DECOLONIZING GLOBAL HEALTH FOR BETTER POPULATION HEALTH
The concept and discussion on OUR post-colonial relations are important for population health outcomes and deserve our attention. Here are my thoughts. What are yours?
During the AFREhealth conference held in Harare, Zimbabwe last August 2022 there were some presentations on the topic of decolonization of global health which were followed by vigorous discussions. I have since taken more interest in this subject and have been surprised to find that the subject of globalization is huge with many websites addressing diverse aspects of the subject including a group focusing on decolonizing contraception!
There are a number of highly regarded schools of public health and other institutions that are introducing new programs for students under Schools of Decolonizing Global Health and awarding Masters of Public Health degrees in Decolonizing Global Health.
So, what is decolonization with respect to global health? Decolonization of global health is variously defined as a movement that fights against entrenched systems of dominance and power imbalance in the work to improve the health of populations. This power imbalance may take place between countries, and institutions, in commerce and trade in health commodities and in the policy dialogue arena. Generally, the imbalance and inequity are between previously colonized regions on the one hand and the successors of the colonizer countries and regions on the other hand. It is between the governments and institutions and individuals in the global north and the global south or the so-called rich and poor countries. At the individual level, relics of our colonial history have left behind overt and covert ingrained perceptions and attitudes of superiority that result in behavior that patronizes colleagues and institutions based on which region we originate from. The net result is that a small outsider elite gets to determine what health interventions get implemented in what context, what resources go to whom, and, in short, who lives and who dies.
At the level of institutions, there are many organizations active in global health that knowingly or unknowingly perpetuate the very power imbalances they claim to rectify, through extractive attitudes, policies, and practices that concentrate resources, expertise, data, and branding within high-income country institutions.
We also have philanthrocapitalism where global resources are concentrated in fewer and fewer hands and some of these companies and foundations are able to fund the global health industry and exercise disproportionate power in global health decision-making by moving global health governance from democratic spaces to secretive high-diplomacy affairs away from the public arena.
On the other hand, before piling all the blame on our northern colleagues, we from the south have to accept and take some responsibility. I have participated in high-level negotiation spaces on global health issues where our delegations from the global south have gone to meetings not well prepared, in small numbers compared to our northern partners and we have lost arguments because of our own weaknesses. An example is a decision to vest the leadership of the Global Fund to Fight Aids, Malaria, and TB with a country partnership; the Country Coordinating Mechanism (CCM) and not with government agencies was forced on Southern delegations by Northern partners because we had not prepared our arguments well and in advance which the others had done.
On another hand when we have been well prepared we have got our way. An example here was the drafting and adoption of the WHO Code on the International Recruitment of Health Personnel at the World Health Assembly (WHA). In this case, we held an African and partner retreat in Madrid one week ahead of the WHA where we rehearsed the arguments and procedures for the adoption of the Code and everything went exactly as we planned.
At the country level, where I served as Director General of Health Services as well as donor coordinator in the health sector, we worked well with the Ministers of Health and technical colleagues to ensure that we led the policy dialogue with partners. The Sector Wide Program that we implemented worked well producing results that attracted more and more donors. Based on this experience I am convinced that when countries lead donors will follow, especially when positive results in health outcomes can be demonstrated.
Returning to the discussion on the decolonization of global health, I want to argue that the solution to the current imbalances starts with the southern partners taking charge and demonstrating leadership in our countries. With the political independence that we won over half a century ago, we have the mandate and duty to show this leadership with respect to our health policies and health systems. When we are clear and united about what we want to do for the good health of our people the northern partners will respect and support us. Sometimes we do not speak with one voice as a continent which makes it difficult for partners to support our policies and programs. There is evidence for this from African countries that take clear positions that are followed by northern partners who have good intentions. Those with wrong intentions are shown the road or find their way to the airport and they go away and stay away.
Similarly, global health sector negotiations need high-quality advance preparation, consultation, and solidarity among southern countries. If this approach is adopted at the African Regional level and in partnership with other southern countries, I have no doubt that global health will be decolonized. Some attitudes and mindsets die hard and persist but their negative consequences on the health of our people will be negligible.
What do you all think?
Dr David Mukanga
a. Collectively defining our points of view and aligning on these within the 'formally colonized' including what the values are that drive our trade-off decisions;
b. Tact in our negotiations; sometimes a series of 'coordinated bilateral discussions prior to going to a large roundtable may be more appropriate, but not in other situations;
c. Costing what we bring to the table and making sure this is clear to allow a robust and respectful negotiation to proceed;
d. Building strong Africa institutions that can set agenda, and negotiate on behalf of their members, while being fully alert that those who want to perpetuate the status quo will drive bilateral conversations to disable collective engagement. No easy solutions here, but your point on solidarity is one we need to deep-dive into; we need to peel the onion as they say and figure out how we build this solidarity.
I pass the ball to the next colleague.