Here Is How We Can Do Better


Here Is How We Can Do Better

Currently, global health is failing in equity, reciprocity, and genuine bi-directional partnerships. Global health is dominated by individuals and institutions in high-income countries (HICs) who benefit more than their partners (usually in low- and middle-income countries [LMICs]). My previous post highlighted why and discussed 10 big challenges to reciprocity.

But these challenges must be overcome. This post, second of a two-part series, will cover some potential solutions and strategies.

Measuring and tracking reciprocity

Measurement is powerful. Global health programs and funders in HICs must do a better job of tracking reciprocity and ask these simple questions: who is benefiting from our funds and training programs? For every trainee/faculty who visited an LMIC, how many did we host? What proportion of our global health graduates are from LMICs? What percent of donor gifts and endowments are used for HIC versus LMIC trainees? What fraction of collaborative grant budgets are allocated to LMIC partners? By tracking such metrics, HIC institutions can uncover and address inequities.

Funders and donors can enhance reciprocity

Funders and donors can ensure a more equitable distribution of funding and overheads. They could, for example, directly give grants to LMIC institutions, without routing funds via HIC institutions. Such grants could include budgets for international training and exchanges. Iruka Okeke, a professor at the University of Ibadan, Nigeria, endorses this approach and argues for increasing the overheads for LMIC agencies. “True overhead costs can be higher in LMICs, where equipment servicing, internet, visas, travel, and many basic utilities cost more,” she said.

Johanna Crane, a medical anthropology professor at Albany Medical College concurs. “The US NIH could raise their indirect costs reimbursement for foreign sites. Even making it 15% (still well below typical US rates) could make a big difference and help build research and administrative infrastructure and capacity in low-income countries,” she said.

Universities can enhance reciprocity

There are dozens of global health programs in North America and Europe, and many offers graduate degrees (e.g. Master’s in public or global health). These programs can and must allocate a certain proportion of their slots for LMIC students, and offer full funding support. Here, the NIH Fogarty program is an exceptional model that other HICs should consider.

While global health degrees are now offered online, their tuition fees are not necessarily lower for LMIC applicants. This is a huge missed opportunity, since distance education can reach many more students than on-campus degrees. There is a real need for affordable, quality, online graduate training programs in public health for LMICs. This is a wonderful opportunity for HIC universities to demonstrate their reciprocity.

Anant Bhan, a global health and bioethics researcher in India, argues that “reciprocity should be an important component of ranking (or accreditation of) global health programs.”

Negotiating the rules of engagement

Yap Boum, a researcher at MSF Epicentre, would like to see bidirectional exchanges explicitly included in agreements or MoUs between HIC and LMIC institutions. “That should stimulate both institutions to seek funding to increase reciprocity,” he said. Other African researchers have also voiced their need to ‘set the rules of engagement.’

Anant Bhan concurs. “Reciprocity needs to be explicitly identified as a fundamental equity issue in any partnership which is developed including partners from HICs and LMICs,” he said. “It must be thought through right at the time of initial planning of partnerships,” he added.

“Reciprocity should be negotiated both individual-to-individual, but also institution-to-institution,” said Bethany Hedt-Gauthier, a global health researcher at Harvard. “However, I don’t think that reciprocity needs to be equal. I don’t think of this as “for every 10 students I send to Rwanda, I will absorb 10 students here”. I may want to send a student there as a priority for my trainee or my program, but in turn, my partner’s goal may not be to send a student here. In my mind, these can be different types of equations – they need to balance, but don’t need to be the same opportunities on both sides. she added.

Michael Lipnick, a professor of anesthesiology at UCSF, concurs. “In my anesthesia global health circles, the idea of reciprocity mostly focuses on ‘if we send one trainee/faculty, we should also host one trainee/faculty.’ While I don’t disagree with the concept, I am trying to push for more innovative, impactful and valuable forms of reciprocity (as defined by our collaborators),” he said. He provides the Health Equity, Action Leadership (HEAL) Initiative as an example, where more than 100 fellows from multiple disciplines have completed the 2 year, full time fellowship. Each year the fellowship accepts fellows 1:1 with partner sites internationally as well as in under-served areas of the US.

