In an open letter to international funders of science and development in Africa, a group of prominent African scientists, policy analysts, public-health practitioners and academics have criticized the funding model of the US President’s Malaria Initiative (PMI), which recently awarded $30 million to an American NGO to lead a malaria project in Africa. The five-year research and evaluation project will be led by organisations in the US, the UK and Australia, and will work in collaboration with African institutions to fight malaria across the continent. The letter, published in the scientific journal Nature, criticizes the PMI for failing to fund African institutions based in Africa, or list them as primary research partners. The authors have amplified calls to “decolonise global health” and are demanding funding organizations examine their internal practices and establish more inclusive and equitable policies.
“International funding … has contributed a model of implementation that puts the delivery of several health interventions directly in the hands of Western non-governmental organizations, which further diminishes the capacities and ownership of national programs to deliver to their populations and ultimately leads to weak health systems and a lack of sufficient local capacity,” the letter states. In response, the PMI acknowledged that it has not done enough in working directly with local institutions and that it needs to do more. The initiative has committed to publishing a draft strategy for public comment in the coming weeks to address some of the concerns raised in the letter.
Dr Michael Jennings, a reader in international development at SOAS, said the issue has captured an important aspect of decolonising global health, and that the response from PMI shows a willingness to engage with and find solutions for more equitable funding models. But, he said, this is only part of a broader approach needed to decolonise the global health system as a whole. “There isn’t a single answer, and nothing can be transformed overnight,” he said. “But rather than waiting for a group of scientists to point out the flaws for funding organizations in the Global North … [institutions] need to think more critically about setting up research projects and doing work in a way that is genuinely supportive of global health.”
How Global is Global Health?
According to the Global Health 50/50 report, 85% of global health organisations are headquartered in Europe and North America. Two-thirds of those organisations are headquartered in just three countries: Switzerland, the UK and the US. This high concentration of knowledge, expertise and resources in the West shapes global health priorities and policies, meaning that many of the decisions for local communities across the Global South are made externally. The decolonisation movement, which has its roots in social sciences, calls for attention to knowledge construction outside of the traditional centres of power, and to give voice to alternative or critical viewpoints that have been silenced or neglected. Jennings has written that “decolonisation of global health matters because the continuation of colonial models still shapes interventions. It has contributed to the ‘verticalisation’ of health systems as donors support specific diseases rather than general health, leaving regions such as sub-Saharan Africa highly vulnerable to Covid-19 as well as a huge number of other health risks.”
Approaches to decolonising global health
Despite widespread acknowledgement of the need to address inequities and power dynamics in global health, many practitioners are unsure of how to approach decolonisation. One challenging issue is that donors often face strong pressures to demonstrate the effectiveness of health interventions through a cost-benefit analysis, where the amount of money spent relates to the number of lives saved. But Jennings said that to achieve broader health and economic impacts, donors must be willing to spend more money on strengthening national governments and research institutions that have been bypassed in the name of efficiency. “By ignoring the politics and the global power disparities, [donors] are creating and feeding into other inequities that may also be having an impact on global health,” he said.
The COVID pandemic has laid bare the extent of these inequities, and many in the global health sector have raised concerns that the pandemic could undermine years of progress in combating other health crises, including malaria. According to the Global Fund’s Disruption Report, malaria diagnoses fell by 31% between April and September 2020, compared to the previous period across Africa and Asia. But Jennings said that even before the effects of the pandemic were felt, not enough meaningful attention was given to addressing unequal power structures. He points to other neglected tropical diseases and mental health issues, for example, which have received less international attention and funding over the last several decades yet continue to cause major harm in affected communities. However, Jennings acknowledges that the current COVID crisis may prove an important inflection point for the global health community to strengthen or rebuild the current system. “This seems to be an ideal opportunity for thinking about what it would mean to have a system that takes power downwards and outwards as opposed to being concentrated in the Global North.”
The Nature letter calls upon all major international funders to commit to finding and implementing both short-term and long-term changes to the current model. They suggest funding African scientists and institutions directly to empower and enable them to shape and conduct their research across the continent. For long-term progress, they demand a total transformation of the current funding model that centres local researchers and organizations working in health. Jennings offered additional solutions including establishing multilateral, as opposed to bilateral, funding programs, and enabling national and regional governments across the Global South to contribute to setting global health priorities.
Evidently, the process of decolonising global health will be a long and difficult one. But, as the Nature letter and the PMI response have shown, there are many people working in the sector who are committed to creating equal partnerships and ensuring a truly global health system. As Jennings put it: “Decolonisation doesn’t have to mean only one thing. The letter showed a willingness to debate and come up with solutions on all sides that are equitable, ethical and effective.”
Maxine Betteridge-Moes is a SOAS Digital Ambassador pursuing an MA Media in Development. Born and raised in Canada, she has worked in Asia and Africa as a journalist, podcast producer and occasional music blogger. Follow her on Twitter @maxine_moes