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Decolonising global health in 2021

Khan M, et al. BMJ Global Health 2021;6:e005604. doi:10.1136/bmjgh-2021-005604 1
Decolonising global health in 2021: a
roadmap to move from rhetoric
to reform
Mishal Khan,1
Seye Abimbola ,2
Tammam Aloudat,3
Emanuele Capobianco,4
Sarah Hawkes ,5
Afifah Rahman-Shepherd 1
To cite: Khan M, Abimbola S,
Aloudat T, et al. Decolonising
global health in 2021: a
roadmap to move from rhetoric
to reform. BMJ Global Health
2021;6:e005604. doi:10.1136/
Received 5 March 2021
Accepted 7 March 2021
Faculty of Public Health
and Policy, London School of
Hygiene and Tropical Medicine,
London, UK
School of Public Health,
University of Sydney, Sydney,
New South Wales, Australia
Médecins Sans Frontières,
Geneva, Switzerland
International Federation of
Red Cross and Red Crescent
Societies, Geneva, Switzerland
Institute for Global Health,
University College London,
London, UK
Correspondence to
Dr Mishal Khan;
[email protected]
© Author(s) (or their
employer(s)) 2021. Re-use
permitted under CC BY-NC. No
commercial re-use. See rights
and permissions. Published by
Decolonising global health was a hot topic
in 2020. It was the subject of more than 50
academic articles between January and
December 2020, appeared as a new area
covered in numerous conferences, and
featured in public statements by leaders of
global health organisations.
Although its aims have not been formally
defined, we see ‘decolonising global health’
as a movement that fights against ingrained
systems of dominance and power in the work
to improve the health of populations, whether
this occurs between countries, including
between previously colonising and plundered
nations, and within countries, for example
the privileging of what Connell calls researchbased knowledge formation over the lived
experience of people themselves.1 2 It is well
documented—although often overlooked—
that global health has evolved from colonial
and tropical medicine, which were ‘designed
to control colonised populations and make
political and economic exploitation by European and North American powers easier’.3
The operations of many organisations active in
global health thus perpetuate the very power
imbalances they claim to rectify, through colonial and extractive attitudes, and policies and
practices that concentrate resources, expertise, data and branding within high-income
country (HIC) institutions.4 5
As a group of global health practitioners
from different backgrounds, we reflect on
our personal and professional experiences
of systems and processes that institutionalise power imbalances. In this article, we
propose a roadmap for global health practitioners, like us, who want to see rhetoric turn
into reforms, focusing on systemic changes
needed in organisations led from HICs. This
is important now, because the flurry of statements and virtue signalling in 2020, could, in
fact, be counterproductive, if this builds an
impression of commitment that allows the
leadership of organisations in HICs to escape
accountability. We fully acknowledge that
colonial mindsets and systems that perpetuate power imbalances in global health are
not confined by geographical boundaries;
they are found in organisations based in low/
middle-income countries (LMICs) too. While
we focus here on one part of the problem and
the solution, we encourage individuals and
groups in LMICs to challenge the status quo.
We start by laying out the uncomfortable
honesty that is needed. Dialogues centred
on the notion that all stakeholders are always
supportive of the decolonisation agenda can
be serious impediments to progress. It is
important to acknowledge that there will be
conflict and discomfort. People in powerful
positions, who have likely benefited from
current systems, may be concerned about
systemic change, be it overtly or covertly.
These acknowledgements are essential for
moving forward to more impactful and meaningful discussions in 2021.
Once we acknowledge that there will be
supporters and opponents of decolonising
global health, it becomes clear that a social
justice argument or that increasing diversity of leadership alone will likely be insufficient to initiate widespread reforms that
redistribute power or resources. Drawing
parallels with the feminist movement, it is
often the case that an individual accepts the
tenets of feminism, while the individual, at
the same time, treats women unfairly. The
case for systemic change to enable equality
in women’s opportunities to hold leadership
positions benefited from an emphasis on the
impacts of feminist leadership on the effectiveness of organisations as well; framing the
argument only in terms of human rights and
justice was not enough for all people and
Thus, dispelling the myth that
on September 27, 2021 at San Diego Consortia. Protected by http://gh.bmj.com/ BMJ Glob Health: first published as 10.1136/bmjgh-2021-005604 on 23 March 2021. Downloaded from
2 Khan M, et al. BMJ Global Health 2021;6:e005604. doi:10.1136/bmjgh-2021-005604
BMJ Global Health
everyone working in global health is focused predominantly on health equity and capacity building will allow
us to approach the reforms we are seeking with realistic expectations about barriers, incentives and how to
frame the issue. The ‘decolonising global health’ movement may benefit from finding strength in numbers by
identifying like-minded allies across other progressive
social movements targeting system-wide change based on
equity, such as the feminist movements.
With the above in mind, we propose steps that global
health practitioners could take to drive reforms.
Step one, identify specific ways in which organisations
active in global health play interlinked roles in perpetuating inequity—see illustrative examples in table 1. We
recognise that the global health sector is broad, encompassing organisations in the public and private domains.
