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International non-governmental organisations (INGOs) play an increasingly prominent role in global health. They serve as global health advocates, participants in global health policy development, partners, and implementers of donor projects and programmes. To international health donors, INGOs are popular actors to work with. This thesis examines how INGOs navigate the aid chain and negotiate reproductive health policy and norms in a field that is politicised and tense. Based on 9 months fieldwork in Malawi, as well as in Norway and at international meetings and conferences, the thesis focuses on two international NGOs and their projects in Malawi. One project aimed to improve maternal health by reducing teenage pregnancies through interventions designed to keep girls in school and the other aimed to influence the reproductive health policy environment. The thesis explores how international NGOs manoeuvre strategically in the global landscape of institutions, financial flows, discourses, and practices that constitute the fields of ‘international development’ and global health. The thesis defines three broader shifts that to a large extent shape what INGOs can be and do. These shifts entail (1) the move from an understanding of health as a political issue to a technical issue, which makes INGOs operate in what appears as a deeply depoliticised field; (2) an increased focus on individual people detached from the society in which they ‘grow up, live, work and die’; and lastly (3) the value of what INGOs do is now spelled out in terms of the number of individuals reached rather than the need to challenge structural issues of ‘representation’, power and inequality . This study shows how the INGOs studied struggle with navigating a landscape conceptualised as technical but simultaneously highly tense and politicised. Within the bifurcated field of reproductive health, INGOs and their staff have to negotiate meaning and legitimacy for their organisations and for their political projects towards differently situated audiences (e.g. the state, other NGOs). A better understanding of these practices, and how legitimacy is negotiated, is crucial to understanding how INGOs manoeuvre in the global flow of reproductive health policy, knowledge, and norms.

In July 2015, Malawi’s Special Law Commission on the Review of the Law on Abortion released a draft Termination of Pregnancy bill. If approved by Parliament, it will liberalize Malawi’s strict abortion law, expanding the grounds for safe abortion and representing an important step toward safer abortion in Malawi. Drawing on prospective policy analysis (2013–2017), we identify factors that helped generate political will to address unsafe abortion. Notably, we show that transnational influences and domestic advocacy converged to make unsafe abortion a political issue in Malawi and to make abortion law reform a possibility. Since the 1980s, international actors have promoted global norms and provided financial and technical resources to advance ideas about women’s reproductive health and rights and to support research on unsafe abortion. Meanwhile, domestic coalitions of actors and policy champions have mobilized new national evidence on the magnitude, costs, and public health impacts of unsafe abortion, framing action on unsafe abortion as part of a broader imperative to address Malawi’s high level of maternal mortality. Although these efforts have generated substantial support for abortion law reform, an ongoing backlash from the international anti-choice movement has gained momentum by appealing to religious and nationalist values. Passage of the bill also antagonizes the United States’ development work in Malawi due to US policies prohibiting the funding of safe abortion. This threatens existing political will and renders the outcome of the legal review uncertain.

In a recent Viewpoint in the Lancet , some of us shared our experience of censorship in donor-funded evaluation research and warned about a potential trend in which donors and their implementing partners use ethical and methodological arguments to undermine research.1 Reactions to the Viewpoint—and lively debate at the 2018 Global Symposium on Health Systems Research —suggest that similar experiences are common in implementation and policy research commissioned by international donors to study and evaluate large-scale, donor-funded health interventions and programmes, which are primarily implemented in low resource settings. ‘We all have the same stories’, was one of the first comments on the Viewpoint, followed by many private messages divulging instances of personal and institutional pressure, intimidation and censorship following attempts to disseminate unwanted findings. Such pressure comes from major donors and from international non-governmental organisations (NGOs) obliged to have an external assessment but who then maintain a high degree of confidentiality and control. That such experiences are widespread reflects the deeply political nature of the field of ‘global health’ and the interconnections between priority setting, policy making and project implementation, which sit within a broader set of deeply entrenched power structures.2 3 Researchers in this field routinely find themselves working within—and studying—complex power relations and so experience challenges in negotiating their own position between interests of commissioning agencies and funders, implementers and country governments, as well as those of their own research institutions and their partnerships with other researchers spanning high-income, middle-income and low-income countries.4–7 They often receive research funding from major donor agencies like the UK Department of International Development (DFID), the US Agency for International Development (USAID), the Agence Francaise de Developpement (AFD), UNITAID and the Bill and Melinda Gates Foundation,8 who commission evaluations for their own funded projects, even though they have …

Throughout the last decade the Norwegian development assistance for health has gone through some profound changes, both regarding implementation and organization. Norwegian development assistance for health has been known until recently for its strong focus on health systems, developed through bilateral relationships with developing countries. In addition, strong priority has been given to multilateral institutions, specifically the UN and the WHO. Today, the high priority of the multilateral system remains within Norwegian development assistance for health, yet the manner in which health aid is understood, approached and implemented has changed. Development assistance for health has increasingly become ‘global assistance’. The aim of this thesis is to explore these shifts. Due to the interdisciplinary nature of this study, I have used a flexible research design and theoretically, I am using three central concepts from health policy analysis (actor, context, and process) in addition to Foucault’s understanding of modern political power – governmentality.