Elevating country voice.

The diagnostic frame of elevating country voice presents ineffective aid as the problem of global health and attributes this problem to lack of inclusiveness in global health governance and decision-making roles, suppressed LMIC voice and amplified voice of HIC actors in global health agenda setting, and lack of ownership of global health initiatives by LMICs (I1, I23, I25) [29, 47]. A respondent argued that the majority of members of the working groups of global health initiatives are individuals from Europe and North America, representing donor foundations and research organizations (I14). Referring to a personal experience with one such working group, the respondent argued:

“We had an initial meeting and I realized that there wasn’t a single person in that meeting from any of our partnering countries and, like this is absolutely ridiculous; like why are we all coming together trying to decide what we should be focusing on and why are we not listening to our colleagues who are on the front lines and dealing with post-partum haemorrhage on a daily basis?” (I14).

Another respondent further stressed how aid tilts the scale in favor of HIC actors and suppresses LMIC voice in global health:

“I think there’s been this dynamic always of he who has the dollar holds the power and so this feeling of, you know, donors having their agenda or governments having their agenda, that they’d then go in and try to get the receiving or the recipient country to go along with, as opposed to starting with where those priorities are” (I5).

Another respondent reflected on how those holding the resources shape global health given power differentials:

“It’s very hard because the development partners are the ones who are funding things…. So, they actually ultimately control the power. So, they have the power in the room. The countries do not have the power in the room” (I22).

Funders prioritize immediate results to justify investment in global health initiatives above local priorities and long-term outcomes. They have complex application submission and reporting systems that local actors are not familiar with. The implication is that only large HIC organizations that are experienced in working in the terrain, and which have previously received and managed grants by these international donors, will continue to get funded. Local organizations can hardly compete with them (I14; I22). Even when funders wish to work with local organizations, the complex application and reporting systems and desire to get results compel them to stick with established HIC organizations while working in LMICs (I14).

As a result, the aid provided is not as impactful in LMICs—a major problem raised in the ‘elevating country voice’ frame. According to a respondent:

“… the impact of aid has been minimal on countries of the South because of the idea of controlling the aid and managing the aid, not just the funding, but its implementation, its direction, the conceptual elements, it’s all being done by the powerful countries of the North…” (I23).

Decolonizing global health.

The decolonizing global health frame, by contrast, presents racialized hierarchization of humanity and health systems, and exploitative neoliberalism as the problems of global health. Consequently, this frame attributes blame to systemic racism (I1, I10, I15) and neoliberalism and its purveyors (I1, I15). It suggests that the problem of suppressed LMIC voice in global health agenda-setting results from coloniality. One respondent reflected:

“… the way that we approach international development is still Europe and the US donating money or funding projects in Africa and there’s still that hierarchy …” (I20).

In line with the diagnostic framing of racialized hierarchization of humanity and health systems, Affun-Adegbulu & Adegbulu [27] point to the lack of ontological and epistemic pluralisms in the conceptualization of humanity in global health circles as the problem. Global health initiatives run on the assumption of a superior Western medical knowledge and health practice, and this fails to give room for the integration of alternative knowledges and healing systems into health systems of countries. Where this integration appears to happen, it is one-sided, and the conditions and terms of integration are determined by biomedical professionals [48]. The result is a health system that is unjust, non-inclusive, lacking in diversity, and unable to offer equal access to health [4].

Racialized hierarchization of humanity manifests in a notion of supremacy and a mentality of saviorism in HIC actors involved in global health working in LMICs (I14). According to some respondents, many HIC actors side-track and delegitimize governments in LMICs (I21) and work with the mentality that “Well they’re not going to do it for themselves and so we’ve got to come in and do it for them” (I14). A couple respondents reflected on the underlying racism that underpins global health practice:

“I think in the way we think and practice global health, you know, the idea that knowledge flows from the North to the South, you know, still persists. The idea that, you know, there’s this kind of burden, the white man’s burden, right, to save the black man or to save the rest of the world. That still persists, which again it still has tinges of racism in it” (I15).

“We [HIC actors] were not accepting the expertise and the leadership in the countries where we were working. We have come in again as helpful colonists…” (I10).

Akugizibwe [36] employed the frame of exploitative neoliberalism while arguing that global health operates a system that treats LMICs as subjects of HICs’ philanthropy, but in reality, this system exists to serve the economic interest of HICs. Global health is therefore an exploitative tool which needs to be examined through the lens of the global political economy. Stretching this argument, Akugizibwe [36] argued that donors provided more than a fifth of health spending in 20 sub-Saharan African countries, and over 40 percent of health spending in nine countries. While this is often framed as a one-way flow of charity, it is in reality an indication of a complex power dynamic that yields benefits for the donors by improving their relations with the recipient countries, giving them control over global health agenda and establishing an incentive for those LMICs to align their policies with the interests of donor [28, 36]. This philanthropy also safeguards HIC pharmaceutical industry profits [2]. The problem of exploitative neoliberalism is attributed to lack of government investment in health systems in LMICs [28]. Key international global health players such as the World Bank give aid/loans that come with conditions, including the inclusion or exclusion of specific programs (I7). In this way, the priorities of LMICs are determined by HIC players.

