Equitable global health research collaborations with a mind of human dignity
Felix Achana1 
Michael Boah1 Dennis Chirawurah2 Joseph Owusu-Marfo1 Joyce Aputere Ndago3 Colette Santah3 Abdul-Raheem Mohammed3 
Martin Nyaaba Adokiya1*- 1Department of Epidemiology, Biostatistics and Disease Control, School of Public Health, University for Development Studies, Tamale, Ghana
- 2Department of Occupational and Environmental Health, University for Development Studies, Tamale, Ghana
- 3Department of Social and Behavioral Change University for Development Studies, Tamale, Ghana
This paper explores the importance of equitable global health research collaborations that prioritize human dignity. It addresses the need for Global North partners to increase their efforts in raising awareness among all actors in global health. The aim is to bridge the gap in research collaborations and promote equitable practices that uphold the principles of human dignity and equity. A comprehensive review of existing literature and case studies was conducted to examine current practices and challenges in global health research collaborations. The review focused on the role of Global North partners in promoting equitable collaborations, capacity building efforts, and the impact of colonial legacies on research dynamics. The findings highlight the need for deliberate actions by Global North partners to raise awareness and promote equitable research collaborations. Initiatives such as Principal Investigator positions to partners from low- and middle-income countries (LMICs) during grant applications have been observed. Assigning first/last authorship positions to LMIC members is gaining momentum. However, further efforts are necessary to enhance the inclusivity of global health research collaborations. We emphasize the need for standardized definitions of global health that encompass human dignity and equity. Urgent action is required to ensure that all actors in global health research collaborations embrace human dignity. By deploying new techniques and tools where they are most needed, we can effectively promote equitable research collaborations that contribute to improving the health of individuals worldwide.
Introduction
This paper presents a perspective on fostering equitable global health research collaborations with a focus on prioritizing human dignity (Aellah et al., 2016; Green et al., 2023). Our discussion draws upon extensive experiences in the field of education and research, primarily from the Global South, supplemented by limited insights from the Global North. Furthermore, we have incorporated ideas and insights derived from other publications, which have contributed to the formation of our paper (Gostin and Sridhar, 2014; Boum Ii et al., 2018).
We firmly believe that a thoughtful reflection on the disparities and uncertainties prevalent in global health research and education collaborations can significantly enhance the consideration of the human dignity dimension throughout the entire process, including conception, planning, development, and implementation of such collaborations (Pratt and Loff, 2014). To address this, our paper focuses on four broad subsections or themes of global health research and education collaborations. These themes encompass the lack of clarity around the term “Global Health”(Sridhar, 2012), an analysis of current global health research and education collaborations (Gostin and Sridhar, 2014; Aellah et al., 2016; Boum Ii et al., 2018), identification of the driving forces behind existing research and education partnerships (Sridhar, 2012), and finally, discussion in the form of proposing future actions aimed at cultivating equitable global health research and education collaborations (Sridhar, 2012; Pratt and Loff, 2014; Green et al., 2023).
By exploring these aspects, we aim to shed light on the challenges and opportunities present in global health collaborations, with the ultimate goal of promoting fairness, inclusivity, and respect for human dignity.
Subsections relevant for the subject
Meaning of global health and actors
The term “Global Health” carries various meanings and interpretations among stakeholders, with significant implications for health. Given the lack of clarity surrounding global health, this paper aims to contribute to the ongoing debate by emphasizing the need to have a shared understanding and clear definition.
Before delving into the discussions, it is essential to reflect on the evolution of concepts that have shaped global health research and global health collaborations. Several decades ago, developed countries (referred to as Global North) colonized nations and territories, which led to the formulation of concepts and approaches to provide healthcare to the occupied lands. This historical context has influenced the power dynamics, resource distribution, and priorities in global health research collaborations. The legacy of colonialism and its impact on health systems and research practices has been widely discussed in academic literature and critical global health perspectives (Fanon, 1961; Farmer, 2004; Pfeiffer and Chapman, 2010). These discussions highlight the need for critical reflection and a shift toward more equitable and decolonized approaches in global health research collaborations.
