV/AIDS. This illustrates that
civil society needed to modify the preference of the business sector. As the scenario C argues,
PPP is less likely to be created in an issue area where the business sector does not economically
benefit through a greater provision of the goods or the industry does not anticipate financial
damages from the lack of the provision. This would be the case even if CSOs in the issue area
are pursuing the greater provision of the goods and advocating for the creation of PPPs.
At the beginning, the pharmaceutical industry did not see any economic reason to join the
coalition. The industry thought that allowing the use of generic versions of their AIDS drugs
would undermine the system of intellectual property rights, and without such system, they could
not secure financial benefits from pharmaceutical research and development. This logic of the
market was clearly illustrated by the legal case filed by the groups of large pharmaceutical
companies against South African government.
Yet, the case of HIV/AIDS also illustrates the modifiability of the business sector’s
preferences. This is where civil society actors can make a difference by exploiting the power of
social movements. CSOs used various strategies to affect economic calculations of the
pharmaceutical industry. They first convinced the governmental actors (most importantly the US
governments) to change the position in the battle between property rights vs. human rights.
Actors such as governments and universities are more susceptive to social pressure, and the US
government, European governments, and universities changed their position, agreeing that access
to medicines should be prioritized to the protection of pharmaceutical patent. The “betrayal” of
the close allies put the pharmaceutical industry in an isolated situation, and the strong use of
179
human rights framing also tarnished the public image of the industry: pharmaceutical companies
were casted as “human rights violators.” The entrance of the generic manufacturers to the market
of AIDS medicine was becoming inevitable, and there was a legal threat that the interpretation of
international intellectual property rights would be dramatically modified if the companies did not
give up the single issue of HIV/AIDS. In the end, the criticism reached to the extent that sticking
with the position against social movements would cause financial damages to the industry.
So, yes, it is possible to alter the preferences of the business sector in order to facilitate the
creation of PPPs and promote a greater access to certain products. However, there is no
guarantee that civil society can effectively affect the economic calculations of a targeted
industry. As the episode of the cancer drug, Glivec, illustrates, the access to cancer medicines
(and more broadly, access to medicines in the field of non-communicable diseases) has yet to see
an overlap between the preference of civil society and the business sector. As Chapter 4 on non-
communicable diseases indicates, there has been a movement to accelerate access to medicine in
this issue area, but the vast focus of civil society in this issue area has been on the control of
health-harming products such as tobacco. There is a possibility that the activists in the area of
NCDs alter the preferences of the pharmaceutical industry, as in the case of HIV/AIDS, but it
remains to be seen whether the activist will pursue this rout and whether such effort will succeed
or not.
One important caveat regarding the case of HIV/AIDS is that I am not arguing that it is a
“success” story that every health issue should follow. The excessive focus on treatment might be
problematic in terms of sustainability of this governance model, Because AIDS treatment is in
general costly, it might be hard to sustain this focus on treatment for a longer run. In order to win
the fight against HIV/AIDS, prevention needs to attract more attention and resources, and some
180
donor governments such as Nordic countries have attempted to put more emphasis on
prevention. This story of HIV/AIDS depicts the victory of civil society in a way, but it is worthy
of acknowledging that it might not necessary be the best way of governing a health issue. The
main takeaway from the HIV/AIDS case is that the preferences of the business sector work as an
important factor affecting the creation of PPPs, and there is a possibility that such preferences
can be modified by another type of actor; Hence, the politics of making PPPs is about interaction
of different types of actors. It is not about one kind of actor can dominate the decision making
and push the creation of PPPs all the time.

