Opinion: 5 ways to decolonize global health and build greater equity

As a health economist from Ghana, I’m often asked about my take on the decolonization of global health.

For me, any discussion of decolonization brings to mind Ghana’s first president, Kwame Nkrumah, who — along with other African liberation leaders — spearheaded the decolonization of other countries on the continent.

He also frequently spoke of the more difficult struggle against neocolonialism, in which a nominally independent state has its economic system and political choices directed from outside.

Nkrumah’s insights have proved remarkably prescient in foreshadowing the current movement to decolonize global development.

Within the field of global health — and development more generally — there is broad agreement that unfair power balances exist. Donors wield most of the power and determine what gets funded, who is an expert, what gets researched, and who researches it. A large amount of money and power flows to organizations in high-income countries — not to the countries where their programs are focused.

The struggle for global equity

Now, we are living through a period when global equity — both between and within countries — is emerging as one of the fundamental questions. The decolonization of global health; the quest for diversity, equity, and inclusion; and racial justice are all strands of this larger movement.

Though the debate over global equity has been going on for decades, decolonization discussions have picked up steam amid the COVID-19 pandemic and the rise of the Black Lives Matter movement.

We see that people of color in higher-income countries are often not treated fairly or afforded justice in encounters with police. We see that the primary victims of the pandemic are members of Black communities and other people of color.

And we feel the glaring inequity and discrimination of the global system, which is so starkly exemplified by the inadequate supply of vaccines in our own countries.

How to decolonize global health

The victims of these injustices must be the primary drivers of change. But change is more likely to happen faster if allies — or progressive sections among those who benefit from the system — join forces with those who are oppressed. We’ve seen that over and over throughout history, including during the struggle against colonialism.

In addition to finding allies in high-income countries, the development community can take steps to help decolonize global health and contribute to greater global equity:

1. Let local experts tell their own stories. Global health and development journals and media platforms sometimes perpetuate colonial models and external dominance through their externally driven agendas, as well as by preferring technical, quantitative models and otherwise minimizing the dynamics of local contexts, thus turning local experts into objects rather than subjects of their own development stories and narratives. This has to change.

2. Improve vaccine equity. Africa has the lowest COVID-19 vaccination rate of any continent by far. This is largely due to inadequate vaccine production and unfair global distribution of existing vaccines, which benefited from publicly funded research.

Additional vaccine production is hindered by trade and patent policies, which seek to maximize profits for pharmaceutical companies. The needs of people without access to vaccines ought to trump huge profits for Big Pharma. There is an urgent need to bolster the case of lower-income countries — led by India and South Africa — arguing for the World Trade Organization to relax some intellectual property rules, which would permit increased vaccine manufacturing to help those still lacking access to doses.

3. Grant greater research autonomy. Research in low- and middle-income countries should reflect priorities set by local experts — and not driven by higher-income countries’ priorities and concerns. Local experts must also lead its implementation.

4. Fund local organizations. We now see a slow-moving shift toward a greater share of donor funding going to local organizations instead of international ones, though we are far from a complete change of approach. We have seen, for example, the Bill & Melinda Gates Foundation require that a greater share of its funding go to local organizations. This process needs to be accelerated and started by other donors.

5. Re-imagine technical assistance. Because COVID-19 restricted travel, including technical assistance trips, the pandemic has stimulated a debate in the donor community about re-imagining technical assistance. An important step that donor organizations can take is to do more to empower country change agents and partners instead of relying on the usual “fly in, fly out” approach.

As one example, Results for Development has launched two initiatives: a platform called The Experts Database, which is similar to LinkedIn and allows experts in low- and middle-income countries to advertise their skill sets and experience to a global audience; and one called The Coaching Approach, which is different from traditional approaches to technical assistance because of who provides the support and how it is delivered.

Advances in these areas of decolonizing global health would certainly contribute to equity. However, there is still a long way to go in terms of the growing income inequities globally and within countries and ensuring that development is responsive to the needs of the people affected. The development community could consider these ideas as a way to start work on this long road.

Visit the Building Back Health series for more coverage on how we can build back health systems that are more effective, equitable, and preventive. You can join the conversation using the hashtag #BuildingBackBetter.