As a result, different concepts and approaches emerged, including community health, public health and tropical medicine and others, which were expected to be embraced and implemented by all countries. This progression continued with programs like the primary health care (Alma-Ata Declaration, 1978) (WHO and UNICEF, 1978) and international health, culminating in the contemporary concept of Global Health.
These concepts were received with different interests and intentions. In recent times, donors and researchers from the Global North have taken the lead, believing that they possess the capacity to conceive and initiate interventions for the greater good of the world (Ooms et al., 2008; Hafner and Shiffman, 2013) However, the term “global health” lacks a clear understanding among actors in the field (Koplan et al., 2009; Sridhar, 2012; Chen et al., 2020). It holds different meanings for various individuals and organizations involved in global health, underscoring the need for critical reflection (Pfeiffer and Nichter, 2008; Koplan et al., 2009). This lack of consensus and discrepancy in the definitions of global health also contributes to an unclear understanding of global health research.
Definition of global health
The term “global health” has undergone progressive changes over time. It has been referred to by various names, such as community health, public health, primary health, international health, tropical medicine, and now, global health (Farmer, 2004; Kickbusch et al., 2007; Koplan et al., 2009; Chen et al., 2020). All these developments have been conceived, packaged, and disseminated by actors from the Global North or high-income countries, with the intention of implementation in the Global South or low- or lower-middle-income countries (LICs or LMICs). In this section, we aim to provide a concise summary of the key terms.
The term “global” refers to a comprehensive or holistic view of the world, encompassing a sense of alignment with one’s goals and values, as well as the feeling that one’s existence matters. This subjective sense of meaning or purpose in life consists of coherent perspectives, goals, values/beliefs, and a subjective sense of purpose (George and Park, 2017). The World Health Organization (WHO) defines health as a state of complete physical, mental, and social well-being, rather than merely the absence of disease or infirmity (World Health Organization, 1946). One definition of global health states that it pertains to the health of populations in a worldwide context (Beaglehole and Bonita, 2010). Another definition describes global health as an area of study, research, and practice that prioritizes improving health and achieving equity in health for all people worldwide (Salm et al., 2021). Over the years, Koplan et al. of the Consortium of Universities for Global Health (CUGH) Executive Board have proposed a definition of global health, hoping to distinguish it from previous definitions (Koplan et al., 2009). However, significant changes have occurred since then, including the Ebola and Covid-19 pandemics.
A recent paper “Transforming global health education during the COVID-19 era” presents perspectives from global health students (Krugman et al., 2022). It points out that global health educators missed a significant opportunity during the pandemic to transform global health education by fostering north–south collaboration and building partnerships.
The paper highlights current shortcomings in global health education curricula, particularly in fully integrating lessons from the COVID-19 pandemic. It emphasizes the perpetuation of power asymmetries in global health and the exclusion of critical perspectives, including those of Indigenous peoples. Positive changes in global health education have mainly arisen from the efforts of action-oriented educators and students committed to justice, equity, antiracism, decolonization, and anti-oppression.
The shift to online learning during the pandemic offered an opportunity for global health education to become more inclusive and explore new models that promote power redistribution and amplify marginalized voices through transnational collaborations and diverse perspectives, moving beyond the dominance of high-income country-based male voices (Atkins et al., 2021). Institutions have implemented diversity, equity, and inclusion committees and strategies to address global health issues. However, the paper indicates that such initiatives often lack meaningful structural change and fail to impact policies and systemic environments.
The paper advocates for student-led organizing as a crucial approach to drive change in global health education. By involving educators and fostering solidarity, these efforts can connect individuals across institutions, nation-states, and disciplines, facilitating co-generative learning and action toward common goals (Atkins et al., 2021; Krugman et al., 2022).
Global health research
In the context of unclear understanding and interpretations, one possible outcome is the misapplication of aims, objectives, and activities in global health. This calls for a reflection on our limitations as actors deeply engaged in global health research and seeking equitable collaborations. Recent examples, such as the actions leading to the formation of “Black Lives Matter”(Ray et al., 2023) and the unequal distribution of COVID-19 vaccines, demonstrate a lack of human dignity. Some global health researchers from the Global North proposed conducting vaccine trials with negative connotations in Africa and other LMICs, implying that their lives may not matter (Tagoe et al., 2021; Ali et al., 2022). These proposals from actors with authority, power, and resources may lack human dignity.