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Chapter 7. Conclusion

7-1. Summaries of the Argument and Findings

Transnational PPPs have become a dominant governance modality in the 21
st
century. Public and
business donors are working together to address various global issues, from climate change to
the vaccination of children. However, not all global issues that are widely considered important
have generated an equal level of PPP usage. By employing the basic techniques of social
network analysis, this dissertation reveals that there is variation in the use of transnational PPPs
even withing a single sector of global health. Some health issues such as women’s health and
neglected tropical diseases have created many and/or large-scale PPPs, while other health issues
like non-communicable diseases and nutrition have not. What explains this variation? This
dissertation tackled this question by focusing on the role of a usually neglected actor in the
creation of transnational PPPs: civil society organizations. The dissertation argued that PPPs tend
to be created in issue areas where two different types of stakeholders – CSOs and the business
sector – have overlapping preferences.
The empirical chapters compared the cases of non-communicable diseases, neglected tropical
diseases, and HIV/AIDS to assess the plausibility of the theoretical argument. These three issue
areas have generated different levels of PPP usage: The area of neglected tropical diseases has
seen a proliferation of many PPPs since the late 1980s, even before transnational PPPs became a
popular governance modality in a broader health and development fields. In contrast, non-
communicable diseases have not created many PPPs up to date, although the issue has come to
be recognized as a major killer of the 21
st
century. HIV/AIDS shows an interesting trajectory,
182
with a mega PPP and several large PPPs suddenly emerged at the end of the 1990s to early
2000s. The different patterns of PPP usage across these three issues enabled me assessing the
mechanisms of not only creation but also non-creation of transnational PPPs. This allowed me to
overcome the empirical limitations of the existing literature: the strong focus on the cases where
famous PPPs emerged; and the relative neglect of the cases where such PPPs did not emerge.
In contrast to the existing explanations of the creation of PPPs which focus on the role of the
business sector or/and IGOs, my argument puts a special emphasis on the role of CSOs. In
particular, I argued that it is hard to create transnational PPPs where CSOs are promoting
regulatory measures instead of a greater provision of certain goods, highlighting the veto power
of CSOs even though this stakeholder is usually considered as relatively weak without any
formal legal authority in international decision making. The case of NCDs demonstrated the
point, revealing that large and wealthy corporations cannot take over the governance of NCDs
when they face resistance from CSOs. In the series of discussions, CSOs actively advocated for
controlling NCDs by using regulatory measures such as taxation on tobacco, alcohol and
unhealthy food and beverage. They are very cautious about the idea of cooperating with the
industries, being aware of conflicts of interests in such cooperation. The business sector was
trying to push back, arguing that alcohol, food and beverage companies are not an enemy but an
ally in addressing the burden of NCDs. However, such a self-portrait has not been successful in
convincing other stakeholders to create PPPs. The result of this case study supports my argument
that PPP is less likely to be created when CSOs are pursuing regulations as an appropriate policy
intervention.
My argument, however, is not a “CSO takeover” approach. Preferences of the business sector
also play a crucial role in the process of making transnational PPPs. The case of neglected
183
tropical diseases demonstrated that it was actually the business sector who initiated the creation
of many drug donation PPPs in this issue area. Because there was no substantial cost for the
business sector to donate successful veterinary drugs for a human use in tropical regions, the
companies willingly launched partnerships that would greatly improve their public image. These
drug donation partnerships made mass drug administration cost-effective, and CSOs were overall
welcoming the benevolent initiatives by the pharmaceutical industry. Indeed, many CSOs in this
issue area have more focused on the implementation of projects to expand the provision of
healthcare (including drug distribution) rather than advocacy or rule making, hence the
collaboration with the industry became the major operational task of the CSOs after the
companies decided to donate their medicines. The friendly relationship between the
pharmaceutical industry and CSOs provides a basis for further development of R&D
partnerships. Here again, the two stakeholders could find a sweet spot to cooperate: CSOs can
pursue their preferred intervention (a provision of treatments by developing better medicines)
and the industry can improve publicity without substantial financial costs through partnerships.
While neglected tropical diseases provide a story of relatively steady growth of PPPs, the case
of HIV/AIDS illustrates how changes can be made. As I discussed in the theory chapter,
preferences of the actors are malleable, hence an issue area can move from one scenario to
another. This is where the power of CSOs and social movements can be exercised. The
relationship between AIDS activists and the pharmaceutical industry was quite confrontational
for a long time: Activists pursued a greater access to (and the provision of) life-saving treatment
while the industry tried to secure profits. The fact that PPPs were not created until the early
2000s suggests that CSOs willingness alone does not facilitate the creation of PPPs. Civil society
actors have been advocating for a greater access to AIDS medicines from the very beginning, but
184
there is a large time gap between the emergence of such advocacy and the creation of PPPs in the
issue area of HIV/AIDS. This illustrates that civil society needed to modify the preference of the
business sector. In fact, it was only after the social movements imposed a real economic threat to
the industry that pharmaceutical companies changed its stance and came to commit to the greater
provision of AIDS treatment at the international level. AIDS activists around the world
successfully convinced the US government, European governments, and universities to change
their position, encouraged generic manufacturers to enter the market of AIDS medicine, and
attempted to change the interpretation of international intellectual property rights in a way it
would dramatically damage profits of the pharmaceutical industry.
These three cases all demonstrate that CSOs play a significant role in the politics of making
or not-making transnational PPPs in the health sector. They can block the creation of PPPs when
they believe another policy intervention – namely, regulation – is more appropriate to address an
issue of their concern. They can also mobilize protests and employ various strategies to alter the
business calculations so that the industries join collaborative initiatives to expand a provision of
certain products. This is not to say that CSOs can unilaterally decide whether a health issue
should have transnational PPPs or not; ultimately, PPPs are a product of the interaction between
CSOs and the business sector. Still, it is worthy of pointing out that CSOs, despite being
neglected in the existing literature, can and actually have played a crucial role in the politics of
facilitating or hindering the creation of PPPs.
An interesting point we can see from the comparative case study is that the politics of creating
PPPs is issue-specific. The HIV/AIDS case provides an interesting contrast with the case of
neglected tropical diseases. The pharmaceutical industry has been praised as a generous partner
in the control of neglected tropical diseases and the two types of PPPs have grown very smoothly
185
without much contestation between the industry and civil society. On the other hand, the same
industry was criticized as “human rights violators” in the area of HIV/AIDS. This contrast
suggests that political dynamics of making (or not making) PPPs is, to a certain extent, bounded
by issue areas. An industry could be a great partner in one issue area, and the same industry
could be an evil enemy targeted by social movements in another issue area. This issue-specific
relation between CSOs and an industry helps provide a more nuanced explanation for the
variation in the use of PPPs across different issue areas, even within a single sector of global
health.

