You may have read about the three initial "Es" for building a framework for global health partnerships in my recent Thinking Globally column in the Health Progress Summer 2024 issue. It is a continuing journey, but I had an "aha!" moment at the
culmination of several recent trips that led me to Uganda, Italy and Ukraine. All the trips focused on global health partnerships but from very different perspectives.
The deliberations, experiences and conversations in each place were unique, yet I walked away from each knowing that we had to rethink how we approach global health partnerships. As I reflected on the collective experience, some rethinking, reimagining
and a framework for future collaborations emerged.
EXAMINING HEALTH THROUGH A GLOBAL LENS
Global health has its roots in the late 19th century, in the largely colonial, biomedical pursuit of "international health." The 20th century saw a change in the field's emphasis toward
a much broader conceptualization of global health, encompassing broader social determinants of health and a truly global focus.1 The concept of global health partnerships emerged in the mid-20th century, when the world began recognizing
the interconnectedness of health issues across regions, borders and continents. As a result, the creation of organizations, like the World Health Organization (WHO), fostered international collaboration on health matters.
The premise of navigating the intricacies of international health systems, legal frameworks and geopolitical dynamics is inherently complex and has proven to be complicated. Yet, the potential to achieve significant, lifesaving outcomes makes pursuing
these partnerships essential to the future of global health.
COMPLEXITIES OF GLOBAL HEALTH COLLABORATIONS
The endeavor to forge global health partnerships and collaborations is fraught with challenges. These initiatives, aimed at addressing pressing health issues, require coordination among
diverse stakeholders with varying agendas, resources and cultural backgrounds. Threats to ethical, equitable and effective partnerships include funding and co-funding disparities between partners from high-income and low-income countries, inequalities,
lack of shared vision and priorities, skewed decision-making levels, and limited flexibility to minimize inequalities and make changes.
Further, imbalances in power, privilege, position, income levels and institutional resources create opportunities for the exploitation of partners, particularly those in low-income countries, which widens the disparities and limits the success and sustainability
of partnerships.2 Finally, the energy created by participating in a global project or partnership can often be misplaced. Too often, due to such factors as systemic issues, misaligned priorities, and a lack of understanding of local context
and culture, the energy that motivates global health partnerships is created by the act of giving and not the resulting outcomes.
INTRODUCING THE FOUR Es FRAMEWORK
To navigate the complexities and enhance the efficacy of global health partnerships, I have begun to consider a guiding framework based on four critical Es: ethical, equitable, effective and energizing
collaborations. This approach seeks to align stakeholders around shared values and goals, fostering partnerships that are not only productive but also sustainable.
1. Ethical collaborations prioritize transparency, accountability and respect for all participants. They also ensure that all actions and decisions are just and fair, acknowledging the dignity and rights of the collaborating organizations,
individuals, communities and those affected by the collaboration.
2. Equitable collaboration and equity in outcomes are essential to address the imbalances in resources, access and power that often characterize global health initiatives. Equitable partnerships strive to distribute benefits and responsibilities
fairly, recognizing each partner's unique contributions and needs.
3. Effective collaborations are measured by the tangible impact on health outcomes. This necessitates a commitment to evidence-based practices, continuous learning and adaptability. Effective collaborations focus on achieving specific,
agreed-upon goals that address the needs of the populations served.
4. Energizing sustainable collaborations will require ongoing motivation and commitment to inspire and mobilize all participants and stakeholders, thus fostering a shared vision and enthusiasm for the work and, most importantly, its outcomes.
This involves recognizing and valuing the contributions of all stakeholders, facilitating professional growth, addressing barriers, monitoring progress and celebrating successes.
BEYOND PERSONAL PERSPECTIVES
Achieving the Four Es in global health partnerships requires transcending personal biases and experiences. It demands a willingness to engage in open, honest dialogue that bridges diverse perspectives
and expertise. This involves actively seeking to understand the challenges and opportunities from the standpoint of different stakeholders, including local communities, health care workers, policymakers and international partners.
The essence of global health collaborations lies in recognizing that no single entity holds all the answers. Instead, it is through collective effort, mutual respect and shared vision that impactful and sustainable health improvements can be realized.
This approach challenges us to look beyond our assumptions and work together in new and innovative ways.