Additionally, there was also a proposal to conduct Ebola trials in West Africa in 2014 (Thompson, 2021). Furthermore, the World Health Organization (WHO) failed to timely declare the Ebola outbreak a Public Health Emergency of International Concern (PHEIC), showing some lack of human dignity in responding to outbreaks in LMICs (Soghaier et al., 2015).
Global health research collaboration
Globally, research projects tend to favor partners from the Global North, resulting in inequitable collaborations in global health (Boum Ii et al., 2018; Charani et al., 2022) Inequities in global health research collaborations are also evident in the design, packaging, and implementation of projects from the Global North (Atuire and Hassoun, 2023; Green et al., 2023). Efforts have been made to address this practice by encouraging LMICs to serve as Principal Investigators (PI) and promoting shifts in authorship positions (Boum Ii et al., 2018; Rees et al., 2022; Pulford et al., 2023). Although efforts have been made, these measures are insufficient (Rees et al., 2022). Thus, the majority of research collaborations still heavily favor partners from the Global North (Mbaye et al., 2019). Additionally, resources for collaborations primarily come from HIC and their institutions, further exacerbating the power imbalance and control (Charani et al., 2022). Funding requirements often mandate a collaborator from the Global North, limiting the possibilities for South–South collaborations (Tindana et al., 2007; Ooms et al., 2008; Pratt and Hyder, 2016). This lack of resources and investment in global health research from authorities in LMICs hinders their engagement in equitable collaborations (Atuire and Hassoun, 2023).
The mindset of Global North and South collaborators also plays a role. The legacy of colonization has created mindset inequities in LMICs, leading to reluctance among actors in the Global South to collaborate with each other (John et al., 2016; Pratt and Hyder, 2016; Monette et al., 2021). Therefore, there is a need to address the mindset inequity between the Global North and South, moving beyond the concept of decolonizing global health, and focusing instead on the inclusion of human dignity in global health research collaboartion (Monette et al., 2021; Atuire, 2023; Atuire and Hassoun, 2023). Furthermore, collaborations among LMICs themselves are rare, primarily due to funding limitations and the lack of interest and investment in global health research within LMICs (Charani et al., 2022).
The diverse interests and varying capacities of collaborators lead to imbalances in research outcomes and hinder equitable collaborations. The current education system and mindset perpetuate inequitable research collaborations. The language of instruction and curriculum in many LMICs still reflect traces of colonization, impacting research interest and collaboration.
Capacity building and education also contribute to inequitable collaborations (Atuire, 2023). Institutions providing resources for research are primarily located in the Global North, creating a disparity in resource allocation (Tindana et al., 2007; Pratt and Hyder, 2016; Charani et al., 2022). Efforts to improve equity should consider the diverse interests and capacities of collaborators and recognize the contributions of Global South partners.
The outcome of research collaborations is often measured by the number and quality of publications, which can disadvantage Global South collaborators. Their contributions, such as commitment and dedication, often go unrecognized, and the research outcomes may not always be applicable to the contexts in which the research was conducted (Kickbusch et al., 2007; Kickbusch and Liu, 2022; Saleh et al., 2022). Political will and commitment to research are lacking in many LMICs, affecting their engagement in global health research (Kickbusch and Liu, 2022).
Discussion
This paper presents our view on a common understanding of global health research collaboration, which aims to provide answers and solutions for everyone in need, for the common good of humanity and better health and dignity. Current realities deviate from a mindset of human dignity. We believe that including human dignity in the definition improves the understanding and equity of global health research. In this paper, we propose to define global health as all actions and inactions aimed at addressing health needs and solutions within the context of human dignity for all people worldwide.
Global North partners should increase their efforts to raise awareness among all actors in the field of global health. Some have already taken steps in this direction, such as PI positions to partners from LMICs during grant applications (Pratt and Loff, 2014; Rees et al., 2022; Pulford et al., 2023). Another important initiative is advocating for LMIC members to be assigned first and last authorship positions based on merit. The decolonization of global health is a relevant and important movement, but more can be done to further improve and narrow the gap in equitable global health research collaborations.
