Publishing priorities in global health: A framework and empirical analysis.

Though vital to health policymaking processes, little is known about the distribution of attention to issues global health journals focus on or their alignment with commitments to health equity. We developed a new framework and methods to help address these analytical gaps. We used content analysis to systematically identify and novel methods to measure attention to themes, subthemes and geographies represented in more than 2,000 research articles published in two of the longest-running multidisciplinary global health journals, Bulletin of the World Health Organization and Health Policy and Planning, between 2004 and 2018. We found four major themes-health systems and conditions received the most attention, followed by population groups and policy dynamics. Finer grained analysis shows that the broad-based journals feature many common themes and some, including subthemes like communicable diseases, financing and children, are heavily favoured over others, such as workforce and noncommunicable diseases. It reveals publishing gaps for some highly marginalised groups and shows attention to health equity fluctuates. The new framework and methods can be used to (1) check the distribution of publishing attention for consistency with global health and specific journal aims and (2) support inquiry into priority setting dynamics in the broader research publishing arena.

Generating Political Priority for the Health Needs of the 21st Century: A Qualitative Policy Analysis on the Prioritization of Rehabilitation Services in Uganda.

BACKGROUND: Few low- or middle-income countries (LMICs) have prioritized the expansion of rehabilitation services. Existing scholarship has identified that problem definition, governance, and structural factors are influential in the prioritization of rehabilitation. The objective of this study was to identify the factors influencing the prioritization and implementation of rehabilitation services in Uganda. METHODS: A case study design was utilized. The Prioritization of Rehabilitation in National Health Systems framework guided the study. Data sources included 33 key informant interviews (KIIs) with governmental and non-governmental stakeholders and peer-reviewed and grey literature on rehabilitation in Uganda. A thematic content analysis and concept map were conducted to analyze the data. RESULTS: Rehabilitation is an unfunded priority in Uganda, garnering political attention but failing to receive adequate financial or human resource allocation. The national legacy of rehabilitation as a social program, instead of a health program, has influenced its present-day prioritization trajectory. These include a fragmented governance system, a weak advocacy coalition without a unified objective or champion, and a lack of integration into existing health systems structures that makes it challenging to scale-up service provision. Our findings highlight the interactive influences of structural, governance, and framing factors on prioritization and the importance of historical context in understanding both prioritization and implementation. CONCLUSION: Our findings demonstrate challenges in prioritizing emerging, multi-sectoral health areas like rehabilitation. Strategic considerations for elevating rehabilitation on Uganda's policy agenda include generating credible indicators to quantify the nature and extent of the population's need and uniting governmental and non-governmental actors around a common vision for rehabilitation's expansion. We present opportunities for strengthening rehabilitation, both in Uganda and in similar contexts grappling with many health sector priorities and limited resources.

How to evaluate a multi-country implementation-focused network: Reflections from the Quality of Care Network (QCN) evaluation.

Learning about how to evaluate implementation-focused networks is important as they become more commonly used. This research evaluated the emergence, legitimacy and effectiveness of a multi-country Quality of Care Network (QCN) aiming to improve maternal, newborn and child health (MNCH) outcomes. We examined the QCN global level, national and local level interfaces in four case study countries. This paper presents the evaluation team's reflections on this 3.5 year multi-country, multi-disciplinary project. Specifically, we examine our approach, methodological innovations, lessons learned and recommendations for conducting similar research. We used a reflective methodological approach to draw lessons on our practice while evaluating the QCN. A 'reflections' tool was developed to guide the process, which happened within a period of 2-4 weeks across the different countries. All country research teams held focused 'reflection' meetings to discuss questions in the tool before sharing responses with this paper's lead author. Similarly, the different lead authors of all eight QCN papers convened their writing teams to reflect on the process and share key highlights. These data were thematically analysed and are presented across key themes around the implementation experience including what went well, facilitators and critical methodological adaptations, what can be done better and recommendations for undertaking similar work. Success drivers included the team's global nature, spread across seven countries with members affiliated to nine institutions. It was multi-level in expertise and seniority and highly multidisciplinary including experts in medicine, policy and health systems, implementation research, behavioural sciences and MNCH. Country Advisory Boards provided technical oversight and support. Despite complexities, the team effectively implemented the QCN evaluation. Strong leadership, partnership, communication and coordination were key; as were balancing standardization with in-country adaptation, co-production, flattening hierarchies among study team members and the iterative nature of data collection. Methodological adaptations included leveraging technology which became essential during COVID-19, clear division of roles and responsibilities, and embedding capacity building as both an evaluation process and outcome, and optimizing technology use for team cohesion and quality outputs.

