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Abstract
Introduction There have long been critiques of colonial legacies influencing global health. With growing public awareness of unjust systems in recent years, a new wave of calls for antiracist and decolonisation initiatives has emerged within the sector. This study examined research inequities in the water, sanitation and hygiene (WASH) sector, centring the perspectives of researchers from low-income and middle-income countries (LMICs), to identify barriers faced by WASH researchers in order to support more equitable changes in this subsector of global health.
Methods Nineteen semistructured interviews were conducted with researchers of different backgrounds regarding nationality, gender and research experience. Researchers from eight countries were asked about their experiences and direct observations of discrimination across various stages of the research process. Five interviews were conducted with key WASH research funders to assess perceptions of obstacles faced by LMIC researchers, successes achieved and challenges faced by these organisations when working towards more equitable research processes within the WASH sector.
Results The results were analysed using an emergent framework that categorised experiences based on power differentials and abuse of power; structural barriers due to organisational policies; institutional and individual indifference; othering speech, action and practices; and context-specific discrimination. The social-ecological model was combined with this framework to identify the types of actors and the level of co-ordination needed to address these issues. Researchers who worked in both LMICs and high-income countries at different career stages were particularly aware of discrimination. Ensuring pro-equity authorship and funding practices were identified as two significant actions to catalyse change within the sector.
Conclusion Sector-wide efforts must centre LMIC voices when identifying research questions, conducting research, and in dissemination. Individuals, organisations and the entire WASH sector must examine how they participate in upholding inequitable systems of power to begin to dismantle the system through the intentional yielding of power and resources.
- Hygiene
- Public Health
- Environmental health
Data availability statement
Data are available upon reasonable request. All data relevant to the study are included in the article or uploaded as supplementary information.
This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.
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WHAT IS ALREADY KNOWN ON THIS TOPIC
The water, sanitation and hygiene (WASH) sector lags behind the larger global health community in discourse surrounding decolonisation, equity and justice. However, diversity, equity, and inclusion (DEI) efforts within the field show the sector is cognizant of the change needed to embody equity in health and research.
WHAT THIS STUDY ADDS
This study provides qualitative data, a collection of narratives and reaffirms the challenges faced by low-income and middle-income country (LMIC) WASH researchers fortifying the applicability and relevance of decolonisation and equity-building initiatives.
HOW THIS MIGHT IMPACT RESEARCH, PRACTICE OR POLICY
This study intends to bolster research equity and decolonisation efforts in the WASH sector by providing WASH-specific data. As a result of this study, key actors such as organisational leaders, funders of WASH research and journals that publish WASH research can see clear examples of how their organisational policies and even interpersonal actions may disenfranchise LMIC researchers.
Introduction
The linkage between global health and colonialism can be traced from its origins to current global health paradigms, especially continued partnerships between former colonising countries and colonised countries.1 2 Global health is ‘Western modernity masquerading as the universal quest for scientific knowledge and healing’.3 The contemporary global health model derives ‘from colonial and tropical medicine, which were designed to control colonised populations and make political and economic exploitation by European and North American powers easier’.4 Colonial history deeply informs the current function and operation of global health by determining who has power, resources and control of the episteme.5 Multilateral organisations, which often set the global health agenda and control much of its funding, have been heavily criticised for allowing international politics to affect their operations resulting in vast inequities in funding allocations and the politicisation of health information.5 6 These organisations are also considered tools for advancing the economic and political power of their key members who are largely former colonising countries, which can be seen as preserving empires’ control of former colonies.7 8 Additionally, private philanthropy, foundations and non-governmental organisations also have active roles in perpetuating such inequalities, promoting the ‘hegemony of neoliberal institutions while reinforcing the ideology of the Western ruling class’.9 10
Water, sanitation and hygiene (WASH) is a distinct subsector within global health. There are various actors addressing components of Sustainable Development Goal 6 to ‘ensure availability and sustainable management of water and sanitation for all’, including the global monitoring system of the WHO/UNICEF Joint Monitoring Programme for Water Supply, Sanitation, and Hygiene, academic conferences and a distinctive sectoral recognition led by UNICEF within the humanitarian cluster system. Within the context of WASH, there is an increasing focus on inequity, especially on gendered user experiences of WASH services and disparities in sectoral leadership.11 12 However, there are no similar efforts to address inequities in WASH knowledge systems. The history of global health undoubtedly influences the power dynamics of WASH knowledge systems, favouring high-income country (HIC) institutions and researchers and marginalising low-income and middle-income country (LMIC) researchers, institutions and communities. However, the extent to which global health literature directly applies to the WASH context is uncertain. Recently, scholarly interest in antiracism and decolonisation has increased seemingly due to increased awareness of racialised state violence (via police brutality) and economic and health inequities highlighted by the global COVID-19 pandemic. More academics have begun to examine the colonial conditionings of academia resulting in increased visibility of longstanding injustices in systems within universities and the scientific literature.13–16
Global health research funding is often awarded to or routed through HIC institutions even when research is being conducted within LMICs.17 HIC researchers frequently enter LMICs and establish HIC-led and staffed facilities to extract research, which often results in a limited impact on the LMIC’s health systems and research capacity.2 Low rates of LMIC authorship of academic publications exemplify the nominal extent to which global health institutions have contributed to capacity-building initiatives in the Global South.18 Consequently, there is little scholarly research that has been conducted to understand barriers and inequalities faced by researchers who are based in or come from LMICs.19 This project aimed to investigate inequalities in the WASH sector by centring the experiences of LMIC researchers, examining the root causes of inequity and exploring feasible strategies for moving toward a more equitable future. It is pertinent to acknowledge the interconnectedness and complexity of colonialism, imperialism and other modes of domination that influence the current state of WASH to begin to address violence and harm. The primary objective of this work was to build an anonymised base of evidence from which future research, guidance and initiatives that support LMIC research can be built, ensuring that the contributions of LMIC researchers are not marginalised, but centred.