A respondent supported the view that economic interests often override positive health outcomes in global health practice:

“For at least ten years, if not more, I’ve heard low- and middle-income countries saying we want the ability to produce our own vaccines in our countries or at least in our regions; and XXX was always like this is impossible, it cannot be done…” (I27).

The words used to describe different parties in global health initiatives are also suggestive of absence of equity; a sentiment highlighted by this respondent:

“And if you look at the amount of money that comes from donors to low- and middle-income countries, sometimes it’s a drop in the ocean compared to the national budget. It’s not always, but in some cases, it is, right. So why are we calling them donors and why are we saying recipient countries rather than implementing countries?” (I27).

The respondent explains further:

“So even the language that we use or, you know, even at the XX Foundation I think it’s even worse, we call them markets. You know, they’re not even countries anymore. They’re markets! … and the incentive is to get results from your grantees, you have a lower return on investments sometimes with a local partner than with an international partner that understands the dynamics of the XX Foundation” (I27).

Since LMICs are seen as markets, respondents also argued that HIC organizations compete for returns on investment and prioritize justifying to their government how they have used ‘taxpayers’ money’, giving less attention to the involvement of local LMIC organizations or what recipient countries consider priority in the implementation of health initiatives (I7).

Decolonizing global health also considers the way LMICs are represented on the boards and working groups of major global health organizations and initiatives. Some respondents argued that people are often selected to represent LMICs, simply because they are friends with the HIC actors in charge (I17). The same set of people are invited repeatedly as ‘country voice’ (I11). Sometimes the representatives lack the technical competence to elevate country voice (I16); and they are often an obstruction to elevating country voices because if true representation happens, the power of these specific representatives is diminished as prioritizing the interests of LMICs often does not serve their personal interests (I15, I17). When representatives have conflict of interests, it is difficult to know the priorities of the LMICs they represent (I10, I15, I17). Sometimes, senior government officials are bought off with development assistance money (I21), and the hierarchy in government bureaucracy unfortunately gives little room for junior officers with contrary views to present them. So, the decolonizing global health frame queries the logic behind equating tokenism or the invitation of a few representatives to an agenda-setting meeting with elevating the voice of the entire country (I10, I22). A respondent asked rhetorically:

‘Okay, we threw in a country voice, we had this one tokenistic person show up and we can now check the box!?’ (I10).

Further complicating representation is the cost and logistics of participating in meetings that hold in Geneva or Washington, which naturally skew the table against LMICs (I27).

Within the decolonizing global health frame, widespread attitudes and beliefs that support coloniality in global health practice among key LMIC actors are seen as a problem which they call ‘colonialism of the mind’. One respondent said:

“That’s really the worst type of colonialism, [the] colonialism of the mind, you know, because it affects the way you think about yourself, it affects the way you think about your abilities, but also affects the way you think about the white man, you know, or woman, and so there’s, I think, that mindset still exists in the South where, you know, some still expect ideas to come from the North” (I15).

Finally, the global health decolonization diagnostic frame situates global health within a larger political and economic structure of power asymmetry beyond global health practice and policies themselves. It posits that global health purports to operate in an apolitical vacuum, but in reality, it operates within an international political and economic context that perpetuates inequality among nations, and poverty in LMICs, the result being poor health outcomes and the need for aid in LMICs [21, 49].

Elevating country voice.

Within the elevating country voice frame, the solution to the problem of suppressed country voice is improved LMIC representation and leadership in global health agenda setting (I5, I11, I14, I17, I27) [37]. This is reflected, for example, in the membership of Technical Working Groups and Steering Committees of global health initiatives implemented in LMICs—a strategy meant to elevate LMIC needs and priorities before programs are designed (I20). Referring to a new health initiative funded by a HIC organization, a respondent provided an example of improvement in representation as a solution to the suppressed voice of LMICs:

“The steering committee is made up completely of colleagues from low- and middle-income countries, as opposed to colleagues from the global North or Westerners …” (I11).