Evaluating theory of change to improve the functioning of the network for improving quality of care for maternal, newborn and child health.

In 2017, WHO and global partners launched 'The Network for Improving Quality of Care for Maternal, Newborn and Child Health' (QCN) seeking to reduce in-facility maternal and newborn deaths and stillbirth by 50% in health facilities by 2022. We explored how the QCN theory of change guided what actually happened over 2018-2022 in order to understand what worked well, what did not, and to ultimately describe the consequences of QCN activities. We applied theory of change analysis criteria to investigate how well-defined, plausible, coherent and measurable the results were, how well-defined, coherent, justifiable, realistic, sustainable and measurable the assumptions were, and how independent and sufficient the causal links were. We found that the QCN theory of change was not used in the same way across implementing countries. While the theory stipulated Leadership, Action, Learning and Accountability as the principle to guide network activity implementation other principles and varying quality improvement methods have also been used; key conditions were missing at service integration and process levels in the global theory of change for the network. Conditions such as lack of physical resources were frequently reported to be preventing adequate care, or harm patient satisfaction. Key partners and implementers were not introduced to the network theory of change early enough for them to raise critical questions about their roles and the need for, and nature of, quality of care interventions. Whilst the theory of change was created at the outset of QCN it is not clear how much it guided actual activities or any monitoring and evaluation as things progressed. Enabling countries to develop their theory of change, perhaps guided by the global framework, could improve stakeholder engagement, allow local evaluation of assumptions and addressing of challenges, and better target QCN work toward achieving its goals.

Factors shaping network emergence: A cross-country comparison of quality of care networks in Bangladesh, Ethiopia, Malawi, and Uganda.

The Quality-of-Care Network (QCN) was conceptualized by the World Health Organization (WHO) and other global partners to facilitate learning on and improve quality of care for maternal and newborn health within and across low and middle-income countries. However, there was significant variance in the speed and extent to which QCN formed in the involved countries. This paper investigates the factors that shaped QCN's differential emergence in Bangladesh, Ethiopia, Malawi, and Uganda. Drawing on network scholarship, we conducted a replicated case study of the four country cases and triangulated several sources of data, including a document review, observations of national-level and district level meetings, and key informant interviews in each country and at the global level. Thematic coding was performed in NVivo 12. We find that QCN emerged most quickly and robustly in Bangladesh, followed by Ethiopia, then Uganda, and slowest and with least institutionalization in Malawi. Factors connected to the policy environment and network features explained variance in network emergence. With respect to the policy environment, pre-existing resources and initiatives dedicated to maternal and newborn health and quality improvement, strong data and health system capacity, and national commitment to advancing on synergistic goals were crucial drivers to QCN's emergence. With respect to the features of the network itself, the embedding of QCN leadership in powerful agencies with pre-existing coordination structures and trusting relationships with key stakeholders, inclusive network membership, and effective individual national and local leadership were also crucial in explaining QCN's speed and quality of emergence across countries. Studying QCN emergence provides critical insights as to why well-intentioned top-down global health networks may not materialize in some country contexts and have relatively quick uptake in others, and has implications for a network's perceived legitimacy and ultimate effectiveness in producing stated objectives.

Comparing priority received by global health issues: a measurement framework applied to tuberculosis, malaria, diarrhoeal diseases and dengue fever.

