Article Text

Exploring equity in global health collaborations: a qualitative study of donor and recipient power dynamics in Liberia
  1. Brigid E Cakouros1,
  2. Johannah Gum1,
  3. Defne L Levine1,
  4. Joseph Lewis1,
  5. Antoinette H Wright2,
  6. Bernice Dahn2,
  7. Kristina Talbert-Slagle1
  1. 1Yale University, New Haven, Connecticut, USA
  2. 2College of Health Sciences, University of Liberia, Monrovia, Liberia
  1. Correspondence to Dr Brigid E Cakouros; brigid.cakouros{at}yale.edu

Abstract

Introduction

Global health collaborations between individuals from high-resource and low-resource settings are complex and often built on hierarchical structures and power differentials that are difficult to change. There have been many calls and frameworks developed to facilitate more equity within these collaborations, yet little is known about the lived experiences of global health donors and recipients working within such collaborations and how those experiences can facilitate more equitable collaboration. Liberia, a postconflict, post-Ebola country, provides an ideal setting to study lived experiences of global health collaborations.

Methods

Our qualitative analysis used key informant interviews representing the perspectives of those working on behalf of the Liberian government, Liberian academics, foreign donors and non-governmental organisations and implementing partners. Thematic analysis guided this analysis to explore topics such as financial control, accountability and decision making.

Results

The first phase of the analysis mapped the existing patterns of priority setting. Priority-setting power was most strongly held by those with financial control (donors), and implementation plans tended to be built on metrics that aim to meet donor expectations. The second phase of the analysis explored the interplay between underlying factors that we identified in our data associated with driving collaborative inequity: history of prior of engagement, level of transparency and patterns of accountability.

Conclusions

Our findings highlight that global health collaborations in Liberia are structured to hinder equitable partnerships. The power structure tied to financial ownership offers little space for recipients to have an equitable role in collaborations, which maintains dependence on external aid and ensures that weak systems remain weak. While our study is limited to Liberia, we anticipate that these dynamics are common elsewhere and reinforce the importance of intentional efforts to ensure equitable decision making and power structures in similar settings worldwide.

  • qualitative study
  • global health
  • Liberia
  • decision making
  • accountability

Data availability statement

No data are available. In order to uphold the confidentiality agreements that we made to our participants, we will not be sharing our data.

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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

  • Global health collaborations are often driven by underlying, unaddressed power dynamics that can perpetuate inequity.

WHAT THIS STUDY ADDS

  • This study offers empirical evidence of the underlying structural vulnerabilities that hinder equitable collaborations in Liberia.

HOW THIS STUDY MIGHT AFFECT RESEARCH, PRACTICE, OR POLICY

  • While frameworks exist to facilitate equity within these collaborations, there is scant knowledge on their impact.

  • We encourage those engaging in global health collaborations, especially the donors and funders, to critically examine their own practices to truly address factors that can cause inequitable collaboration.

Introduction

Understanding and navigating the power dynamics in global health, defined as ‘the area of study, research and practice that places a priority on improving health and achieving equity in health for all people worldwide’, is a complex process.1 Global health collaborations are often formed to meet public health needs or to control global threats of disease emergence in low-resource settings.2 The dynamics imposed by significant resource disparities among participants in the collaboration can result in a hierarchical power imbalance, diminishing the ability of participants from low-resource settings to participate equally and equitably in ‘collaborative’ decision making.

This power imbalance can allow for structural vulnerabilities, which are defined in public health as ‘an individual’s or a population groups’ condition of being at risk for negative health outcomes through their interface with socioeconomic, political and cultural/normative hierarchies’.3–6 In global health collaborations, power imbalances from the onset of a collaboration could allow for outcomes that favour the higher-power, higher-resource group over the lower-power, lower-resource group, such as prioritisation of donor agendas, lack of intervention sustainability and fragmentation of national agendas, leaving those in the low-resource setting with less control and at risk of remaining dependent on outside resources.7

In an effort to facilitate more equitable collaborations, global health practicioners and researchers have proposed new models for these types of partnerships and have called for funders to play a key role in addressing inequitable power dynamics.8–11 Commonalities of these models include the need to focus on national priorities in the low-resource setting as well as emphasising the development of trust between partners. Despite these efforts, which emphasise knowledge-sharing, promotion of self-sustainablility and building pathways for independent growth in low-resource settings, studies show that these practices are often not prioritised in structuring global health collaborations, highlighting a need for additional emperical studies to understand the lived experience in such collaborations.2 12–19 Accordingly, we sought to explore the power dynamics and influences on collaboration in the West African country of Liberia.

