This document analyzes the emergence and evolution of global health initiatives (GHIs) such as GAVI, the Global Fund, PEPFAR, and the World Bank MAP. It focuses on how individuals, organizations, and networks have influenced the design and policy priorities of these institutions. Through documentary reviews and interviews with stakeholders, the study examines how GHIs were formed and how they have changed over time. While GHIs have had some success in addressing health issues, consensus has been lacking around supporting health systems strengthening, and GHIs have had an uncomfortable relationship with prioritizing broader health systems goals.

1. Emergence & Evolution of GHIs
Carlos Bruen & Ruairí Brugha
Royal College of Surgeons in Ireland

2. Aims & Methods of Study
Analysis of the emergence & evolution of GHIs
•GHIs: GAVI Alliance, Global Fund, PEPFAR, World Bank MAP
•Focus at the global level and global-country interface
•Focus on issues of partnership, governance, influence of individuals, organizations and
networks in the evolving design and policy priorities of GHIs
Methods
•Documentary Reviews
•Stakeholder mapping & in-depth telephone interviews of purposively
selected individuals (n=36) (2009-11)
•Recorded, transcribed, anonymised, thematic analysis
Interviewee Characteristics
•Constituency Affiliation at time of interview
•Constituency Crossing
•Multiple Roles

3. Actor-Centered Analysis
Health Policy Analysis
•Global Health
Object of Research: GHIs Governance
-New institutions within the field of Global Health •Comparative
Governance that drive a global agenda at the
country level Institutional Analysis
-Comprised of individuals and organizations
across multiple constituencies, aim of which is •Network Analysis
to address collective action problems
•Strategic Action
Theory
Cf: Adam & Krisei (2007); Fligstein & McAdam (2011); Hein et al (2009);Jackson (2010); Walt & Gilson (1994)

4. General Overview - Actors in GHI
Emergence
• Modus operandi rooted in the influence of different stakeholders at the time of GHI
formation
PEPFAR Global Fund GAVI Alliance
Policy Semi-open - influential small, closed
Open - Multiple policy communities
Community Closed - Small policy community
within broad issue network
policy community in broader issue
network
Type
•Core: Transitional Working Group •Core: PATH, vaccine reps from
Key Actors •Core: US Federal agencies •G8(financial), African govs multilateral institutions, private
(symbolic) sector and Gates Foundation
in GHI •US Congress negotiations &
•Consultations with countries, civil •Reps from European donor orgs
NGO/private sector lobbying
design soc , private sector (+ traditional •Consultation through personal
actors) networks
•Global Fund slow in releasing •Need for a ‘war chest’ •Counteract falling priority of
finances, PEPFAR as emergency vaccines & UN systems’
Cited response and ‘catalyst’. •Address failures of existing weaknesses
strategies, incl. UN system
Justification •Soft power focus on Africa
•Involve public and private
• Involve public + private
s •Need to improve coordination of stakeholders
stakeholders (eg WHO) in an
US agencies ‘alliance’ to get buy-in
•‘Lean and Mean’, ‘quick wins’ •‘Lean and Mean’
•1/3 spending for abstinence only •No country presence
programs, anti-prostitution pledge & •Worked with (separate to) UN •No country presence but use EPI
no funding to needle exchange agencies (immunisation) infrastructure
Examples of programs •Focus on 3 diseases, but early •Focus on new and increased
policy •System preference for US-NGOs focus on HIV/AIDS treatment scale- access to existing vaccines
outcomes •Top-down influence on national up •Use performance-based funding
reforms •Use performance-based funding •Increased NGO role for service
•Greater NGO role in service •Increased NGO role for service delivery
delivery delivery and governance

5. Case Study 1: Global Fund & Civil Society:
From Transnational Advocacy to Actors in
Governance
• Transnational civil society treatment advocacy network formed throughout
1990s
• Influence over negotiations
• Directly though high-level cross-constituency ties to political and bureaucratic elites
• Indirectly though wider network tactics (information, symbolic, leverage and accountability
tactics)
• Reflected in resulting Global Fund architecture and priorities
• Influence over evolution of structure and policies
• Including i) communities voting rights; ii) dual-track financing; iii) pressure to approve
procurement of generic medicines; iv) widening of original GF framework despite high-level
opposition; v) increasing influence of Southern NGOs
• Enduring Challenges
• Perceptions of undemocratic processes and limited stakeholder representation by a small
number of NGOs in global and country Fund governance structures
• ‘Civil society’ complexity, masking divisions and rivalries between NGOs at the global and
country levels and the divisions of lab our that have emerged
• Managing multiple ‘upwards’ +‘downwards’ lines of accountability + avoiding donor co-
option

