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Health issues vary in the amount of attention and resources they receive from global health organisations and national governments. How issues are framed could shape differences in levels of priority. We reviewed scholarship on global health policy making to examine the role of framing in shaping global health priorities. The review provides evidence of the influence of three framing processes-securitisation, moralisation, and technification. Securitisation refers to an issue's framing as an existential threat, moralisation as an ethical imperative, and technification as a wise investment that science can solve. These framing processes concern more than how issues are portrayed publicly. They are socio-political processes, characterised by contestation among actors in civil society, government, international organisations, foundations, and research institutions. These actors deploy various forms of power to advance particular frames as a means of securing attention and resources for the issues that concern them. The ascription of an issue as a security concern, an ethical imperative, or a wise investment is historically contingent: it is not inevitable that any given issue will be framed in one or more of these ways. A health issue's inherent characteristics-such as the lethality of a pathogen that causes it-also shape these ascriptions, but do not fully determine them. Although commonly facing resistance, global health elites often determine which frames prevail, raising questions about the legitimacy of priority-setting processes. We draw on the review to offer ideas on how to make these processes fairer than they are at present, including a call for democratic representation even as necessary space is preserved for elite expertise.

In 2011, the US state of Mississippi mandated its school districts to adopt a sexuality education curriculum. Approximately half of districts chose a more comprehensive abstinence-plus curriculum o...

