Public-Private engagement and health systems resilience in times of health worker strikes: a Ghanaian case study.

In low and middle-income countries like Ghana, private providers, particularly the grouping of faith-based non-profit health providers networked by the Christian Health Association of Ghana (CHAG), play a crucial role in maintaining service continuity during health worker strikes. Poor engagement with the private sector during such strikes could compromise care quality and impose financial hardships on populations, especially the impoverished. This study delves into the engagement between CHAG and the Government of Ghana (GoG) during health worker strikes from 2010 to 2016, employing a qualitative descriptive and exploratory case study approach. By analysing evidence from peer-reviewed literature, media archives, grey literature and interview transcripts from a related study using a qualitative thematic analysis approach, this study identifies health worker strikes as a persistent chronic stressor in Ghana. Findings highlight some system-level interactions between CHAG and GoG, fostering adaptive and absorptive resilience strategies, influenced by CHAG's non-striking ethos, unique secondment policy between the two actors and the presence of a National Health Insurance System. However, limited support from the government to CHAG member facilities during strikes and systemic challenges with the National Health Insurance System pose threats to CHAG's ability to provide quality, affordable care. This study underscores private providers' pivotal role in enhancing health system resilience during strikes in Ghana, advocating for proactive governmental partnerships with private providers and joint efforts to address human-resource-related challenges ahead of strikes. It also recommends further research to devise and evaluate effective strategies for nations to respond to strikes, ensuring preparedness and sustained quality healthcare delivery during such crises.

A socio-political history of South Africa's National Health Insurance.

BACKGROUND: Spurred by the WHO's endorsement of universal health coverage as a goal of all health systems, many countries are undertaking health financing reforms. The nature of these reforms, and the policy processes by which they are achieved, will depend on context-specific factors, including the history of reform efforts and the political imperatives driving reforms. South Africa's pursuit of universal health coverage through a National Health Insurance is the latest in a nearly 100-year history of health system reform efforts shaped by social and political realities. METHODS: We conducted an interdisciplinary, retrospective literature review to explore how these reform efforts have unfolded, and been shaped by the contextual realities of the moment. We began the review by identifying peer-reviewed literature on health system reform in South Africa, and iteratively expanded the search through author tracking, citation tracking and purposeful searches for material on particular events or processes referenced in the initial body of evidence. Data was extracted and organised chronologically into nine periods. RESULTS: The analysis suggests that in South Africa politics; the power of the private sector; competing policy priorities and budgetary constraints; and ideas, values and ideologies have been particularly important in constraining, and sometimes spurring, health system reform efforts. Political transitions and pressures - including the introduction of apartheid in 1948, anti-apartheid opposition, the transition to democracy, and corruption and governance failures - have alternately created political imperatives for reform, and constrained reform efforts. In addition, the country's political history has given rise to dominant ideas, values and ideologies that imbue health system reform with a particular social meaning. While these ideas and values increase opposition and complicate reform efforts, they also help to expose the inequities of the current system as problematic and re-emphasise the need for reform. CONCLUSION: Ultimately, this analysis demonstrates the context-specific nature of health system reform processes and the influence of history on what sorts of reforms are politically feasible and socially acceptable, even in the context of a global push for universal health coverage.

An analysis of migration and implications for health in government policy of South Africa.

For over a decade, the global health community has advanced policy engagement with migration and health, as reflected in multiple global-led initiatives. These initiatives have called on governments to provide universal health coverage to all people, regardless of their migratory and/or legal status. South Africa is a middle-income country that experiences high levels of cross-border and internal migration, with the right to health enshrined in its Constitution. A National Health Insurance Bill also commits the South African public health system to universal health coverage, including for migrant and mobile groups. We conducted a study of government policy documents (from the health sector and other sectors) that in our view should be relevant to issues of migration and health, at national and subnational levels in South Africa. We did so to explore how migration is framed by key government decision makers, and to understand whether positions present in the documents support a migrant-aware and migrant-inclusive approach, in line with South Africa's policy commitments. This study was conducted between 2019 and 2021, and included analysis of 227 documents, from 2002-2019. Fewer than half the documents identified (101) engaged directly with migration as an issue, indicating a lack of prioritisation in the policy discourse. Across these documents, we found that the language or discourse across government levels and sectors focused mainly on the potential negative aspects of migration, including in policies that explicitly refer to health. The discourse often emphasised the prevalence of cross-border migration and diseases, the relationship between immigration and security risks, and the burden of migration on health systems and other government resources. These positions attribute blame to migrant groups, potentially fuelling nationalist and anti-migrant sentiment and largely obscuring the issue of internal mobility, all of which could also undermine the constructive engagement necessary to support effective responses to migration and health. We provide suggestions on how to advance engagement with issues of migration and health in order for South Africa and countries of a similar context in regard to migration to meet the goal of inclusion and equity for migrant and mobile groups.

