Understanding the political economy of reforming global health initiatives – insights from global and country levels
Authors: Witter Sophie , Palmer Natasha , James 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 
Published: November 2024

Introduction
Since 2000, the number and role of global health initiatives 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. However, these reform attempts hit up against political economy realities 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 (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 within 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 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. Narratives about achievements and challenges are 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 funding pressures and new threats are creating a sense of urgency, which may shift positions. Political economy analysis can model and influence these debates.