7-2. Contributions of the Dissertation

This dissertation made three kinds of contributions. First is theoretical contributions to the IR
literature. Second is empirical contributions, and third is policy and social implications.

Theoretical Contributions
This research has important theoretical implications for the prolonged debate on the relative
power balance between the state and the market in global politics. By analyzing the conditions
under which global health partnerships are created, this dissertation demonstrated that the rise of
private actors in a broader sphere of global governance cannot be understood as a simple
competition between the state and the market. Starting with the famous arguments on whether
the state has retreated or not (Strange 1996; Held et al. 1999), the growing literature on global
governance has assessed the causes and consequences of the rise of “private authority” in
186
international affairs (Cutler et al. 1999; Higgott et al. 2000; Hall and Biersteker 2002; Grande
and Pauly 2005; Risse 2014). However, as I already noted in the introduction, a large part of the
literature has conceptualized the rising private authority as the growth of self-regulations by non-
state actors and thus overlooked a wider range of corporate activities, such as their growing
collaboration with governmental and inter-governmental organizations through transnational
partnerships. This dissertation was an attempt to complete the missing piece of the literature,
bridging the two broad modalities of global governance through the zero-sum perception of
CSOs between the modalities. It is an open empirical question whether the two modalities –
regulations and provision of certain goods – are actually in zero-sum relationship, but at least
there is such a notion among global health CSOs, and this perception affects their preferences
regarding the creation of PPPs.