A discourse and content analysis of representation in the mainstream media of the South African National Health Insurance policy from 2011 to 2019.

BACKGROUND: Media is a crucial factor in shaping public opinion and setting policy agendas. There is limited research on the role of media in health policy processes in low- and middle-income countries. This study profiles South Africa as a case example, currently in the process of implementing a major health policy reform, National Health Insurance (NHI). METHODS: A descriptive, mixed methods study was conducted in five sequential phases. Evidence was gathered through a scoping review of secondary literature; discourse analysis of global policy documents on universal health coverage and South African NHI policy documents; and a content and discourse analysis of South African print and online media texts focused on NHI. Representations within media were analysed and dominant discourses that might influence the policy process were identified. RESULTS: Discourses of 'health as a global public good' and 'neoliberalism' were identified in global and national policy documents. Similar neoliberal discourse was identified within SA media. Unique discourses were identified within SA media relating to biopolitics and corruption. Media representations revealed political and ideological contestation which was not as present in the global and national policy documents. Media representations did not mirror the lived reality of most of the South African population. The discourses identified influence the policy process and hinder public participation in these processes. They reinforce social hierarchy and power structures in South Africa, and might reinforce current inequalities in the health system, with negative repercussions for access to health care. CONCLUSIONS: There is a need to understand mainstream media as part of a people-centred health system, particularly in the context of universal health coverage reforms such as NHI. Harmful media representations should be counter-acted. This requires the formation of collaborative and sustainable networks of policy actors to develop strategies on how to leverage media within health policy to support policy processes, build public trust and social cohesion, and ultimately decrease inequalities and increase access to health care. Research should be undertaken to explore media in other diverse formats and languages, and in other contexts, particularly low- and middle-income countries, to further understand media's role in health policy processes.

The Multiple Lenses on the Community Health System: Implications for Policy, Practice and Research.

Community health systems (CHSs) have historically been approached from multiple perspectives, with different purposes and methodological and disciplinary orientations. The terrain is, on the one hand, vast and diverse. On the other hand, under the banner of universal health coverage (UHC) and the Sustainable Development Goals (SDGs), a streamlined version of 'community health' is increasingly being consolidated in global health and donor communities. With the view to informing debate and practice, this paper seeks to synthesise approaches to the CHS into a set of 'lenses,' drawing on the collective and multi-disciplinary knowledge (both formal and experiential) of the authors, a collaborative network of 23 researchers from seven institutions across six countries (spanning low, middle and high income). With a common view of the CHS as a complex adaptive system, we propose four key lenses, referred to as programmatic, relational, collective action and critical lenses. The lenses represent different positionalities in community health, encompassing macro-level policy-maker, front-line and community vantage points, and purposes ranging from social justice to instrumental goals. We define and describe the main elements of each lens and their implications for thinking about policy, practice and research. Distilling a set of key lenses offers a way to make sense of a complex terrain, but also counters what may emerge as a dominant, single narrative on the CHS in global health. By making explicit and bringing together different lenses on the CHS, the limits and possibilities of each may be better appreciated, while promoting integrative, systems thinking in policy, practice and research.

Health system responsiveness: a systematic evidence mapping review of the global literature.

