While the idea of decolonizing global health has gained prominence recently, it is not new. Discussions about the impact of the colonial legacy on health systems began with the end of the colonial system. A discussion among academics, activists, health practitioners, and others, that is taking on new urgency, as actors look to identify and correct imbalances in power. Much of the conversation has centered on decolonizing global health, which can mean reversing the immediate legacies of colonialism, including the lack of investments in health systems and robust research institutions in former colonies. But it can also mean dismantling “global health,” a term that often stands in for the system of international institutions and donors that govern the public health agenda and control levers of power.
The field of Health Policy System Research (HPSR) offers us valuable theorisations and empirical work to guide us on how we can engage with the complex social, economic and political nature of health systems today. However, the field has not been able to fully grapple with the blind spots that are ever present in our reality. This is why we argue that more needs to be done to actively build the capacity of HPSR scholars to question the implied assumptions of the dominant discourse that helps us make sense of the world we inhabit.
Munshi S, Louskieter L and Radebe K (2020) Decentering power in Health Policy and Systems Research: theorising from the margins, International Health Policies Blog
This problem of consulting malpractice is merely one facet of a larger issue of how global health, even today, is still colonial in many ways, and how high-income country experts and institutions are valued much more than expertise in low- and middle-income countries. This article makes suggestions on how global health consulting can be decolonised.
Pai M (2019) 10 Fixes for Global Health Consulting Malpractice, Global Health Now
In a Viewpoint in the Lancet, experiences of censorship in donor-funded evaluation research were shared. The authors warned about a potential trend in which donors and their implementing partners use ethical and methodological arguments to undermine research.
Reactions to the Viewpoint—and lively debate at the 2018 Global Symposium on Health Systems Research—suggest that similar experiences are common in implementation and policy research commissioned by international donors to study and evaluate large-scale, donor-funded health interventions and programmes, which are primarily implemented in low resource settings.
Researchers are responsible for conducting research ethically and with integrity. Yet, without strong and reliable institutional support, they are often in a vulnerable position when faced with vested interests. What action is needed to avoid undermining independent and critical research findings? What kind of institutional structures and practices might support researchers in dealing with the ethical and political dilemmas associated with the dissemination of (potentially) contested research findings and evaluation results?
To start a discussion on ways forward, the authors invited input from an international network of global health, health systems and policy researchers from diverse disciplines. They discuss suggestions, endorsed by more than 200 researchers based in 40 different countries on how the organisations that commission, undertake and publish research and evaluations can safeguard independence and integrity.
Storeng KT, Abimbola S, Balabanova D on behalf of the signatories, et al, Action to protect the independence and integrity of global health research, BMJ Global Health 2019;4:e001746.
No one likes a parachute researcher: the one who drops into a country, makes use of the local infrastructure, personnel, and patients, and then goes home and writes an academic paper for a prestigious journal. This Lancet article suggests some ways in which this can be avoided and some of the ethical issues associated with this style of research practice.
The Lancet (2018) Closing the door on parachutes and parasites, The Lancet, Vol 6, June 2018
This editorial is based on the author’s experiences as a journal editor, and an academic who has been a local researcher and a foreign researcher. It is also based on a constructed ‘ideal’ of how things might have been without global health research partnerships, and when (circa late 19th to mid-20th century) many of the countries that are now high-income countries experienced significant improvements in health outcomes and equity, that is, an ‘ideal’ of local people writing about local issues for a local audience. They deploy this ‘ideal’ not as a prescription, but as a heuristic device. By applying this sense of ‘ideal’, they wrestle, rhetorically, with three questions related to imbalances in authorship. The questions are: (1) What if the foreign gaze is necessary? (2) What if the foreign gaze is inconsequential? (3) What if the foreign gaze is corrupting?
Abimbola S (2019) The foreign gaze: authorship in academic global health, BMJ Global Health 2019; 4:e002068.
Countries in the Global South continue to struggle to train and retain good researchers and practitioners to address local, regional and global health challenges. As a result, there is an ongoing reliance on the Global North for solutions to local problems and an inability to develop alternative approaches to problem solving that take local (non-northern) contexts into account.