To determine the reasons for the lack of priority given to addressing violence against children, and to identify the challenges that proponents must address to improve prioritization of this issue.We reviewed relevant literature to identify experts to interview. We carried out a thematic analysis of the literature and interview transcripts. We iteratively developed data coding on the many characteristics of violence against children, on the framing of the issue by proponents, and on the problem of governance - that is, how proponents organize themselves for collective action.The analysis of our data sources reveals many obstacles for global prioritization of addressing violence against children, including the forms of violence considered, inadequate data to describe prevalence and a lack of evidence of the effectiveness of proposed solutions. There exists fundamental disagreement among proponents on the recently introduced frame of violence against children, including differences in the types of violence that should be prioritized and in the proposed solutions (e.g. prevention or remediation). On governance, competition between networks focused on specific forms of violence is hampering efforts to create strong governing institutions.Despite the complex challenges identified, proponents have made some progress in global prioritization of addressing violence against children. To improve this prioritization further, proponents must resolve framing tensions and strengthen governance mechanisms to promote shared goals, while ensuring that networks focused on particular forms of violence are able to maintain their distinct identities.Définir les raisons expliquant pourquoi la violence envers les enfants n'est pas une priorité, et identifier les défis que les acteurs de cette lutte doivent relever pour améliorer sa visibilité.Nous avons effectué une revue documentaire afin de trouver des experts à interroger. Nous avons également réalisé une analyse thématique de la littérature et des transcriptions d'entretiens. Nous avons développé sous forme itérative un codage des données reprenant les nombreuses caractéristiques de la violence envers les enfants, la formulation des enjeux par les acteurs de la lutte, et le problème de la gouvernance. En d'autres termes, comment ces acteurs s'organisent pour mener des actions collectives.L'analyse de nos sources de données révèle de multiples obstacles dans la gestion mondiale des priorités inhérentes à la lutte contre la violence envers les enfants, parmi lesquels les types de violences pris en compte, l'inadéquation des données décrivant leur prévalence, et le manque de preuves d'efficacité des solutions proposées. Il existe des désaccords profonds parmi les acteurs de la lutte sur le cadre récemment instauré pour définir la violence envers les enfants, notamment des divergences au niveau des types de violences considérées comme prioritaires et des solutions proposées (par exemple la prévention ou la réparation). Quant à la gouvernance, la concurrence que se livrent les réseaux dédiés à des violences spécifiques nuit aux efforts de création d'institutions gouvernementales solides.Malgré la complexité des défis identifiés, les acteurs de la lutte contre la violence envers les enfants ont accompli quelques progrès dans l’établissement des priorités en la matière. Pour poursuivre sur cette lancée, ils doivent résoudre les tensions que suscite le cadre de référence et renforcer les mécanismes de gouvernance afin de promouvoir des objectifs communs, tout en veillant à ce que les réseaux dédiés à des violences spécifiques puissent conserver leur identité propre.Determinar las razones por las que no se da prioridad al tratamiento de la violencia contra los niños, e identificar los retos que los defensores deben abordar para mejorar la priorización de esta cuestión.Revisamos la bibliografía pertinente para identificar a los expertos a los que entrevistar. Realizamos un análisis temático de la bibliografía y de las transcripciones de las entrevistas. Desarrollamos de forma iterativa la codificación de los datos sobre las múltiples características de la violencia contra los niños, sobre la estructuración de la cuestión por parte de los defensores y sobre el problema de la gobernanza, es decir, cómo se organizan los defensores para la acción colectiva.El análisis de nuestras fuentes de datos revela muchos obstáculos para la priorización global del tratamiento de la violencia contra los niños, incluyendo las formas de violencia consideradas, datos inadecuados para describir la prevalencia y la falta de pruebas de la eficacia de las soluciones propuestas. Existe un desacuerdo fundamental entre los defensores sobre el marco recientemente introducido de la violencia contra los niños, incluidas las diferencias en los tipos de violencia que deben priorizarse y las soluciones propuestas (por ejemplo, prevención o remedio). En cuanto a la gobernanza, la competencia entre redes centradas en formas específicas de violencia está obstaculizando los esfuerzos por crear instituciones de gobierno fuertes.A pesar de los complejos desafíos identificados, los defensores han realizado algunos progresos en la priorización global del tratamiento de la violencia contra los niños. Para mejorar aún más esta priorización, los defensores deben resolver las tensiones de encuadramiento y fortalecer los mecanismos de gobernanza para promover los objetivos compartidos, asegurando al mismo tiempo que las redes centradas en formas particulares de violencia puedan mantener sus identidades distintivas.الغرض تحديد أسباب عدم منح الأولوية لمواجهة العنف ضد الأطفال، وتقرير التحديات التي يجب على المؤيدين مواجهتها لتحسين أولوية هذه القضية. الطريقة قمنا بمراجعة المنشورات ذات الصلة لتحديد خبراء لإجراء مقابلات معهم. قمنا بتحليل موضوعي للمنشورات ونصوص المقابلات. قمنا بوضع ترميز للبيانات بشكل متكرر حول العديد من خصائص العنف ضد الأطفال، وحول وضع إطار للقضية بواسطة المؤيدين، وحول مشكلة الحوكمة، أي كيفية تنظيم المؤيدين لأنفسهم في العمل الجماعي. النتائج يكشف تحليل مصادر البيانات لدينا عن العديد من العوائق التي تواجه وضع أولوية عالمية لمواجهة العنف ضد الأطفال، بما في ذلك أشكال العنف المنظورة، والبيانات غير الكافية لوصف مدى الانتشار، وعدم وجود أدلة على فعالية الحلول المقترحة. هناك خلاف أساسي بين المؤيدين حول الإطار المطروح مؤخرًا للعنف ضد الأطفال، بما في ذلك الاختلافات في أنواع العنف التي يجب أن تُمنح الأولوية، وفي الحلول المقترحة (مثل الوقاية أو العلاج). وبخصوص الحوكمة، فإن المنافسة بين الشبكات والتي تركز على أشكال محددة من العنف، تعوق جهود إنشاء مؤسسات حوكمة قوية. الاستنتاج على الرغم من التحديات المعقدة التي تم تحديدها، إلا أن المؤيدين قد حققوا بعض التقدم في تحديد أولوية عالمية لمواجهة العنف ضد الأطفال. لتحسين هذه الأولوية بشكل أكبر، يجب أن يقوم المؤيدون بحل توترات التأطير، وتقوية آليات الحوكمة لتعزيز الأهداف المشتركة، مع ضمان أن الشبكات التي تركز على أشكال معينة من العنف قادرة على الحفاظ على هوياتها المحددة.确定对解决暴力侵害儿童问题缺乏优先考虑的原因，并确定支持者为改善这一问题的优先次序必须解决的挑战。.我们查阅了相关文献评论以确定访谈需要邀请的专家，然后对文献和访谈记录开展了主题分析。经过反复测试，，我们对儿童遭受暴力侵害的特征、支持者对该问题的界定，以及治理问题进行了数据编码，研究支持者应如何组织开展集体行动。.我们对我们的数据来源进行了分析，揭示了在全球优先处理暴力侵害儿童问题上的许多障碍，包括所考虑的暴力形式、描述普遍程度的数据不足，以及缺乏证据证明所提议解决方案的有效性。支持者对最近提出的如何界定对儿童的暴力存在根本分歧，包括在应列为优先事项的暴力类型和拟议的解决办法（例如预防或补救）方面存在差异。在治理方面，专注于不同暴力形式的不同组织网络之间所存在的竞争关系，阻碍着建立强大的治理机构这一目标的实现。.尽管存在一些严峻的挑战，但支持者在全球优先处理暴力侵害儿童问题方面已经取得了一些进展。为了进一步改善该问题的优先级别，支持者必须解决在该问题界定方面的紧张关系，加强治理机制，以促进实现共同目标，同时确保专注于特定暴力形式的不同组织网络能够坚守他们各自的准则。.Определить причины недостаточного внимания, уделяемого решению проблем насилия в отношении детей, и задачи, которые необходимо решать инициаторам мер для повышения приоритетности этого вопроса.Авторы изучили соответствующую литературу с целью отбора экспертов для проведения интервью. Был проведен тематический анализ литературы и стенограмм интервью. Авторы итеративно разрабатывали алгоритмы кодирования данных по многим характеристикам видов насилия в отношении детей, по формулировке проблемы инициаторами мер, а также по проблеме организации управления, то есть по тому, как инициаторы мер организуют себя для коллективных действий.Анализ источников данных показывает множество препятствий на пути к установлению глобальных приоритетов в борьбе с насилием в отношении детей, включая рассматриваемые формы насилия, недостаточность данных для описания их распространенности и отсутствие доказательств эффективности предлагаемых решений. Среди инициаторов мер существуют серьезные разногласия по поводу недавно введенной классификации видов насилия в отношении детей, включая различия в видах насилия, которым следует уделять первоочередное внимание, и предлагаемых решениях (например, предотвращение или устранение последствий). Что касается организации управления, конкуренция между сетями, ориентированными на борьбу с конкретными формами насилия, препятствует усилиям по созданию сильных институтов управления.Несмотря на выявленные сложные проблемы, инициаторам мер удалось добиться определенного прогресса в определении глобальных приоритетов в борьбе с насилием в отношении детей. Для дальнейшего совершенствования приоритизации инициаторы мер должны устранить структурные разногласия и укрепить механизмы управления для содействия достижению общих целей, при этом гарантируя, что сети, ориентированные на борьбу с конкретными формами насилия, останутся неизменными.