Empirical Contributions
This research project also has important empirical contributions. First of all, this dissertation
provided a first quantitative analysis of how PPPs are used across different areas in global health.
Although there was some anecdotal evidence (or more accurately, impression) that certain issue
areas, such as HIV/AIDS and vaccination seem to have created many large-scale PPPs than other
issue areas, there was no comprehensive assessment comparing the level of PPP usage across
various health issue areas. This dissertation conducted a network analysis of selected health issue
areas, revealing a quantifiable difference across these issue areas in the use of PPPs.
Moreover, the dataset this dissertation generated in the process of the network analysis offers
a novel empirical asset to the study of global health partnerships. Practitioners and IR scholars
alike have noticed that transnational PPPs have become a popular (or “trendy”) governance
187
instrument to address global issues in the era of the Sustainable Development Goals. However,
there is only a limited number of empirical assessments on the creation and effectiveness of
transnational PPPs. This is by and large because of the lack of comprehensive dataset that can be
used for systematic empirical examinations. In this project, I developed an original dataset of
global health partnerships. This would provide a first dataset that can be used for quantitative
analysis of various questions regarding global health partnerships. In a longer-term, I will
publish a cleaned dataset of global health PPPs so that other scholars can use it for empirical
analysis of the creation and effectiveness of these partnerships.

Policy and Social Impacts
Exploring the mechanism of why only certain global issues have attracted transnational PPPs has
crucial policy implications, since transnational PPPs have huge impacts on resolving
international development goals. A preliminary assessment found that the issue areas that have
generated large-scale transnational PPPs tend to attract overall larger amounts of investments
compared to other issue areas. Issues with large-scale PPPs are also more likely to achieve the
goals of improving indicators related to the issues, such as reducing the number of deaths from
the cause. If the creation of PPP works as a catalyst to mobilize funding and leads to goal
achievement, there is an urgent need to understand why only some issues are chosen for the
creation of transnational PPPs. My research project contributes to this policy discussion by
revealing how political factors such as policy preferences of civil society affect the creation and
non-creation of transnational PPPs in issue areas of global health.
If the power of the business sector in the making of transnational PPPs is restrained by CSOs,
it might be good news for the proponents of global democracy. As the scholars in the incentive-
188
based approach raised, there has been a concern regarding whose interests transnational PPPs are
serving. It requires careful assessments as for whether CSOs truly represent global citizens,
including the peoples of Global South. But with this caveat in mind, the finding that CSOs can
veto the creation of PPPs even when both powerful industries and IGOs have stakes in launching
partnerships suggests that transnational PPPs are not solely driven by the interests of Northern
donors.

7-3. Limitations and Future Directions

This dissertation has revealed that the role of CSOs matters in the politics of making PPPs and
argued that PPPs are likely to emerge in an issue area where preferences of CSOs and the
business sector overlap. There are some unfulfilled tasks in this research project, however, and I
plan to address especially the following points in the future research.
First is the articulation of the role of IGOs in my theoretical framework. The current
dissertation treated IGOs more as a forum where opinions of different stakeholders (mainly the
business sector and CSOs) are shared, but as many scholars have demonstrated, IGOs could act
as an actor themselves. Future research needs to address this point, further elaborating how
preferences of IGOs are formed regarding the creation of PPPs and how independent the
formation of such preferences is from the preferences of CSOs and the business sector.
Second, this dissertation focused on explaining the emergence or non-emergence of PPPs
across different issue areas. In arguing the lack of PPPs in certain issue areas, such as non-
communicable diseases, I emphasized a perceived zero-sum relationship between two broad
189
modalities of global governance – regulations and provisions of certain goods – and positioned
PPPs as a representative instrument for the latter modality. However, PPP is not the only way to
facilitate a greater provision of goods. Public and private donors can work on provision of goods
on their own, without forming partnerships with another type of donors. This leads to at least two
possible instruments other than PPPs for the provision of goods: official development assistance
and corporate social responsibility (CSR) activities. Official development assistance (ODA),
whether it is bilateral or multilateral, is a traditional way to fund activities such as vaccination of
children and allocation of foods in emergency situations. Indeed, some issue areas such as
nutrition have not created many PPPs but there are a number of partnerships among
governmental donors. This suggests that the issue area of nutrition has used a more traditional
instrument of providing nutritious foods instead of PPPs, and it does not necessarily mean this
issue area has focused on making regulation (as opposed to provisions) as a priority modality of
governance. My dataset includes partnerships other than PPPs, such as partnerships between
governmental donors and among companies, and hence it is empirically possible to assess a
greater variation in the outcome: what governance modality and instrument is prioritized in each
issue area? Future research needs to take into account a broader governance instruments, beyond
the simple dichotomy of regulations vs. PPPs in order to better understand the power balance
among different types of actors in global governance.
Third, it is also important to consider and examine a generalizability of the theoretical
framework. This dissertation limits the focus of analysis to a single sector of global health, but it
is reasonably inferred that similar political dynamics might be operating in other sectors, such as
environmental governance and reducing gender inequality. Because the provision of certain
goods may not be a major modality in governing conflicts and peace, it is probably a stretch to
190
apply the theoretical argument to the sphere of international security. Yet, it is worth assessing
the applicability of the theory to a broader range of sectors in international development.