INTRODUCTION: The relative priority received by issues in global health agendas is subjected to impressionistic claims in the absence of objective methods of assessment of priority. To build an approach for conducting structured assessments of comparative priority health issues receive, we expand the public arenas model (2021) and offer a framework for future assessments of health issue priority in global and national health agendas. METHODS: We aimed to develop a more comprehensive set of measures for conducting multiyear priority comparisons of health issues in six agenda-setting arenas by identifying possible measures and data sources, selecting indicators based on feasibility and comparability of measures and gathering the data on selected indicators. We applied these measures to four communicable diseases-tuberculosis (TB), malaria, diarrhoeal diseases and dengue fever-given their differing impressionistic claims of priority. Where possible, we analysed the annual and/or 5-year trends from 2000 through 2022. RESULTS: We observed that TB and malaria received the highest priority for most periods in the past two decades in most arenas. However, a stagnation in development funding for these two conditions over the last 8-10 years may have fuelled the neglect claims. Despite having a higher disease burden, diarrhoea has been slipping in global priority with reduced spending, fewer clinical trials and stagnating publications. Dengue remains a low-priority condition but has witnessed a sharp rise in attention from the pharmaceutical industry. DISCUSSIONS: We expanded the arenas model by including a transnational arena (international representation) and additional measurements for various arenas. This analysis presents an approach to enable comparative trend analysis of the markers of agenda status over a multiyear period. More such analyses can bring much-desired objectivity in understanding how attention to global or national health issues changes over time in different arenas, potentiating a more equitable allocation of resources.

Shifting patterns and competing explanations for infectious disease priority in global health agenda setting arenas.

The highly decentralized nature of global health governance presents significant challenges to conceptualizing and systematically measuring the agenda status of diseases, injuries, risks and other conditions contributing to the collective disease burden. An arenas model for global health agenda setting was recently proposed to help address these challenges. Further developing the model, this study aims to advance more robust inquiry into how and why priority levels may vary among the array of stakeholder arenas in which global health agenda setting occurs. We analyse order and the magnitude of changes in priority for eight infectious diseases in four arenas (international aid, scientific research, pharmaceutical industry and news media) over a period of more than two decades in relation to five propositions from scholarship. The diseases vary on burden and prominence in United Nations Sustainable Development Goal 3 for health and well-being, including four with specific indicators for monitoring and evaluation (HIV/AIDS, tuberculosis, malaria, hepatitis) and four without (dengue, diarrhoeal diseases, measles, meningitis). The order of priority did not consistently align with the disease burden or international development goals in any arena. Additionally, using new methods to measure the scale of annual change in resource allocations that are indicative of priority reveals volatility at the disease level in all arenas amidst broader patterns of stability. Insights around long-term patterns of priority within and among arenas are integral to strengthening analyses that aim to identify pivotal causal mechanisms, to clarify how arenas interact, and to measure the effects they produce.

The emergence and regression of political priority for refugee integration into the Jordanian health system: an analysis using the Kingdon's multiple streams model.

BACKGROUND: The prolonged presence of Syrian refugees in Jordan has highlighted the need for sustainable health service delivery models for refugees. In 2012, the Jordanian government adopted a policy that granted Syrian refugees access, free of charge, to the national health system. However since 2012, successive policy revisions have limited refugee access. This paper seeks to understand factors that initially put refugee integration into the health system on the policy agenda, as well as how these same factors later affected commitment to sustain the policy. METHODS: This paper draws on data from a document review of 197 peer-reviewed and grey literature publications, a media analysis of newspaper articles retrieved from four officially recognized newspapers in Jordan, and 33 semi-structured key informant interviews. We used Kingdon's Multiple Streams Model - a well-established tool for analyzing policy adoption - to understand how political priority developed for integration of refugees into the health system. RESULTS: We find that several factors helped bring attention to the issue, namely concerns over infectious disease transmission to host communities, high rates of chronic conditions among the refugee population and the increasingly urban and dispersed nature of refugees. At the outset of the conflict, the national mood was receptive to refugees. Politicians and government officials quickly recognized the crisis as an opportunity to secure material and technical support from the international humanitarian community. At the same time, global pressures for integrating refugees into national health systems helped move the integration agenda forward in Jordan and the region more broadly. Since 2012, there were several modifications to the policy that signal profound changes in national views around the continued presence of Syrian refugees in the country, as well as reduced external financial support which has undermined the sustainability of the policy. CONCLUSION: This case study underscores the dynamic nature of policymaking and the challenge of sustaining government commitment to the right to health among refugees. Our analysis has important implications for advocates seeking to advance and maintain momentum for the integration of refugees into national health systems.

How integration of refugees into national health systems became a global priority: a qualitative policy analysis.

