Private capital in a public field: a qualitative study of philanthropic influence in Germany's global health governance.

Background: International philanthropic foundations have become prominent actors in global health, influencing funding priorities, institutional partnerships, and governance practices at a scale that increasingly rivals many state actors. While their role in multilateral organisations and low- and middle-income countries (LMICs) has been widely debated, less is known about how these actors operate within high-income donor countries themselves. Over the past two decades, Germany has emerged as a key contributor to global health initiatives and has developed close working relationships with international foundations, particularly the Gates Foundation and the Wellcome Trust. This study examines how global health stakeholders in Germany perceive the evolving role and influence of international philanthropic foundations within the country's domestic global health landscape and explores the implications for global health governance. Results: Across political, academic, civil society, private sector, and philanthropic stakeholders, four principles roles were attributed to international philanthropic foundations: strategic funding, thematic prioritisation, knowledge brokerage, and convening. Foundations were widely perceived as simultaneously enabling and constraining, providing resources, political momentum and continuity in global health engagement, particularly during periods of political uncertainty, while also concentrating agenda-setting power and shaping the boundaries of legitimate intervention. Five principal domains of perceived impact were identified: priority- and agenda-setting, governance fragmentation, organisational dependency, stabilisation of global health, and legitimacy debates. Influence was perceived to operate not only through financial resources but also through networks, expertise, and symbolic credibility, with growing dependency on private foundations described as deepening structural asymmetries within the field. Conclusion: The German case illustrates how international philanthropic foundations interact with public development institutions within a major donor state, simultaneously strengthening and reshaping national engagement in global health. The dynamics identified, including strategic alignment, thematic narrowing and organisational dependency, are not confined to LMIC contexts but are structurally embedded within the broader architecture of global health governance, reinforcing critique of the donor/recipient binary that often frames this field of inquiry. As public financing contracts and philanthropic actors assume a more prominent role in filling resulting gaps, greater transparency, safeguards for pluralism, and governance frameworks that preserve accountability and equity in global health become increasingly important.