This article outlines an agenda for political science engagement with global mental health. Other social sciences have tackled the topic, investigating such questions as the link between poverty and mental health disorders. Political science is noticeably absent from these explorations. This is striking because mental health disorders affect one billion people globally, governments spend only about 2% of their health budgets on these disorders, and most people lack access to treatment. With its focus on power, political science could deepen knowledge on vulnerabilities to mental illness and explain weak policy responses. By illustrating how various forms of power pertaining to governance, knowledge, and moral authority work through the concepts of issue framing, collective action, and institutions, the article shows that political science can deepen knowledge on this global health issue. Political science can analyse how incomplete knowledge leads to contentious framing, thus hobbling advocacy. It can explain why states shirk their obligations in mental health, and it can question how incentives drive mental health mobilisation. The discipline can uncover how power undergirds institutional responses to global mental health at the international, national, and community levels. Political science should collaborate with other social sciences in research networks to improve policy outcomes.

Background‘Resilience’, ‘self-reliance’ and ‘increasing country voice’ are widely used terms in global health. However, the terms are understood in diverse ways by various global health actors. We analyse how these terms are understood and why differences in understanding exist.MethodsDrawing on scholarship concerning ideology, framing and power, we employ a case study of a USAID-sponsored suite of awards called MOMENTUM. Applying a meta-ethnographic approach, we triangulate data from peer-reviewed and grey literature, as well as 27 key informant interviews with actors at the forefront of shaping these discourses and those associated with MOMENTUM, working in development agencies, implementing organisations, low-income and middle-income country governments, and academia.ResultsThe lack of common understanding of these three terms is in part a result of differences in two perspectives in global health—reformist and transformational—which are animated by fundamentally different ideologies. Reformists, reflecting neoliberal and liberal democratic ideologies, largely take a technocratic approach to understanding health problems and advance incremental solutions, working within existing global and local health systems to effect change. Transformationalists, reflecting threads of neo-Marxist ideology, see the problems as inherently political and seek to overhaul national and global systems and power relations. These ideologies shape differences in how actors define the problem, its solutions and attribute responsibility, resulting in nuanced differences among global health actors in their understanding of resilience, self-reliance and increasing country voice.ConclusionsDifferences in how these terms are employed and framed are not just linguistic; the language that is used is reflective of underlying ideological differences among global health actors, with implications for the way programmes are designed and implemented, the knowledge that is produced and engagement with stakeholders. Laying these distinct ideologies bare may be crucial for managing actor differences and advancing more productive discussions and actions towards achieving global health equity.