Theoretical framing
While decolonisation and antiracism may be understudied in a WASH context, critical theorists in the past several decades have created sizeable bodies of literature, including well-defined concepts of decolonisation, intersectionality and epistemic violence, which were used as the framing for this study. Kessi et al’s definition of decolonisation, that is, ‘a political and normative ethic and practice of resistance and intentional undoing – unlearning and dismantling unjust practices, assumptions, and institutions – as well as persistent positive action to create and build alternative spaces and ways of knowing’, was used.20 Intersectionality highlights that experiences of discrimination are often not due to a single facet of an individual’s personality and is thus ‘a lens through which you can see where power comes and collides, where it interlocks and intersects’.21 The concept of epistemic violence emerged from the critical postcolonial feminist scholarship of Gayatri Chakravorty Spivak; however, the following definition was used ‘violence against one’s status as a knower; one’s role as a creator and communicator of knowledge… the dismissal of people as credible sources of information, because of our presumptions about them’.22 23
Methods
The primary method of data collection was through semistructured interviews with LMIC researchers which were then analysed using an iterative coding process. The interview guide was designed after conducting a literature review and a series of discussions that included input from additional LMIC researchers external to the core research team. Open-ended questions were used to capture a depth of experiences regarding discrimination faced by LMIC researchers in the research process.
Interview guide
The semistructured interview guide (see online supplemental file 1) elicited experiences with discrimination faced by LMIC researchers and mitigating strategies to combat discrimination. Participants were prompted to voice their own experiences or those they directly observed. Directly observed incidents were included partially to provide anonymity related to describing personal experiences that could be traumatic or potentially harm their careers. Additionally, observations also broadened the potential information gleaned from the participants without compromising the data by including second-hand information. Responses were limited to these situations to avoid including unverified reports in the study while also providing participants with the option to respond that they had no relevant examples to share for any question(s). In consideration of the positionality of the researchers informing the research outcomes, the interview guide was formulated with neutral clarifying and prompting questions to minimise the bias of the research team influencing the study’s findings. The interview guide was not piloted; however, feedback was elicited from LMIC researchers and incorporated into the finalised guide. A similar but separate semistructured interview guide was developed for interviews with donor representatives (see online supplemental file 2), who were invited to focus their responses on organisational experience.
Supplemental material
Supplemental material
Participants were provided with a definition of discrimination to mean ‘the unjust making of a distinction on the basis of some attribute about that person by a person or policy that reinforces inequalities’. In facilitating nuanced discussions of the various challenges faced, questions were grouped based on aspects of the research cycle, which included funding acquisition, project execution and research dissemination, along with more general career advancement.
Research participant selection
The study participants were LMIC researchers targeted to capture the experiences of men and women in early-career and late-career stages in approximately equal proportions. The outreach decisions were made to capture a breadth of experiences of researchers at different points in their careers and of different gender identities to better understand the effect of these identities on discrimination faced by researchers.
The intention was to recruit as many participants as willing and able to form an evidence base capturing a microcosm of the WASH research landscape. Existing networks and the social media platform Twitter were leveraged to recruit interested participants who were then directly contacted. Twitter was specifically used to recruit female late-career researchers. Nineteen LMIC-origin researchers were interviewed. Study participants included LMIC-origin researchers with a majority of participants being based in LMICs and some based in HICs. Most participants in LMICs had experience collaborating with HIC partners or received funding from HIC institutions. Participants were also at a range of research institutions including universities, non-governmental organisations and international organisations. The study population was not considered to be statistically representative as the project was exploratory and was conducted with the intent to take a tractable first step to advance research equity.
Early-career researchers were defined as those who, if they had received a PhD, had done so in the past 5 years. Late-career researchers were defined as researchers who had received a PhD at least 10 years ago, had obtained funding as lead investigators for at least three projects and had at least one full-time staff member or student. These definitions were established not to comprehensively cover the types of participants in the research ecosystem, but to intentionally involve those seeking their funding at an early-career stage versus those who were focused on developing and retaining staff and growing a team or organisation.