BACKGROUND: The World Health Organisation framed responsiveness, fair financing and equity as intrinsic goals of health systems. However, of the three, responsiveness received significantly less attention. Responsiveness is essential to strengthen systems' functioning; provide equitable and accountable services; and to protect the rights of citizens. There is an urgency to make systems more responsive, but our understanding of responsiveness is limited. We therefore sought to map existing evidence on health system responsiveness. METHODS: A mixed method systemized evidence mapping review was conducted. We searched PubMed, EbscoHost, and Google Scholar. Published and grey literature; conceptual and empirical publications; published between 2000 and 2020 and English language texts were included. We screened titles and abstracts of 1119 publications and 870 full texts. RESULTS: Six hundred twenty-one publications were included in the review. Evidence mapping shows substantially more publications between 2011 and 2020 (n = 462/621) than earlier periods. Most of the publications were from Europe (n = 139), with more publications relating to High Income Countries (n = 241) than Low-to-Middle Income Countries (n = 217). Most were empirical studies (n = 424/621) utilized quantitative methodologies (n = 232), while qualitative (n = 127) and mixed methods (n = 63) were more rare. Thematic analysis revealed eight primary conceptualizations of 'health system responsiveness', which can be fitted into three dominant categorizations: 1) unidirectional user-service interface; 2) responsiveness as feedback loops between users and the health system; and 3) responsiveness as accountability between public and the system. CONCLUSIONS: This evidence map shows a substantial body of available literature on health system responsiveness, but also reveals evidential gaps requiring further development, including: a clear definition and body of theory of responsiveness; the implementation and effectiveness of feedback loops; the systems responses to this feedback; context-specific mechanism-implementation experiences, particularly, of LMIC and fragile-and conflict affected states; and responsiveness as it relates to health equity, minority and vulnerable populations. Theoretical development is required, we suggest separating ideas of services and systems responsiveness, applying a stronger systems lens in future work. Further agenda-setting and resourcing of bridging work on health system responsiveness is suggested.

Towards an Explanation of the Social Value of Health Systems: An Interpretive Synthesis.

BACKGROUND: Health systems are complex social systems, and values constitute a central dimension of their complexity. Values are commonly understood as key drivers of health system change, operating across all health systems components and functions. Moreover, health systems are understood to influence and generate social values, presenting an opportunity to harness health systems to build stronger, more cohesive societies. However, there is little investigation (theoretical, conceptual, or empirical) on social values in health policy and systems research (HPSR), particularly regarding the capacity of health systems to influence and generate social values. This study develops an explanatory theory for the 'social value of health systems.' METHODS: We present the results of an interpretive synthesis of HPSR literature on social values, drawing on a qualitative systematic review, focusing on claims about the relationship between 'health systems' and 'social values.' We combined relational claims extracted from the literature under a common framework in order to generate new explanatory theory. RESULTS: We identify four mechanisms by which health systems are considered to contribute social value to society: Health systems can: (1) offer a unifying national ideal and build social cohesion, (2) influence and legitimise popular attitudes about rights and entitlements with regard to healthcare and inform citizen's understanding of state responsibilities, (3) strengthen trust in the state and legitimise state authority, and (4) communicate the extent to which the state values various population groups. CONCLUSION: We conclude that, using a systems-thinking and complex adaptive systems perspective, the above mechanisms can be explained as emergent properties of the dynamic network of values-based connections operating within health systems. We also demonstrate that this theory accounts for how HPSR authors write about the relationship between health systems and social values. Finally, we offer lessons for researchers and policy-makers seeking to bring about values-based change in health systems.

Health systems constraints and facilitators of human papillomavirus immunization programmes in sub-Saharan Africa: a systematic review.

Given the vast investments made in national immunization programmes (NIPs) and the significance of NIPs to public health, it is important to understand what influences the optimal performance of NIPs. It has been established that well-performing NIPs require enabling health systems. However, systematic evidence on how the performance of health systems impacts on NIPs is lacking, especially from sub-Saharan Africa. We conducted a qualitative systematic review to synthesize the available evidence on health systems constraints and facilitators of NIPs in sub-Saharan Africa, using human papillomavirus immunization programmes as a proxy. Fifty-four articles published between 2008 and 2018 were found to be eligible. Data extraction was guided by an analytical model on the interface between NIPs and health systems. A cross-cutting thematic analysis of the extracted data was performed. This systematic review provides evidence necessary for informing ongoing health systems strengthening initiatives in sub-Saharan Africa. There is evidence to suggest that NIPs in sub-Saharan Africa have surmounted significant health systems constraints and have achieved notable public health success. This success can be attributed to strong political endorsement for vaccines, clear governance structures and effective collaboration with global partners. Despite this, significant health systems constraints persist in service delivery, vaccine communication, community engagement, the capacity of the health workforce and sustainable financing. These constraints could derail further progress if not addressed through health systems strengthening efforts. There is a need to expand the research agenda to include the comprehensive evaluation of health systems constraints and facilitators of NIPs within sub-Saharan Africa.

