LAUSR

Objectives Despite increases in global health actors and funding levels, health inequities persist. We empirically tested whether global health governance (GHG) operates under the rational actor model (RAM) and characterised GHG power dynamics. Design We collected approximately 75 000 tweets of 20 key global health actors, between 2016 and 2020, using Twitter API. We generated priorities from tweets collected using topic modelling. Priorities from tweets were compared with stated priorities from content analyses of policy documents and with revealed priorities from network analyses of development assistance for health funding data. Comparing priorities derived from Twitter, policy documents and funding data, we can test whether GHG operates under RAM and characterise power dynamics in GHG. Participants 20 global health actors were identified based on a consensus of three peer-reviewed articles mapping global health networks. All tweets of each actor were collected in 3-month intervals from November 2016 to May 2020. Policy documents and developmental assistance for health (DAH) financial data for each actor were collected for the same period. Results We find all 20 actors and the global health system collectively fulfil the three conditions of RAM based on stated and revealed priorities. We also find compulsory and institutional power asymmetries in GHG. Funding organisations have compulsory power over channels of DAH and implementing institutions they directly fund. Funding organisations also have transitive influence over implementing institutions receiving DAH funding. Conclusions We find that there is a correlation between the priorities of large funders and the priorities of health actors. This correlation in conjunction with GHG operating under the RAM and the asymmetric power held by funders raises issues. GHG under the RAM grants large funders majority of the power to determine global health priorities and ultimately influencing outcomes while implementing organisations, especially those that work closest with populations, have little to limited influence in priority-setting.