To achieve this, Global North partners, who hold power and control resources, must actively work to raise awareness about equitable research collaborations (Tindana et al., 2007; Charani et al., 2022; Kickbusch and Liu, 2022). This should include training programs for students, both from the Global North and South, focusing on equitable research collaborations that prioritize human dignity and equity. It is also crucial to provide training to funders, donors, and political leaders to promote equitable global health research collaborations. Efforts should be made to establish funding mechanisms for South–South collaborations within the Global South. Existing collaborations between the Global North and the Global South should also be strengthened and scaled up.
Addressing capacity building in LMICs and their institutions is an urgent priority. Researchers in LMICs often have multiple responsibilities and lack the necessary capacity, which affects their scientific output in terms of publications and article quality. Additional training opportunities are needed for early, mid, and late-career faculty members, each with different goals and needs. Capacity building is crucial, and additional training opportunities should be provided for researchers at different career stages.
Affirmative action should be taken to increase capacity building efforts. LMIC institutions should be supported in managing research funds and creating an enabling environment for mentoring.
Efforts to develop equitable research collaborations must include deliberate actions to free LMICs from the mindset influenced by colonial legacies. Both Global North and South actors need to change their mindsets. Furthermore, the focus of global health should extend to addressing health-related issues in both LMICs and HICs, striving for equitable access and utilization of health services (Kickbusch et al., 2007; Hafner and Shiffman, 2013). In this context, the term “decolonizing global health” may not be the most appropriate approach; instead, the focus should be on promoting human dignity inclusion in global health. The word “decolonization” can evoke negative memories of past negative activities, and considering the persistent disparities even in the midst of decolonization, it may raise concerns, especially among LMICs.
In the development of equitable research collaborations, appropriate acknowledgment should be given to Global South partners. Most publications are in English, which is one of the colonial legacies and can pose challenges for LMIC collaborators in articulating their thoughts during grant applications and manuscript preparation. Global North partners can adopt innovative approaches, such as holding oral discussions to allow Global South partners to contribute their thoughts during the interpretation and preparation stages of manuscript writing. The Global North partners can then assist in packaging these ideas in standard English for scientific audiences, enhancing the chances of publication acceptance. The recognition of “illiterate partners” for their invaluable contributions, commitment, and dedication is an important aspect of equitable research collaboration. Their immeasurable contributions such as commitment, and dedication should be acknowledged as a form of equitable research collaboration. A collective effort is required to increase collaborations between the Global North and the Global South, as well as within the Global South itself. These are essential steps toward achieving equitable research collaborations.
In conclusion, there is a need for actors in the field of global health to come up with a standardized definition that captures the essence of human dignity and equity. Urgent action is required to address the discrepancies that exist in Global Health research collaborations, ensuring that all actors embrace a mindset of human dignity and equity. This mindset should strive to improve the health of individuals in both high-income countries (HICs) and LMICs. Deploying new techniques and tools to areas where they are most needed is crucial for their effective implementation.
Data availability statement
The original contributions presented in the study are included in the article/supplementary material, further inquiries can be directed to the corresponding author.
Author contributions
MNA, FA, and DC conceived and designed the study. MB, JO-M, JAN, CS, and A-RM searched for the literature for the review. MNA and FA reviewed and drafted the manuscript. MB, DC, JO-M, JAN, CS, and A-RM reviewed it for scientific quality. All authors contributed to the article and approved the submitted version.
Acknowledgments
The authors wish to thank the CUGH Education Committee for the opportunity to learn from others during the 2023 Conference.
Conflict of interest
The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.
Publisher’s note
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Keywords: equitable, global health, research collaboration, decolonizing, human dignity, Ghana
Citation: Achana F, Boah M, Chirawurah D, Owusu-Marfo J, Ndago JA, Santah C, Mohammed A-R and Adokiya MN (2023) Equitable global health research collaborations with a mind of human dignity. Front. Educ. 8:1233018. doi: 10.3389/feduc.2023.1233018
Edited by:
Jessica Evert, Child Family Health International, United StatesReviewed by:
Maria Merritt, Johns Hopkins University, United StatesCopyright © 2023 Achana, Boah, Chirawurah, Owusu-Marfo, Ndago, Santah, Mohammed and Adokiya. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.
*Correspondence: Martin Nyaaba Adokiya, mnyaaba11@uds.edu.gh