In February, the New York Times Editorial Board announced: “Foreign Aid is Having a Reckoning.” This reckoning based on the Black Lives Matter movement is not just isolated to foreign aid. It extends to the entire global health field which has been in a self-reflection mode since this summer. And yet, not even a year after organizations put out statements that committed to better achieve racial health equity by consulting with and deferring to communities most impacted, new funding for global public health programs are following old patterns.
At the beginning of the year a $30 million grant for malaria operational research went from U.S. President’s Malaria Initiative to PATH, a global non-profit organization, and then to seven sub recipients based in the U.S., the U.K., and Australia. None of these countries have malaria. This is the latest example of scientific colonialism. None of the main partners are based in the countries where the research will happen, even though capable research institutions exist. I and several African scientists recently wrote an open letter calling out this grant and the practice in general.
Global health is dominated by individuals and institutions in high-income countries. We need to rethink the structure of funding and who is funding the project and whether or not they are embedding equitable practices as a requirement for the program they fund. But what will it actually take for funding organizations to move from rhetoric to remedial actions that initiate and nurture equitable global public health programs and research?
The initial steps to repair global health are not as complex as one may think. Academics and implementers alike have long argued that to start, health priorities must be set by the community that is most proximal to the issue. One doesn’t have to look far beyond the Covid-19 pandemic to see what problems can occur when a one-size fits all model is offered as a solution to health challenges that exists in different societal and cultural milieus.
For example, when handwashing was trumpeted as the main way to protect oneself from the invisible threat, it was initially ignored that in 2019, more than 25 percent of people worldwide lacked access to a handwashing station with soap and water. While poorer countries in Africa and Asia have lower rates of access, the disparity in ability became even more apparent when looking at communities. Like the Navajo nation in the United States where, before COVID, 30 percent of the residents lacked running water in their home.
This means that funding organizations must not only decentralize funding so that local organizations and communities are equipped, but that funding structures must center community leadership in defining the problem(s) to be solved. Otherwise, investments can be wasted by missing specific community issues that, if addressed, could have real impact to help combat health threats.
Another starting point in repairing the broken infrastructure of aid and financing of global health starts before the money is even distributed, when grant applications and proposals are reviewed. Currently, every part of this process favors researchers and practitioners from high income countries. They often have relationships with the funding organizations, they have the required evidence of ‘expertise’ (e.g., many peer-reviewed journal articles) that allows them to swiftly check boxes. Funding application valuation panels are also mostly populated by individuals from Global North institutions.
Due to these imbalances and the biases in publishing, which often keep researchers from Africa, Asia, the Middle East, and Latin America at a disadvantage, current “fixes” to equity often are tokenistic at best. Due to the distasteful reception of programs and projects that are completely run by organizations based in the West but are implemented in poorer countries, today many funding calls require a partnership with a host institution in the country that the research will take place. Unfortunately, many researchers in these host institutions have described that in reality the host institution does not have decision-making power and can often play a tokenistic role.
“Expertise” must be redefined so that this process can be more fair and less restrictive. Funding organizations can start by:
This notion of equity and justice in global health should ascend to the funding and financing mechanisms behind these programs. By focusing on equitable funding for partnerships we are able to center equity at the start of a project giving equal opportunities in both space and time for a diverse set of people with different capabilities to succeed.
Equitable partnerships build trust among research partners and fosters health research that targets solutions to local problems. By establishing equity early in the process with partners, it allows specific goals to encompass the needs of all partners, focusing on both short term and long-term goals. Without equitable partnerships as a priority for funders, global health remains a patronizing and neocolonial activity.
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