Liberia, both a postwar and post-Ebola country, is a prime example of a low-resource country navigating multiple global health collaborations and extensive, ongoing development investments. After a violent coup in 1980, Liberia erupted into a 14-year period of violence in 1989, a result of extreme tension between indigenous peoples and Americo-Liberian descendents of repatriated slaves who were settled in this part of Africa by the American Colonization Society in the mid-1800s.20 By the end of the civil war period in 2003, 83% of Liberia’s public health facilities were destroyed and fewer than 30 physicians remained in the country.21 The majority of schools also closed during the war. Following a period of regrowth, Liberia’s health system was once again challenged by the Ebola virus (2014–2016.) Liberia had just over 10 000 probable cases and just under 5000 deaths.22 Approximately 8% of the the country’s skilled health workforce (physicians, nurses and midwives) died during the 2-year outbreak, effectively crushing the already-strained health system.23

These humanitarian crises led to a sustained influx of donor funding into the country. According to the Liberia Project Dashboard, an aid information management system used by the Ministry of Finance and Development Planning in Liberia, at least 41 different external funding projects and programmes had affiliated with the government since 2013.24 This number does not include the many other externally funded programmes and entities that came to Liberia but did not formally affiliate with Liberia’s government. The 2014–16 Ebola outbreak led to additional, chaotic changes in the landscape of donor funding in Liberia: some donors pulled out while others increased spending, adopting an ‘all hands on deck’, crisis-focused mentality to handle the emergency without reflecting on individual strategies and goals.25 As of 2023, Liberia is still heavily reliant on external funding, with 18% of the gross national income being from foreign aid, totalling US$599 million in development assistance.26

A 2017 report on donor influence and collaboration in Liberia, commissioned by the United States Agency for International Development, recommended that donor governments and organisations foster early engagement with the government of Liberia and local stakeholders in addition to mapping priorities alongside national guidelines.27 However, there is little information on whether or how these recommendations have been carried out. To our knowledge, this is the first empirical study that explores the dynamics and lived experiences of global health collaborations in Liberia. This qualitative study explores the power dynamics between foreign donors, Liberian recipients and implementors in the Liberian health sector and uses thematic mapping to elucidate patterns of underlying driver of these dynamics.

Methods

Setting

Liberia is a country in west Africa on the Atlantic Ocean and is bordered by Guinea to the north, Sierra Leone to the northwest and Ivory Coast to the east. The population is roughly 5.5 million people, and approximately one-fifth of the population lives in the capital city of Monrovia.28 Liberia ranks 178 out of 191 on the Human Development Index, which is a composite measurement composed of life expectancy, educational attainment and standard of living, and is categorised in the low human development category29; 50.9% of the population lives below the national poverty line, meaning that half of the population cannot meet their basic food and living needs. On average, Liberians devote 67% of their household spending budget to food alone, creating a high rate of food vulnerability.30 Liberia has a wealth of natural resources, and the main exports out of Liberia include iron ore, gold, rubber and palm oil. However, poor infrastructure (including telecommunications, transportation, electricity and sewage), corruption, financial constraints, labour shortages and low institutional capacity limit the ability for economic growth.31

Procedures

Participants in this study were initially recruited through a purposeful sampling strategy. To be included in the study, participants had to have had substantial work experience in Liberia as a donor or recipient of health development funding. A letter was drafted by the study team and emailed to potential participants to explain the study. Recruitment follow-up included emails, phone calls and text messages from BD. Snowball sampling was subsequently used to recruit additional participants during data collection. Following verbal consent, key informant interviews were conducted following a semi-structured interview guide. These interviews took place between July and August 2022 and lasted between 30 and 60 min each. Interviews were conducted online over Zoom and in person, and the location of the interview was determined to be where the participant felt most comfortable, considering space and resources. To reduce interviewer bias, all interviews were conducted with two interviewers present, and all but one interview had one Liberian and one American interviewer. As this project also aimed to provide training to junior research members on participating in global health research collaborations, allowing two interviewers to be present maximised our opportunity to train researchers while also ensuring that the relative inexperience of some members of our team did not compromise data collection. Having two data collectors present allowed for us to cross-check our data collection approaches in a continuous manner that did not impede on our respondents’ time. Please see our Reflexivity Statement (online supplemental appendix 1) for additional insight to our research team considerations. Questions focused on perceptions of funding priorities, partnership accountability and project sustainability. All interviews were conducted in English and transcribed by the data collection team, and all data were stored on a password-protected, shared drive. Analyses were conducted in NVivo.

