Big thoughts Tom! They echo so eloquently what I've known and felt since ethiopia 2011 but have yet struggled to articulate.Reply
19 September 2019
Collaboration. Partnership. Mutual interest. Such easy words to say, and great copy for the various inspirational documents which circulate in global health. So, for that matter are some of the other associated buzzwords we surround ourselves with: sustainability, local ownership, co-creation. Yet what do these really mean in practice? To what extent are we really able to deliver on them?
My experience of global health began in 2011, when I spent a year with VSO working as an anaesthetist in a busy clinical department in Addis Ababa. This taught me some hard lessons about clinical medicine, quality improvement, global health, and my relationship with these concepts. Among these was the insight that while a single clinician can drive change, this comes with both great risk and great limitation. An individual collaborating with a range of interested parties can do more, but might also be restrained from doing something daft.
Since then, I’ve been privileged to work with some truly inspirational people and organisations including THET, Lifebox, Cambridge Global Health Partnerships (CGHP), the World Anaesthesia Society (WA), and the NIHR Global Health Research Group on Neurotrauma (GHRGN). I’ve been lucky to be involved in a number of global health projects, including a long-term institutional health partnership which for me exemplifies collaboration: the Cambridge Yangon Trauma Intervention Partnership links Cambridge University Hospitals NHS Trust and Yangon General Hospital (YGH), bringing together clinicians, educators, and academics from a range of specialities and backgrounds – all geared toward trying to help improve trauma care in YGH. This has been funded through THET, DFID Burma, and the Rangoon General Hospital Reinvigoration Trust, as well as being supported through its partnership with the GHRGN.
I’m always amazed by the readiness of the global health community to collaborate with each other. I suspect much of this is grounded in the nature of many of the people who are drawn to the field: cause-motivated, compassionate individuals who are working toward a common goal. Many of us see collaboration as a pathway to both efficiency and efficacy, as a tool to increase impact, and as a way prevent past mistakes.
However, there are a few hard truths. We are far from all being saints all of the time, and it is easy for noble objectives to be subverted by personal ambition or the pursuit of institutional prestige. Collaboration is difficult, and the machinery which needs to be navigated to pursue global health projects does not always facilitate it. Money is limited, funding deadlines are tight, and everyone is desperate to show the impact of their project. Communication is difficult, and relationships complicated by language, culture, politics, and distance. Superficial collaboration is easy, genuine co-working is much more complex. Furthermore, as collaboration grows, so too does the complex task of managing the deliverables which each partner needs. We may all agree the end game is improving the health of a particular community, but individuals and organisations need other things: publications, media content, monitoring and evaluation data to help write the next grant application.
However, there is a more fundamental difficulty. While we get used to seeing documents or websites with a host of logos, often of charities, international bodies, and professional associations, the voice of the intended beneficiaries in the global south is often lost. The ‘global health community’ is at risk of becoming an echo chamber within the global north – dominating the agenda, controlling the funding, setting the tone for what constitutes success.
We often talk about sustainability and collaboration with ‘local champions’ to drive projects. How often are honest conversations had as to the pressures placed upon them, and the network of collaborations they are trying to maintain? I have certainly met local champions in LMICs who are frankly overwhelmed by the number of well-meaning collaborative partners knocking on their doors. These are often at key institutions which become hubs for global health projects at the expense of other, sometimes more deserving, centres. To what extent do global health teams seek to collaborate with other visiting HIC teams (especially from different countries), with local NGOs, with patients and their representatives, with Ministries of Health? When we do, what does collaboration really mean?
I think that even within the last decade, ideas around development and global health have changed significantly. From a post-colonial ‘white saviour’ model we are moving – I hope – to a more respectful partnership of equals. However, to assume this transition is binary, or complete, would be naïve. High income countries continue to profit at the expense of their poorer neighbours. The flow of aid money from one to the other is a tacit recognition of this imbalance – it is not a redress for past colonial atrocities, but a tiny recompense for the continual flow of people and resources out of the global south. This imbalance means that the discourse around development is dominated by the global north. We cannot be immune from this: we write the grant application that fits the prescribed funding brief. The application form is in English, the money is from a UK donor, the reporting structures imply a theory of change grounded in Western thought. We need to demonstrate impact of our intervention. We need to publish the results. We need to continue to be funded. Are these needs shared by our LMIC colleagues? Are we sharing their needs for personal and professional advancement or financial security?
To me collaboration means two things. One is working toward a common goal. However, the other is the understanding that your collaborators’ needs become your own. This, I think, requires some conceptual running. If academic publication is needed by one of the parties in a partnership, then this becomes one of the necessary outcomes of the project – but this needs to be honestly brokered and owned by all. If one of the parties needs personal advancement, this should be out in the open, and fairly addressed.
My challenge to myself – and others – is to look the problem of collaboration squarely in the face. We must be critical of our own efforts, and try to orientate ourselves not by what we can (or want to) do, but by what can, and should, be done. Collaboration is not about adding more and more logos to every document, or smiling photos in exotic locations, or feeling good about the friends we feel we have made. It is about rigorously identifying the needs of all those involved, and working to align them so as to best effect change for the ultimate beneficiaries – the patients. It is about having the humility to seek expertise, and recognise where others may be more equipped to help than we are. It is about challenging the structures by which we operate to include the voices of those who are not heard, and recognising that in collaboration, the needs of one are the needs of all.