We further reached out to representatives of significant funders in the WASH research space to (1) gauge institutional awareness of research inequity, (2) gather information on ongoing equity initiatives and (3) better understand institutional barriers. Five interviews were conducted with six donor representatives.
All participants were informed that the purpose of the study was to gain an understanding of their perspectives and then synthesise and anonymise experiences to then communicate the reality of power imbalances in the sector while minimising personal risk. Participants were also told that sharing personal or organisational names was not necessary and that they would not be identified in any way except by gender or career status.
Interviews, transcription and coding method
Semistructured interviews were conducted remotely and recorded via Microsoft Teams between March and September 2021. Participants participated in informed consent before the interviews. Approximately half of the interviews were conducted with two members of the study team present and half with only one study team member. Only participants and researchers were present during the interviews and no repeat interviews were conducted. The recordings were then uploaded to an automated transcription website and manually cleaned by a member of the study team. Transcripts were then independently coded by at least two members of the research team using the Dedoose software package.24
Data was stored on a password-protected server, and any identifying details were removed from the transcriptions.
Multiple members of the team reviewed transcripts and participated in coding; the collaborative processes used in this study allowed for dialogue and comparing notes to ensure that research findings reflected the data collected with limited bias from individual researchers.
Patient and public involvement
Patients and the public were not directly involved in the design of this study or the formulation of research questions and outcome measures. At the 2021 University of North Carolina Water and Health Conference, two large group discussion sessions were hosted by the research team sharing preliminary research findings and cogenerating a list of feasible actions to be taken across the WASH sector and by different stakeholders to facilitate a more equitable research process with attendees.
Reflexivity and research team formation
The research team is composed of four early-career women of colour of LMIC origin or with ties to LMICs in the Caribbean, Southeast Asia or Africa and one late-career American man. All authors hold or are pursuing higher education degrees and currently work or study in the USA. Please see online supplemental file 3 for an expanded reflexivity statement.
Supplemental material
From the outset of this project, six other LMIC-origin WASH researchers were consulted on the direction of the work, including asking about their desired level of involvement (see online supplemental file 4) The WASH researchers consulted were happy to be involved but did not want to be authors of this initial paper. In all cases where a reason was provided, it was because of concerns about repercussions, although there may have been other unstated reasons. As there also was not significant funding for this initial work enlisting the formal collaboration of researchers would mean they would be under or unpaid, it seemed preferable to embark on this exploratory work imperfectly with the hope of sparking follow-up conversation and research.
Supplemental material
Results
Participant characteristics
The study included a total of 25 participants of which 19 (76%) were LMIC WASH researchers and 6 (24%) were donor representatives. Of all LMIC-originated researchers, 58% were early-career researchers and 42% late-career researchers. Researchers were from eight different countries in sub-Saharan Africa and South Asia. There were 58% women researchers and 42% men researchers in the LMIC researcher subset and 50% men and women in the donor representative subset. In total, 44% of participants identified as men and 56% as women. A summary of the participants’ characteristics is provided in table 1. Most researchers were based in LMICs, although some were based in HICs but of LMIC origin. One donor representative was of LMIC origin but was based in an HIC, and the other donor representatives were of HIC origin and were based in HICs.
Participant characteristics of LMIC WASH researchers and donor representatives
Coding framework
Interviews were analyzed by grouping similar challenges expressed by researchers, then arranging these groups into a hierarchy of codes and subcodes based on relationships observed. The data-derived codes were as follows:
Power differentials and abuse of power.
Structural barriers due to organisational policies.
Institutional and individual indifference.
Othering speech, action and practices.
Context-specific discrimination.
A more descriptive visual of the coding structure describing codes and providing quotes as examples was developed, as shown in table 2. With deeply complex and nuanced issues such as discrimination, oppression and inequity, the recounted experiences described had points of convergence and interrelation as did the codes generated from them. Therefore, many cases were categorised by multiple codes.
Emergent framework for understanding discrimination and barriers to equity
Power differentials and abuse of power
Participants reported cases of overt abuse of power as well as power differentials that resulted in inequitable and unchallenged assumptions or defaults within the research process. Researchers noted experiences of inequitable distribution of authorship and acknowledgement based on power and privilege. HIC–LMIC partnerships are typical in the WASH research space. In these instances, HIC researchers were either awarded prime authorship and desirable leadership roles by default or would demand these positions. In some cases, this was because funding was directly awarded to the HIC institution (sometimes due to funder policies); consequently, the principal investigator, often a senior researcher from an HIC organisation, would prioritise their graduate students for prime authorship roles.
In many other cases, LMIC researchers were disproportionately assigned fieldwork and less technical tasks such as day-to-day data collection, while HIC researchers were able to focus on analysis, interpretation and writing. This division of labour translated to the HIC researcher maintaining primary ownership over the publication and future presentation opportunities. This workload imbalance stalled career advancement for LMIC researchers and even affected immigration or visa opportunities. Some LMIC researchers felt that despite meeting the metrics to earn leadership opportunities they were still not considered for advanced roles. Funders appeared to be aware of the power imbalances within the sector, especially the division of labour and recognition, and the resulting discrimination faced by LMIC researchers that led to career stagnation.
