Health systems research is inherently political. It prompts us to grapple with issues of status and inequality. Issues of power and privilege can be built into the systems and institutions of research and academia which shape researchers’ views, actions, and room for manoeuvre when it comes to ethics. Researchers also need to consider how they relate to different groups with a stake in the outcomes of health systems research for example, health service users, communities, health workers, managers, policy makers and donors. Within these relationships various organisations and individuals wield different levels of power and influence over the research process.
Social science and feminist approaches to research ethics tend to have a strong emphasis on the relational elements of ethical practice, and of producing quality data. They stress the need to be aware of and pay attention to conflicting interpersonal relationships and power imbalances inherent in many research relationships, and there is interest in the political implications of the research endeavour.
At the institutional and structural levels there is a need to consider power imbalances and unearned privileges in the ways in which research partnerships and knowledge economies are conceptualised, financed and managed.
The resources begin with a review of the literature on power and health systems research by Sriram et al. (2018). A commentary by Sheikh et al. (2016) explores how power relations and privilege play out in the ways that global health agendas are set and argues for a more intersectional approach to recognising and tackling power imbalances. The paper by Benatar (2016) prompts us to look at global health framings, priorities and strategies – and how they shape or constrain thinking and action. The blog by Molyneux and Theobald (2018) explores both power and vulnerability in field work and the relationships between research partners.
A number of resources in this section address the issue of gendered power relations and health systems research. Three overview papers look at gender and intersectionality within the process of conceptualising and conducting health systems research. The article by Nordling (2017) explores what patriarchal power relations mean for field work in the Africa region. While the blog by Morgan (2016) asks us to consider power and privilege within our teaching practices.
Also included are articles on research partnerships with a focus on shared sovereignty and capacity development, inequities in global health and the need to decolonise health systems research. These resources cover issues like ‘trickle-down science’, foreign authorship, parachute researchers and donor censorship. Blogs on decolonising focus on consulting, theorising and activism.
In the book Structural Injustice: Power, Advantage, and Human Rights (2019) Madison Powers and Ruth Faden develop an innovative theory of structural injustice that links human rights and fairness norms. Norms of both kinds are grounded in an account of well-being. They explain the depth of unfairness of systematic patterns of disadvantage, and locate the unfairness of power relations in forms of control some groups have over the well-being of other groups.
Providing practical advice, the framework from the Canadian Coalition for Global Health Research suggests how greater equity might be fostered through applying principles of authentic partnering, inclusion, shared benefits, commitment to the future, responsiveness to causes of inequities, and humility.
The Coronavirus Disease 2019 (COVID-19) pandemic, the Black Lives Matter and Women in Global Health movements, and ongoing calls to decolonise global health have all created space for uncomfortable but important conversations that reveal serious asymmetries of power and privilege that permeate all aspects of global health.In this article, we, a diverse, gender-balanced group of […]
A systematic review on ethical challenges of ‘field’ research in low-income and middle-income countries: respect, justice and beneficence for research staff?
Primary data collection in low-income and middle-income countries (LMICs) is associated with a range of ethical complexities. Considerations on how to adequately ensure the well-being of research staff are largely neglected in contemporary ethics discourse. This systematic review aims to identify the ethical challenges that research staff across different hierarchical levels and scientific disciplines face […]
Sharing power in global health research: an ethical toolkit for designing priority-setting processes that meaningfully include communities
To promote social justice and equity, global health research should meaningfully engage communities throughout projects: from setting agendas onwards. But communities, especially those that are considered disadvantaged or marginalised, rarely have a say in the priorities of the research projects that aim to help them. So far, there remains limited ethical guidance and resources on how […]
The COVID-19 pandemic has so far revealed that the virus (SARS-CoV-2) does not only infect, weaken, and highlight weaknesses in human biological systems, but also the structural weaknesses of health systems at international and national levels. In this paper we examine the COVID-19 pandemic in Africa through a decolonization lens. Keeping in mind that there are […]
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 […]
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 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) […]
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 […]
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 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 […]
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) […]
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 […]
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, […]
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 […]
Striking disparities in access to healthcare and in health outcomes are major characteristics of health across the globe. This inequitable state of global health and how it could be improved has become a highly popularized field of academic study. In a series of articles in this journal the roles of power and politics in global […]
This blog summarises a set of discussions on vulnerability, agency and resilience in a meeting organised by REACH it is framed around the paradox that: on the one hand research can be powerful tool for social justice in ensuring that interventions are evidence based; but on the other, there is need to protect ‘the vulnerable’ […]
Carrying out research on the mechanisms and treatments of disease in sub-Saharan Africa is often conducted in the most traditional and patriarchal communities. These social structures complicate such processes as gaining consent and giving participants feedback on the findings. But researchers have begun to learn an important lesson: by making an effort to better understand […]
In this blog Rosemary Morgan outlines the ways in which power and privilege can be manifested within the teaching of health systems research. This includes in teaching processes as well as institutions. It touches on efforts to decolonise curricula and whether traditional teaching reproduces inequities; explores how gender effects how students view their tutors; and […]
Health inequities are often avoidable consequences of actions and contexts that disproportionately advantage some groups over others. These negatively affect human rights, including the right to health. Global health research aims to promote greater equity worldwide. The principles of Authentic Partnering, Inclusion, Shared Benefits, Commitment to the Future, Responsiveness to Causes of Inequities, and Humility […]
A number of individuals and organizations have considerable influence over the selection of global health priorities and strategies. For some that influence derives from control over financial resources. For others it comes from expertise and claims to moral authority—what can be termed, respectively, epistemic and normative power. In contrast to financial power, we commonly take […]
Intersectionality has emerged as an important framework for understanding and responding to health inequities by making visible the fluid and interconnected structures of power that create them. It promotes an understanding of the dynamic nature of the privileges and disadvantages that permeate health systems and affect health. It considers the interaction of different social stratifiers […]
In dealing with complex systems and multiple actors, operating at different levels of the health system and influenced by power relations, the research lends itself to intersectionality analysis – an approach that focuses attention on studying the interaction of different factors or social categories (rather than each in isolation or as simply additive), and the power […]
This commentary argues that, “addressing the gap in research capacity in low- and middle-income countries is pivotal in ensuring broad-based systems improvement, with local knowledge and training being central to responsive health system development, proper governance, and responsible government.” Commentary: Beran D, Byass P, Gbakima A, Kahn K, Sankoh O, Tollman S, Witham M and […]
Governance of global health research consortia: Sharing sovereignty and resources within Future Health Systems
Global health research partnerships are increasingly taking the form of consortia that conduct programs of research in low and middle-income countries (LMICs). An ethical framework has been developed that describes how the governance of consortia comprised of institutions from high-income countries and LMICs should be structured to promote health equity. It encompasses initial guidance for […]
Gender—the socially constructed roles, behaviours, activities and attributes that a given society considers appropriate for males, females and other genders—affects how people live, work and relate to each other at all levels, including in relation to the health system. Health systems research (HSR) aims to inform more strategic, effective and equitable health systems interventions, programs […]