BACKGROUND: Despite a long history of political discourse around refugee integration, it wasn't until 2016 that this issue emerged as a global political priority. Limited research has examined the evolution of policies of global actors around health service provision to refugees and how refugee integration into health systems came onto the global agenda. This study seeks to fill this gap. METHODS: Drawing on a document review of 20 peer-reviewed articles, 46 global policies and reports, and 18 semi-structured interviews with actors representing various bilateral, multilateral and non-governmental organizations involved with refugee health policy and funding, we analyze factors that have shaped the global policy priority of integration. We use the Shiffman and Smith Policy Framework on determinants of political priority to organize our findings. RESULTS: Several important factors generated global priority for refugee integration into national health systems. Employing the above-mentioned framework, actor power increased due to network expansion through collaborations between humanitarian and development actors. Ideas took hold through the framing of integration as a human rights and responsibility sharing. While political context was influenced through several global movements, it was ultimately the influx of Syrian refugees into Europe and the increasing securitization of the refugee crisis that led to key policies, and critically, global funding to support integration within refugee hosting nations. Finally, issue characteristics, namely the magnitude of the global refugee crisis, its protractedness and the increasing urbanicity of refugee inflows, led integration to emerge as a manageable solution. CONCLUSION: The past decade has seen a substantial reframing of refugee integration, along with increased financing sources and increased collaboration, explains this shift towards their integration into health systems. However, despite the emergence of integration as a global political priority, the extent to which efforts around integration have translated into action at the national level remains uncertain.

Effectiveness of a multi-country implementation-focused network on quality of care: Delivery of interventions and processes for improved maternal, newborn and child health outcomes.

The Network for Improving Quality of Care for Maternal, Newborn and Child Health (QCN) aims to work through learning, action, leadership and accountability. We aimed to evaluate the effectiveness of QCN in these four areas at the global level and in four QCN countries: Bangladesh, Ethiopia, Malawi and Uganda. This mixed method evaluation comprised 2-4 iterative rounds of data collection between 2019-2022, involving stakeholder interviews, hospital observations, QCN members survey, and document review. Qualitative data was analysed using a coding framework developed from underlying theories on network effectiveness, behaviour change, and QCN proposed theory of change. Survey data capturing respondents' perception of QCN was analysed with descriptive statistics. The QCN global level, led by the WHO secretariat, was effective in bringing together network countries' governments and global actors via providing online and in-person platforms for communication and learning. In-country, various interventions were delivered in 'learning districts', however often separately by different partners in different locations, and pandemic-disrupted. Governance structures for quality of care were set-up, some preceding QCN, and were found to be stronger and better (though often externally) resourced at national than local levels. Awareness of operational plans and network activities differed between countries, was lower at local than national levels, but increased from 2019 to 2022. Engagement with, and value of, QCN was perceived to be higher in Uganda and Bangladesh than in Malawi or Ethiopia. Capacity building efforts were implemented in all countries-yet often dependent on implementing partners and donors. QCN stakeholders agreed 15 core monitoring indicators though data collection was challenging, especially for indicators requiring new or parallel systems. Accountability initiatives remained nascent in 2022. Global and national leadership elements of QCN have been most effective to date, with action, learning and accountability more challenging, partner or donor dependent, remaining to be scaled-up, and pandemic-disrupted.

The Health Justice Policy Tracker: COVID-19 Policies To Advance Health Justice For Vulnerable Populations.

The rapid spread of COVID-19 throughout the world in early 2020 created unprecedented challenges for national governments. Policies developed during the early months of the pandemic, before the first mRNA vaccines were authorized for emergency use, provide a window into national governments' prioritization of populations that were particularly vulnerable. We developed the COVID-19 Health Justice Policy Tracker to capture and categorize these policies using a health justice lens. In this article we present the results of a preliminary analysis of the tracker data. The tracker focuses on policies for six population groups: children, the elderly, people with disabilities, migrant workers, incarcerated people, and people who were refugees or were seeking political asylum. It includes 610 policies, most targeting children and the elderly and providing financial support. National governments also prioritized measures such as policies to ensure access to mental health care and social services, digital and teleservices, continuity of children's education, and food security. The tracker provides a resource for researchers and policy makers seeking model language and tested policy approaches to advance health justice during future crises.

Influences on policy-formulation, decision-making, organisation and management for maternal, newborn and child health in Bangladesh, Ethiopia, Malawi and Uganda: The roles and legitimacy of a multi-country network.