Participant #13, a late-career man researcher, reflected on the impact of restrictive funding calls with set research agendas influencing the type of knowledge production occurring in LMICs and limiting research capacity building:
Another huge frustration because you as an LMIC researcher [may] want to begin to indulge in more fundamental science or in more discovery, but often funding doesn't allow [LMIC researchers] to get into those spaces; it very much wants you to go in the field and collect samples.
There was often a disregard for community members' and LMIC researchers' input in research priorities that perpetuated a cycle of HIC-centred research agenda setting. A lack of LMIC reviewers on both funding and publishing committees also amplified the problem.
Gender, age and seniority, as well as the intersection of these identities, were also a facet of power imbalances within the sector. Researchers with less work experience stated that they encountered additional barriers in the research process. Participant #19, an early-career woman researcher, reflected on gender inequality as a point of imbalanced power distribution:
There is [a] bias that comes with being a woman in the WASH sector…in terms of how much I have to work to ensure that my feedback is taken up or solicited or respected or incorporated.
The disparity of power and resources within the sector leads to an extractive and unidirectional relationship between HIC institutions and communities where research studies are situated. This power dynamic manifests into an internalised pressure to perform on the part of LMIC researchers due to external assumptions of incompetency. The sentiment of internalised pressure was more commonly expressed by women researchers.
Many participants noted that more gender equity initiatives are becoming a norm. A growing number of funding, education and research opportunities state that ‘females are especially encouraged to apply’. Most participants were pleased with these initiatives; however, some participants—both women and men—felt like men were being displaced by this initiative. Funder representatives also noted that there were quotas and mandates intended to improve equity in the field and had mixed views on these initiatives. Funders also noted that their organisational policies affected equity in procurement, but generally said that the cost of monitoring the internal workings of grantees would be too high and that developing quantitative metrics would be needed for more equitable funding opportunities. Some funders have not been able to address the issues of community input, while others saw success by focusing on a small number of countries, deeply involving local stakeholders in developing research agendas and shifting power from HIC-based grantees to local stakeholders early in the research process.
Structural barriers due to organisational policies
Researchers in LMICs face many structural barriers that are attributed to either formal organisational policies or informal relationships. Foreign funders and local institutional systems were often fundamentally incompatible. Reporting requirements for foreign funders could often not be met by local university accounting systems operations, and LMIC institutions struggled to comply with the tax codes of foreign countries.
Funders were also often restricted either by having to contract directly with institutions in their own country or by legal restrictions on contracting processes between funders and recipients in certain countries. Participant #12, an early-career woman researcher, noted that the requirement of working with an HIC institution, which would ultimately benefit more financially from the arrangement, deterred LMIC researchers from applying for funding opportunities. Participants also reported that partnerships with HIC institutions seemed to be expected or outright required for grant applications to be successful, with HIC institutions often being the lead on proposals. This was a common practice even when there were no legal requirements.
Relatedly, the overall operations of LMIC universities were often viewed as incompatible with the research needs of the sector as LMIC universities placed more emphasis on education than on research and experiential learning. Participants also attributed this to limited funding for research in these institutions, stating that LMIC universities often lacked significant grant-making resources and pipelines of funded PhD and postdoctoral students in comparison to HIC universities. As a result, early-career researchers were often encouraged by different actors in the research ecosystem to go to HIC universities if possible.
Beyond official policies and systems, barriers existed due to a lack of ‘insider knowledge’ on the part of LMIC-based researchers. LMIC-based researchers often lacked in-person exposure to funders at international conferences or meetings in funders’ headquarters located in HICs. Several LMIC-origin researchers based at HIC institutions also noted that the experience of HIC institutions internally sharing successful proposals ultimately leads to considerable advantages in these institutions receiving funding. Differences in exposure were compounded by other unjust practices. For example, when conference decisions are not given sufficiently far in advance, obtaining visas for some LMIC passport holders may be challenging leading to missed dissemination opportunities further delaying or disrupting career progression.
Finally, inequities related to fees and indirect costs tangibly demonstrated to researchers the disparity in how HIC-based and LMIC-based researchers are valued in global academia. LMIC-based researchers were often subject to locally based pay scales determined by their university, whereas HIC-based researchers would often charge higher standard rates or engage through consultancy agreements. On the topic of wages, participant #16, a late-career woman researcher, stated:
For the time that you're going to put into that project, ultimately you realize that you are underpaid and yet the bulk of the work is actually going to take place in this part of the world. And I've kind of found that always unfair.
There were also large discrepancies between indirect cost rates. Participant #13, a late-career researcher, noted that their LMIC institution was only able to allocate 8% of the grant amount for overheads, while HICs were able to charge up to 40%.
