The GAVI Alliance and the 'Gates approach' to health system strengthening

Glob Public Health. 2014;9(8):865-79. doi: 10.1080/17441692.2014.940362. Epub 2014 Aug 26.


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. Despite GAVI's self-proclaimed 'single-minded' focus on vaccines, HSS support is fronted as a key principle of GAVI's mission. 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. Contrary to broader conceptualisations of HSS that emphasise social and political dimensions, GAVI's HSS support has become emblematic of the so-called 'Gates approach' to global health, focused on targeted technical solutions with clear, measurable outcomes. In spite of adopting rhetoric supportive of 'holistic' health systems, GHIs like GAVI have come to capture the global debate about HSS in favour of their disease-specific approach and ethos.

Keywords: ethnography; global health initiatives; health systems; history; policy.

Publication types

  • Research Support, Non-U.S. Gov't

MeSH terms

  • Anthropology, Cultural
  • Delivery of Health Care / economics
  • Delivery of Health Care / organization & administration*
  • Financial Support
  • Global Health / economics*
  • Global Health / ethnology
  • Humans
  • Immunization Programs / economics
  • Immunization Programs / methods
  • Immunization Programs / organization & administration*
  • International Cooperation*
  • Organizational Case Studies
  • Program Evaluation
  • Public-Private Sector Partnerships

Grants and funding

Funding: This research has been funded by the Norwegian Research Council's Global Health and Vaccination Research programme (GLOBVAC) as part of a larger research project, Health systems strengthening within vaccination programmes: an ethnographic study (project number 196382).