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Background: Strong management is important for high-value health-care systems if returns on global health investments are to be delivered and the Sustainable Development Goals met by 2030. Managers are responsible for care delivery systems and strategies, making sure that health services benefit the population they intend to serve. Most managers in resource-limited settings work at the district level and below, with little training in non-clinical skills. They are often health care providers who have been promoted into management roles. Here, we aimed to understand the most challenging aspects of the health-care management role in resource-constrained settings and to identify gaps in managers' skills and knowledge in order to better design programmes and tools to support managers in their delivery of care. Methods: We sent a web-based branching survey to frontline global health managers via Devex between October, 2014, and January, 2015. The survey used multiple-choice and Likert-scale questions about skills within five categories of management in global health: finance; human resources; facility/supply chain or inventory management; clinical, field, or laboratory team management; and relationships with community and partners. Before the survey, we did a literature review, held a virtual discussion with experts, and piloted the survey to refine areas of management and enable targeted training. The pilot survey was also completed by mid-career professionals attending the Global Health Delivery Intensive at the Harvard T H Chan School of Public Health in July, 2013. Findings: We included data from from 350 survey respondents in 44 low-income countries, the virtual discussion panel with 131 experts from five continents, and responses from 33 Global Health Delivery Intensive attendees from 11 countries. Our findings indicated that health-care managers are short on time, are required to multitask without an understanding of priorities, and that they lack management skills, motivation, and information. We refined our intensive global health delivery course to meet what were identified as the most pressing challenges, and we offer an online community of practice to facilitate peer-to-peer learning and expert guidance to these areas. In 2016, 52 professionals from 24 countries participated in the eighth annual Global Health Delivery Summer Intensive. More than 90% of respondents (n=49) said they planned to incorporate their learning to make changes to their professional approach or practice. Interpretation: Universities can play an important role in convening managers and helping them to facilitate knowledge dissemination and translation. Future investments are needed to ensure global health professionals can access continuous professional development opportunities. Funding: The Abundance Foundation.

Background: South Africa's Health Minister Aaron Motsoaledi inherited an HIV epidemic and a weak public health system when he took office in 2009. His priorities were to establish a national programme to address HIV and to create a system of national health insurance (NHI) to increase access to affordable and high-quality health care. By 2015, Motsoaledi's work on HIV was considered as a success; however, work on the creation of NHI was stymied. Here, we aimed to compare the design, promotion, and implementation of the national HIV programme—a primarily vertical programme—with that of NHI, a horizontal programme. Methods: In January and February, 2015, we conducted 20 semi-structured interviews in South Africa with government leaders, civil society, researchers, health-care practitioners, private insurers, and international non-governmental organisations. We analysed interviews and available quantitative data from government, academic, and industry sources and distilled key themes in two teaching cases. Findings: We identified several key differences between the HIV programme and NHI efforts, including the role that leadership and politics play in health policy and care delivery; the effect of historical, economic, and cultural context on outcomes and leaders' ability to institute change; and the importance of strategy in planning and decision making. We noted both contextual barriers (such as public distrust of government) and catalysts (demand for HIV treatment) in the programmes. Furthermore, the approach used by the Minister of Health sometimes hindered programme success (for example, the exclusion of private insurers from NHI design) and sometimes enabled success (such as the engagement of civil society in the HIV response). For both programmes, the availability or absence of outcomes data affected the Minister's ability to advocate for change and to make strategic decisions about how to invest in health. Interpretation: The comparison of South Africa's well known and effective HIV programme with its stalled NHI efforts—both led by the same person with very different results––sheds light on important considerations when approaching complex, large-scale change. Our analysis of the politics of health systems shows how explicit acknowledgement of the political nature of health will lead to more effective health promotion strategies and policies. Political leaders can either drive or hinder the implementation of evidence-based public health practices. Funding: The Ministerial Leadership in Health Program of the Harvard TH Chan School of Public Health, and Children's Investment Fund Foundation (CIFF), UK.