Introduction

Global health in its broadest term is defined as "the area of study, research and practice that places a priority on improving health and achieving equity in health for all people worldwide” [1]. In this article we focus on the current disparities in global health research, focusing on inequities and power asymmetries in current research structures and funding mechanisms. These inequities in research are reflected in inequities in global health outcomes. Researchers and journals within the global health community have been increasingly vocal regarding these inequities contributing to the discourse about what is wrong with global health [2, 3]. The epistemic injustices in global health research funding are shaped by deeply entrenched unequal power dynamics, rooted in a colonial history that has to date consistently applied an outsider gaze to local problems and needs [4]. For their part, funders and donors, though they have diverse platforms for expressing their voice, often in ways that go unchallenged, are not engaged in this discourse, nor is there any evidence of their reflection on their responsibility, accountability and positionality in global health research and the injustices that perpetuate in this space. This, together with the lack of transparency in the decision-making process in funding is a critical blind spot [5, 6].

There have been calls for example for urgent review of the current funding mechanisms in the UK research environment specifically in global health research collaborations with low- and middle-income countries (LMICs) [7]. The need to align the positionality and gaze of global health funding models has been described, providing recommendations for how to address the power imbalances which inhibit epistemic diversity [4]. This approach calls for greater division of power between North and South actors which will require active engagement on both sides. It is important to note that inequities in research and in health outcomes are linked to deeper and sustained inequities in the structural determinants of the global political economy that affect both health and research. Within high income countries (HICs) too, the racial and socioeconomic status of populations impacts their access to health and health outcomes, with research into their health needs often under-resourced [8].

Understanding and changing the status quo requires closer examinations of the strategic goals and incentives that drive funders’ decisions, and influences what they fund. It also requires engaging with funders in HICs, and potential funders in LMICs in conversations that aim to collectively shape a new approach to global health research funding. Adding to the existing discourse on this topic, we describe the current drivers of injustice and the complicity of different actors working in systems designed to perpetuate a division of labour that is highly detrimental to those who hold less power, the majority of whom are in LMICs.

Current challenges in funding global health research

The current power asymmetries influence control of resources and knowledge generation and prioritisation [4]. Global health research funding primarily comes from HICs and may not correlate with the burden of disease [9]. Major donors such as the US and European country governments, and philanthropies like Bill & Melinda Gates Foundation (BMGF), the World Bank and Global Fund are highly influential in shaping the global health agenda [10]. When HIC donors give grants, they predominantly fund institutions, contractors, and principal investigators in their own countries. For example, 70% of Fogarty grants go to US and HICs, 73% of Wellcome Trust grants support UK-based activity, 80% of USAID contracts go to US firms, and 88% of grants by the BMGF is estimated to be held by global North institutions [11–14].

In the development and humanitarian sector, a large proportion of funds are granted to global North non-governmental organisations (NGOs) [15]. This concentration of funds in HICs gives them power to dictate what research is done, how it is done, who carries out the research, ownership of the data and knowledge generated, and subsequent representation on research outputs. Hence, the authorship on global health publications is heavily skewed towards HIC researchers who are often first or senior authors [16]. Parachute research is also a likely consequence of the power dynamics inherent in research funding. This domination is also seen in global health leadership. Reports by Global Health 50/50 indicate the lack of diversity in global health leadership with potential impact on priorities and policies. In the latest Global Health 50/50 report, more than 70% of global health leaders were men and half came from just two countries: UK and US. Moreover, only 5% of women from LMICs were in leadership roles [17, 18].

The topic of global health research differentially benefits populations of the global North [4, 19]. Examples of such inequities include the trickle-down science of adopting technology from HICs to LMICs, often with limited consideration for the contextual needs of LMICs [20]. While there are common interests (between funders and grantees) in generating and sharing new knowledge, there are divergent interests in the distribution of power. The asymmetry of power and voice is a design feature of the system, not a bug. Disrupting the asymmetries in these systems will need active reflexivity and participation from funders, who to date due to their privileges have been shielded from the effect of injustices which shape the global health environment. The critical question is how to make such disruption to the system palatable and acceptable, as to those who hold power within the system it is working as it should. The first step is to create an environment where there is ownership, participation, and equity [4, 21, 22].