The Network for Improving Quality of Care for Maternal, Newborn and Child Health (QCN) is intended to facilitate learning, action, leadership and accountability for improving quality of care in member countries. This requires legitimacy-a network's right to exert power within national contexts. This is reflected, for example, in a government's buy-in and perceived ownership of the work of the network. During 2019-2022 we conducted iterative rounds of stakeholder interviews, observations of meetings, document review, and hospital observations in Bangladesh, Ethiopia, Malawi, Uganda and at the global level. We developed a framework drawing on three models: Tallberg and Zurn which conceptualizes legitimacy of international organisations dependent on their features, the legitimation process and beliefs of audiences; Nasiritousi and Faber, which looks at legitimacy in terms of problem, purpose, procedure, and performance of institutions; Sanderink and Nasiritousi, to characterize networks in terms of political, normative and cognitive interactions. We used thematic analysis to characterize, compare and contrast institutional interactions in a cross-case synthesis to determine salient features. Political and normative interactions were favourable within and between countries and at global level since collective decisions, collaborative efforts, and commitment to QCN goals were observed at all levels. Sharing resources and common principles were not common between network countries, indicating limits of the network. Cognitive interactions-those related to information sharing and transfer of ideas-were more challenging, with the bi-directional transfer, synthesis and harmonization of concepts and methods, being largely absent among and within countries. These may be required for increasing government ownership of QCN work, the embeddedness of the network, and its legitimacy. While we find evidence supporting the legitimacy of QCN from the perspective of country governments, further work and time are required for governments to own and embed the work of QCN in routine care.

Global priority for the care of orphans and other vulnerable children: transcending problem definition challenges.

BACKGROUND: Tens of millions of children lack adequate care, many having been separated from or lost one or both parents. Despite the problem's severity and its impact on a child's lifelong health and wellbeing, the care of vulnerable children-which includes strengthening the care of children within families, preventing unnecessary family separation, and ensuring quality care alternatives when reunification with the biological parents is not possible or appropriate-is a low global priority. This analysis investigates factors shaping the inadequate global prioritization of the care of vulnerable children. Specifically, the analysis focuses on factors internal to the global policy community addressing children's care, including how they understand, govern, and communicate the problem. METHODS: Drawing on agenda setting scholarship, we triangulated among several sources of data, including 32 interviews with experts, as well as documents including peer-reviewed literature and organizational reports. We undertook a thematic analysis of the data, using these to create a historical narrative on efforts to address children's care, and specifically childcare reform. RESULTS: Divisive disagreements on the definition and legitimacy of deinstitutionalization-a care reform strategy that replaces institution-based care with family-based care-may be hindering priority for children's care. Multiple factors have shaped these disagreements: a contradictory evidence base on the scope of the problem and solutions, divergent experiences between former Soviet bloc and other countries, socio-cultural and legal challenges in introducing formal alternative care arrangements, commercial interests that perpetuate support for residential facilities, as well as the sometimes conflicting views of impacted children, families, and the disability community. These disagreements have led to considerable governance and positioning difficulties, which have complicated efforts to coordinate initiatives, precluded the emergence of leadership that proponents universally trust, hampered the engagement of potential allies, and challenged efforts to secure funding and convince policymakers to act. CONCLUSION: In order to potentially become a more potent force for advancing global priority, children's care proponents within international organizations, donor agencies, and non-governmental agencies working across countries will need to better manage their disagreements around deinstitutionalization as a care reform strategy.

Individual interactions in a multi-country implementation-focused quality of care network for maternal, newborn and child health: A social network analysis.

The Network for Improving Quality of Care for Maternal, Newborn and Child Health (QCN) was established to build a cross-country platform for joint-learning around quality improvement implementation approaches to reduce mortality. This paper describes and explores the structure of the QCN in four countries and at global level. Using Social Network Analysis (SNA), this cross-sectional study maps the QCN networks at global level and in four countries (Bangladesh, Ethiopia, Malawi and Uganda) and assesses the interactions among actors involved. A pre-tested closed-ended structured questionnaire was completed by 303 key actors in early 2022 following purposeful and snowballing sampling. Data were entered into an online survey tool, and exported into Microsoft Excel for data management and analysis. This study received ethical approval as part of a broader evaluation. The SNA identified 566 actors across the four countries and at global level. Bangladesh, Malawi and Uganda had multiple-hub networks signifying multiple clusters of actors reflecting facility or district networks, whereas the network in Ethiopia and at global level had more centralized networks. There were some common features across the country networks, such as low overall density of the network, engagement of actors at all levels of the system, membership of related committees identified as the primary role of actors, and interactions spanning all types (learning, action and information sharing). The most connected actors were facility level actors in all countries except Ethiopia, which had mostly national level actors. The results reveal the uniqueness and complexity of each network assessed in the evaluation. They also affirm the broader qualitative evaluation assessing the nature of these networks, including composition and leadership. Gaps in communication between members of the network and limited interactions of actors between countries and with global level actors signal opportunities to strengthen QCN.