Supplemental material

Participants

Interviews were conducted with 38 participants who were either based in Monrovia, Liberia or had prior substantial experience working in Liberia. Three respondents declined to be recorded, and the research team deemed that notes taken during those interviews were not adequately reflective of their content, so those interviews were discarded. We conducted a total of 34 interviews as two participants were interviewed together due to scheduling logistics, bringing our total number of participants to 35.

The research team classified each participant into one of four categories: Liberian government, foreign donor (including those representing bilateral and multilateral donors), Liberian academic, non-governmental organisations (NGOs) and implementing partners. Many participants either had multiple classifications across their career or spoke about roles other than their current one. For our analysis, the team did a close reading of all transcripts and categorised each respondent according to the most prominently discussed role (table 1). This process was continued throughout coding and analysis to best capture the predominant perspective of each individual as they discussed their experiences working in global health partnerships in Liberia.

Table 1

Overview of the position discussed in the interview by nationality and gender

Of those classified as NGOs and implementing partners, one NGO was local to Liberia and the rest of this category represented international NGOs and implementing partners with head offices outside of Liberia.

Codebook Development & Thematic Analysis

The interview guide was developed with the overall goal of evoking multiple perspectives towards understanding how global health funding mechanisms and practices impacted equity in global health partnerships. However, we allowed reflection points during both coding and thematic development to inform and refine our guiding questions for analysis. The analysis was guided by the thematic analysis methodology by Braun and Clarke, which applies a reflexive practice of revisiting the data to create a thematic map.32 33 Based on the use of a codebook to allow the engagement of multiple coders and the practice of continuously reflecting on and refining the codebook during analysis, our thematic analysis process aligns most clearly with codebook analysis in addition to elements of reflexive analysis.33

The research team initially read through three interviews to construct the codebook and then applied this codebook to two additional interviews for revisions. Next, five members of the team continued coding on two teams, with one member coding on both teams to promote reliability without imposing inter-rater reliability as a measure of quality. We allowed the codebook to adapt and grow as needed throughout the process until it was consistently representing the dataset. The codebook was finalised after approximately half of the transcripts were coded and transcripts from initial versions were recoded for consistency. The final version reflected both inductive and deductive codes.

After all members worked to initially identify themes, two team members analysed the data for the continued reviewing, defining and naming of themes. A thematic map was developed to give visual aid to the patterns that emerged with our analysis. As we engaged more with the data following coding and during thematic review, we continued to probe with data-informed questions. We intentionally organised the themes to highlight the layered exploration and depth of our analysis.

Results

We began this analysis by exploring how priority setting dynamics manifested in partnerships between donors and recipients in Liberia, with consideration for whether those dynamics occurred within an equitable collaboration. We worked with a definition of equitable as ‘dealing fairly and equally with all concerned’, and collaboration as ‘working jointly with others or together, especially in an intellectual endeavour’.34 35 It is important to note that our analysis often reflects on these terms separately.

Priority-setting power is most strongly tied to whoever has financial control

As mapped in figure 1, we found a pattern in which financial control is closely tied to donor-driven agendas. Those speaking from the perspective of the Liberian government often said that plans were given to them by donors and partners rather than developed in consultation with them. While some noted that this process is getting more equitable with time, respondents consistently reported that external funders had a strong say in the direction of what was given attention, so priority-setting power sits primarily with those who have financial control.

Figure 1

Cyclical process of priority setting.

Most of the time the international partners come with what they want to do. So they prioritize what they want to do in a particular environment, or in a particular area. And in many instances, you either accept it, or it is pushed into your throat. […] It is a bad process. Because when you are building a system, if you want to help, it is good to work with the people that you want to help, [for them] to tell you what their priorities are. And you can work around it so that at the end of the day, they have an ownership to it. But if you decide on what you want to do for [the recipient], there is no ownership. So it’s just thrown at them. (KII 108, Liberian government)

While some respondents spoke of more collaborative partnerships, respondents often noted that there was a hesitancy to say no to donors. As noted by a respondent representing an NGO and implementing partner, this all “comes from a place of fear because of the power dynamic, because these donors. You’re at the whim of these donors, and it’s true: if you do somehow rub one or two personalities the wrong way, that could equal less funding in your country” (KII 202). Another respondent representing an NGO and implementing partner discussed the tension between a foreign university and a Liberian academic partner, noting that while the Liberian academic had specific needs for their university lab to function, the foreign university had its own set of restrictions based on the overall donor funding. This can dilute communication, leading to what one respondent described as ‘misaligned priorities’:

But at the end of the day, the funding is still coming from a third party that you have to negotiate, and that triangle always creates opportunities for miscommunication, misunderstanding, misaligned priorities. Like unless the money is directly [controlled by] the people who are supposed to be benefiting from it, there’s always a risk. And relying on goodwill can only go so far. (KII 207, NGO and implementing partner)

Some respondents, even those in the Liberian government, noted increased efforts in collaboration and agenda-setting during collaboration. However, these increased efforts were often voluntary actions by willing donors. One respondent representing the perspective of a foreign donor detailed the donor engaging in an annual portfolio review with the Liberian government, although also saying that it is ‘not a formal requirement’ (KII 111). However, the same underlying power dynamics still seemed to drive the collaboration, causing recipients to adapt to the priorities of the donors.

A lot of times, the donors already have their priorities, and it’s sometimes difficult to align their priorities with yours, and then you have to adapt to meet the funding requirements. And sometimes it might not end up within the direct alignment that you would have hoped for; that is, the initial benefits that you hope you would accrue from the funding that’s available. You don’t achieve that, because the priority, the end result, has been modified somewhat. So that can be a problem. Some donors tend to be more flexible than others, some are not at all. And unless you can stick to what their position is, you lose the funding. (KII 203 and 204, Liberian academics)

Another perspective indicated that gestures made towards equity during collaboration were more intended to ‘check the box’ of collaborative actions:

I think there’s the power dynamic where funders have a lot of power in designing partnerships and they’re not fully consultative the way that they should be, and even if they’re consultative—I’ve learned to really sort of despise the word consult, consultation—just meeting with someone and shaking their hand doesn’t actually empower that individual. It just means that you’re checking the box. (KII 202 NGO and implementing partner)

Implementation plans are driven mostly by donor priorities, with outputs that often reflect donor measures and metrics

Most of those speaking on behalf of the Liberian government were fully aware that donors had obligations to their own organisations. Some respondents representing foreign donors acknowledged this tension, noting that in the end, the final decisions of how money was spent in Liberia was not controlled by the government of Liberia:

So we have to find the balance of what we think here, from our perspective, is the right thing to do, and what also meets [foreign donor’s] priorities and expectations. But the approval is not… it’s not the government of Liberia that gets to decide what we do. This is [foreign] taxpayer money. And the [foreign donor] is the one ultimately we have to work within that constraint. (KII 111, Foreign donor)

This approach often leads to outcomes being defined to meet the priorities of the donor, which results in outcome metrics centred on the donor framework of achievement.

It’s like not just priorities, but even the results are like, who decides what success looks like? […] Part of the problem is the way that the funders define success. The way that a lot of donor-funded projects are measured, their success is measured by performance-based indicators. And I think, you know, an important measure of success is contribution towards building systems and a lot of long-term things that are difficult to measure within funding cycle of even five years. That also distorts what how things are planned and how success is defined, and that’s a cycle. (KII 305, NGO and implementing partner)

Often, those speaking from the perspective of the Liberian government and NGO and implementing partners described wanting to impact long-term systems, as noted in the quote above. While long-term systems interventions were not discussed as directly by those representing the perspective of foreign donors, one respondent did note that ‘time and relationships dominate as indicators of the success of a project’ (KII 104). However, shorter timelines for measuring success benefited those working for foreign donors more than the recipients, as these timelines can allow for individuals to meet personal milestones that advance their own career. Foreign nationals are rarely in one foreign officer role for >5 years, for example, and there is a pressure to meet certain metrics for career advancement.

If you’re a kind of new donor agent in the field, what you want to do is have something that’s your own, right, you want to change something. If nothing changes, and you just implement your predecessor’s plan, well, that’s not really going to help you get promoted. So there’s an HR dynamics problem on top of this kind of general credible commitment problem. (KII 304, implementing partner and NGO)

Underlying structures influencing collaborative inequities

After identifying the cyclical connections between financial control, priority-setting power, the implementation of a plan and the determination of success, we then aimed to explore factors that influenced collaborations between donors and recipients.

