A recent issue of Medicine Anthropology Theory devoted to the critique of global health partnerships (GHPs) raises a question of great significance to many Somatosphere readers: ‘In real world partnerships… after proposed innovations are tested, community health workers are trained, or an intervention has been piloted, what happens next?’ (Okeke 2018, 10). All too often, the answer is ‘little if anything’ (ibid). For some ardent critics, lack of impact reinforces the suspicion that GHPs ‘have a distinctly rancid colonial appearance even though participants state the best intentions’ (Okeke 2016, 461) as their ‘lopsided’ interactionsfunction through varying forms of extraction and paternalism(Geissler 2013, Brown 2015). GHPs involve complex power dynamics. This is not just because GHPs are both justified by and involve working across profound inequities (Crane 2013), but also because the very political question of ‘what happens next?’ reveals the precariousness of the power they lay claim to. Here then, rather than delve into a more familiar neo-colonial account of GHPs, I want to focus on their structural weaknesses in general and their precarious claims to power in particular drawing on some reflections from the Sierra Leonean context. My aim is not to dispute that power relations unfold in dramatically unequal and uneven ways in GHPs, but rather that this is only one aspect to the nature of power within such partnerships. And, as GHPs evolve and emerge as ever-more central to the global health landscape, their claims to power within the local and national contexts within which they operate are arguably becoming less certain and more unstable than accusations of their ‘rancid colonial appearance’ might suggest.
The power of GHPs is precarious for two main reasons that must be better acknowledged if they are to deliver on their promises of sustainable change. First, the ‘projectification’ (Meinert and Whyte 2014)of partnership is clearly a logical response to Northern funding contexts, but this landscape also has significant consequences for achieving the Health Systems Strengthening (HSS) ambitions that many GHPs lay claim to. The short time-span of funded project timelines, outcomes and deliverables do not always match the slow, holistic work needed to drive sustainable systems change. Moreover, projects usually deal with delineated research ideas or interventions and cannot conceptualise (or act upon) the barriers posed by different components of weak health systems to overall health improvement and the multifarious social and structural determinants of health. For example, a project funded by multiple international donors in Sierra Leone to train hospital referral coordinators cannot ever be sustained unless there are functioning and fuelled ambulances with which to transport patients to tertiary sites which, at present, falls across multiple responsibility jurisdictions – from international NGOs to the Ministry of Finance. The project’s positives can also not be sustained without donor-paid staff being transferred onto the Ministry of Health’s payroll in the long term. Moreover, in a system reliant on out-of-pocket expenditure, simply making a referral does not mean that a patient can afford to either get to hospital or be treated once there within a system entirely reliant on formal and informal out of pocket expenditure. The wider aspects of the health system needed to sustain the well-intentioned work of GHP projects are, ultimately, a question of national, regional and local capacities and politics. Yet, the political literacy and advocacy needed to affect real change are usually absent within the research projects and interventions that characterise GHPs lest the delicate relationships that hold partners together is compromised. Politics, in essence, can never be a measurable deliverable, a project objective or an outcome and so GHPs remain detached.
Second, achieving impact through wider, sustained health systems strengthening rests on the willingness of those at the very top of national government to implement new or existing health policies based on evidence generated by GHP projects. This is where the real power begins and ends (McGoey 2014) and a source of the under-recognised precarity of GHPs. It is interesting that, as many GHPs have registered as local NGOs in order to by-pass perceived inefficiencies in African bureaucracy (Crane, Andia Biraro et al. 2017), they have also found new sources of status and power. However, it is also important to recognise and critically reflect on how these strategic moves have rendered GHPs more vulnerable to political vagaries and regime changes. Indeed, as many local and international NGOs have found, hostile regimes can create very difficult operating environments, with the health sector far from immune from government interference in their operations. Thus, as GHPs try and skirt local systems by registering as NGOs an underexplored and somewhat ironic side effect is that they also become more embedded and vulnerable to the politics that have tried to evade. And, as the number of NGOs, projects and partnerships proliferate, some African countries are now requiring NGOs to sign Service Level Agreements in order to operate and pay a percentage of funds received to the government. In the case of Sierra Leone, for example, these SLAs require them to abide by a plethora of regulations on employment and expenditure structures, training, accounting and reporting and registration. From the perspective of the state, SLAs allow them some measure of strategic oversight and control over what is happening in a cacophonous NGO sector. But from the NGO perspective, adherence to these stringent rules risk the freedoms of operation and expression necessary to do the kind of work they deem to be essential. SLAs, therefore, introduce new forms of precarity amid efforts to recalibrate the power relationship between donors, NGOs and the state.
