Ideas matter: An analysis of the effects of framing on health system strengthening in Zimbabwe.

Background: Health system strengthening (HSS) has been a well-endorsed concept globally since the 2000s. However, few studies have utilized theory to examine its evolution at the country level and potential implications for policy. This study used framing theory to examine changes in the portrayal of HSS in Zimbabwe from the mid-2000s to the period post-2020.

Methods: We employed a framing analysis methodology encompassing documentary review and key informant interviews.

Results: Four main frames were identified, namely HSS as (i) a donor imperative, (ii) a pathway to resolve crisis, (iii) a strategy for achieving long-term stability and (iv) a foundational investment for a resilient health system. HSS as a remedy for a crisis frame has been the most influential, but the greater involvement of donors in crisis response may have entrenched the mis-framings of HSS as a donor imperative. Donors have shifted from outlining strategies to assigning responsibility for HSS, with framing for more governmental funding. The government's response to those framing shifts has been more symbolic rather than substantive, undermining health system performance. Recently, donors have started to reduce their funding to align with framing towards more governmental responsibility, resulting in health system shocks in critical areas such as human resources.

Conclusions: The vulnerability and emotional frames that attracted donor funding during peak crisis have lost potency over time. Shifts in framing require proactive action, as policy underreaction can lead to exacerbated problems, missed opportunities for improvement and a loss of public trust in government effectiveness and responsiveness. Nascent, overly futuristic framings such as "resilience" need to be interpreted with caution, as they may cloud the reality that HSS is simply sufficient investment in basic functions. HSS needs to be reframed as a routine, country-owned strategy aimed at improving health system performance rather than a crisis response shaped by donor interventions. Zimbabwe has a rich history of effectively framing events to design and implement pragmatic, domestic -led policies towards HSS, and such latent potential should be tapped into to steer progressive reforms.