Power across the global health landscape: a network analysis of development assistance 1990–2015

Power distribution across the global health landscape has undergone a fundamental shift over the past three decades. What was once a system comprised largely of bilateral and multilateral institutional arrangements between nation-states evolved into a varied landscape where these traditional actors were joined by a vast assemblage of private firms, philanthropies, non-governmental organizations and public–private partnerships. Financial resources are an explicit power source within global health that direct how, where and to whom health interventions are delivered, which health issues are (de)prioritized, how and by whom evidence to support policies and interventions is developed and how we account for progress. Financial resource allocations are not isolated decisions but rather outputs of negotiation processes and dynamics between actors who derive power from a multiplicity of sources. The aims of this paper are to examine the changes in the global health actor landscape and the shifts in power using data on disbursements of development assistance for health (DAH). A typology of actors was developed from previous literature and refined through an empirical analysis of DAH. The emergent network structure of DAH flows between global health actors and positionality of actors within the network were analysed between 1990 and 2015. The results reflect the dramatic shift in the numbers of actors, relationships between actors, and funding dispersal over this time period. Through a combination of the massive influx of new funding sources and a decrease in public spending, the majority control of financial resources in the DAH network receded from public entities to a vast array of civil society organizations and public–private partnerships. The most prominent of these was the Bill and Melinda Gates Foundation and the Global Fund for AIDS, TB and malaria, which rose to the third and fourth most central positions within the DAH network by 2015.