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Redefining global health and shifting the balance: the ARC-H principle
  1. Anisa Jabeen Nasir Jafar1,2,
  2. Shama Patel3,
  3. Rob Mitchell4,5,
  4. Anthony Redmond2
  1. 1Department of Emergency, Royal Manchester Children's Hospital, Manchester, UK
  2. 2HCRI, The University of Manchester, Manchester, UK
  3. 3Department of Emergency Medicine, University of Florida, Jacksonville, Florida, USA
  4. 4Department of Emergency & Trauma Centre, Alfred Hospital, Melbourne, Victoria, Australia
  5. 5School of Public Health & Preventive Medicine, Monash University, Melbourne, Victoria, Australia
  1. Correspondence to Dr Anisa Jabeen Nasir Jafar; anisa.jafar{at}

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Summary box

  • The colonial origins which led to the development of global health as a terminology are long-established.

  • While definitions of global health have evolved to assume a more equitable position, the high to low-income operational direction remains.

  • The ARC-H principle (Access-limited, Resource-limited, Context-limited Healthcare) redefines global health a posteriori according to the practical meaning it has taken on.

  • By reframing the definition using the ARC-H principle, global health expertise can more organically and equitably be allocated.


On one hand, ‘global health’ is a straightforward notion of health around the world. On the other, it is a complex concept subject to increasing scrutiny, particularly in light of the evolving discourse on decolonisation.1 Although the definition proposed by Koplan et al (ie, ‘an area for study, research, and practice that places a priority on improving health and achieving equity in health for all people worldwide…’) is widely referenced, the term ‘global health’ is subject to a broad range of interpretations.2 This article unpacks the concept’s origins and proposes the ‘ARC-H’ principle as a pragmatic step to rebalance the narrative, not least in pursuit of epistemic justice within global health.3

Origins and interpretations

A recent survey of emergency care practitioners in the UK highlighted the spectrum of interpretations of ‘global health’.4 For instance, a few participants considered that the term applied to international projects undertaken in highly resourced settings. Meanwhile, the label of ‘global health’ is commonly used in relation to:

  • ‘Humanitarian’ response following disasters (including sudden onset, man-made and conflict).

  • The delivery of care in resource-constrained settings.

  • The provision of healthcare to internally displaced populations, refugees, asylum-seekers and undocumented migrants.

  • Efforts to fortify fragile healthcare systems in low-income and middle-income countries (LMICs).

These applications tend to reinforce a high-income-centric narrative that global health takes place ‘elsewhere’ and involves engagement with ‘others’. This infers that expertise flows from settings with higher resources towards those who have less.

In part, this reflects that ‘global health’ originated in Western, high-income parlance. Although it aims to be inclusive as a terminology, it has deep-seated roots in colonialism. When the field of tropical medicine arose in the 19th century, it was unashamedly focused on protecting the health of the colonisers.5 Over time, the discipline began to take greater account of the key sociopolitical determinants of health outcomes and incorporated subjects beyond infectious diseases. With these insights, the more inclusive term of ‘international health’ emerged.6 As the 20th century came to a close, the cross-border implications of healthcare policy and practice became more apparent, and the global south increasingly expressed concern that ‘international’ practice was being used to refer to ‘them’ and not everyone. In this context, ‘global health’ emerged as a term that was intended to be less directional and more universal.7

The legacy of meaning

Despite shifts in terminology, the legacy of this history is that the global health agenda continues to be defined, for the most part, by high-income countries. Power and decision-making are often concentrated in resource-rich institutions at the expense of LMIC partners, often with little or no acknowledgement of their voices and expertise.8 9 Although the concept of global health has evolved to centre around transnational healthcare and universal health equity, it retains an undertone of directionality (ie, ‘doing’ global health involves practitioners from more advanced economies engaging in ‘underdeveloped’ contexts).10 This is despite the fact that mature healthcare systems also face significant and ongoing challenges in equity of access and outcomes (the USA, for instance).11 The majority of published and cited ‘experts’ in global health reside or work in the global north (a geographically dubious term, as is the ‘global south’), and are disproportionately responsible for global health work that is ‘abroad’ and unrelated to domestic healthcare inequity.12