We rotated the cyclical process of priority setting (figure 1) to demonstrate our findings that explore how additional factors influence and drive the ‘surface level’ cycle of collaboration (figure 2). How donors determined which projects or programmes would be funded, and how those projects or programmes would be implemented within their priority agenda in Liberia was described by respondents as a unidirectional, inequitable process. We aimed to understand what embedded, obscure forces continue to allow for such inequity in collaborations, especially considering global calls for equity. We found interplay between three underlying factors in our data that were associated with driving collaborative inequity: history of prior of engagement, level of transparency and patterns of accountability. While each are described independently below, we acknowledge many points of overlap among them.

Figure 2

Underlying structures influencing collaborative inequity.

History of prior engagement

The history of prior engagement refers to the ways in which prior engagement in Liberia has informed current collaborations. Many respondents speaking from the perspective of the Liberian government noted that the history of engagement with Liberia as a postconflict country still influences the ways that incoming partners engage, often with an approach that reflects decision making in times of crisis. Most Liberian respondents from both the government perspective and those in academia did talk about wanting to change patterns that were established in a previous, more crisis-focused time, but have encountered several barriers. As one Liberian academic noted, there was “no room to change the dynamics. People wanted to do what they wanted to do, I guess it made it easier for them, or they felt that this is something everybody else was doing so we do it” (KII 307).

On the other hand, respondents speaking from the perspective of foreign donors noted that a history of ‘corruption, mismanagement and poor prioritisation’ (KII 105, Foreign donor) in Liberia drives them to behave in certain ways with disbursing funds: “We don’t turn money over to a country that has a big history of corruption” (KII 113, Foreign donor). Most respondents, both Liberian and foreign, were not dismissive of the issue of corruption in the Liberian government. However, one NGO and implementing partner speculated that the fear of corruption prevents trust in local partnerships:

Because of this innate fear of corruption in African countries, people hide behind that to say, ‘Well, these are taxpayer dollars, so we have to have all these controls and mechanisms’. So we’ve created these systems of layers of staff within a donor agency and working through [donor country] partners to implement a program as opposed to what we do in the [donor country]: do we trust this institution to run this project? Is the leadership behind this project good? [Then they] give the money directly to the institution, and then just monitor it, lightly, and trust that the work is going to get done. That isn’t done for most of the partnerships that I work with in East and West Africa, and I think the root of it is this fear around corruption. (KII 202, NGO and implementing partner)

As a result of broad distrust of the government, there was a general view that donors would avoid giving funds directly to the Liberian government. A respondent representing the perspective of NGOs and implementing partners noted that the fiduciary risk makes donors hesitant to engage until a recipient country is deemed functional, therefore impeding the ability of a government to achieve its own trajectory of growth:

They [donors] resist channeling their money to a recipient country government until it’s running as well as their own. You know, like at that point, they don’t need your money, you know, the country’s already running really well. So, it’s, you know, you want to wait for the country be perfect before you take any risk. […] And what that does, a preoccupation with fiduciary risk, ends up becoming a strategic risk that your programs can fail. You're not helping the country to achieve its development goals and progress. (KII 101, NGO and implementing partner)

Beyond a crisis-oriented approach, postconflict patterns and government corruption, some Liberian respondents described foreign partners (donors, NGOS, academics, etc) operating in Liberia in ethically questionable ways that reflect ongoing, historical patterns. This included foreign partners practising extractive research or operating projects in ways that would typically not be accepted in other settings.

Most of us professionals are timid, and we realize because we are too poor, that we don’t have a right to question somebody when he comes to say, ‘I’m bringing money to help you’. I don’t believe that. Poverty is not a reason to shut up. [NGO] is conducting research I don’t know, and I can almost guarantee they have never reported to anybody in this country. Nobody knows what [NGO] is doing. Nobody. Is that right, or wrong? That happens only in Liberia. And perhaps only in certain conditions in Africa. That’s grossly wrong. (KII 308, Liberian academic)

The NGO and implementing partners did tend to have an awareness of the tension of working in a country that is not their own, especially coming from western training or practice. This spoke mostly to a colonial history of engagement where blatant saviorism and emphasis on western knowledge drove partnerships. As put from the perspective of an NGO and implementing partner:

If you want to really serve, if you want to be useful to them, the first thing is to forget about your expertise. You bring some technology, bring knowledge, but you are not an expert in people’s suffering. You are not the expert in the context in which you are here to work: people on the ground are. Therefore, if you really want to make good use of what you know, let the experts actually teach you what you need to learn how to be useful. In my words: learn how to be useful, and they will be the one to teach you. (KII 209, NGO and implementing partner)

