Opinion: Beyond the buzz words: 'DEI' and 'decolonizing' global health

Diversity, equity, and inclusion, or DEI, has gained significant attention over the past few years in the global health and development space. As more organizations commit to DEI in their workplaces, the discussions around “decolonization” in relation to international development and humanitarian aid have also been elevated. Several organizations based in North America and Europe are making efforts to operationalize and institutionalize changes to address these issues.

In 2022, the World Health Organization/IBP Network conducted a survey with NGOs and civil society organizations about DEI issues and found many inconsistencies when using this terminology among North American and European-based organizations compared with regional and local organizations based in other countries. In addition, the term “decolonizing” felt like a buzzword being magnified by those living in North America or Europe. As one participant expressed: “It is as if the decolonizing global health agenda has been colonized.”

To distill these issues, we hosted a virtual workshop to discuss questions around terminology and how the global health community can address some of these challenges. Our role was to create a platform for local partners to voice their perspectives on the complexity of these issues. First was an effort to better define terms that are often used interchangeably. These definitions were shared to help shape the discussion, but are not exhaustive:

• Decolonization entails acknowledging colonial legacies of harm in order to support efforts to build more equal societies.
• Diversity is the presence of differences that may include race, gender, religion, sexual orientation, ethnicity, nationality, socioeconomic status, language, disability, age, religious commitment, or political perspective.
• Equity is promoting justice, impartiality and fairness within the procedures, processes, and distribution of resources by institutions or systems.
• Inclusion is an outcome to ensure those that are diverse feel and/or are welcomed. Inclusion outcomes are met when a person and their institution and program are truly inviting to all.

Following a clarification on definitions, several reflections emerged based on the ideas, comments, and discussions among individuals from over 65 countries representing a range of organizations and individuals working in global health at global, regional, and local levels.

While we rightly view access to health care as a universal human right, it is important to acknowledge that unequal access to health is inextricably linked to colonialism. What we might loosely term Western medicine has pioneered some incredible achievements that have changed the way some of us live and survive. What often remains invisible, however, is that many of these innovations, such as treatments, drugs, and vaccines, relied on experimentation on the bodies of the enslaved in Europe’s colonies or the poor of London or Paris. We need to recognize how medical progress was undertaken too often in ways that were exploitative, unethical, and immoral, and to recognize the possible ways in which these colonial practices continue to shape unequal access to health, care or support in the field of global health today.

There are reasons why countries in Africa, Asia, and Latin America have struggled with health and development outcomes compared with those in North America and Europe. Hundreds of years of colonization, exploitation, and extraction of resources have resulted in economies that are struggling to keep pace with countries that have benefitted from decades of industrialization at their expense. The entire international aid model has been founded on trying to solve problems that were created by those in power.

DEI efforts are one way to attempt to address the implicit inequities that have been generated from the colonial past. However, the terminology does not resonate in the same way among partners. Much of the DEI language used originates from the United States and tends to focus on racial diversity, specifically, the inclusion of Black and Brown persons marginalized in North America. These issues might not be a priority or perceived as a need in the same way in other countries. As one participant mentioned, “If local people are not prioritizing diversity issues in their area, then should we be imposing this discussion on them?”

At the same time there was recognition that despite perceived language, there are in fact DEI issues in all settings. As one participant articulated: “Discrimination within countries based on ethnicity or tribe or caste is so common,” adding that “DEI is more than addressing racism.” As a general concept, DEI is about advancing equity, inclusion, and belonging.

The agenda around decolonization in global health has gained traction in the past few years, but as many colleagues around the world will attest, this is not new. Individuals at all levels, from government to the grassroots, have been fighting the long-lasting implications of unequal partnerships and funding mechanisms that have marginalized institutions based in Africa, Asia. and South America for decades, even hundreds of years. If the current decolonization agenda is to come up with different results, efforts should focus on how to empower regional and locally based institutions outside Europe and North America to play leading roles in owning, conceptualizing, and managing innovations and programs, and not succumb to the tokenism that has dominated previous efforts. It is important to ensure that new approaches are complementary and build on previous efforts that have been undertaken by local partners for decades.

The powers that are urging for decolonization are still dictating priorities in global health — namely large donors and international organizations. The funding architecture and relationship between how global health is funded and implemented needs to change.

As one participant said: “Is it really reasonable to expect complete neutrality and decolonization when funding comes predominantly from the West? The funder sets the agenda.” Efforts to prioritize local needs even when not in line with global priorities should be acknowledged and applied.

Understanding the history, background, and terminology allowed for additional discussion on solutions. Below are three key actions identified to start to address these complex issues.

1. Let local priorities lead

Local organizations, individuals, and communities are the experts in identifying challenges their communities are facing. These are the priorities that should be driving global health and development agendas, not those of global donors or international organizations. There are multiple stories of local partners identifying needs at a country level only to be told they do not meet the priorities of a donor: perhaps they are not perceived as sustainable, or they do not build capacity.

This imbalance of meeting local needs with global funding further perpetuates this power imbalance and the colonial mindset. While many donors are working to change structures to support local organizations, the underlying issue of what they will fund remains a challenge. Trust-based philanthropy and other forms of “unrestricted giving” are an effort to shift priority setting to the end users, but more work is needed. A paradigm shift to one of mutual trust and implementation rather than overly rigorous monitoring and reporting is needed to fully empower local partners to invest in solutions that are most impactful and sustained.

2.   Support local organizations in their structures, not only activities

Global partners are very keen to partner with local organizations when applying for large funding awards. However, funds are often limited only to activities around implementation and not to support the organization itself with other costs such as staff, building expenses, or other operational expenses. Additionally, when awarded, there are inequities in how funds are used. For example, financial disclosures required for local NGOs or CSOs are not required with the same level of transparency for international NGOs. There are efforts by some large donors to support local institutions, but more is needed to change the way funding is structured for local engagement that includes allowing unrestricted funding and/or opportunities to truly build local organizations.

3.   Create space and make room for others

Power dynamics between those with the resources and those implementing on the ground will take time to change. In the meantime, those working in large organizations or with funding might serve local partners well by using their privilege to make space for others. For example, leveraging global conferences to create opportunities in local languages and using culturally sensitive approaches that foster collaboration to truly listen to those working at a local level will facilitate meaningful engagement and local solutions. In addition, funding and support for marginalized populations, young people, and other groups to sit on boards, attend and present at global meetings, host global networks and communities, and set global agendas is instrumental to shifting the power between global organizations and those working at the grassroots level.

Efforts in global health and development are important and valuable investments that continue to support the lives of many around the world. With a renewed focus on DEI and discussions around decolonizing global health, strategies to promote more equitable ways in which this work is structured and implemented to support the needs of local partners should be prioritized.  

Editor’s note: This opinion piece was co-authored by Nandita Thatte of WHO/IBP Network Secretariat; Angela Bruce Raeburn of DiverseDev; Lata Narayanaswamy of University of Leeds; Eliya Zulu of the African Institute for Development Policy; Anup Adhikari of SURUWAT Nepal; and Ados May of IBP Network Secretariat. The authors would like to recognize and thank all the workshop participants for sharing their perspectives and valuable experiences that have contributed to this synthesis of ideas.