Funder representatives were aware of the challenges of formal contracting, especially those who were intermediaries funded by a country’s own broader aid budget, and several interviewees were actively working to address those barriers. Non-governmental funding agencies seemed to be slowly making changes, while funders representing government agencies were less optimistic. Few noted approaches underway to share more ‘insider knowledge’ gained by successful applicants over time or had solutions to address costing inequities between institutions. Some expressed awareness of individual organisations active in adjacent research spaces outside of WASH, especially around developing informal networks to foster collaborative bids. Others mentioned cross-cutting capacity-building efforts meant to offset differences in indirect cost rates, but such efforts were still in the early stages and there had been few efforts to co-ordinate or establish norms or guiding principles for these efforts.
Institutional and individual indifference
Institutional and individual indifference to inequity appeared in several ways. Apathy toward the challenges experienced by people of differing backgrounds was identified as a recurring theme throughout the interviews. The most significant obstacle researchers faced was the use of English as the primary language of dissemination. Researchers whose first language was not English expressed that the language barrier disadvantages them from competing with researchers whose first language is English, regardless of their academic competencies. This barrier is apparent in grant applications, selection to present at conferences, presence of translation services at conferences and publication decisions. This indifference also occurred in the field, where meetings with HIC researchers would by default be conducted largely in English with some translation for field staff, rather than the other way around. Participant #8, an early-career woman researcher, spoke to the intersection of class and English speaker status, sharing that she noticed some “people that are not given a chance to speak, or cut off, or not taken seriously because they fail to articulate very well, whether that’s by socioeconomic status or literacy.” This intersectionality and the resulting harm are further explored by participant #19, a late-career man researcher, when reflecting on power hierarchies within the grouping of LMIC researchers:
LMIC researchers, those who are from an urbanized, English-speaking background, find it easier for career advancement and people who do not have. [It is] easier for career advancement because their projects have a higher chance of getting funded.
Additionally, it was observed that researchers from LMICs were being evaluated by metrics originating largely in HICs including formal credentialing and citation of works largely outside the context of the research setting, rather than on the benefit provided by the research on either its direct subjects or those in similar situations. Conventional academic knowledge is legitimised while indigenous and local knowledge and knowledge from lived experience are not valued without the accompaniment of graduate-level education. In the community setting, research populations are often not ‘the most marginalised’ as the research community does not have access to these populations as they do not represent them. Participant #17, a late-career man researcher, laments on the need to include indigenous and local perspectives in research:
Economic perspectives, social discrimination, or [association with better-off community members], potentially inhibit your ability to collect information from the truly marginalized…And therefore your own teams have to represent that diversity for you to be able to access.
The lack of culturally competent and equitable evaluation metrics invalidates the experiences of the LMIC researchers, who may face greater barriers to achievement on metrics such as authorship, mastery of standard and academic English, graduate-level education and years of experience. Over-reliance on such metrics often leads to stagnating or negative career trajectories and personal outcomes regarding position, status or leadership.
From a donor perspective, there was an acknowledgement that language issues were a challenge, but often limited their focus to trying not to review proposals with consideration for use of ‘proper English’. Few noted efforts that would affect their creation or translation before being seen by reviewers or related to activities after grants were awarded. Similarly, alternative impact metrics were sometimes noted as desirable to funders, but there have been challenges in identifying appropriate and accessible metrics to be used.
Othering speech, action and practices
Othering speech, action and practices refer to the intentional and unintentional discrimination of an individual based on one or more social categories or identities that an individual may hold. Researchers often recounted experiences of feeling othered by funders, their own or other research institutions, organisations involved in publishing and even the communities in which research takes place.
The power dynamics between funders and researchers often resulted in othering practices that impeded LMIC institutions and researchers’ sense of agency. LMIC researchers noted experiences where they were micromanaged by funders and lacked autonomy throughout the research process. Throughout the publication process, researchers faced many discriminatory practices. A concern frequently raised was the biased review process for journal publications, where researchers perceived that LMIC institutions without strong partnerships with HIC institutions were not given equal access to publishing opportunities and insider information.
One early-career man researcher reflected on an experience that demonstrated publications preferred HIC credentials and scholars to their LMIC counterparts. The researcher noted that he worked at an HIC institution but serves as a guest lecturer at an LMIC institution when visiting home. He had worked with a student with interesting research questions, and they submitted a paper to a journal with their affiliation being the LMIC institution and it was rejected. Participant #5, an early-career man researcher, recounted:
We wrote it back with my affiliations as [HIC University] and putting me as the first author in the same journal, it was accepted.
Beyond othering practices by those within the sector, communities representing society as a whole also speak and act in ways that are discriminatory to researchers. Reported discrimination in the community was largely gender-based, however, some reported instances of racial and colour bias were reported. Participant #17, a late-career man researcher, noted that his team’s work takes place in a ‘fiercely patriarchal society’ where women researchers do not have the same access to information and resources as their male peers.
Participant #5, an early-career man researcher, recounted discrimination based on skin colour when their research team entered communities. He stated the way the team was able to collect the data eventually was by “deploy[ing] other people [from the area] with the electronic survey tools, so they can just be the ones that [research participants] are looking at.”