Level of transparency

The level of transparency refers to what information regarding resource availability that partners are willing to reveal to one another. Respondents noted a pattern of donors’ contracting with NGOs to implement work as opposed to the government, often creating a gap in knowledge for the government regarding what is happening on the ground. Foreign donors were aware of this pattern as well. One such example, noted below, discussed that while engagement with the Liberian government could inform the redacted national document, this process was not obligated to involve the government:

We should definitely, where we can, build our work plan side by side with [the Liberian government] so that what we put down as our activities is approved by them. But some of the money flows, not to the government, some of the money flows to implementing partners and our work plans are developed with the implementing partner, and the government may not even have any visibility into what they’re supposed to be doing. Like I said, we inform what the partners do based on [national document.] But the process isn’t obliged to take [the government’s] opinion. (KII 105, Foreign donor)

Disparities in overhead costs furthered this issue. Overhead costs, also called indirect costs or management fees, are the operational costs (such as rent, utilities, facilities management, administrative costs, etc) that are incurred by the institution(s) that house a project. Indirect costs are often calculated as a percentage of the overall award amount, but the actual percentages charged for indirect costs vary among donor institutions and recipients. When indirect costs were not disclosed or discussed, Liberian government representatives were unsure of how much money was coming into the country.

One thing that was of concern was the NGOs, not the donors, because, you know, the donors will channel funding through the international NGOs. The concern was that they [NGOs] will come and give the narrative of what needs to be done, you know, but the actual financial display was kept secret. […] And I always told them we know that you write proposals, we know that a certain percentage of that money is there for your administrative cost, you know, we know but we also want to know how much is there for service delivery. You cannot get up and tell Liberia, ‘Oh we channel $2 million through [external organization], you know’, and then you come and you use 50% of that money on administrative costs. It is wrong. (KII 103, Liberian government)

Another example highlighted how such lack of disclosure can cause poor public perception of the government. Yet again, when foreign donors make public announcements of the amount of an investment but do not publicly disclose what percentage goes to overhead or indirect costs, it creates an illusion that some portion of the money has been lost by the Liberian government. A few respondents from the perspective of the Liberian government spoke of this communication divide.

So in other words, if you come in with 9 million dollars and you go public that this entity is coming with 9 million dollars, you stand there as a government representative of the country. The typical Liberians are not looking at that entity; you are the one they are looking at. So after a couple of months, or a couple of years, and they do not see anything tangible, is alluded to you that, ‘oh the people said they had $9 million, it seems that you have eaten the $9 million, and this, this’. And so forth. They won’t understand that the $9 million has an overhead that has to go back, that expatriates and other people will have to come, their salaries and everything going to come from it and other things and so forth. (KII 108, Liberian government)

Finally, most Liberian academics spoke of how their funding typically comes filtered through a partner determined by the donor: “The funding usually goes directly to a [foreign] based organization or institution, and then we collaborate with them. So they then dictate how the processes are in line with whatever agreement you have with them” (KII 203 and 204). This dynamic highlighted that even if foreign donors dedicated money to Liberian academic institutions, the Liberian recipients still had to work within the expectations of the middle party. The same respondents also noted that principal investigators who spend limited time in Liberia are often unaware of the complexity these issues can create for the Liberian institution.

Patterns of accountability

The donor, who holds the priority-setting power, is also able to create structures to hold the recipient accountable while often overlooking their own accountability back to the Liberian government.

There aren’t really any systems for accountability in the other direction; that is, for a funder to be even really questioned for maybe withdrawing funding or changing their priorities, or not providing the amount of funding originally promised or, you know, any number of things, the decisions they make about what can be paid for and what can’t. [The] extent that they’re being held accountable, that’s internal itself. They’re self-regulated really. (KII 305, NGO and implementing partner)

Many respondents spoke of accountability as forms of auditing and reporting. Often, this was a one-way street in which the Liberian government was held accountable by foreign donors. Meanwhile, there were very few discussions and concrete examples as to how foreign donors were held accountable to the Liberian government.

While the interview guide did not specifically ask about auditing, auditing was often spoken about from the perspective of those working in the Liberian government, although respondents representing the perspectives of foreign donors never discussed audits as a means for accountability. Many members of the Liberian government noted the importance of auditing for “recognizing the limitations in your system and [that] building it over time really does help to strengthen your partnership” (KII 110). However, it was noted that “you can audit on both sides but again I’m saying to audit NGOs and international partners is difficult. They will audit themselves and what they give you, that’s it” (Liberian government, KII 302). Auditing of the Liberian government was discussed as being conducted in two ways: internal and external auditing. Internal audits reflected the government’s ability to manage projects and financing on their own, ‘to determine what are some of the gains and pitfalls identified in implementation’ (KII 119). External audits reflected those being implemented by external sources, such as foreign funders sending in outside auditors to monitor the progress of projects. A respondent from the perspective of NGOs and implementing partners noted that when they worked with the Liberian government, “they were audited 17 times by international audit firms and passed all of them” (KII 101).