REEVALUATING EMPOWERMENT
A pervasive term in the discourse on global health partnerships has been "empowerment." However, this concept requires reexamination. Empowerment is frequently advocated as a positive approach to addressing
individual and community-level health needs. Despite its popularity, relatively little has been said about the unintended consequences of empowerment, which may give rise to some troubling ethical issues or result in outcomes that may not be considered
health-promoting.3
To say that one party will empower another presupposes a power dynamic antithetical to equity and partnership principles and suggests a transaction where power is transferred. In 2021, Flor Avelino, a professor and researcher with Utrecht University,
reviewed several theories of power and social change and found that multiple authors highlighted mistaken assumptions on which various failing empowerment programs were based. They instead emphasized that power cannot be shared or delegated but only
attained and exercised from within: "We can confer authority; but power or capacity, no man can give or take."4
By moving beyond the notion of sharing or delegating power to a collaborative environment where all parties can exercise their agency and contribute meaningfully, we can foster a more genuine collaboration that acknowledges and leverages the strengths
and capacities of all involved.
DIVING DEEPER INTO THE FOUR Es
Engaging in the Four Es of ethical, equitable, effective and energizing collaborations fosters productive and sustainable partnerships that align stakeholders around shared values and goals. Below are
a few considerations critical in ensuring the success and sustainability of partnerships and safeguarding the dignity and rights of the communities they aim to serve.
Ethics lie at the heart of any successful collaboration. When building a global health workforce, we must adhere to principles prioritizing the well-being of individuals, communities and societies. Here are some key ethical considerations.
• Informed consent: Ensure all stakeholders understand their roles, responsibilities and potential impact. Informed consent fosters trust and transparency.
• Cultural sensitivity: Acknowledge diverse cultural norms, values and practices. Respectful engagement is crucial for ethical collaborations.
• Beneficence and nonmaleficence: Strive to do good while minimizing harm. Prioritize actions that benefit the workforce and the populations they serve.
Equity in global health workforce collaborations is challenging to achieve. Here's how we can work toward it:
• Resource distribution: Equitably allocate training, funding and infrastructure resources. Address disparities between high-income and low-income collaborators.
• Capacity building: Invest in development across all regions. Reinforce the importance of local talent through education, mentorship and skill-building.
• Representation: Ensure diverse representation in decision-making processes. Amplify voices from underrepresented communities.
Effectiveness should be the litmus test for any collaboration. To enhance global health collaborations, consider the following:
• Shared goals: Align efforts toward common objectives. Whether it's disease prevention, research or health care delivery, a shared purpose drives effectiveness.
• Data-driven decision-making: Leverage data to assess impact, identify gaps and refine strategies. Evidence-based approaches lead to better outcomes.
• Ongoing learning: Develop a culture of learning and adaptation. Effective collaborations evolve based on lessons learned.
Energizing collaborations infuse vitality into global health partnerships. Here are some ways we can work toward energizing these relationships.
• Motivation and passion: Cultivate enthusiasm for the mission. Individuals who are connected to a larger purpose tend to contribute more intentionally.
• Recognition and appreciation: Acknowledge achievements and celebrate milestones. Recognition fuels motivation.
• Collaborative learning: Create spaces for knowledge exchange. Energize the workforce by fostering curiosity and intellectual growth.
SHIFT TO PROPEL CHANGE
Rethinking global health partnerships through the lens of the Four Es — Ethical, Equitable, Effective and Energizing — offers a pathway to more meaningful and productive collaborations. By refocusing
our energy, moving beyond the concept of empowerment, and embracing a more collaborative model, there is the potential to address the immediate and long-term global health challenges. This shift requires a commitment to continuous dialogue, learning
and adaptation, grounded in the understanding that the strength of global health initiatives lies in our collective endeavor to foster a more resilient, responsive and impactful global health system.
BRUCE COMPTON is senior director, global health, for the Catholic Health Association, St. Louis.
NOTES
- Mike Rowson et al., "Conceptualising Global Health: Theoretical Issues and Their Relevance for Teaching," Globalization and Health 8, no. 1 (November 2012): https://doi.org/10.1186/1744-8603-8-36.
- Damalie Nakanjako et al., "Building and Sustaining Effective Partnerships for Training the Next Generation of Global Health Leaders," Annals of Global Health 87, no. 1 (July 2021): https://doi.org/10.5334/aogh.3214.
- Verena Biehl, Thomas Gerlinger, and Frank Wieber,"Professional Characteristics of Health Promotion: A Scoping Review of the German and International Literature," International Journal of Public Health 66 (July 2021): https://doi.org/10.3389/ijph.2021.1603993.
- Flor Avelino, "Theories of Power and Social Change. Power Contestations and Their Implications for Research on Social Change and Innovation," Journal of Political Power 14, no. 3 (March 2021): 425-448, https://doi.org/10.1080/2158379X.2021.1875307.