Table 1

Examples of ways in which global health organisations based in high-income countries can perpetuate inequities and systemic changes needed

Example of practice that perpetuates inequitiesExample of change needed
Limited participation of LMIC experts and community representatives in the governance structures and advisory bodies of organisations focusing on improving health in LMICs.The majority of powerful positions on governing bodies and decision-making panels of global health organisations should be held by people with the relevant in-country (or regional) expertise and lived experience of the main health issues, contexts and geographies that the organisation focuses on. Governing bodies should have diversity in thought, gender, social, geographical and ethnic backgrounds. They should be selected transparently with input from stakeholders that the organisation seeks to serve.
Arbitrary choice of interventions or research topics with, little coordination or engagement with people on the receiving end, leading to top-down health programmes that cannot be sustained and can perpetuate inequalities in communities.Decentralisation of resource allocation and programme design to better engage communities served. Keeping global level staff as technical advisers and coordinators rather than decision-makers, allowing sovereignty of patients and communities while supporting mutual learning. Moving away from a biomedical model of global health programmes towards internalisation and integration of local knowledge, indigenisation of assessments and solutions, and following the lead of the affected communities in the assessment of their problems and the appropriate application of medical and public health evidence to their situations
Typically place European or North American ‘experts’ with minimal experience working in the project setting in leadership positions, with a staffing model that assumes they are able to generate more valuable insights than those with local or indigenous expertise.Ensure that selections are made on the basis of a range of positive attributes, including a minimum level of local intelligence which can be judged considering factors such as: years living and working in the country or region; knowledge of local language(s); outputs of long-term collaborations.
Staff, offices and other resources are based in high-income countries when they could instead be directing resources and employment opportunities to LMICs.More equitable geographical concentration of resources—including staff and offices—and decision-making power, reflecting the geographical focus of the organisations’ work.
Funding application evaluation panels without or with limited representation from affected communities or stakeholders in which work will be done; grants awarded without due consideration for partnership ethics.A wider range of experts should be in decision-making positions for grant evaluations, and assessments should be more transparent; funding agencies should develop and provide frameworks for ethical and equitable partnerships; funding should be conditional on commitment to uphold, and evidence of, ethical and equitable partnership practice.
  • LMIC, low/middle-income country.