In contrast, when asked about forms of accountability, respondents representing the foreign donor perspective spoke more often about reporting back to their own organisations or home countries as opposed to any binding auditing or accountability requirements to the Liberian government. When there were systems of accountability in place to the Liberian government, they were still directed by the foreign donor. One respondent noted that they voluntarily delivered reports to the Liberian government even though the government never asked for them. On the other hand, another respondent representing the perspective of foreign donors noted the development of formal measures of accountability with the government such as joint agreements, quarterly expenditure reports, annual portfolio reviews and work planning processes, highlighting inconsistency regarding how foreign donors worked with the government. When asking for more joint accountability and oversight, one respondent from the perspective of the Liberian government noted that this was often a time-consuming battle:

Next, another example, and one thing I always try to push for, I’ve been very unsuccessful in getting there, is, to ensure that no implementing partner, regardless of who you are, should submit any report for implementation on any activity in Liberia, without it being sanctioned by the agency of government or the institution that you work with over time. That is not always the case. That is not always the case. I’ve tried, I’ve been successful on few occasions, especially when I was [title], but again, it takes too much time, energy and effort getting some of these international groups to understand this. If you work a lot of programs, organizations that implement particular tasks, the report should be done jointly, so that everyone agrees on what goes into that report before it is shared. That is technical accountability. (KII 112, Liberian government)

Discussion

We approached this dataset aiming to understand the priority-setting power dynamics that exist between foreign donors and recipients in Liberia, and we approached the data in two distinct phases: (1) by initially studying how the current patterns of funding determine power in collaborations and (2) by analysing the underlying structures that drive forward inequitable collaborations stemming from financial control between foreign donors and recipients. We identified multiple patterns of inequity in the collaborations between various actors working in health and development in Liberia. To our knowledge, this is the first empirical study that explores global health collaborations in Liberia.

The results from the first phase highlight a cyclical pattern of funding that is difficult to break: the actor who is in financial control has priority-setting power when deciding how to spend the money. As a result, implementation plans and evaluative measures that reflect the goals and timelines of the funder are likely to be created and, hopefully, met, leading a funder to continue to engage with and fund projects. This cycle allows for the entity with financial control to dictate who decides what is important, how the work gets done and how success is measured. This cycle also aligns more with short-term, donor-prioritised timelines rather than long-term, government-prioritised timelines. Collectively, these findings indicate a lack of true agreement during consensus within global health collaborations between externally funded entities and local entities in Liberia. It is feasible to have the appearance of consensus during the decision-making process in a collaboration without agreement, as the agreement-making process is often when actors negotiate over how to prioritise their own needs with others. If, however, there is a pressure to remain cooperative for the sake of a collaboration to continue, often consensus then reflects consent to go forward with a group decision rather than group agreement on the decision itself.36 The analysis described here indicates many accounts where agreement is highly skewed to meet the donor priorities, resulting in inequitable collaborations.

The results from the second phase of this analysis highlight underlying structures that reinforced the cyclical process of donor-driven priority setting and kept recipients from gaining financial control, thereby perpetuating the power structure imbalances and inequitable collaboration. While we approached the analysis with a neutral definition of collaboration, we know that in the world of global health and development, collaboration is generally accepted as a positive and progressive term. However, as derived from our data, the power imbalances that drive the underlying patterns of inequity lead to collaborations with questionable levels of agreement among partners. This reinforces, rather than dismantles, the structural vulnerabilities scaffolded by working relationships between those with funds from high-resource settings and those who need funds from low-resource settings. While we do not know the contractual agreements between the actors we interviewed, our qualitative inquiry suggests that many recipients are not satisfied with their ability to negotiate within these collaborations. Silence from those with less power could be driven by the fear of losing support from those with power, creating a state where a seeming consensus is reached without full, equitable agreement.