IntroductionThe high burden of emergency medical conditions has not been met with adequate financial and political prioritisation especially in low and middle-income countries. We examined the factors that have shaped the priority of global emergency care and highlight potential responses by emergency care advocates.MethodsWe conducted semistructured interviews with key experts in global emergency care practice, public health, health policy and advocacy. We then applied a policy framework based on political ethnography and content analysis to code for underlying themes.ResultsWe identified problem definition, coalition building, paucity of data and positioning, as the main challenges faced by emergency care advocates. Problem definition remains the key issue, with divergent ideas on what emergency care is, should be and what solutions are to be prioritised. Proponents have struggled to portray the urgency of the issue in a way that commands action from decision-makers. The lack of data further limits their effectiveness. However, there is much reason for optimism given the network’s commitment to the issue, the emerging leadership and the existence of policy windows.ConclusionTo improve global priority for emergency care, proponents should take advantage of the emerging governance structure and build consensus on definitions, generate data-driven solutions, find strategic framings and engage with non-traditional allies.

The Sustainable Development Goals offer the global health community a strategic opportunity to promote human rights, advance gender equality, and achieve health for all. The inability of the health sector to accelerate progress on a range of health outcomes brings into sharp focus the substantial impact of gender inequalities and restrictive gender norms on health risks and behaviours. In this paper, the fifth in a Series on gender equality, norms, and health, we draw on evidence to dispel three myths on gender and health and describe persistent barriers to progress. We propose an agenda for action to reduce gender inequality and shift gender norms for improved health outcomes, calling on leaders in national governments, global health institutions, civil society organisations, academic settings, and the corporate sector to focus on health outcomes and engage actors across sectors to achieve them; reform the workplace and workforce to be more gender-equitable; fill gaps in data and eliminate gender bias in research; fund civil-society actors and social movements; and strengthen accountability mechanisms.

Child sexual abuse (CSA) is widespread. Few countries, however, prioritize the issue. The United Kingdom is an exception, ranked first in its response to the issue in a 2019 country comparison. In 2015, Prime Minister David Cameron designated the issue one of three national threats. Funding commitments and policies to address CSA followed.To investigate how CSA emerged as a national political priority in the United Kingdom, and to identify insights for proponents seeking to advance priority for addressing the issue.Documents were analyzed and semi-structured interviews conducted with actors in the United Kingdom central to CSA advocacy, research, and/or programming, as well as with policymakers.Drawing on the multiple streams public policy model, a thematic analysis was conducted on collected documents (n = 160) and 21 interview transcripts.Our analysis delineates three critical developments that led to national prioritization for addressing CSA. First, high-profile scandals and the re-framing of CSA survivors as deserving of support raised public awareness of the problem. Second, champions concerned with CSA developed evidence-based and politically-feasible solutions. Third, the Prime Minister's concern and other political developments opened a policy window.The case provides insights for proponents on generating political priority for addressing CSA. Proponents need to (1) ensure survivors are not seen as culpable but rather as deserving of support, (2) be ready with solutions and (3) cultivate high-level political support, so that when policy windows open they can jump to push the issue onto the national agenda.

Background The global health agenda is ill-defined as an analytical construct, complicating attempts by scholars and proponents to make claims about the agenda status of issues. We draw on Kingdon’s definition of the agenda and Hilgartner and Bosk’s public arenas model to conceptualize the global health agenda as those subjects or problems to which collectivities of actors operating nationally and globally are paying serious attention at any given time. We propose an arenas model for global health agenda setting and illustrate its potential utility by assessing priority indicators in five arenas, including international aid, pharmaceutical industry, scientific research, news media and civil society. We then apply the model to illustrate how the status of established (HIV/AIDS), emergent (diabetes) and rising (Alzheimer’s disease) issues might be measured, compared and change in light of a pandemic shock (COVID-19). Results Coronavirus priority indicators rose precipitously in all five arenas in 2020, reflecting the kind of punctuation often caused by focusing events. The magnitude of change varied somewhat by arena, with the most pronounced shift in the global news media arena. Priority indicators for the other issues showed decreases of up to 21% and increases of up to 41% between 2019 and 2020, with increases suggesting that the agenda for global health issues expanded in some arenas in 2020— COVID-19 did not consistently displace priority for HIV/AIDS, diabetes or Alzheimer’s disease, though it might have for other issues. Conclusions We advance an arenas model as a novel means of addressing conceptual and measurement challenges that often undermine the validity of claims concerning the global health agenda status of problems and contributing causal factors. Our presentation of the model and illustrative analysis lays the groundwork for more systematic investigation of trends in global health agenda setting. Further specification of the model is needed to ensure accurate representation of vital national and transnational arenas and their interactions, applicability to a range of disease-specific, health systems, governance and policy issues, and sensitivity to subtler influences on global health agenda setting than pandemic shocks.