Funders infrequently mentioned this kind of interpersonal or interorganisational discrimination on their part as a topic of which they were aware or acting to address, though some initiatives underway were noted in specific journals. More general societal discrimination was also infrequently mentioned, and though funders understandably viewed their ability to affect larger cultural values as limited, few microlevel solutions were brought up.
Context-specific discrimination
Context-specific discrimination refers to the issues of tribal discrimination, caste-based discrimination and other forms of discrimination characteristic to specific communities where research is taking place. There is significant convergence between these and other types of discrimination previously noted. Participant #17, a late-career man researcher, reflected on the interlocking oppressions that affect the research process:
When we look at the marginalized, we can go by traditional criteria, which in [this LMIC’s] context families will consider either caste, or scheduled tribe, or those considered below the poverty line. But the reality is that discrimination and vulnerability in terms of poverty can transcend castes and economic statuses - a good example of it is women-headed households. Women in our zones will not necessarily fall into the scheduled caste or tribe. And yet can be extremely marginalized. Therefore, as researchers or development practitioners, you need to be open to the fact that discrimination takes multiple forms or marginalization can take multiple forms.
Funders rarely addressed discrimination at such context-specific levels, though some working in more limited geographies did bring up the issue, especially noting the non-homogeneity of LMICs and the idea that researchers from local institutions may be viewed as outsiders or foreigners to other locations within the same country.
Discussion
This study sought to highlight the experiences of LMIC-origin researchers as a basis for establishing more equitable approaches to research and the generation of knowledge around WASH as a subsector of global health by better understanding the different modes of discrimination or injustices. The use of discrimination as a measure of inequity faced by LMIC researchers is contextualised with an awareness of the systemic oppression of racialised and gendered people as well as the colonial roots of systems of power that govern today’s world.25 The process of achieving equity, decolonisation and/or justice is reparative. From a sectoral perspective, there is an added value in achieving more accurate research leading to better health outcomes as well as more effective global knowledge and skill exchange.25
The structure of the WASH sector, including the establishment of global targets primarily focused on minimum standards, and international collaborations between HIC and LMIC institutions and researchers all lend themselves to power disparities at the personal and interorganisational levels. This is largely due to the deeply enmeshed history of global health, international development, humanitarian aid and academia in the context of colonial and imperial domination. The modern WASH sector is therefore situated at the convergence of multiple violent systems. Universities and research institutions also serve as the birthplace of epistemic violence in the context of colonialism. The physical, social and psychic violence of colonisation that forms the modern university as the sole credible producer and regulator of knowledge erases both the indigenous and local knowledges of colonised people and their validity.26
The formation of international organisations is aligned with the decolonisation period of the 1940s–1960s when former colonies gained independence. While international organisations drive much of the international development initiatives, they have been critiqued as ‘agents of former imperialist countries’27 and actors functioning to foster and uphold neocolonialism.28 Focusing on the impact of imperialism on global public health, Brown and Bell note that ‘the [WHO’s global strategy] represents merely an imperial approach to public health that attempts to integrate periphery countries into a largely western vision of global health governance’.1 Humanitarian aid which has increasingly funded many global health initiatives has been described as an ‘[instrument] to serve the continuation of centuries of colonialism, warmongering, and economic exploitation.’29 Global health philanthropy, though the actors are non-governmental, often also bolsters the hold of Western imperialism in the Global South.10
The current power differentials in the WASH landscape encourage inequitable research partnerships, conflicting research priorities and disparities in funding, authorship and recognition.18 30 The absence of LMIC representation within funding organisations and review committees perpetuates inequality within the sector. Incompatibilities across different levels of the research ecosystem result in inequity, but a lack of cognizance and prioritisation by powerful actors allows incompatibilities to persist. Internalised pressures encountered by LMIC researchers, lack of informal networks and discriminatory metrics hinder progression towards more just frameworks and practices in WASH research. While there is growing awareness of the presence of these issues in the WASH space, there is also complicity and inertia where structural violence and systems of injustice are concerned leading to a lack of solutions and actions to remedy the disproportionate discrimination faced by LMIC researchers throughout the research process and their careers.
Limitations
Although participants were diverse in terms of country of origin, there is no claim of representativeness considering the wide range of settings where WASH research is conducted. This limitation is attributed to both the size of the study and the method of recruitment via existing relationships and referrals Additionally, the selection of researchers active in the field does not capture the experiences of people who were not able to enter or continue in the field.
Many LMIC researchers interviewed noted that despite feeling frustrated by particular experiences, they did not realise the discriminatory nature of the incidents until further reflection, often when moving to another context such as working in an HIC. There was also hesitancy in labelling a policy or action discriminatory. Experiences are inevitably biased by the individual’s perspective which makes it challenging to objectively quantify discrimination and the outcomes. Finally, although representation based on national origin, gender and career stage was ensured, other significant categories of marginalisation such as sexuality and disability were challenging to observe without participants potentially risking job security, criminalisation and further discrimination.
