Week 4 Learning Worksheet: Policy Implementation in Global Health

Learning Objectives

• Understand what distinguishes successful from failed global health programs through systematic analysis of real-world cases
• Identify the key drivers of success that appear consistently across different health interventions and contexts
• Analyze how state capacity, partnerships, and community engagement shape implementation outcomes
• Evaluate the roles of governments versus NGOs in delivering health programs and when each approach works best
• Develop frameworks for adapting interventions across contexts rather than directly replicating them

Pre-Session Reflection

Think about a policy or program (in any field) that sounded good on paper but faced challenges in real-world implementation. What factors do you think explained the gap between policy design and actual implementation outcomes? You can draw from examples you've seen or read about.

[Your response here]

Required Readings

• Cross Country Synthesis - Exemplars In Global Health
• "Premature Imitation and India's Flailing State" by Rajagopalan & Tabarrok
• Explains how mismatches between policy design and state capacity lead to implementation failures. Read pages 1-15 only.
• Centre for Global Development's Millions Saved Project:
• CGD Brief that summarizes the scope and findings of the project
• Overview of the largest collection of rigorously documented global health successes.
• "Malaria Eradication Report" by World Health Organization, Executive Summary and pp.13-24
• Explores the history and drivers of successful, ambitious global health programs on malaria, polio and smallpox.
• "How NGOs Can Act as Learning Labs for Government" — Stanford Social Innovation Review
• Explores how NGOs and governments can partner effectively, with NGOs testing approaches that governments later adopt.

Optional Readings

• Case 1: Eradicating Smallpox
• https://www.cgdev.org/sites/default/files/archive/doc/millions/MS_case_1.pdf
• Classic example of what large-scale success looks like and the factors that enabled it.
• "Scaling Up Global Health Interventions: A Proposed Framework for Success" by Yamey (2011)
• "Lessons of Millions Saved 'holding up very well': CGD's Glassman" — Exemplars Interview (2021)
• Accessible conversation about the 4 key criteria that determine whether programs succeed at scale.
• "What We've Learned About Scaling With Governments: A Three-Part Series" — IPA
• Practical lessons on government partnerships, systems change, and getting incentives right for implementation.

(Optional) You can use the box below for taking notes about the readings.

[Your reading notes here]

Understanding Implementation Challenges

1. Rajagopalan & Tabarrok use India to develop the concept of the "flailing state" — a state where the head (policy design, central planning) is capable, but the limbs (frontline implementation, local administration) are weak. Setting India aside, where do you see this pattern in global health programs you've encountered or read about? What does this concept help explain that pure cost-effectiveness or evidence-based framings miss?

[Your response here]

2. The SSIR piece argues NGOs can serve as "learning labs" for governments — testing approaches that governments later adopt and scale. But Starr (from last week) argued NGO project delivery often creates parallel systems that vanish when funding ends. Are these views reconcilable? Under what conditions does NGO delivery genuinely build government capacity versus substitute for it?

[Your response here]

3. The Exemplars Primary Health Care synthesis looks at how Ghana, Peru, Zambia, and Rwanda improved their primary health care systems. What are 2-3 common practices or approaches that helped across these countries? Pick one and explain why you think it worked.

[Your response here]

Implementation Analysis Exercise

Select one case study from Millions Saved and analyze:

Post-Session Reflection

What new insights about policy implementation have you gained from these readings?

[Your response here]

Looking at successful cases across different contexts, what do you see as common elements that enable effective implementation?

[Your response here]

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