With these limitations in mind, the dissertation demonstrated empirical variations in the use of
PPPs across various health issues, and it explained the outcome from the interaction between
CSOs and the business sector. A better understanding of the political dynamics behind the
creation of transnational PPPs has crucial theory and policy implications. As I repeated
throughout the dissertation, the creation of PPPs does not necessarily mean “success” of the
governance in a given issue area. If there is no remarkable PPP in an issue are, it might be the
case that CSOs and the people affected by the health issue are advocating for a governance
instrument other than PPPs to address the issue. Recent proliferation of PPPs in general and the
inclusion of “global partnerships for sustainable development” in the UN SDGs indicate that
there is a very strong trend towards the use of PPPs in current international development
communities. However, PPP is only one of the several possible instruments to govern global
issues. It is important to take a moment and reconsider whether making a PPP itself should be
pursued as a goal. The lack of PPP might not be an indicator of “failing governance,” but a
product of political interaction among the business sector, IGOs, and civil society of the world.

191
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Appendix: List of PPPs

ID Name of Partnership Start Date Issue Area
6 Asia Pacific Malaria Elimination Network (AMPEN) 2009 Malaria
8 The Global Alliance for Musculoskeletal Health 2000 Other non-infectious diseases
14 Drugs for Neglected Diseases Initiative (DNDi) 2003 HIV, Malaria, NTDs
18 Every Woman Every Child (EWEC) 2010 Women
19 Partnership for Maternal, Newborn & Child Health (PMNCH) 2005 Women
20 Family Planning 2020 2012 Women
21 Global Financing Facility 2015 Women
23 GAVI 2000 VPDs
25 Global Alliance to Eliminate Lymphatic Filariasis (GAELF) 2000 NTDs
26 Global alliance for rabies control 2007 NTDs
28 Global Buruli Ulcer Initiative 1998 NTDs
30 Global Fund to Fight AIDS, Malaria and Tuberculosis (GFAMT) 2002 HIV, TB, Malaria
36 Global Noncommunicable Disease Network 2008 4NCDs
38 Global Road Safety Partnership 1999 Road Safety
45 Implementing Best Practices in Reproductive Health Initiative 1999 Women
47 Innovative Vector Control Consortium (IVCC) 2005 Other infectious diseases
49 International Coalition for Trachoma Control 2004 NTDs
51 International Federation of Biosafety Associations 2001 Biosafety
59 Measles and Rubella Initiative 2001 VPDs
60 Medicines for Malaria Venture (MMV) 1999 Malaria
61 Meningitis Vaccine Project (MVP) 2001 VPDs
62 Onchocerciasis Elimination Program for the Americas (OEPA) 1991 NTDs
63 One million Community Health Worker Campaign 2013 UHC
70 Regional Collaborating Committee on Tuberculosis Control and Care (RCC-TB) 2012 TB
71 Roll Back Malaria 1998 Malaria
74 Stop Tuberculosis Partnership 2001 TB
80 Global Polio Eradication Initiative 1988 VPDs
86 Food Fortification Initiative 2002 Nutrition
87 Global Alliance for Improved Nutrition (GAIN) 2002 Nutrition
88 Global Alliance for the Elimination of Leprosy (GAEL) 1999 NTDs
91 Global Public-Private Partnership for Hand Washing with Soap 1998 Water and Sanitation