The profound burden of disease associated with musculoskeletal health conditions is well established. Despite the unequivocal disability burden and personal and societal consequences, relative to other non-communicable diseases (NCDs), system-level responses for musculoskeletal conditions that are commensurate with their burden have been lacking nationally and globally. Health policy priorities and responses in the 21st century have evolved significantly from the 20th century, with health systems now challenged by an increasing prevalence and impact of NCDs and an unprecedented rate of global population ageing. Further, health policy priorities are now strongly aligned to the 2030 Sustainable Development Goals. With this background, what are the challenges and opportunities available to influence global health policy to support high-value care for musculoskeletal health conditions and persistent pain? This paper explores these issues by considering the current global health policy landscape, the role of global health networks, and progress and opportunities since the 2000-2010 Bone and Joint Decade for health policy to support improved musculoskeletal health and high-value musculoskeletal health care.

Background Many global health organisations have adopted formal strategies to integrate gender in their programming. In practice, few prioritise the issue. Institutions with considerable global power therefore largely overlook fundamental drivers of adverse health outcomes: gender inequality and harmful gender norms. We analyse the factors shaping attention to gender in organisations involved in global health governance. Methods Drawing on scholarship from the fields of organisational behavior and management, sociology, international relations and the policy process, we undertook a thematic analysis of peer-reviewed scholarship and organisational documents. We also conducted 20 semi-structured interviews over Skype with individuals working at the cross-section of gender and health. Results In seeking to reform the policies and practices of global health organisations, gender proponents confront patriarchal organisational cultures, hostile political environments and an issue that is difficult to address as it requires upsetting existing power structures. Proponents also face three linked challenges internal to their own networks. First, there is little cohesion among champions themselves, as they are fragmented into multiple networks. Second, proponents differ on the nature of the problem and solutions, including whether reducing gender inequality or addressing harmful gender norms is the primary goal, the role of men in gender initiatives, which health issues to prioritise, and even the value of proponent cohesion. Third, there are disagreements among proponents on how to convey the problem. Some advance an instrumental case, while others believe that it should be portrayed as a human rights issue and using any other argument undermines that fundamental justification. Conclusions Prospects for building more gender-responsive global health organisations will depend in part on the ability of proponents to address these disagreements and develop strategies for negotiating difficult organisational cultures and political environments.

Background Proponents have promoted sexuality education as a means of empowering adolescents, yet it has been thwarted in many low and middle-income countries. Nigeria represents an exception. Despite social opposition, the government in 1999 unexpectedly approved sexuality education policy. Since then, implementation has advanced, although efficacy has differed across states. We draw on theory concerning international norm diffusion to understand Nigerian policy development. Results We find that a confluence of international and national norms and interests shaped policy outcomes, including concern over HIV/AIDS. A central dynamic was an alliance of domestic NGOs and international donors pressing the Nigerian government to act. Conclusions We argue that theory on international norms can be applied to understand policy dynamics across a variety of health and population areas, finding value in approaches that integrate rather than juxtapose consideration of (1) international and national influences; (2) long and short-term perspectives on policy change; and (3) norms and interests.

Commercial gambling is increasingly viewed as being part of the unhealthy commodities industries, in which products contribute to preventable ill-health globally. Britain has one of the world’s most liberal gambling markets, meaning that the regulatory changes there have implications for developments elsewhere. A review of the British Gambling Act 2005 is underway. This has generated a range of actions by the industry, including mobilising arguments around the threat of the “black market”. We critically explore industry’s framing of these issues as part of their strategy to resist regulatory change during the Gambling Act review. We used a predefined review protocol to explore industry narratives about the “black market” in media reports published between 8 December 2020 and 26 May 2021. Fifty-five articles were identified and reviewed, and themes were narratively synthesised to examine industry framing of the “black market”. The black market was framed in terms of economic threat and loss, and a direct connection was made between its growth and increased regulation. The articles mainly presented gambling industry perspectives uncritically, citing industry-generated evidence (n = 40). Industry narratives around the “black market” speak to economically and emotionally salient concerns: fear, safety, consumer freedom and economic growth. This dominant framing in political, mainstream and industry media may influence political and public opinion to support the current status quo: “protecting” the existing regulated market rather than “protecting” people. Debates should be reframed to consider all policy options, especially those designed to protect public health.

