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The Institute for Global Health and Development

Permanent URI for this collectionhttps://eresearch.qmu.ac.uk/handle/20.500.12289/9

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Subject: search.filters.subject.Political Economy Analysis

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    Understanding the political economy of reforming global health initiatives – insights from global and country levels
    (Springer, 2025-07-09) Witter, Sophie; Palmer, Natasha; Jouhaud, Rosemary; Zaidi, Shehla; Carillon, Severine; English, Rene; Loffreda, Giulia; Venables, Emilie; Habib, Shifa Salman; Tan, Jeff; Hane, Fatouma; Bertone, Maria Paola; Hosseinalipour, Seyed-Moeen; Ridde, Valery; Shoaib, Asad; Faye, Adama; Dudley, Lilian; Daniels, Karen; Blanchet, Karl
    Introduction Since 2000, the number and role of global health initiatives (GHIs) has been growing, with these platforms playing an increasingly important role in pooling and disbursing funds dedicated to specific global health priorities. While recognising their important contribution, there has also been a growth in concerns about distortions and inefficiencies linked to the GHIs and attempts to improve their alignment with country health systems. There is a growing momentum to adjust GHIs to the current broader range of global health threats, such as non-communicable diseases, humanitarian crises and climate change, and against the backdrop of the recent aid cuts. However, reform attempts are challenged by the political economy of the current structures. Methods In this article, we draw on research conducted as part of the Future of Global Health Initiatives process. The study adopted a cross-sectional, mixed-methods approach, drawing from a range of data sources and data collection methods, including a global and regional level analysis as well as three embedded country case studies in Pakistan, South Africa and Senegal. All data was collected from February to July 2023. 271 documents were analysed in the course of the study, along with data from 335 key informants and meeting participants in 66 countries and across a range of constituencies. For this paper, data were analysed using a political economy framework which focused on actors, context (especially governance and financing) and framing. Findings In relation to actors, the GHIs themselves have become increasingly complex (both internally and in their interrelations with other global health actors and one another). They have a large range of clients (including at national level and amongst multilateral agencies) which function as collaborators as well as competitors. Historically there have been few incentives for any of the actors to maximise collaboration given the competitive funding landscape. Power to exert pressure for reforms sits ultimately with bilateral and private funders, though single-issue northern non-governmental organisations (NGOs) are also cited as important influencers. Funders have not collaborated to enable reforms, despite concerns amongst a number of them, because of the helpful functional role of GHIs, which serves funder interests. Some key global boards are reported to be engineered for stasis, and there are widespread concerns about lack of transparency and over-claiming (by some GHIs) of their results. Framing of narratives about achievements and challenges is important to enable or block reforms and are vigorously contested, with stakeholders often selecting different outcomes to emphasise in justifying positions. Conclusion GHIs have played an important role in the global health ecosystem but despite formal accountability structures to include recipient governments, substantive accountability has been focused upwards to funders, with risk management strategies which prioritise tracking resources more than improved national health system performance. Achieving consensus on reforms will be challenging but current funding pressures and new threats are creating a sense of urgency, which may shift positions. Political economy analysis can model and influence these debates.
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    The political economy of results-based financing: The experience of the health system in Zimbabwe
    (Springer Nature, 2019-07-15) Witter, Sophie; Chirwa, Yotamu; Chandiwana, Pamela; Munyati, Shungu; Pepukai, Mildred; Bertone, Maria Paola
    Background: Since 2000, results based financing (RBF) has proliferated in health sectors in Africa in particular, including in fragile and conflict affected settings (FCAS) and there is a growing but still contested literature about its relevance and effectiveness. Less examined are the political economy factors behind the adoption of the RBF policy, as well as the shifts in influence and resources which RBF may bring about. In this article, we examine these two topics, focusing on Zimbabwe, which has rolled out RBF nationwide in the health system since 2011, with external support.
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    The bumpy trajectory of performance-based financing for healthcare in Sierra Leone: agency, structure and frames shaping the policy process
    (BioMed Central, 2018-10-20) Bertone, Maria Paola; Wurie, Haja; Samai, Mohamed; Witter, Sophie
    Background - As performance-based financing (PBF) has been increasingly implemented in low-income countries, a growing literature has developed, assessing its effectiveness and, more recently, focussing on the political dynamics of PBF introduction and implementation. This study contributes to the latter body of literature by exploring decision-making processes on PBF in Sierra Leone during the 2010–2017 period. Sierra Leone presents an interesting case because of the ‘start-stop-start’ trajectory of PBF. Methods - The qualitative case study is based on a document review and 25 key informant interviews with national stakeholders and international actors. Documents and interviews were analysed based on a political economy framework focusing on actors and structure, but also making use of concepts drawn from interpretive policy analysis to look at frames. Results - Our analysis describes the process of negotiation and re-negotiation of PBF in Sierra Leone, highlighting the role of different players, both internal and external, their ideas, capacity and power relations, and the shifting narratives around PBF. It is shown that external actors driving the debate make use of ‘frames’, both actual (i.e., defining the timing and pace of the discussions, the funding available, etc.) and metaphorical (i.e., how PBF is interpreted, defined and understood) to fit in and influence the debate. This is facilitated by the lack of capacity and resources in the fragile setting. Other strategies, such as ‘venue shopping’ are employed, though they may add to fragmentation in the volatile context. Conclusions - The retrospective view of the study has an analytical advantage, but findings are also relevant to guide practice. Although power relations and rent-seeking issues are difficult to overcome in resource and capacity-constrained settings, more attention could be paid to other elements. In particular, adopting shared frames to ensure a common and inclusive understanding of technical concepts such as PBF may be useful to ensure the political sustainability of reforms. Also, the ‘actual frames’ which define negotiation and implementation should remain flexible, allowing for disrupting events (e.g., the Ebola epidemic in Sierra Leone) as well as for time to develop national capacity and ownership in order to ensure longer-term political support and better health system integration.