Refresh and re-engagement: the ARC-H principle

Regardless of the definitional complexity of ‘global health’, the term is firmly embedded both theoretically and operationally. Until a concise alternative is identified, it will remain in use. Instead of replacing it, we suggest that greater clarity and precision are required when referring to global health activities and programmes. Rather than navigating a priori definitions in the manner of Koplan et al, or exploring its challenges like Taylor, we look at what it has come to mean pragmatically, a posteriori, and qualify its meaning in order to apply it more inclusively.2 13

ARC-H stands for Access-limited, Resource-limited and/or Context-limited Healthcare. When used as an adjunct to the term global health, ARC-H identifies more clearly the environments, populations and practitioners that are being referenced. The term also reinforces that access, resource and context limitations all contribute to health inequity, resulting in unmet healthcare needs and suboptimal health outcomes.


Access-limited healthcare refers to situations where a well-resourced health system exists but access is not equitable or universal. This challenge manifests especially in middle-income and high-income countries, often as a result of geographical and/or financial barriers to care. Access limitations may also become apparent following sudden-onset disasters (the 2023 earthquake in Turkiye, for example).14 Critics of the focus on ‘access’ will question whether this definition extends to wilderness adventure or remote military medicine. While there is crossover, the difference is that this type of access limitation is often constructed, and the health risks can be offset through resource provision.


Resource-limited healthcare refers to situations where there is a mismatch between demands for care and the supply of human and other resources (infrastructure and equipment, for example). This term is frequently used in the context of global health to describe the challenges faced by LMIC healthcare systems.


Context-limited healthcare refers to situations where healthcare access is compromised by specific sociopolitical circumstances. Asylum-seeking, internally displaced, refugee and undocumented migrant populations, who often endure barriers to care for unique economic, linguistic and cultural reasons, fall into this category.15 To capture this group purely under the banner of ‘access limitation’ dilutes the specific challenges they face, including in relation to the broader social determinants of health.

The ARC-H principle explicitly labels populations and environments typically associated with global health. As a deliberate by-product, it also serves to re-emphasise the expertise of those with lived (and ongoing) experience of access-limited, resource-limited and context-limited practice, who should rightly be identified as global health practitioners. These individuals have skills, knowledge and attributes that should be highly regarded, irrespective of any affiliation with a ‘global health programme’ produced, exported or influenced by a high-income country.

The natural consequence of this definition is that ownership of the specialty of global health will more logically lie with ARC-H populations. A practical application of this approach is that any programme grant, educational event or conference session labelled ‘global health’ will hopefully resonate with a broader spectrum of participants, amplifying the voices of those with lived experience of access, resource and context limitations.


The ARC-H principle, while neither trail-blazing nor revolutionary, seeks to offload colonial vestiges present within the field and terminology of ‘global health’. It offers a more nuanced perspective on the scope of global health practice and recognises where true global health expertise lies. Its apparent simplicity should not undermine its significance, given the pervasive influence of language among the healthcare community.16

In proposing this revised terminology, we acknowledge our bias and privilege as practitioners currently based in high-income countries. This too warrants critique. Regardless, it is hoped that this perspective creates a constructive dialogue about the potential applicability of ARC-H within the global health lexicon. Its application can assist high-income country practitioners to explain the nature of their work more clearly, while simultaneously redressing residual power imbalances. For colleagues in LMICs, use of the ARC-H terminology will hopefully emphasise their inherent expertise, reinforcing that ‘global health’ is something they actively practice, and not the exclusive domain of those outside looking in.

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  • Handling editor Seye Abimbola

  • Twitter @EmergeMedGlobal, @robdmitchell

  • Contributors AJNJ developed the concept of this paper and wrote the manuscript. SP contributed to writing and editing of the manuscript. RM contributed to writing and editing of the manuscript. AR contributed to writing and editing of the manuscript.

  • Funding This article was funded by the University of Manchester (with no grant award number).

  • Competing interests AJNJ’s salary is paid by NIHR, and she holds a grant by RCEM which also supports some attendance at RCEM meetings in her capacity as a committee member. SP, RM and AR have no conflicts of interest to declare.

  • Provenance and peer review Not commissioned; externally peer reviewed.