If ‘partnership’ implies ownership on all sides, then African partners should own something when they dissolve. In reality, the fervor and excitement of high-level innovation and teamwork at a partnership ball may leave just a little more than a perishable pumpkin and a single glass slipper behind. We scientists on the African continent are going to have to demand more from partnerships than a full buffet and a quick ballroom whirl.

Iruka N. Okeke, Medicine Anthropology Theory, 2018 (http://medanthrotheory.org/read/10853/partnerships-for-now)

Upending traditional models

The traditional model in global health is North to South. This is true in research, training, consultancy, and technical assistance. This model is ripe for disruption.

There are examples of training models that explicitly address equity and diversity. For example, the Global Health Corps program has trained over 1000 fellows over the past decade, including 43% African nationals, and 68% women.

“We need to consider examples of south-south collaboration. This should also be an example of reciprocity,” said Yogan Pillay, Deputy Director-General at the South African National Department of Health.

Indeed, if LMICs increased their investments in health, research, and training, there will be lesser reliance on HIC researchers, institutions and donors. This is already happening in the area of global health technologies, public health training, and technical assistance.

Why should an African trainee come to London or Boston to learn about sleeping sickness (and pay top dollars for such training)? As I have pointed out earlier, building top-notch schools and institutions in LMIC is critical. A few recent examples include the Public Health Foundation of India, BRAC School of Public Health in Bangladesh, the University of Global Health Equity in Rwanda, and the Africa Health Research Institute in South Africa.

Seye Abimbola, the Editor of BMJ Global Health, argues for reciprocity beyond academic and clinical global health. “I think there is greater space for cross-learning in the area of technical support to governments at different levels, which could involve exchange fellowships among government entities that are active in global health or public health. Such exchange programs are not expensive. And I’m sure it’s possible to create a matching program where different potential agencies can enlist and consider applications to go both ways,” he said. The Africa CDC, Nigeria CDC, and African Society for Laboratory Medicine are examples of technical agencies that are collaborating within Africa on issues such as pandemic preparedness.

Currently, global health meetings are mostly held in HICs, posing great challenges for LMIC participants. “Hold those major conferences, courses and workshops in countries that everyone can get to with easy visas. As well as improving LMIC attendance, it will boost developing economies and let HIC scholars see realities of the countries where they study the health of the poor,” said Iruka Okeke.

Dismantling underlying structural problems

In the longer term, we must work to dismantle the structural problems in global health that compromise equity, genuine partnerships and reciprocity. Everyone working in global health must put Winners Take All by Anand Giridharadas on their reading list. At a minimum, we should all watch the episode “How Billionaires Will Not Save Us” on Patriot Act by Hasan Minhaj.

“Because so many of the problems are rooted in global inequality, it’s hard to think of targeted, manageable changes that might make a difference.” said Johanna Crane. Her research exposes a critical tension that makes reciprocity such a challenge: “the field of academic global health depends on steep inequalities for its very existence, as it is the opportunity to work in impoverished, low-tech settings with high disease burdens that draws North American researchers and clinicians to global health programs and ensures their continued funding. This paradox – in which inequality is both a form of suffering to be redressed and a professional, knowledge-generating, opportunity to be exploited – makes the partnerships to which global health aspires particularly challenging.”

“We need to change the story from global health being about charity to one about social justice,” said Sridhar Venkatapuram, a professor of global health ethics at King’s College, London. I agree. And global health should be about social justice and equity everywhere, not just in low-income countries. “Why aren’t the problems and burdens of wealthy societies emphasized in ‘global health’ and why aren’t LMIC students prioritized to study them and bring an uncommon perspective as preparation for a future that is already here?” asks Iruka Okeke.

Indeed, global health programs in HICs must pay more attention to addressing inequities in their own countries. This will, hopefully, make them less exploitative of inequities in low-income countries.


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