From the margins to centre: imagining equitable WASH research
The WASH sector provides services to vulnerable communities primarily in the Global South. Research equity begins with the acknowledgement of systems of inequalities by all actors, specifically LMIC and HIC research institutions, funders, governments, multilateral organisations and scientific journals. The WASH sector speaks extensively of the inequities in access to WASH infrastructure and knowledge and the human right of access to clean drinking water and adequate sanitation. Several individuals have also penned articles both explaining the state of the WASH sector and calling for action to begin a decolonisation process, for example, see an article by Luseka.14 However, peer-reviewed literature on decolonising WASH research and larger knowledge generation practices is sparse. We must, therefore, draw on generations of scholars within the areas of postcolonial, decolonial, queer and ethnic studies as well as black and global feminist and liberation movements whose strategies and frameworks of justice and decolonisation can be used as a basis for improving equity in the context of WASH.
We have organised recommendations generated by this process at four levels based on the social-ecological model of behaviour including interpersonal, organisational, community/systemic and global/societal issues visually presented in table 3.31 This model was used to frame recommendations and highlight the different actors needed to achieve equity from an individual to organisational to sectoral and then finally on a societal scale. Some issues at the interpersonal or organisational levels could be resolved by unilateral action, but many structural changes require collective action.
Adapted version of the social-ecological model
Based on this study’s findings and a review of global health literature, LMIC authorship is determined as a critical part of a more equitable research process and more accurate research findings. Authorship and other leadership opportunities for LMIC researchers allow access to more options for career advancement and agency in the research process.32 However, ‘approximately half the indexed publications on [community health] programmes are first authored by LMIC authors… The relative absence of LMIC lead and last authors in multicountry studies suggests an implicit international hierarchy in the field’.19 Inequitable authorship and research leadership experienced by LMIC researchers cannot be addressed without the disruption of the current status quo of neo-coloniality in WASH research. ‘Authorship per se is not the fundamental issue; undoing what those imbalances represent—a continuity of the colonial project in global health—is often the issue’.33
At an organisational and community level, the practice of HIC researchers being automatically awarded prime authorship and leadership roles must be ended. Additionally, it must be recognised that excuses of LMIC researchers lacking research and academic writing capacity for successful projects only further strengthen colonialist and imperialist paradigms, as research methods and writing skills can be taught, while context-specific knowledge which local experts gained from lived experiences cannot be taught. As HIC researchers benefit from the power imbalance that has allowed the practice of excluding LMIC researchers from leadership and authorship roles, there is also the interpersonal responsibility of HIC researchers to acknowledge these unfair practices and advocate for LMIC researchers as project leads and first authors.
The results also found that epistemic violence is prevalent in the WASH research arena, as there are common assumptions of LMIC researchers’ competence based on nationality, command of the English language and other Western metrics as well as a disregard for community member input in the research process. This finding agrees with the literature that states ‘members of the global health community often witness a cycle in which researchers assume that locals in marginalised areas and members of marginalised groups do not have the capacity to contribute to research, and thereby bypass such people’s participation’.34 The WASH sector must ask whether WASH is currently a space where LMIC researchers are empowered to share histories, context and non-Western ways of knowing to produce academic and community knowledge and then realign to realise this vision in the future. The epistemic injustice of discrediting researchers based on their national origin, ethnicity and higher education status, as well as furthering the hegemony and colonial legacy of English as the global language, must be addressed. The maintenance of the culture of domination and hierarchy rooted in colonialism cannot materialise in just research practices. Rather than placing the burden on LMIC researchers to assimilate into unjust systems, we propose the following as the first steps in addressing the epistemic violence faced by LMIC researchers.
At the community and societal level, meaning within and beyond the WASH sector, funding agencies and journals must develop application requirements and standards that are not antagonistic to LMIC researchers, but culturally competent. Requirements for partnerships with HIC countries must go. Biases based on languages, geographies and educational attainment levels must be addressed, and context-specific safeguards must be put in place to protect LMIC researchers. Lived experiences and local and indigenous knowledge must be valued as valid sources of knowledge that inform research. Community-engaged and community-led research along with community-centric dissemination and evaluation practices are further recommendations for a more equitable research future. On the organisational front, there must also be shifts in cultures to prevent discrimination based on languages, geographies and educational attainment levels as well as advocacy and organising for the sector and societal changes to dismantle systems. Again, on an interpersonal level, everyone engaged in the WASH sector on an individual level must analyse their positionality and relationship to power and dominant cultures to enact changes in their behaviour such as unlearning assumptions and stereotypes of competence based on the colonial episteme.
Based on the findings of discriminatory funding and publishing practices that emphasise collaboration with HIC institutions and skew funding allocations between HIC institutions and LMIC ones, there is a need to further promote the development of research capacity in LMICs. Although funding calls that recommend or require collaboration with an HIC institution may intend to nurture international knowledge exchange, they may do more harm than good by inhibiting LMIC researcher career advancement and autonomy. Additionally, if not adequately resourced and planned, capacity building cannot be effective. Direct and indirect research funding is vital for increased justice in WASH research.