Opportunities to sustain a multi-country quality of care network: Lessons on the actions of four countries Bangladesh, Ethiopia, Malawi, and Uganda.

The Quality of Care Network (QCN) is a global initiative that was established in 2017 under the leadership of WHO in 11 low-and- middle income countries to improve maternal, newborn, and child health. The vision was that the Quality of Care Network would be embedded within member countries and continued beyond the initial implementation period: that the Network would be sustained. This paper investigated the experience of actions taken to sustain QCN in four Network countries (Bangladesh, Ethiopia, Malawi, and Uganda) and reports on lessons learned. Multiple iterative rounds of data collection were conducted through qualitative interviews with global and national stakeholders, and non-participatory observation of health facilities and meetings. A total of 241 interviews, 42 facility and four meeting observations were carried out. We conducted a thematic analysis of all data using a framework approach that defined six critical actions that can be taken to promote sustainability. The analysis revealed that these critical actions were present with varying degrees in each of the four countries. Although vulnerabilities were observed, there was good evidence to support that actions were taken to institutionalize the innovation within the health system, to motivate micro-level actors, plan opportunities for reflection and adaptation from the outset, and to support strong government ownership. Two actions were largely absent and weakened confidence in future sustainability: managing financial uncertainties and fostering community ownership. Evidence from four countries suggested that the QCN model would not be sustained in its original format, largely because of financial vulnerability and insufficient time to embed the innovation at the sub-national level. But especially the efforts made to institutionalize the innovation in existing systems meant that some characteristics of QCN may be carried forward within broader government quality improvement initiatives.

Prioritizing rehabilitation in low- and middle-income country national health systems: a qualitative thematic synthesis and development of a policy framework.

BACKGROUND: There is a large and growing unmet need for rehabilitation - a diverse category of services that aim to improve functioning across the life course - particularly in low- and middle-income countries. Yet despite urgent calls to increase political commitment, many low- and middle-income country governments have dedicated little attention to expanding rehabilitation services. Existing policy scholarship explains how and why health issues reach the policy agenda and offers applicable evidence to advance access to physical, medical, psychosocial, and other types of rehabilitation services. Drawing from this scholarship and empirical data on rehabilitation, this paper proposes a policy framework to understand national-level prioritization of rehabilitation in low- and middle-income countries. METHODS: We conducted key informant interviews with rehabilitation stakeholders in 47 countries, complemented by a purposeful review of peer-reviewed and gray literature to achieve thematic saturation. We analyzed the data abductively using a thematic synthesis methodology. Rehabilitation-specific findings were triangulated with policy theory and empirical case studies on the prioritization of other health issues to develop the framework. RESULTS: The novel policy framework includes three components which shape the prioritization of rehabilitation on low- and middle-income countries' national government's health agendas. First, rehabilitation lacks a consistent problem definition, undermining the development of consensus-driven solutions which could advance the issue on policy agendas. Second, governance arrangements are fragmented within and across government ministries, between the government and its citizens, and across national and transnational actors engaged in rehabilitation service provision. Third, national legacies - particularly from civil conflict - and weaknesses in the existing health system influences both rehabilitation needs and implementation feasibility. CONCLUSIONS: This framework can support stakeholders in identifying the key components impeding prioritization for rehabilitation across different national contexts. This is a crucial step for ultimately better advancing the issue on national policy agendas and improving equity in access to rehabilitation services.

Why 'elevating country voice' is not decolonizing global health: A frame analysis of in-depth interviews.