Evidence map of knowledge translation strategies, outcomes, facilitators and barriers in African health systems.

BACKGROUND: The need for research-based knowledge to inform health policy formulation and implementation is a chronic global concern impacting health systems functioning and impeding the provision of quality healthcare for all. This paper provides a systematic overview of the literature on knowledge translation (KT) strategies employed by health system researchers and policy-makers in African countries. METHODS: Evidence mapping methodology was adapted from the social and health sciences literature and used to generate a schema of KT strategies, outcomes, facilitators and barriers. Four reference databases were searched using defined criteria. Studies were screened and a searchable database containing 62 eligible studies was compiled using Microsoft Access. Frequency and thematic analysis were used to report study characteristics and to establish the final evidence map. Focus was placed on KT in policy formulation processes in order to better manage the diversity of available literature. RESULTS: The KT literature in African countries is widely distributed, problematically diverse and growing. Significant disparities exist between reports on KT in different countries, and there are many settings without published evidence of local KT characteristics. Commonly reported KT strategies include policy briefs, capacity-building workshops and policy dialogues. Barriers affecting researchers and policy-makers include insufficient skills and capacity to conduct KT activities, time constraints and a lack of resources. Availability of quality locally relevant research was the most reported facilitator. Limited KT outcomes reflect persisting difficulties in outcome identification and reporting. CONCLUSION: This study has identified substantial geographical gaps in knowledge and evidenced the need to boost local research capacities on KT practices in low- and middle-income countries. Evidence mapping is also shown to be a useful approach that can assist local decision-making to enhance KT in policy and practice.

Towards universal health coverage: a mixed-method study mapping the development of the faith-based non-profit sector in the Ghanaian health system.

BACKGROUND: Faith-based non-profit (FBNP) providers have had a long-standing role as non-state, non-profit providers in the Ghanaian health system. They have historically been considered to be important in addressing the inequitable geographical distribution of health services and towards the achievement of universal health coverage (UHC), but in changing contexts, this contribution is being questioned. However, any assessment of contribution is hampered by the lack of basic information about their comparative presence and coverage in the Ghanaian health system. In response, since the 1950s, there have been repeated calls for the 'mapping' of faith-based health assets. METHODS: A historically-focused mixed-methods study was conducted, collecting qualitative and quantitative data and combining geospatial mapping with varied documentary resources (secondary and primary, current and archival). Geospatial maps were developed, providing a visual representation of changes in the spatial footprint of the Ghanaian FBNP health sector. RESULTS: The geospatial maps show that FBNPs were originally located in rural remote areas of the country but that this service footprint has evolved over time, in line with changing social, political and economic contexts. CONCLUSION: FBNPs have had a long-standing role in the provision of health services and remain a valuable asset within national health systems in Ghana and sub-Saharan Africa more broadly. Collaboration between the public sector and such non-state providers, drawing on the comparative strengths and resources of FBNPs and focusing on whole system strengthening, is essential for the achievement of UHC.

Implementing large-scale health system strengthening interventions: experience from the better health outcomes through mentoring and assessments (BHOMA) project in Zambia.

