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Since December 2005 the GAVI Alliance (GAVI) Health Systems Strengthening (HSS) window has offered predictable funding to developing countries, based on a combined population and economic formula. This is intended to assist them to address system constraints to improved immunization coverage and health care delivery, needed to meet the Millennium Development Goals. The application process invites countries to prioritize specific system constraints not adequately addressed by other donors, and allows them to allocate their eligible funds accordingly. This article presents an analysis of the first four rounds of countries' funding applications. These requested funding for a variety of health system initiatives that reflected country-specific requirements, and were not limited to improving immunization coverage. Analyses identified a dominance of operational-level health service provision activities, and an absence of interventions related to demand and financing. While the proposed activities are only now being implemented, the results of this study provide evidence that the open application process employed by the HSS window has led to a shift in analysis and planning-from the programmatic to the systemic-in the countries whose applications have been approved. However, the proposed responses to identified constraints are dominated by short-term operational responses, rather than more complex, longer term approaches to health system strengthening.

Summaryobjectives To analyse the first four rounds of country applications to the GAVI Alliance Health Systems Strengthening (GAVI-HSS) funding window; to provide valuable insight into how countries prioritize, articulate and propose solutions for health system constraints through the GAVI-HSS application process and to examine the extent to which this process embodies alignment and harmonization, Principles of the Paris Declaration.methods The study applied multiple criteria to analyse 48 funding applications from 40 countries, submitted in the first four rounds, focusing on the country analysis of health systems constraints, coordination mechanisms, alignment with national and sector planning processes, inclusiveness of the planning processes and stakeholder engagement.results The applications showed diversity in the health systems constraints identified and the activities proposed. Requirements of GAVI for sector oversight and coordination, and the management of the application process through the Ministry of Health's Planning Department, resulted in strong alignment with government policy and planning processes and good levels of stakeholder inclusion and local technical support (TS).conclusion Health Systems Strengthening initiatives for global health partnerships (GHPs) can provide a link between the programmatic and the systemic, influencing policy alignment and harmonization of processes. The applications strengthened in-country coordination and planning, with countries using existing health sector assessments to identify system constraints, and to propose. Analyses also produced evidence of broad stakeholder inclusiveness, a good degree of proposal alignment with national health plans and policy documents, and engagement of a largely domestic TS network. While the effectiveness of the proposed interventions cannot be determined from this data, the findings provide support for the GAVI-HSS initiative as implementation continues and evaluation begins.

Background In the nearly half century since it began lending for population projects, the World Bank has become one of the largest financiers of global health projects and programs, a powerful voice in shaping health agendas in global governance spaces, and a mass producer of evidentiary knowledge for its preferred global health interventions. How can social scientists interrogate the role of the World Bank in shaping ‘global health’ in the current era? Main body As a group of historians, social scientists, and public health officials with experience studying the effects of the institution’s investment in health, we identify three challenges to this research. First, a future research agenda requires recognizing that the Bank is not a monolith, but rather has distinct inter-organizational groups that have shaped investment and discourse in complicated, and sometimes contradictory, ways. Second, we must consider how its influence on health policy and investment has changed significantly over time. Third, we must analyze its modes of engagement with other institutions within the global health landscape, and with the private sector. The unique relationships between Bank entities and countries that shape health policy, and the Bank’s position as a center of research, permit it to have a formative influence on health economics as applied to international development. Addressing these challenges, we propose a future research agenda for the Bank’s influence on global health through three overlapping objects of and domains for study: knowledge-based (shaping health policy knowledge), governance-based (shaping health governance), and finance-based (shaping health financing). We provide a review of case studies in each of these categories to inform this research agenda. Conclusions As the COVID-19 pandemic continues to rage, and as state and non-state actors work to build more inclusive and robust health systems around the world, it is more important than ever to consider how to best document and analyze the impacts of Bank’s financial and technical investments in the Global South.

Chapter 20 describes the way in which the support system provided by the traditional African extended family has given way in recent years to a new dependency by individuals on state organized health systems, charities, and private concerns. It discusses that the result has been increasing health costs and growing inequalities, and how it is now the poorest people who pay proportionately the highest amount for their healthcare out of their own pockets. The chapter sets out in broad terms the challenges faced by countries seeking to offer universal access to health and healthcare for their citizens. These are challenges that, as discussed in earlier chapters, require countries to find a way to meet these challenges that is based both on their culture and history, and on their financial capabilities and circumstances.