The unidirectional nature of Global Health
I listened to a podcast a few months ago and the podcast guest mentioned that much of global health is unidirectional. I’ve been turning this statement over in my mind and I must say that I agree with it. Most of the innovation, knowledge generation and design of global health policies and programmes originate from “experts” based in High Income Countries.
I strongly believe that the operating structure of international global health organisations perpetuates the unidirectional nature of global health.
Having worked in both headquarters and country offices, I have observed a clear separation in the seniority of roles and a glaring imbalance in who holds the decision making power. In my opinion, headquarter offices should serve as the fundraising, support arm assisting and being responsive to programmes implemented in low and middle income countries. The reality however is that headquarter offices run the show, designing projects with their in-house “advisors” and senior “insert fancy sounding positions” dictating from thousands of miles away how global health projects should be implemented and monitored.
My discomfort working at headquarters has been partly due to the autocratic management style of many headquarters offices. I distinctly remember one of my line managers saying I need to “tell my country programmes what to do.” That will never sit well with me. Projects that have a majority of their advisors or directors based in headquarter offices far removed from day-to-day life in low and middle income countries will never sit well with me. Headquarter offices exerting pressure on country offices to meet project targets while fully aware that country offices are operating with skeleton staff will never sit well with me.
Country offices do the donkey share of the work in global health yet they have limited power to effect change within their larger organisations. They are the foot soldiers stewarding relationships with their Governments; implementing projects, collecting data for fancy Headquarter dashboards, conducting interviews for case studies to be plastered on organisation websites, writing reports that headquarters will re-write before submitting to donors. Their list of responsibilities is endless, yet they are most often severely understaffed with burnt out employees running on fumes.
Headquarters on the other hand often have a grossly inflated number of staff, many of whom have barely spent more than two weeks at a time in low and middle income countries yet are playing an advisory role on issues in which they have no lived experience.
It’s time for INGOs to start interrogating their coloniser mentality and their role in perpetuating the unidirectional nature of global health.
Namely organisations should:
Interrogate where their current seats of decision making are. Who is developing or leading your new 5-year strategy and where are they based? Who has the final say on the types of projects being implemented in low and middle income countries?
Reflect on the culture of feedback between headquarters and country offices. How much can your country office feedback on organisational processes and programme design? Can your country office challenge headquarters decisions? Or is there a “because I said so” culture emanating from your headquarters?
Consider the reasoning behind your headquarters being based in a High Income Country. Do you want to be more proximal to the issues you are trying to address or are you based in a High Income Country to appease your donors?
As the decolonising global health movement moves at pace, these types of reflections are necessary to remedy some of the appalling practices we’ve allowed to go unchallenged in global health organisations over the years. If organisations are serious about change, they will have to continue grappling with the ‘who holds the power’ question and then make bold moves to shift the power to where it rightly belongs. Only then will we start seeing more bidirectional exchange in global health.