BACKGROUND: Under the Doris Duke Charitable Foundation's African Health Initiative, five Population Health Implementation and Training partnerships were established as long-term health system strengthening projects in five Sub-Saharan Countries. In Zambia, the Centre for Infectious Disease Research in Zambia began to implement the Better Health Outcomes through Mentorship and Assessments (BHOMA) in 2009. This was a combined community and health systems project involving 42 public facilities and their catchment populations. The impact of this intervention is reported elsewhere, but less attention has been paid to evaluation approaches that generate an understanding of the forces shaping the intervention. This paper is focused on understanding the implementation practices of the BHOMA intervention in Zambia. METHODS: Qualitative approaches were employed to understand and explain health systems intervention implementation practices between 2014 and 2016. We purposively sampled six clinics out of the 42 that participated in the BHOMA project within three districts of Lusaka province in Zambia. At the facility-level we targeted health centre in-charges, health workers, and community health workers. In-depth interviews (n = 22), focus group discussions (n = 3) and observations were also collected and synthesised. RESULTS: The major health system challenges addressed by the BHOMA project included poor infrastructure, lack of human resources, poor service delivery, long distances to health centres and inadequate health information systems. In order to implement this in the districts it was necessary to engage with the Ministry of Health and district managers, however, these partners were not actively engaged in intervention design There was great variation in perceptions about the BHOMA interventions. The implementation team considered BHOMA as a 'proof of concept pilot project', running parallel to the public health system, while district health officials from the Ministry of health understood it as a 'long term partner' and were therefore resistant to the short-term nature of the intervention. CONCLUSIONS: The Normalization Process Theory provided a useful framework to understand and explain implementation processes for the BHOMA intervention in Zambia. We clearly demonstrated the applicability of all the four main components of the NPT: coherence (or sense-making); cognitive participation (or engagement); collective action and reflexive monitoring. We demonstrated how complex and dynamic the intervention played out among different actors and how implementation was affected by difference in appreciation and interpretation of the goal of the intervention. Our findings support the growing demand for process evaluations to use theory based approaches to examine how context interact with local interventions to affect outcomes intended or not. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT01942278 . Registered: September 13, 2013 (Retrospectively registered).

Strategic leadership capacity building for Sub-Saharan African health systems and public health governance: a multi-country assessment of essential competencies and optimal design for a Pan African DrPH.

Leadership capacity needs development and nurturing at all levels for strong health systems governance and improved outcomes. The Doctor of Public Health (DrPH) is a professional, interdisciplinary terminal degree focused on strategic leadership capacity building. The concept is not new and there are several programmes globally-but none within Africa, despite its urgent need for strong strategic leadership in health. To address this gap, a consortium of institutions in Sub-Saharan Africa, UK and North America have embarked on a collaboration to develop and implement a pan-African DrPH with support from the Rockefeller Foundation. This paper presents findings of research to verify relevance, identify competencies and support programme design and customization. A mixed methods cross sectional multi-country study was conducted in Ghana, South Africa and Uganda. Data collection involved a non-exhaustive desk review, 34 key informant (KI) interviews with past and present health sector leaders and a questionnaire with closed and open ended items administered to 271 potential DrPH trainees. Most study participants saw the concept of a pan-African DrPH as relevant and timely. Strategic leadership competencies identified by KI included providing vision and inspiration for the organization, core personal values and character qualities such as integrity and trustworthiness, skills in adapting to situations and context and creating and maintaining effective change and systems. There was consensus that programme design should emphasize learning by doing and application of theory to professional practice. Short residential periods for peer-to-peer and peer-to-facilitator engagement and learning, interspaced with facilitated workplace based learning, including coaching and mentoring, was the preferred model for programme implementation. The introduction of a pan-African DrPH with a focus on strategic leadership is relevant and timely. Core competencies, optimal design and customization for the sub-Saharan African context has broad consensus in the study setting.

Health system's barriers hindering implementation of public-private partnership at the district level: a case study of partnership for improved reproductive and child health services provision in Tanzania.

BACKGROUND: Public-private partnership (PPP) has been suggested as a tool to assist governments in lower to middle income countries fulfil their responsibilities in the efficient delivery of health services. In Tanzania, although the idea of PPP has existed for many years in the health sector, there has been limited coordination, especially at a district level - which has contributed to limited health gains or systems strengthening obviously seen as a result of PPP. METHODS: This case study was conducted in the Bagamoyo district of Tanzania, and employed in-depth interviews, document reviews, and observations methods. A stakeholder analysis was conducted to understand power distribution and the interests of local actors to engage non-state actors. In total 30 in-depth interviews were conducted with key informants that were identified from a stakeholder mapping activity. The initial data analysis guided further data collection in an iterative process. The provision of Reproductive and Child Health Services was used as a context. This study draws on the decision-space framework. RESULTS: Study findings reveal several forms of informal partnerships, and the untapped potential of non-state actors. Lack of formal contractual agreements with private providers including facilities that receive subsidies from the government is argued to contribute to inappropriate distribution of risk and reward leading to moral hazards. Furthermore, findings highlight weak capacity of governing bodies to exercise oversight and sanctions, which is acerbated by weak accountability linkages and power differences. Disempowered Council Health Services Board, in relation to engaging non-state actors, is shown to impede PPP initiatives. CONCLUSION: Effective PPP policy implementation at a local level depends on the capacity of local government officials to make choices that would embrace relational elements dynamics in strategic plans. Orientation towards collaborative efforts that create value and enable its distribution is argued to facilitate healthy partnership, and in return, strengthen a district health system. This study highlights a need for new social contracts that will support integrative collaboration at the local level and bring all non-state actors to the centre of the district health system.