The elevating country voice frame also considers co-creation of health initiatives by funders and recipient countries as an indicator of progress (I10, I14) [9]. Another measure of elevated country voice is local actor’s knowledge of local health programs, an indication of ownership (I16, I24). Country ownership is marked by engagement with national and subnational governments in identifying problems at the priority phase, and consultation in the designing of objectives and project activities. During the implementation phase, country ownership is marked by partnership in the implementation of actions, obtaining feedback, and accountability through consultation in monitoring and evaluation. For example, the Local Engagement Assessment Framework (LEAF) of Oxfam America, Save the Children, and the Overseas Development Institute considers whether local governments are responsible for managing the project resources and whether they contribute resources (human resources in particular) to the project as markers of ownership [9].

In support of the strategy of greater representation and co-creation, a respondent suggested having:

“… an open dialogue about asking for their help in identifying entrenched problems, where we could come up, jointly, with some ideas of what might help them overcome those entrenched obstacles or gaps in their programming, and then we would look for the innovation that might be relevant for that programming” (I5).

Other identified markers of elevated country voice include: local actors taking leadership and decision-making roles in planning and implementing health initiatives and being able to push back when programs from HIC organizations don’t make sense for their country (I15, I16, I18, I20). In addition, elevating country voice frames the use of national/sub-national government funding for programs (I11) [50] and the proportion of external funding that goes directly to local institutions as progress markers (I1, I14, I22).

The elevating country voice frame also proffers the adoption of locally funded initiatives—or putting funds directly in the hands of local actors—as a solution to the problem of the ‘dollar power’ (I3). A respondent explained:

“… we are requiring that a minimum of 45% of funding that goes to our international partners or United States-based partners on MOMENTUM, that 45% of those funds are then sub granted to local partners on the ground” (I14).

Another strategy involves improving the capacity of LMIC actors to take leadership in designing and implementing programs. Specifically, this includes clearly articulating an investment case for where LMICs want donors to provide support that can be more directly accessed by country actoea (I15); and redefining performance indicators to de-emphasize the interests of donors and focus on the priorities of LMICs (I15, I22). One respondent noted:

“I think we have to redefine what we mean by ‘results’” (I22).

Decolonizing global health.

The decolonizing global health prognosis is greatly nuanced ranging from calls to reform ‘the system’ to calls for ‘disposing of it all together’ [51]. A strand proffers–as a solution to the problem of racialized hierarchization of humanity and health systems–indigenous research with its roots in the worldview of indigenous people on an equal footing with Western scientific methods [52–54]. The indigenous methodology is known for equal power sharing between the researcher and the people studied, better community engagement, and respect for cultural beliefs, values, norms and practices. To address the problem of hierarchization of health systems, alternative home-grown solutions and alternative healing practices are to be sought and integrated into health systems to complement existing biomedical solutions [26, 40, 55]. Indigenous ways of knowing helps to address the problem of lack of equity in global health research [56]. The politics of knowledge acquisition needs to be transformed in order to address existing power asymmetry using several means, including encouraging that LMIC studies be published in local outlets or open access to keep knowledge within the reach of local actors (I15) and constantly keeping historical contexts in view. In the words of a respondent:

“You have to just really understand the history of why people are where they are” (I22).

The prognostic frame of decolonizing global health also considers the revision of medical and global health curriculums and program designs as essential to promote awareness of global health history, and to question and address negative traditional narratives, power asymmetry and white supremacist notions in global health [57, 58]. In addition, curriculums need to better emphasize patient safety, fair trade principles, diversity, equity and local and global contexts [54, 59].

The decolonizing global health frame also sees the need to address the problem of power asymmetry in global health governance. It recommends a structural transformation of global health governance that gives power to LMICs to fully control their own health systems (I18; I23; I26). One respondent suggested:

“… it’s time that we remove this colonial element out of aid, and we bring the power, as they say, back to where it belongs, in countries of the South” (I23).

One respondent, stressing the need for LMICs to control their own programs, said:

“… can we tell them to bugger off if they don’t want to do what we want them to do or what we need them to do, right?” (I26)

In the same vein, another respondent calls for a:

“complete shifting of power to those whose lives need to be changed” (I22).

By implication, the prognostic framing of decolonizing global health advocates for improved public health financing in LMICs (I1; I17). This view rests on the assumption that reliance on funds from HIC actors buys ‘donors’ the influence they need to control public policies and programs in LMICs [36]. A key proponent of decolonization considers that, in the near future, the solution may be to “abolish global health” in order for all actors to think of a new reality that is currently unknown (I26). The frame also sees the co-existence of biomedicine and alternative medicines within a health system as a marker of progress. At the global level, it sees the absence of racial and supremacist ideas in global health governance and initiatives as important markers of progress. More specifically, this will mean diversity, equity and inclusion in the boards of global health initiatives and major global health institutions.