97 Micronutrient Initiative / Nutrition International 1992 Nutrition
98 Network for Sustained Elimination of Iodine Deficiency Disorders / Iodine Global Network (IGN) 2012 Nutrition
103 Coalition on Children Affected by AIDS 2008 HIV
107 Accelerating Access Initiative 2000 HIV
108 Aeras, Global TB Vaccine Foundation (AERAS) 2003 TB
116 Sustainable Sanitation Alliance (SuSanA) 2007 Water and Sanitation
117 Safe Drinking Water Alliance 2003 Water and Sanitation
119 European Vaccine Initiative (EVI) 1998 HIV, TB, Malaria, NTDs
121 Infectious Disease Research Institute (IDRI) 1993 HIV, TB, Malaria, NTDs
124 International Vaccine Institute (IVI) 1997 NTDs
126 Scaling Up Nutrition (SUN) 2011 Nutrition
128 WIPO Re:Search 2011 TB, Malaria, NTDs
130 African Project for Onchocerciasis Control (APOC) 1995 NTDs
131 Global Schistosomiasis Alliance (GSA) 2014 NTDs
132 Children without Worms (CWW) 2007 NTDs
134 Global Partnership for Zero Leprosy 2018 NTDs
135 Global Health innovative Technology Fund (GHIT) 2012 TB, Malaria, NTDs
136 Innovative Medicines Initiative (IMI) 2007 4NCDs
137 Mectizan Donation Program (MDP) 1987 NTDs
139 Expanded Special Project for Elimination of Neglected Tropical Diseases (ESPEN) 2016 NTDs
141 Go Further Ending AIDS and Cervical Cancer 2018 HIV, 4NCDs
142 DREAMS 2014 HIV
143 MenStar Coalition 2018 HIV
144 Labs for Life and Infection Prevention and Control 2012 HIV, TB
145 Project Last Mile 2010 HIV

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Asset Metadata

Creator Suzuki, Mao (author)

Core Title Deciding modalities of global health governance: What facilitates or hinders public-private partnerships?

School College of Letters, Arts and Sciences

Degree Doctor of Philosophy

Degree Program Political Science and International Relations

Publication Date 04/26/2021

Defense Date 09/30/2020

Publisher University of Southern California (original), University of Southern California. Libraries (digital)

Tag global governance,global health,non-governmental organizations,OAI-PMH Harvest,state-industry relations,transnational corporations

Language English

Contributor Electronically uploaded by the author (provenance)

Advisor Katada, Saori (committee chair), Sandholtz, Wayne (committee member), Wipfli, Heather (committee member)

Creator Email chiacchiere_piacevole@yahoo.co.jp,maosuzuk@usc.edu

Permanent Link (DOI) https://doi.org/10.25549/usctheses-c89-454094

Unique identifier UC11668620

Identifier etd-SuzukiMao-9539.pdf (filename),usctheses-c89-454094 (legacy record id)

Legacy Identifier etd-SuzukiMao-9539.pdf

Dmrecord 454094

Document Type Dissertation

Rights Suzuki, Mao

Type texts

Source University of Southern California (contributing entity), University of Southern California Dissertations and Theses (collection)

Access Conditions The author retains rights to his/her dissertation, thesis or other graduate work according to U.S. copyright law. Electronic access is being provided by the USC Libraries in agreement with the a...

Repository Name University of Southern California Digital Library

Repository Location USC Digital Library, University of Southern California, University Park Campus MC 2810, 3434 South Grand Avenue, 2nd Floor, Los Angeles, California 90089-2810, USA