Norm diffusion and health system strengthening: The persistent relevance of national leadership in global health governance

Academics and policymakers often argue that global health policy greatly affects and influences national health systems because these policies transfer and implant ‘best practice’ norms and accountability techniques into local health systems. On the whole these arguments about the ‘diffusion of norms’ have merit since there is considerable evidence to suggest the existence of a positive correlation between global norms and national behaviour. Nevertheless, this article argues that traditional analytical frameworks to explain norm diffusion underplay the fact that norms are significantly ‘glocalised’ by national actors and further discount the role that national leadership plays in strengthening health systems. In response, this article presents a ten-year comparative paired study of the participatory governance mechanisms of the South African health system and its health strengthening measures. In doing so, the role of the national government in their relations with the Global Fund to Fight AIDS, Tuberculosis, and Malaria (GFATM) will be examined and how key ‘partnership’ norms were amalgamated into health governance mechanisms. It will be argued that although global policy plays an important guiding role, health norms are never transcribed straightforwardly and a central element to successful health governance remains vested in the nation and the leadership role it exerts.