Background:
The health systems is a domain of policy-based lending for development financing institutions (i.e. the World Bank) to improve the health of the population in the low and low-middle income countries. The aim of this research is to explore the instrumental role of the Bank’s health systems policy. It is a policy process analysis to understand how the Bank’s health systems policy gets formed and formulated (at the international-level of the macro system), then adopted and modified (at the national-level of the meso system) and finally implemented and operated (at the regional-level of the micro system).

Methods:
This policy process analysis has been conducted by using three methods at various levels of the policy; discourse analysis (formation-formulation), situation analysis (adoption-modification), institutional and context analysis (implementation and operation).

Results:
The World Bank has been active in the formulation of health systems policy for the last four decades by developing various health systems approaches (such as, basic health care, health systems development, health systems strengthening). The analysis finds that the Bank’s health systems policy content at the macro level (international) has always been determined by the interactions between global economic governance and global health governance. At the meso system (India as a case study), the health systems policy with the help of policy tools (_Country Assistance Strategy_) and instruments (_research_ and _lending_) forge alliance with the existing national health plan to further percolate down to the state level. Finally, the health systems policy as _health systems approach _(in programmatic form) gets implemented and operated at the micro system by often using the decentralization structure of governance (Karnataka as a case study).

Conclusion:
The economic management of health care and not epidemiological reasoning is getting primacy in policy defining (macro-level), designing (meso-level) and programming (micro-level) decisions. This adversely affects the policy outcomes.