The power asymmetries translate to institutions and investigators in HICs being the major recipients of funds to implement research addressing health inequities in LMICs [13]. For example, malaria and TB primarily impact LMICs, but research funding is mostly held by HIC institutions [14, 23]. In the case of TB, whilst LMICs account for 98% of reported cases, the largest funder remains the USA National Institute for Health which by 2020 had awarded 93% of its allocated TB research budget of $339 million to US-based institutions [24]. The BRICS (Brazil, Russia, India, China, and South Africa) countries jointly account for 47% of worldwide TB cases. Whilst it is not possible to account for their total contributions, investment in TB research from all these countries declined in 2020 [24].

The argument is often made that LMIC researchers do not have the capacity to deliver global health objectives unaided. This is an inappropriate generalisation. There are many laboratories in LMICs for example, capable of high-quality research, and other LMIC laboratories could come up to the same standard, given time and appropriate investment. Furthermore, global health research is not just about technical skills in science, it is also about scaling evidence, fighting systems that perpetuate inequities and injustice, social trust, effective leadership, and the administrative challenges of managing large grants. These skills require scientific credibility, but also local and contextual knowledge and experience [25]. HIC scientists who persist with a ‘saviour’ mentality, while doing very well from being affiliated with LMICs for their own career advancement, often remain unchallenged in presenting LMIC researchers as insufficiently skilled, while ignoring home-grown LMIC opportunities for innovation [26]. This is driven by imbalances in economic and cultural power between HIC and LMIC scientists, which confer unchecked privileges to those in HICs [27]. HIC scientists are better trained in navigating the academic research environment (e.g. grant writing and publishing), which is historically anchored in the global North. This translates into the distinct underrepresentation of LMIC researchers on grant applications. The underrepresentation of LMIC partners is also a continued problem with funding panels [25]. Equally, the persisting mentality of victimhood by many LMIC professionals needs challenging, as does the abdication of responsibility and underinvestment by leaders of many LMICs, a practice that perpetuates dependency of the South on the North [28, 29].

Historically movements for change have been led by those affected–the disenfranchised leading the US Civil Rights Movement, women revolting against patriarchy, families with children with disabilities setting up organisations to serve children with similar issues. Those movements presented credible threats that beneficiaries of the status quo could not ignore. Global health research may need the same. To redress the power imbalances, LMICs need to participate not as supplicants, but as increasingly assertive partners who co-finance a joint enterprise. This expectation is however, complicated by geopolitical and economic drivers [30]. First, the growth of philanthro-capitalism–a way of doing philanthropy which mirrors for-profit business–driven by global rule systems, tax rules, transnational corporate influences, the growth of commercial interests in the health sector, and the focus on a biotech paradigm which impact HIC motivations for occupying space in global health [31]. For example, the BMGF emphasis on technology may be driven by market forces in HICs and overlook the socio-cultural determinants of health [32]. Second, the role of debt servicing in shrinking the fiscal space for health in many LMICs cannot be ignored. In 2019, over 30 African countries spent more on debt servicing than on health [33]. Most LMICs cannot afford to finance health research within their own countries. Third, universal expectations on politically and economically disparate countries that comprise LMICs is not just or appropriate and in many ways reinforces the narrative of the powerful. This too is occurring at a critical time when decisions in what to prioritise and fund in global health are made without equitable representation of LMICs actors [34].

On the other hand, the role of private actors in global health is increasing. For example the Global Fund involves a multiplicity of private actors in a variety of ways in co-responsibility for and co-development of policies and interventions [35]. This increasing power is not necessarily aligned with how much private actors are investing in global health, which in the case of the Global Fund amounts to 5% of the total investment, bringing into question the disproportionate power that private actors have in global health despite low investment [35]. It also raises the question of the interest of private actors in global health, given that the corporate and commercial determinants of health tend to affect LMICs disproportionately [36, 37].

