UC Berkeley

Background: Over the last twenty years, despite unprecedented new resources to global health, there has been insufficient progress to achieve the health-related 2015 Millennium Development Goals. Health systems have been perceived as the binding constraint. Major global health agencies have expanded their funding priorities from disease specific programs to include support for health systems strengthening. Strengthening health systems broadly is beyond the mandate of agencies such as the Global Fund. Nonetheless, since its inception, the Global Fund has supported health systems; however, it has had a long-running organizational struggle with how to do it. Mechanisms for health systems support have varied, and proposals for health systems support consistently have been of a lower quality than disease proposals. The Technical Review Panel of the Fund has criticized it for lack of clarity about what it means by health systems strengthening and called into question the Fund's ability to support effective responses to health systems constraints. Purpose: The purpose of this dissertation is to present a case study of the Global Fund's policies and strategy on health systems strengthening using the lens of neo-institutional theory. This dissertation explores the role legitimacy and the cognitive beliefs about health systems strengthening held by stakeholders in the Global Fund's environment have played in shaping the Fund's policies on health systems strengthening. Methods: Qualitative research methods are used to examine the beliefs about health systems strengthening held by members of Board delegations and the role these beliefs played in shaping the Global Fund's strategy on health systems strengthening. Official Global Fund documents were reviewed and primary data was gathered through 31 semi-structured in-depth interviews with members of the Board delegations, Secretariat, Technical Partner organizations and other relevant stakeholders in the Global Fund's environment to complement the document review. Findings: (1) Health system strengthening is a vague concept. (2) Depending on the context, there are two meanings - a technical one and a political one. (3) There is dispute over what constitutes acceptable health systems strengthening work. (4) Health system strengthening is essential for the success of the Global Fund, but there is disagreement over whether the Global Fund should engage in health system strengthening; if it does, how, and to what extent. (5) Linking funding to measurable health outcomes is essential for legitimacy. Health systems strengthening is beyond the scope of the Fund's mandate, current technical capacity and organizational design. The Fund ought to focus on what it does well, which is financing scale up of essential inputs. The Health Systems Funding Platform provides an opportunity for the Fund to support public health system strengthening in a way that will appease key stakeholders but still allow it to stay within the bounds of its disease-specific mission.