6. Case Study 2: GAVI Alliance as a Strategic
Action Field
• What precipitates major institutional change?
• Context of GAVI Emergence: Collapse of Child Vaccine Initiative, breakdown
in actor relations & low priority for vaccines
• Phoenix rising: Formation of a small immunization community that vied for
strategic advantage in GAVI design phase through use of strategies to
increase financial and social capital and get wider buy-in
• Incumbents Challenge: Processes that led to an increased attention to HSS
as GAVI evolved included:
• Emergence of evidence on health systems’ weaknesses, undermining vertical approaches;
• Changes in GAVI governance structures, actor composition and relative power; and increases in donor
contributions and HSS financing through IFFIm;
• Opening of ‘policy windows’ and political opportunities to advance broader health systems’ support
• Settlement: While partially successful, the challenge was undermined by:
• Weak evidence of the benefits of investments in health systems strengthening, reinforcing the Gates
Foundation’s support at Board level for vertical investments;
• Fragmented health systems coalitions;
• The global financial crisis and reduced donor financing for HSS.

7. GHIs & HSS: An Uncomfortable Co-
Existence
• Global Fund
• Strong opposition to deviating funds from three diseases and hit by a fiduciary, financial and
management crisis - aid effectiveness (a pre-condition of HSS) being overtaken by more
immediate restructuring and financing concerns (McCoy et al, 2012)
• Assessment of systems effect remains built in to GF funding framework
• GAVI
• While HSS remains an important strategy, some Board members opposed to departing from
GAVI goals. Negotiated compromise resulted in a selective HSS strategic goal being
adopted, Strategic Goal 2 (2011-15)
• Consensus has been lacking on HSS, while opposition against financing a
perceived unmeasurable HSS ‘black hole’ remains strong
• Influential political coalitions or resource mobilization for HSS has not been forthcoming,
while HSS policy communities remain fragmented.
• HSS perceived to have a weak evidence base and measurable indicators of impact are
lacking or highly contested
• GHIs and donors have shifted from speed and volume to effectiveness of
disbursements – may lend support for shorter-term performance indicators

8. Conclusion: GHIs, HSS & UHC
• Strong health systems fundamental to achieving UHC. However, HSS rhetoric not matched
by financial commitments (IHME 2011; Hafner & Shiffman, 2012)
• UHC: How might it be realised in this context?

9. References
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Paul A. Sabatier, 129-54. Boulder, CO: Westview Press, 2007
• Brugha, Ruairi. "Global Health Initiatives and Public Health Policy." In International Encyclopedia of Public
Health, edited by Kris and Heggenhougen and Stella Quah, 72-81. San Diego: Academic Press, 2008.
• Fligstein, Neil, and Doug McAdam. "Toward a General Theory of Strategic Action Fields*." Sociological
Theory 29, no. 1 (2011): 1-26.
• Hafner, Tamara, and Jeremy Shiffman. "The Emergence of Global Attention to Health Systems
Strengthening." Health Policy and Planning (2012)
• Hein, Wolfgang, Scott Burris, and Clifford Shearing. "Conceptual Models for Global Health Governance."
In Making Sense of Global Health Governance: A Policy Perspective, edited by Kent Buse, Wolfgang Hein and
Nick Drager, 72-98. Basingstoke: Palgrave Macmillan, 2009.
• IHME. "Financing Global Health 2011: Continued Growth as Mdg Dealine Approaches ". Seattle, WA: Institute of
Helath Metrics & Evaluation, 2011
• Jackson, Gregory. "Actors & Institutions." In The Oxford Handbook of Comparative Institutional Analysis,
edited by Glenn Morgan, John Campbell, Colin Crouch, Ove Kai Pedersen and Richard Whitley, 63-86. Oxford:
Oxford University Press, 2010
• McCoy, David, Carlos Bruen, Peter Hill, and Dominique Kerouedan. "The Global Fund: What Next for
Aid Effectivness and Health Systems Strengthening?". Nairobi, Kenya: Aidspan, 2012
• Walt, Gill, and Lucy Gilson. "Reforming the Health Sector in Developing Countries: The Central Role of
Policy Analysis." Health Policy & Planning 9 (1994): 353-70.