With variations across countries, factors affecting the capacities of LMICs to self-finance greater portions of their health expenditures include the sizes of their economies; the tax-to-GDP ratio, which is very low in some countries (and important because governments can spend only the revenues they collect in taxes, unless they borrow from local or foreign sources); the choices they make within their budget constraints (reflecting their priorities); and revenue lost to corruption. LMICs that can afford to, do finance their own research. The BRICS countries are one such example. With growing local investment in its scientists and institutions, China has taken over from US as the leading country in terms of scientific output [38]. China, South Africa, and India are increasingly assertive and can provide examples for others in fighting for and earning greater clout. We need more such examples from the global South. The caveat is that these countries are vast with a young population increasingly gaining higher education. In regions with smaller countries, regional pooling is a viable option. Another way to create a critical mass of researchers is by increasing funding to the global South by investment in and building of more health research institutes. This is essential for developing and sustaining track records in health research and greater recognition of leadership in LMIC-based institutions.

Hence, despite progress in some LMICs, inequities in opportunities and funding generated in LMICs remain a critical issue putting their researchers and institutions at the mercy of HIC funders, contractors, and principal investigators (PIs). One of the reasons for the difficulty in shifting this inequity is the level at which the decision-making process is open to researchers and other collaborators from LMICs. Current systems continue to regard LMIC collaborators as passive recipients or data collectors, with little representation and voice at the decision-making level. By the time LMIC partners are brought into decision making, the priority areas for research are already determined, funds divided, research questions developed and strategy set. This can be explained by the political, economic, and cultural power invested in global health funding remaining concentrated in the global North [17]. Indeed, the current system is working as it was intended to.

Changing current systems requires equity in representation beginning at the sources of financing and continuing at the top table when priorities for global health are identified and funding streams assigned. To achieve meaningful change, both sides of the coin need to be tackled. Firstly, LMICs need to be held to account to invest more of their own funds in health and research, to free their researchers from dependency on donors dominated by HICs. Secondly, HICs donors need to address the existing processes of funding mechanisms that create these inequities e.g., excessive reliance on the leadership of Northern institutions, a practice that reduces Southern researchers to bit players in their own countries.

Given that currently, donors and funders in HICs contribute most to funding global health research, we focus on inequities that arise from this imbalance. The specific questions for donors in LMICs need to be part of a separate piece considering different challenges in very diverse politico-economic contexts. It is important however, to acknowledge that the questions and challenges for donors and funders in HICs are equally applicable to funders in LMICs as power manifests itself in similar ways.

Funders of global health research should consider, engage with, and reflect on, their role in (in)equitable global health research. Firstly, current funding structures were set up for systems where centuries of political stability have created infrastructure for governance, knowledge acquisition, and dissemination (especially for mainstream populations)–such as in the US, Canada, UK, Australia, Sweden, Netherlands and Singapore [34]. Secondly, current systems for identifying funding priorities do not match the challenge of bridging capacity divides between HICs and LMICs–such that within partnerships, LMIC collaborators often remain no more than glorified data collectors [39]. Thirdly, existing governance frameworks and knowledge acquisition and dissemination were developed based on the experiences and interests of mainstream HIC populations. However, motivation for engagement, activism, and effective participation in global health research varies within and across countries depending on individuals’ experiences, perspectives, and privileges. Fourthly, research calls in global health are often biased towards issues that predominantly affect HICs, and when LMICs are targeted, since the panels that develop these calls are often convened by HIC-minded personnel, key LMIC considerations are often lost. Restrictive criteria for participation in the consultations to develop research areas for funding often leave LMIC partners out. Also, research areas emphasized by major philanthropies, such as BMGF, are often focused on technological solutions, rather than health systems strengthening and primary health care [40].

However, there are examples of global health research funding which aims to address inequities. New mechanisms such as the Joint Programming Initiative for Antimicrobial Resistance (JPIAMR) new mechanisms like JPIAMR, allow for a joint review process across many national funders and allow countries to support other country researchers in a multilateral mechanism [41]. The Consultative Group for International Agricultural Research (CGIAR) that operates globally but mostly in LMICs, has been transformational in the agricultural space by creating a mechanism that is responsive to needs globally. Such mechanisms or platforms provide potential ways forward for global health research funding.

Where are the opportunities for addressing these inequities?