In 2003, Nigeria adopted the Family Life and HIV Education (FLHE) sexuality education curriculum. Our analysis interrogates variation in sub-national implementation. We conducted 52 interviews with persons knowledgeable about the curriculum in three states-Kano, Lagos, and Niger-and reviewed publications on FLHE. In Kano, the socio-cultural context impeded implementation, but the persistence of innovative local champions resulted in some success. In Lagos, the cosmopolitan context, effective champions, funding by international donors, and a receptive government bureaucracy led to successful implementation. In Niger, despite a relatively conservative socio-cultural context, state bureaucratic bottlenecks overwhelmed proponents' efforts. In summary, the interaction of socio-cultural context, domestic champions, adaptive capacity of state bureaucracies, and international funders explains variable implementation of FLHE. The Nigerian experience highlights the need for sexuality education proponents to anticipate and prepare for local opposition and bureaucratic barriers.

Executive summaryDespite dramatic improvements in survival, nutrition, and education over recent decades, today’s children face an uncertain future. Climate change, ecological degradation, migrating populations, conflict, pervasive inequalities, and predatory commercial practices threaten the health and future of children in every country. In 2015, the world’s countries agreed on the Sustainable Development Goals (SDGs), yet nearly 5 years later, few countries have recorded much progress towards achieving them. This Commission presents the case for placing children, aged 0–18 years, at the centre of the SDGs: at the heart of the concept of sustainability and our shared human endeavour. Governments must harness coalitions across sectors to overcome ecological and commercial pressures to ensure children receive their rights and entitlements now and a liveable planet in the years to come.

This chapter examines the politics of global health agenda setting, the process by which global health issues come to receive attention from actors that control or influence the allocation of financial, technical, human, and other kinds of resources. It suggests that the global health agenda is shaped by the capabilities of actors, including policy entrepreneurs, high-level champions, and networks; ideas, especially those surrounding problem definition, solutions, and causal stories; powerful interests, such as the economic and security concerns of wealthy countries and industries; and institutions, such as international law and trade regimes. Most studies of global health agenda setting are of a single case, and many are descriptive. To build the field, future research should supplement these studies with comparative, theoretically grounded inquiry.

Mississippi and Nigeria are two socially conservative places unlikely to prioritise sexuality education. Nonetheless, Mississippi passed a bill in 2011 mandating all school districts to offer sexuality education, and Nigeria approved a national sexuality education curriculum in 2001. To identify the factors that drove the process of prioritisation of sexuality education in each context, we conducted more than 70 semi-structured interviews with nongovernmental organisations/nonprofits, donor organisations and federal and state ministries involved in the prioritisation and implementation of sexuality education in Mississippi and Nigeria. Prioritisation of sexuality education occurred for similar reasons in both Mississippi and Nigeria: (1) local individuals and organisations committed to sexuality education and supported by external actors; (2) the opening of a policy window that made sexuality education a solution to a pressing social problem (teen pregnancy in Mississippi and HIV/AIDS in Nigeria) and (3) strategic action on the part of proponents. We conclude that promoting sexuality education in challenging contexts requires fostering committed local individuals and organisations, identifying external resources to support implementation costs and building on existing relationships of trust between actors, even if those relationships are unrelated to sexuality education.

In 2003, Nigeria adopted the Family Life and HIV Education (FLHE) sexuality education curriculum. Our analysis interrogates variation in sub-national implementation. We conducted 52 interviews with persons knowledgeable about the curriculum in three states-Kano, Lagos, and Niger-and reviewed publications on FLHE. In Kano, the socio-cultural context impeded implementation, but the persistence of innovative local champions resulted in some success. In Lagos, the cosmopolitan context, effective champions, funding by international donors, and a receptive government bureaucracy led to successful implementation. In Niger, despite a relatively conservative socio-cultural context, state bureaucratic bottlenecks overwhelmed proponents' efforts. In summary, the interaction of socio-cultural context, domestic champions, adaptive capacity of state bureaucracies, and international funders explains variable implementation of FLHE. The Nigerian experience highlights the need for sexuality education proponents to anticipate and prepare for local opposition and bureaucratic barriers.