Official websites use. Share sensitive information only on official, secure websites. This is an Open Access article. Non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly attributed, cited, and is not altered, transformed, or built upon in any way, is permitted. The moral rights of the named author s have been asserted. Lauded for getting specific health issues onto national and international agendas and for their potential to improve value for money and outcomes, public-private global health initiatives GHIs have come to dominate global health governance.
Yet, they have also been criticised for their negative impact on country health systems. In response, disease-specific GHIs have, somewhat paradoxically, appropriated the aim of health system strengthening HSS. This article critically analyses this development through an ethnographic case study of the GAVI Alliance, which funds vaccines in poor countries.
Yet, its meaning remains unclear and contested understandings of the health systems agenda abound, reflecting competing public health ideologies and professional pressures within the global health field. Keywords: global health initiatives, health systems, policy, ethnography, history. Critics counter that GHIs are a double-edged sword: while they massively increase the resources available to global health, they also reinforce a business approach to governance and circumscribed, technical solutions to health Birn, , b.
Growing evidence that GHIs have a number of unintended negative health system consequences Biesma et al. Yet, I argue that what is meant by HSS support remains unclear; contested understandings of the health systems agenda abound within the epistemic community around GAVI, reflecting professional pressures and competing public health ideologies.
These speak to an enduring tension in the history of international health between vertical programmes, which are often single disease-focused, and horizontal approaches such as primary health care Cueto, ; Mills, , GAVI's HSS concept also has little in common with more recent theoretical understandings of health systems as core social institutions Freedman, and as potential mechanisms for alleviating social inequalities Mackintosh, Instead, I approach the debates around GAVI's health systems goal as part of a contested social process through which different actors negotiate their positions and claims to legitimacy Mosse, I attempt to embed policy discourse within the expert groups or epistemic communities that generate, organise or are organised by its ideas Mosse, I analysed policy and scientific documents, and observed debates as they played out in research meetings, academic and public lectures, panel discussions and various high-level policy events.