Recent calls for global health decolonization suggest that addressing the problems of global health may require more than 'elevating country voice'. We employed a frame analysis of the diagnostic, prognostic, and motivational framings of both discourses and analyzed the implications of convergence or divergence of these frames for global health practice and scholarship. We used two major sources of data-a review of literature and in-depth interviews with actors in global health practice and shapers of discourse around elevating country voice and decolonizing global health. Using NVivo 12, a deductive analysis approach was applied to the literature and interview transcripts using diagnostic, prognostic and motivational framings as themes. We found that calls for elevating country voice consider suppressed low- and middle-income country (LMIC) voice in global health agenda-setting and lack of country ownership of health initiatives as major problems; advancing better LMIC representation in decision making positions, and local ownership of development initiatives as solutions. The rationale for action is greater aid impact. In contrast, calls for decolonizing global health characterize colonialityas the problem. Its prognostic framing, though still in a formative stage, includes greater acceptance of diversity in approaches to knowledge creation and health systems, and a structural transformation of global health governance. Its motivational framing is justice. Conceptually and in terms of possible outcomes, the frames underlying these discourses differ. Actors' origin and nature of involvement with global health work are markers of the frames they align with. In response to calls for country voice elevation, global health institutions working in LMICs may prioritize country representation in rooms near or where power resides, but this falls short of expectations of decolonizing global health advocates. Whether governments, organizations, and communities will sufficiently invest in public health to achieve decolonization remains unknown and will determine the future of the call for decolonization and global health practice at large.

Understanding resilience, self-reliance and increasing country voice: a clash of ideologies in global health.

BACKGROUND: 'Resilience', 'self-reliance' and 'increasing country voice' are widely used terms in global health. However, the terms are understood in diverse ways by various global health actors. We analyse how these terms are understood and why differences in understanding exist. METHODS: Drawing on scholarship concerning ideology, framing and power, we employ a case study of a USAID-sponsored suite of awards called MOMENTUM. Applying a meta-ethnographic approach, we triangulate data from peer-reviewed and grey literature, as well as 27 key informant interviews with actors at the forefront of shaping these discourses and those associated with MOMENTUM, working in development agencies, implementing organisations, low-income and middle-income country governments, and academia. RESULTS: The lack of common understanding of these three terms is in part a result of differences in two perspectives in global health-reformist and transformational-which are animated by fundamentally different ideologies. Reformists, reflecting neoliberal and liberal democratic ideologies, largely take a technocratic approach to understanding health problems and advance incremental solutions, working within existing global and local health systems to effect change. Transformationalists, reflecting threads of neo-Marxist ideology, see the problems as inherently political and seek to overhaul national and global systems and power relations. These ideologies shape differences in how actors define the problem, its solutions and attribute responsibility, resulting in nuanced differences among global health actors in their understanding of resilience, self-reliance and increasing country voice. CONCLUSIONS: Differences in how these terms are employed and framed are not just linguistic; the language that is used is reflective of underlying ideological differences among global health actors, with implications for the way programmes are designed and implemented, the knowledge that is produced and engagement with stakeholders. Laying these distinct ideologies bare may be crucial for managing actor differences and advancing more productive discussions and actions towards achieving global health equity.

Power dynamics and health initiative design as determinants of peacebuilding: a case study of the Syrian conflict.

Peace-through-health has emerged as a promising concept but with variable evidence of success. Cooptation of health initiatives in conflict is believed to be a major challenge undermining peacebuilding potential. We examine the role that existing power structures and health initiative characteristics play at various levels of a conflict in peacebuilding outcomes. Using the Syrian conflict as a case study, we assess healthcare initiatives' characteristics and their peacebuilding tendencies accounting for power dynamics at the (1) state citizen, (2) interbelligerents and (3) intercommunity conflict levels, drawing on the WHO's framework for health and peace initiatives. Healthcare interventions at state citizen and interbelligerent levels generally addressed combat-related and material-dependent health needs, relied on large-scale international funding and centralised governance structures, and bestowed credit to specific agencies with political implications. These characteristics made such initiatives prone to cooptation in conflict with limited peacebuilding capacity. Healthcare initiatives at the community level addressed more basic, service-dependent needs, had smaller budgets, relied on local organisations and distributed credit across stakeholders, making them less amenable to cooptation in the conflict with more propeace potential. A pilot peacebuilding health initiative designed to leverage these propeace attributes navigated the political environment, minimised cooptation and fostered community collaboration, resulting in peacebuilding potential. In summary, peacebuilding health initiatives are more likely to materialise at the community as compared with higher political levels. Further studies, accounting for conflict power structures, are needed to examine the effectiveness of such initiatives and identify methods that maximise their peacebuilding outcomes.