The decolonizing global health diagnostic frame understands global health coloniality to be a part of a broader system characterized by power asymmetry. A broad-based approach that seeks to decolonize all facets of life is thus required for an impactful change to occur in global health (I25). Based on evidence that poverty is a driver of poor health outcomes, such an approach will also need to address the policies that continue to limit economic growth and keep populations impoverished in LMICs [49]. The decolonization of the minds of key LMIC actors is an essential component of this strategy, as suggested by a respondent:

“the decolonizing of the mind’ is another solution’ (I15).

The decolonizing global health prognostic frame will therefore see power symmetry in global health governance and a non-racist and non-hierarchized (i.e., egalitarian) world to be requirements for decolonizing global health.

Elevating country voice.

The motivational framing of elevating country voice is detailed in the 2005 Paris Declaration on Aid Effectiveness and similar documents that guide development practice involving many multilateral and bilateral organizations and LMICs that receive development aid [8, 9]. The call-to-action rests on the argument that aid to LMICs has the greatest impact when development programs align with local priorities and are owned and led by local actors. The elevating country voice frame calls actors to a gradual change in their approach to global health practice in LMICs. This call, if implemented, will result in a phased transition from global health practice where priorities and agenda are set by external funders to one in which local actors determine the priorities, own and implement local health initiatives, and contribute significantly to the resources used in the implementation of programs. The motivational frame also prioritizes the principles of harmonization of development work to avoid duplication, focusing on measurable results with specific performance indicators, and mutual accountability [8]. To achieve its goals, the motivational framing of elevating country voice calls for the strengthening of local capacity for exercising leadership in development programming, building more effective and inclusive partnerships, and achieving development results and openly accounting for them [17]. This motivational frame targets HIC institutions involved in funding programs in LMICs, local partners, and governments of recipient nations.

The motivational frame is summed up in the message:

“it’s really hard to get things done without that [elevating country voice]” (I20).

It is framed as a way of supporting LMIC institutions in what they do (I2) and as the only way to ensure sustainability (I18; I22). The framing is perceived by some as instrumental, presenting elevating country voice as the means to improving effectiveness of development work in LMICs.

Decolonizing global health.

A part of the motivational frame of decolonizing global health can be summarized in the demand that global health work be done “as an act of justice and not charity or saviorism” (I26). The motivational framing of decolonizing global health has been strongly expressed in commentaries and original articles in journals and blogs [3, 4, 37]. This frame typically emphasizes the ‘injustice’ and ‘inequity’ of global health practice, calling for an overthrow of the worldview on which global health practice currently rests. It presents this worldview as supportive of the notion of the universality of Western knowledge rather than a pluriversal worldview of humanity [27]. By implication, this call-to-action considers power and voice asymmetry in global health as symptoms of racialized hierarchization of humanity and health systems and exploitative liberalism.

However, because of the choice of message outlet, it often leaves out key actors involved in the implementation of global health initiatives in LMICs, as well as key government actors (I3, I10, I16) and sometimes does not resonate with LMIC actors (I26). Several respondents noted that the decolonization of health dialogue largely emerged and has been advanced in academic circles (I22, I27), especially from “developing countries in academic institutions in high income countries” (I27).

Calls for DGH may not resonate yet with many people from LMICs partly because of the mismatch in the preferred media outlets of the thought leaders and local actors, and partly because the current DGH discourse—which is narrower in reach than the broader decolonization discourse—is perceived to be heavily entrenched in HIC networks. One respondent noted how the ideas are yet to be acceptable to local actors:

“… we had colleagues from the Africa team say they’re not comfortable using the ‘decolonizing’ concept” (I27).

An LMIC respondent explained that local actors may have other priorities. They argued that:

“…if you came flinging ‘decolonizing health systems’, people might probably want to say, look we are more interested in maybe weeding out corruption, [achieving] some transparency, and knowing what the money is being used for” (I16).

Another LMIC respondent, when asked whether the concept of decolonization resonates, clarified:

“No. Number one, I would not have bought that [discourse] because they [those advancing ‘decolonizing global health’] are not on the ground…. I am one of those people that are very careful with people that are not in the kitchen and they talk a lot about cooking … For any movement to be effective, it must be home-grown” (I19).

The foregoing shows a tension within the decolonizing global health frame. While it speaks to the themes of power asymmetry, justice and fairness in respecting the views of those most concerned by global health programs, it appears to have left those most concerned about the matter of decolonizing global health behind–those in LMICs. Although the key sponsors of the frame among the respondents in this study are largely from LMICs, they currently operate in HIC institutions and their views may not resonate with LMIC actors in LMICs. They appear to be suggesting what is best for LMICs when they themselves are outside those LMICs, an idea that is inconsistent with the spirit of decolonization.

In summary, the motivational frame of decolonizing global health appears yet to be fleshed out, perhaps on purpose, in order to accommodate multiple views and create a larger coalition of actors who care about different facets of inequality and injustice.