These organisations range from small non-governmental
organisations (NGOs) to large transnational bodies.
An honest and critical examination of the role each
organisation plays in maintaining asymmetries of power
is required.
Step two, publish a clear list of reforms required to
decolonise global health practice, so that organisations
that are committed to moving beyond statements can
better respond to the decolonisation agenda in a more
proactive and coordinated way.
Step three, linked to the reforms identified, develop
metrics to track the progress of organisations active
in global health and transparently share findings via
different public channels. Publishing sets of actions and
metrics that allow (or force) organisations to monitor
progress towards their commitments is crucial for
holding them accountable to these commitments.7
Transparent reporting of these metrics is a core component of
accountability mechanisms that are sorely needed in the
global health sector.
Although examples of actions taken to address the
practices that perpetuate inequities outlined in table 1
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 inequities Example 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
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.
on September 27, 2021 at San Diego Consortia. Protected by http://gh.bmj.com/ BMJ Glob Health: first published as 10.1136/bmjgh-2021-005604 on 23 March 2021. Downloaded from
Khan M, et al. BMJ Global Health 2021;6:e005604. doi:10.1136/bmjgh-2021-005604 3
BMJ Global Health
are scarce, documenting those that do exist is valuable. We highlight two examples to illustrate the types
of actions that can be taken by organisations active in
global health. First, with respect to the composition of
governing bodies, the 20-member Board of The Global
Fund mandates representation from NGOs and affected
communities, with voting rights.8
Second, an example of
more equitable geographical concentration of resources
by organisations was the relocation of Oxfam International’s headquarters to Kenya from the UK in 2014.
Executive Director at the time, Winnie Byanyima, said
the move reflected the need ‘to shift [Oxfam’s] centre
of leadership and to strengthen Southern voices within
its decision-making’.9
We emphasise that the impacts of
such changes on the decolonising agenda need to be
assessed, and this is where metrics are critical.
To achieve the steps outlined in our roadmap, we
are calling for an Action to Decolonise Global Health
(ActDGH) collective that will work towards driving
reforms in organisations headquartered in HICs. We
welcome collaboration and contribution to the collective
(http://decolonise.health). For reforms to be realised,
we recognise that global health practitioners must play a
role in the cultural transformation needed, whereby an
influx of new cultural elements and values enables a shift
away from a dominant, colonialist culture in the global
health sector that attempts to assimilate other cultures
within a Western, ethno-centrist and neoliberal approach
to global health practice.
There is an opportunity to build on the momentum
of 2020, which has been instrumental in drawing widespread attention to unjust practices in global health. But
rhetoric is far easier than reform when power and privilege is at stake. Reform will require not only identifying
specific deficiencies within the current global health
sector, but also actions to radically change the prevailing
systems,10 so that the organisations that currently dominate global health end up being those that demonstrably
address needs of people they claim to serve.
In 2021, we need to see action and evidence of progress.
Twitter Mishal Khan @DrMishalK and Sarah Hawkes @feminineupheave
Contributors MK wrote the first draft. All authors contributed equally to revisions
and approved the final version.
Funding The authors have not declared a specific grant for this research from any
funding agency in the public, commercial or not-for-profit sectors.
Competing interests None declared.
Patient consent for publication Not required.
Provenance and peer review Not commissioned; internally peer reviewed.
Data availability statement There is no data in this work.
Open access 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/.
Seye Abimbola http://orcid.org/0000-0003-1294-3850
Sarah Hawkes http://orcid.org/0000-0003-1062-3538
Afifah Rahman-Shepherd http://orcid.org/0000-0002-8845-9275
1 Abimbola S, Pai M. Will global health survive its decolonisation?
Lancet 2020;396:1627–8.
2 Raewyn Connell. Decolonising the curriculum [Internet], 2016.
Available: http://www.raewynconnell.net/2016/10/decolonisingcurriculum.html
3 Hirsch LA. Is it possible to decolonise global health institutions?
Lancet 2021;397:189–90.
4 Abimbola S. On the meaning of global health and the role of global
health journals. Int Health 2018;10:63–5.
5 Richardson E. Epidemic illusions: on the coloniality of global public
health. The MIT Press, 2020.
6 Sinclair A. A feminist case for leadership. divers Leadersh, 2014.
7 Khan MS, Lakha F, Tan MMJ, et al. More talk than action: gender
and ethnic diversity in leading public health universities. Lancet
8 Global Fund. The Global Fund [Internet]. Available: https://www.
9 Civil Society NewsSharman A. Oxfam International to move
headquarters to Nairobi [Internet], 2016. Available: https://www.
10 Aloudat T. Decolonising medicines and global health: We need
genuine and lasting reform that put patients in the driving seat
[Internet]. MSF Access Campaign, Medium, 2020. Available: https://
on September 27, 2021 at San Diego Consortia. Protected by http://gh.bmj.com/ BMJ Glob Health: first published as 10.1136/bmjgh-2021-005604 on 23 March 2021. Downloaded from

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