Models of public-private engagement for health services delivery and financing in Southern Africa: a systematic review.

In low- and middle-income countries (LMICs), the private sector-including international donors, non-governmental organizations, for-profit providers and traditional healers-plays a significant role in health financing and delivery. The use of the private sector in furthering public health goals is increasingly common. By working with the private sector through public -: private engagement (PPE), states can harness private sector resources to further public health goals. PPE initiatives can take a variety of forms and understanding of these models is limited. This paper presents the results of a Campbell systematic literature review conducted to establish the types and the prevalence of PPE projects for health service delivery and financing in Southern Africa. PPE initiatives identified through the review were categorized according to a PPE typology. The review reveals that the full range of PPE models, eight distinct models, are utilized in the Southern African context. The distribution of the available evidence-including significant gaps in the literature-is discussed, and key considerations for researchers, implementers, and current and potential PPE partners are presented. It was found that the literature is disproportionately representative of PPE initiatives located in South Africa, and of those that involve for-profit partners and international donors. A significant gap in the literature identified through the study is the scarcity of information regarding the relationship between international donors and national governments. This information is key to strengthening these partnerships, improving partnership outcomes and capacitating recipient countries. The need for research that disaggregates PPE models and investigates PPE functioning in context is demonstrated.

Understanding the roles of faith-based health-care providers in Africa: review of the evidence with a focus on magnitude, reach, cost, and satisfaction.

At a time when many countries might not achieve the health targets of the Millennium Development Goals and the post-2015 agenda for sustainable development is being negotiated, the contribution of faith-based health-care providers is potentially crucial. For better partnership to be achieved and for health systems to be strengthened by the alignment of faith-based health-providers with national systems and priorities, improved information is needed at all levels. Comparisons of basic factors (such as magnitude, reach to poor people, cost to patients, modes of financing, and satisfaction of patients with the services received) within faith-based health-providers and national systems show some differences. As the first report in the Series on faith-based health care, we review a broad body of published work and introduce some empirical evidence on the role of faith-based health-care providers, with a focus on Christian faith-based health providers in sub-Saharan Africa (on which the most detailed documentation has been gathered). The restricted and diverse evidence reported supports the idea that faith-based health providers continue to play a part in health provision, especially in fragile health systems, and the subsequent reports in this Series review controversies in faith-based health care and recommendations for how public and faith sectors might collaborate more effectively.

Estimating the development assistance for health provided to faith-based organizations, 1990-2013.

BACKGROUND: Faith-based organizations (FBOs) have been active in the health sector for decades. Recently, the role of FBOs in global health has been of increased interest. However, little is known about the magnitude and trends in development assistance for health (DAH) channeled through these organizations. MATERIAL AND METHODS: Data were collected from the 21 most recent editions of the Report of Voluntary Agencies. These reports provide information on the revenue and expenditure of organizations. Project-level data were also collected and reviewed from the Bill & Melinda Gates Foundation and the Global Fund to Fight AIDS, Tuberculosis and Malaria. More than 1,900 non-governmental organizations received funds from at least one of these three organizations. Background information on these organizations was examined by two independent reviewers to identify the amount of funding channeled through FBOs. RESULTS: In 2013, total spending by the FBOs identified in the VolAg amounted to US$1.53 billion. In 1990, FB0s spent 34.1% of total DAH provided by private voluntary organizations reported in the VolAg. In 2013, FBOs expended 31.0%. Funds provided by the Global Fund to FBOs have grown since 2002, amounting to $80.9 million in 2011, or 16.7% of the Global Fund's contributions to NGOs. In 2011, the Gates Foundation's contributions to FBOs amounted to $7.1 million, or 1.1% of the total provided to NGOs. CONCLUSION: Development assistance partners exhibit a range of preferences with respect to the amount of funds provided to FBOs. Overall, estimates show that FBOS have maintained a substantial and consistent share over time, in line with overall spending in global health on NGOs. These estimates provide the foundation for further research on the spending trends and effectiveness of FBOs in global health.