The Political Dynamics of Decision-Making in Gavi, the Vaccine Alliance (GAVI): Decision-making in the GAVI board on COVAX

Although existing studies have made significant contributions to the field of global health governance by demonstrating the importance of ideas for understanding global health governance, they have not much explored about how global health policies are made within international health organisations. Aiming to address this research gap, this study examines decision-making within GAVI, an international health organisation based on a public-private partnership model. Since the COVID-19 pandemic, GAVI has been co-convening COVAX, the global initiative to ensure equitable access to vaccines globally. GAVI’s Board, the highest decision-making body, has made a series of important decisions for the development of COVAX. Despite the influence of these policies on global health, we know little about how they are made in practice. Through documentary research, non-participant observations of Board meetings in 2020 and 2021, and semi-structured interviews with GAVI stakeholders, I found that: decision-making in the Board was not simply determined by the interests of the most powerful Board members; Board members did not stick to their formal identities and did not pursue a narrow set of constituency interests; and that the secretariat affected decision making too, making a variety of claims authority to influence decision-making in pursuit of its own agendas and perceived interests. I argue that during the COVID-19 pandemic, a broad set of material and ideational factors influenced the Board’s decision-making processes. Ideas (norms, principles, culture, identity, and perceived interests) played an important role in shaping decisions on the development of COVAX: material power was not always decisive. In particular, I show that socialisation took place in the Board during the period through the formal and informal interactions of GAVI’s key policy actors (Board members and staff of the Secretariat) as well as through familiarisation of a set of institutional/cultural rules and norms. In this way, social interactions and socialisation led to the (re)constitution of Board members’ identities and interests, making consensus possible even when it would be assumed that Board members represented diametrically opposed sets of interests. This thesis contributes to the field of global health governance, by: providing an empirical case of decision-making in one of the most important global health organisations during the COVID-19 pandemic; showing that the constructivist tradition provides a useful framework for understanding global health policy-making; and suggesting another source of the authority of an international organisation (‘consultative authority’).