Along the lifetime of a grant, there are missed opportunities for assuring equitable and ethical distribution of funds and resources that speak to the true principles of global health (Fig 1). Considerations for funders to include throughout the life course of grants in global health include:

• Situational awareness: funders need to articulate the power and institutional dynamics in which the grant is being designed, and they need to track who benefits from their funding.
• Develop a mission statement: to support the awardees to ensure equity in research across diverse domains for the life course of the research.
• Equitable allocation of funds: adequate and equitable allocation for all resources including expenses that reflect the needs of different settings, and attention to increased costs for LMICs researchers who may spend periods in HICs.
• Funding structures to uplift the disadvantaged: facilitate an environment where those afflicted with inequities are given sufficient power and resources (through direct funding instead of donor models of grants) to develop their own leadership opportunities to build local capacity and own the research and data generated.
• Capacity-strengthening: opportunities should include reciprocal observerships as well as building bridges between funders and researchers to facilitate LMIC and HIC researchers spending time working with the funder.
• Fostering diversity and inclusion of research teams through the grant cycle: co-development of research; equity in representation of people in outputs including scrutinising authorship, fellowships, conference presentations, and softer outputs such as panels convened for international meetings [6].
• Process of knowledge generation: clarity on ownership of data, interpretive tools (such as methods and frameworks) and the process through which knowledge is generated.
• Reflection and feedback: a nominated HIC and LMIC researcher to work directly with funders to build bridges for communication and learning; and transparency in the reflection and feedback from researchers to learn from mistakes and challenges within existing funding streams.

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Fig 1. Opportunities for funders to redress the inequities in global health research during the different stages of a grant.

https://doi.org/10.1371/journal.pgph.0000583.g001

Time for donors and funders to reflect

Whilst there have been calls for an ethical framework for reforming the funding processes in global health, to our knowledge there has not been a statement from many funders and donors explicitly engaging with these calls [42, 43]. Meaningful change requires candid conversations across institutional boundaries. What factors make it possible to have initiatives and programmes that primarily benefit research institutions in the global South, such as the Africa Centres of Excellence Project [44] or the Africa Centres for Disease Control and Prevention? We cannot move toward change without listening to the stories of the global South. What are the institutional and individual factors at play? Do they enable or hinder employees seeking to innovate? Or does it take extraordinary effort by employees to experiment outside the status quo? To transform this field what is undoubtedly needed is to have an opportunity for candid conversations with donors and funders as part of the process to transform the field [3].

Specific questions that need reflection and response from donors and funders are: 1) How diverse and inclusive are donors and funders, especially at the leadership level? 2) What do they understand as the goals of global health and how do those goals fit with their institutional priorities? 2) What geopolitical and technocratic factors do they see as drivers of global health? 3) What synergies and conflicts do they see between the first two considerations? 4) What percentage of funding will be directly awarded to global South recipients? 5) What do they see wrong with global health, and why? 6) What are the challenges in acting on the recent recommendations to address power asymmetries and decolonise global health? 7) What support do they envisage they need to bring about progress in this field? Reflecting on these questions will help funders to identify their role in addressing the prevailing injustices in global health.

Funders and donors need to work closely with the global health community across LMICs and HICs to define a pathway in global health research and development to address contextual injustices. This is critical to ensure and accounting for and understanding of the diversity of knowledge systems and paradigms. Through review of the literature and current discourse and discussions with stakeholders we propose a framework of key considerations to be used by funders from inception of funding schemes through to their delivery and monitoring and evaluation (Table 1). This framework can be applied to assess the ownership, partnership, and equity of the funding process providing a reflexive tool for funders to assess themselves. These questions are formulated to help funders reflect on the current injustices that existing systems are perpetuating, with potential solutions which funders can actively apply to disrupt asymmetries and progress towards ownership, participation, and equity.

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Table 1. Key considerations and metrics for funders towards more equitable global health.

https://doi.org/10.1371/journal.pgph.0000583.t001

The stark inequities in global health have been amplified during the COVID-19 pandemic. Particularly it has shown us how much the world is connected and how much HICs risk in ignoring research needs in other countries. Current systems are not created to provide an equitable platform to all the actors in global health research. Acknowledging this is the first step in creating opportunities for coming together to create a strong, equitable and inclusive architecture for global health research [46]. This is the principle that we need to apply for transformation of the field. The risk with naming and shaming is resentment and resistance to change. Yet, the risk with skirting hard questions is that real problems will be glossed over. We are looking to generate active discussions, which begin with commitments to empathetic listening and allyship by the global North and commitments to taking greater responsibility by the global South.