Global health and development have been charged with neocolonialism in thousands of scholarly articles over the years, including Beran et al who state that “despite the scale of capital inflows, huge gaps in infrastructure, management systems, and human capital remain for health systems, government and governance structures, and research institutes in LMICs.”35 While these neocolonial practices in global health have contributed largely to the growth of the field, this growth does not result in proportional advancement in the LMIC countries, in target communities or LMIC researcher populations. New approaches to conducting and funding research and building research capacity must be implemented to ensure that there is equity within the WASH ecosystem. At the organisational and community/sectoral level, funders and research institutions must rethink current processes that result in resources being routed through HIC institutions and trickling down to LMIC institutions and communities. While there are non-sectoral barriers that contribute to current practices, justice is not achieved by adhering to the status quo that is deeply informed by colonial world-making.36
In global health, health equity and justice are frequently invoked and are representative of the work that the sector values and wishes to embody. With this consideration, funding agencies and donors must reconsider how current practices contribute to marginalisation. Global health actors cannot achieve equity without resisting legislations and regulations that contribute to inequity in the field. More explicitly, while it may be easier to work with an HIC institution due to symmetry in financial systems between funders and these institutions, the effort to ensure that LMIC institutions are not penalised by their LMIC status is the difference between maintaining thinly veiled discriminatory practices and a more just research future. While partnerships between LMIC and HIC institutions will continue, funding agencies could set more equitable standards for budget allocation and pay equity between LMIC and HIC researchers. Funding should be specifically allocated for capacity building to continue to sharpen the research skills of LMIC researchers and practitioners and for dissemination (publication fees, conference registration and travel). At an interpersonal and organisational level, there must also be resistance to the status quo to demand funders, conference organisers and publications to make the necessary changes to redevelop a WASH sector where the disenfrachisement of LMIC researchers and communities is minimized.
LMIC communities, researchers and institutions often experience being on the margins in WASH research. From interviews, it is evident that researchers with more than one non-dominant identity face multiple forms of discrimination in the research process, therefore this must be considered in addressing inequities in WASH. Women researchers, while especially encouraged to apply to funding calls and career opportunities, expressed still not feeling welcomed or included in their work environments due to patriarchal conditions. Especially encouraging women, minorities and people from marginalised backgrounds is a band-aid as there often is not adequate resource and infrastructural change for true inclusion. Early-career LMIC researchers need to overcome countless hurdles and bear the burden of proving themselves to a point of burnout to get opportunities that are often given to HIC researchers by virtue of being from an HIC or HIC institution, even over late-career LMIC researchers. Community members are only seen as research subjects, and often members of certain communities have societal roadblocks that prevent them from being researchers or WASH practitioners, leading to doubled disenfranchisement. While the language of serving the most marginalised is often used in DEI work, this is seldom the reality.
Hooks, a prominent Black feminist scholar, stated that “to be in the margin is to be part of the whole but outside the main body.”37 Decolonisation and improving research equity must centre LMIC stakeholders, bringing them to the forefront to tell their own stories, set research agendas and gain credit when due. Centring in this context requires the ‘yielding of power’ and resources to stakeholders who are of less privileged identities due to social and geopolitical factors.2 Collective action to support equitable authorship, research funding and capacity-building programmes can begin to distribute the power and bring justice to those too long marginalised. The onus of building equity is on sector leaders, leaders of WASH-focused organisations, funders, conference organisers and publication boards who must reshape their operations to subvert cultures of domination and inequitable resource distribution.
Conclusion
As the question of decolonisation and equity in WASH research and practice continues to be raised, all actors involved in the research process must take action toward meaningful solutions. This study was intended to delve into the specific case of WASH research equity as a microcosm of global health and provide a basis for tangible investment in a more equitable WASH research landscape. LMIC researchers’ and funders’ experiences indicate the extensiveness of unjust practices within the WASH research ecosystem. Acknowledging the experiences of LMIC actors is an important first step to achieving equity. However, the roles of individuals and organisations who build and maintain oppressive systems within global health, and by extension WASH, must be examined and then dismantled. Without an intentional yielding of power, there can be no justice in WASH research and practice.
Data availability statement
Data are available upon reasonable request. All data relevant to the study are included in the article or uploaded as supplementary information.
Ethics statements
Patient consent for publication
Ethics approval
This study involves human participants and was approved by the WCG institutional review board (ref: #1-1412585-1; 17 March 2021). Participants gave informed consent to participate in the study before taking part.
Supplementary materials
Supplementary Data
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Footnotes
Handling editor Seye Abimbola
Twitter @_bentidwell
Contributors The study’s conception and design involved all authors with JBT being the primary point person and the guarantor. Data was acquired, analysed and interpreted by all authors. The manuscript was primarily written and revised by J’A-ML with contributions from all authors.
Funding This project was funded by World Vision.
Competing interests None declared.
Patient and public involvement Patients and/or the public were involved in the design, or conduct, or reporting, or dissemination plans of this research. Refer to the Methods section for further details.
Provenance and peer review Not commissioned; externally peer reviewed.
Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.