Balancing short-term success with long-term sustainability was interesting to consider from a variety of perspectives, especially when considering risk mitigation. As the global health funding system currently operates, the metrics for determining success that are set by the donor organisation need to be met to keep the cycle of funding continuous. However, this leaves little room to focus beyond the defined incentives that come with short-term progress, especially in locations with a history of corruption and weak systems. Short-term projects allow for the feeling of better control over mitigating the risk of a project becoming susceptible to corruption or fraud. It is common nature to impose rules for correcting course when things go wrong and to employ incentives to guide behaviour; however, excessive reliance on incentives to follow rules eventually creates an expectation (and exploitation) of incentives to operate. In effect, this cycle of short-term, donor-driven ways of working ensures that weak systems remain weak with little opportunity to grow and can even allow for means of corruption to manifest as a result. Perhaps we need to reconsider the rules and incentives that define collaboration and measures of success between donors and recipients. What is sidelined by the preoccupation with risk mitigation? How is corruption defined by all actors, and in what ways can overcompensating for risk actually lead to corruption? What inequities and ineffective working practices are reinforced without defining existing structural vulnerabilities within collaborations?

As noted, some of our respondents had experience in multiple employment positions and categories across our analysis. While classifying them according to the perspective they discussed most prominently in the interview was helpful for this analysis, we acknowledge that this could be limiting by not capturing the complexity of career trajectories. In addition, we used convenience and snowball sampling for our recruitment, and we acknowledge that this had potential to limit the breadth of perspective that we were able to include. In future research, we would aim to have better representation of foreign donors and of Liberian academics for gaining additional insight to those perspectives. We also acknowledge the potential of introducing bias with convenience sampling; however, we felt more comfortable working directly with the network generated from a trusted source than unaffiliated outreach to government officials.

Finally, our team included several novice data collectors and students who were new to qualitative analysis. While this process was positive and productive for the entire team, we did not train students on how to properly take notes during key informant interviews whereupon the interviewee declines to be recorded. Subsequent weaknesses in the quality of that data led us to conclude that it was not appropriate to include those data, which was a limitation to the richness of our results. This occurred in only 3 interviews out of 38, however, leaving us with a robust collection of data from 35 recorded interviews.

Conclusion

While qualitative research is not generalisable, we aimed to provide a contextually rich exploration of how these patterns manifest within one location. Considering the priorities outlined in the Paris Declaration in 2005 (which specifically called for donors to prioritise country ownership, align with local systems and objectives and harmonise coordination and procedures to avoid duplicity, and for donors and recipient countries to clearly measure results and to be accountable for such results) to the 2023 midway progress report for the Global Action Plan for Healthy Lives and Well-being for All (which detailed ongoing weaknesses in collaborative efforts), our results indicate that there has not been much movement in creating equitable collaboration in Liberia between donors and recipients.37 38 We would be curious to understand how these patterns align or differ in other low-resource settings.

Data availability statement

No data are available. In order to uphold the confidentiality agreements that we made to our participants, we will not be sharing our data.

Ethics statements

Patient consent for publication

Ethics approval

This study was approved by the University of Liberia and Yale University. The University of Liberia granted approval, while Yale deemed this study to be exempt. We have documentation from both institutions that we are able to provide, if needed. Participants gave informed consent to participate in the study before taking part.

Acknowledgments

An early version of this work was presented as a poster at the Consortium of Universities for Global Health (CUGH) 2023 conference in Washington, District of Columbia, USA.

References

Supplementary materials

  • Supplementary Data

    This web only file has been produced by the BMJ Publishing Group from an electronic file supplied by the author(s) and has not been edited for content.

Footnotes

  • BD and KT-S are joint senior authors.

  • Handling editor Seye Abimbola

  • Twitter @bcakouros

  • Contributors This study topic was stemmed from a lecture given by BD at Yale University that detailed her personal experiences of inequitable global health partnerships in Liberia. BD, KT-S (guarantor), DLL and JL conceptualised the research design and proposal. BEC (guarantor) was the qualitative lead during data collection, analysis and presentation. All authors contributed to the design of the data collection tools and all assisted with the analysis, with BEC and JG being most the directly involved in analysis. All authors reviewed and approved final drafts of the manuscript, with BEC and KT-S leading the revision process. We acknowledge the invaluable contributions of our study participants, as this manuscript would not have been possible without their time and expertise.

  • Funding BEC, AHW, BD and KT-S were funded through the USAID grant titled 'BRIDGE-U: Applying Research for a Healthy Liberia' (award number: 7200AA21CA00010). JG, DLL and JL were funded through fellowships obtained by Yale University, Yale School of Public Health and Yale College.

  • Disclaimer The funders had no role in study design, data collection and analysis, decision to publish or preparation of the manuscript.

  • Competing interests None declared.

  • Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.

  • 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.