GHPs have to constantly vie for highly competitive funding sources that require them to navigate the complex path of finding the local collaborators needed to satisfy Northern funding rules while remaining mindful of ever-changing local power hierarchies. This means that they need to be expansive and inclusive in choosing collaborators and partners. But, it also increasingly means that they need to exercise delicate forms of diplomacy by speaking to the right people in the right order at the right time. This is something that only gets more challenging as the number of projects grows and the pool of local expertise and potential partners gets increasingly over-stretched. This, in turn, does not enhance the power of GHPs vis-à-vis partners, but rather places their very existence in greater precarity if the correct domestic diplomatic channels are not followed and local collaborators not incorporated in the design of grant applications. A recent visit to Freetown brought this home when a well-intentioned visit to a high-profile local stakeholder to discuss a recently-funded project resulted not in promises of collaboration, but rather a swift rebuke for not including the “right” Sierra Leonean Co-Investigators on the application. There had been multiple pragmatic reasons why these Co-Investigators had not been approached and identified prior to the grant submission that many readers will be all too familiar with – the sheer scale of the project with multiple countries, stakeholders, academic leads and partners involved, the unfamiliarity of the overall Principle Investigator with the micro-politics of each country and the short lead-in time from project call to submission that meant that many collaborations were promised rather than pre-negotiated. Yet, in country, a keen awareness of the funding at stake and the extractive tendencies of some research projects meant that promises of collaboration and partnership was fragile. This was especially so when local stakeholders felt that the “correct” process had been circumvented, they had not been included in the grant development process and, therefore, the project questions and objectives may not have been truly reflective of the actual gaps in knowledge or the real needs that the project purported to address.
The ultimate and most overlooked of all partners are Presidents and top-level bureaucrats at Ministries of Health, Education and Finance. These actors are generally outside the direct purview of GHPs and the research that orbits them, but they are the only ones with the power to really strengthen health systems. Without state buy-in and action, changes remain limited to small-scale contexts: one hospital, one area of clinical practice etc. When elections are held and governments re-shuffle – as has recently happened in Liberia and Sierra Leone – the diplomacy process must re-start and the trust and momentum built up around GHPs can rapidly be shattered. Again, in Freetown, as a new UK-funded project that would design and test out a surgical intervention was explained to clinicians at the capital’s main hospital, the response was somewhat muted and frustration bubbled. Those that spoke out at the end of the presentation expressed their reservations that yet another intervention was being trialled that would require their time and buy-in, but that unless the President himself could be convinced about the efficacy and use of the intervention, it would all be for nothing. The audience agreed that the Ministries of Health and Finance would both need to be convinced, but that ultimately any change rested on the President releasing funds and ordering the Ministry of Health to change processes at the government-run hospital. The resignation that this was unlikely to happen and, again, nothing would change as a result of their time and input into the development and deployment of a yet another clinical intervention, offered a marked contrast to the enthusiasm of the UK team for the upcoming work.
GHPs are often deemed to be self-evidently good, especially in the medical literature. Yet, multiple anthropological engagements suggest that this “good” is fractal, partial and more complex than often assumed. The ability to be and do good requires GHPs to have the power to effect changes that are both wanted and necessary to improve the lives and wellbeing of others. However, this power is innately precarious due to the very nature and limits posed by working ‘in partnership’. This precarity is further entrenched by a neglect of translational and advocacy work and by dissemination strategies that are centred on international audiences rather than the local outlets that might sway public opinion and catalyse governments to action (Boum II 2018, Fourie 2018). Sustaining systems change rests outside the remit of any single GHP or project, therefore being cognisant of where power ultimately resides and the delicate, long-term diplomacy needed to access it is essential if ‘what happens next’ is to be of the greatest good for the greatest number. The medical anthropological work on partnership has been enormously instructive and insightful, especially with regards to critically reflecting on where power resides and how it manifests. However, there is still a need to better acknowledge and explore that the power possessed by GHPs is far more precarious than accusations of their neo-colonial characteristics can ever acknowledge. Ultimate power still resides at the very top of the state and, therefore, outside the ideological and practical purview of much critical anthropological work despite calls to “study up” (Peters and Wendland 2016). The mosaic of agencies now vying to influence and strengthen health systems means commensurate complexity with regards to questions of responsibility, accountability and the capacity to effect change. Recognising the precarity of and the limits to GHPs also means re-locating power at the highest levels of the state: the very places that partnership can never really reach.
Dr Clare Herrick is a Reader in Human Geography at King’s College London where she has worked since 2007. Her research explores the intersections between health behaviours, risk, regulation and urban environments across a range of geographic contexts. You can find out more about her research and writing here.
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Crane, J. T., I. Andia Biraro, T. M. Fouad, Y. Boum and D. R. Bangsberg (2017). “The ‘indirect costs’ of underfunding foreign partners in global health research: A case study.” Global Public Health: 1-8.
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Meinert, L. and S. R. Whyte (2014). “Epidemic projectification: AIDS responses in Uganda as event and process.” The Cambridge Journal of Anthropology32(1): 77-94.
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