Current paradigms of scientific advancement provide no long-term models to challenge the status quo or privilege knowledge that is generated primarily in the Global South. This has major impacts on access to funding which perpetuates the problem.
There needs to be a concerted and demonstrable shift to value and promote the development of research and scientific traditions that are borne out of the reality of local contexts that complement knowledge and evidence generated in the Global North.
Reidpath DD and Allotey P (2019) The problem of ‘trickle-down science’ from the Global North to the Global South, BMJ Global Health 2019;4:e001719
In this book Madison Powers and Ruth Faden develop an innovative theory of structural injustice that links human rights norms and fairness norms. Norms of both kinds are grounded in an account of well-being. Their well-being account provides the foundation for human rights, explains the depth of unfairness of systematic patterns of disadvantage, and locates the unfairness of power relations in forms of control some groups have over the well-being of other groups. They explain how human rights violations and structurally unfair patterns of power and advantage are so often interconnected.
Unlike theories of structural injustice tailored for largely benign social processes, Powers and Faden’s theory addresses typical patterns of structural injustice-those in which the wrongful conduct of identifiable agents creates or sustains mutually reinforcing forms of injustice. These patterns exist both within nation-states and across national boundaries. However, this theory rejects the claim that for a structural theory to be broadly applicable both within and across national boundaries its central claims must be universally endorsable. Instead, Powers and Faden find support for their theory in examples of structural injustice around the world, and in the insights and perspectives of related social movements. Their theory also differs from approaches that make enhanced democratic decision-making or the global extension of republican institutions the centerpiece of proposed remedies. Instead, the theory focuses on justifiable forms of resistance in circumstances in which institutions are unwilling or unable to address pressing problems of injustice.
The insights developed in Structural Injustice will interest not only scholars and students in a range of disciplines from political philosophy to feminist theory and environmental justice, but also activists and journalists engaged with issues of social justice.
Powers M and Faden R (2019) Structural Injustice: Power, Advantage, and Human Rights, Oxford University Press
Power is a critical concept to understand and transform health policy and systems. Power manifests implicitly or explicitly at multiple levels—local, national and global—and is present at each actor interface, therefore shaping all actions, processes and outcomes. Analysing and engaging with power has important potential for improving our understanding of the underlying causes of inequity, and our ability to promote transparency, accountability and fairness. However, the study and analysis of the role of power in health policy and systems, particularly in the context of low- and middle-income countries, has been lacking. In order to facilitate greater engagement with the concept of power among researchers and practitioners in the health systems and policy realm, we share a broad overview of the concept of power, and list 10 excellent resources on power in health policy and systems in low- and middle-income countries, covering exemplary frameworks, commentaries and empirical work. We undertook a two-stage process to identify these resources. First, we conducted a collaborative exercise involving crowdsourcing and participatory validation, resulting in 24 proposed articles. Second, we conducted a structured literature review in four phases, resulting in 38 articles reviewed. We present the 10 selected resources in the following categories to bring out key facets of the literature on power and health policy and systems—(1) Resources that provide an overarching conceptual exploration into how power shapes health policy and systems, and how to investigate it; and (2) examples of strong empirical work on power and health policy and systems research representing various levels of analyses, geographic regions and conceptual understandings of power. We conclude with a brief discussion of key gaps in the literature, and suggestions for additional methodological approaches to study power.
Sriram V., Topp S.M., Schaaf M., Mishra A. Flores W., Rajasulochana S.R. and Scott K. (2018) 10 best resources on power in health policy and systems in low- and middle-income countries Health Policy and Planning, Volume 33, Issue 4, 1 May 2018, Pages 611–621
Northern voices dominate Global Health discussions. How can it be acceptable that these groups continue to dominate in deciding what problems we think about in Global Health and how we approach them? The most excellent research study or Global Health program risks failure unless it is informed by and contextualized by the people close to where change is sought. The question of inclusivity calls for multiple approaches. Intersectionality—the study of how privilege and disadvantage are linked to overlapping social identities—holds promise in deepening our understanding of inclusivity.
Sheikh, K., Bennett, S.C., el Jardali, F., Gotsadze, G. (2016) Privilege and inclusivity in shaping Global Health agendas, Health Policy Plan (2017) 32 (3)