COSMAS MUGAMBI: Why we must decolonise global health systems

Global health entails partnerships between institutions in low- and middle-income countries ­and high-income countries – colonised nations colonisers.

The persistent influence of coloniality threatens the response to the Covid-19 pandemic, hence, calls to decolonise global health. The Covid-19 pandemic and the Black Lives Matter and Women in Global Health movements reveal serious asymmetries of power and privilege that permeate all aspects of global health.

Territorial colonialism ended but global health crises such as HIV and Aids, Ebola and Covid-19 indicate that colonisation of medicine, economics, and politics, remains alive. Histories of slavery, redlining, racism and capitalism underpin inequities in the design of global health systems.

An equal global health architecture without a hint of supremacy is not global health as we know it today since HICs shape the language and response to pandemics resulting in adverse health outcomes.

In the Covid-19 pandemic, the colonial dynamics of global health have particularly struck a nerve on the African continent, reminding us that global health originated in the colonial-era field of ‘tropical medicine’ and transitioned to ‘international health’ with LMICs being treated as subjects of a quasi-philanthropic complex controlled by HICs.

The pandemic has shone a light on the pre-existing inequalities in global health; 77 per cent of the globally administered Covid-19 vaccines have been given in just 10 of the 195 countries across the world.

The disadvantaged and marginalised make up the global majority but power imbalances are by design. For example, health research partnerships often benefit the better-resourced partner, only one per cent of past malaria funding goes to in-country research institutions.

It is in public knowledge that 85 per cent of global health organisations are headquartered in Europe and North America, and nationals of HICs constitute over 80 per cent of these organisations’ leadership.

The 2014–2016 Ebola outbreak in West Africa was the largest and most complex since the virus was first discovered but borders were drawn to isolate the virus from the global health priorities since it only affected Africans at that time. Similarly, Singapore’s treatment of migrant workers illustrates how ignoring structural determinants of health has disastrous consequences for the broader society.

Inequalities are also evident in medical education, knowledge production, knowledge brokering (publications), healthcare funding, governance, accountability, and ethics through which LMICs policies must be aligned to donor priorities.

The 2019 World Health Organization report on global health financing indicates that donors provided more than one-fifth of health spending in 20 sub-Saharan African countries, and more than 40 per cent in nine but these were incentives for the recipient country to align their policies to donor interests.

In the heat of the HIV pandemic (2003 and 2008), condoms were excluded from donor support by some Western countries under pressure from religious conservatives to push for pre-marital abstinence and post-marital faithfulness.

Multinational drug companies hide behind monopoly patents for HICs but are quick to allow either manufacture or exportation of generic versions of medical products for emergency responses in low- and middle-income countries.

A lot of biomedical advancements have been done in LMICs using their labour and bearing research risks but these countries end up losing rights to access these advancements and the profits thereof.

Dependency in the form of debts diminishes LMICs’ autonomy over their spending through debt servicing and broader economic reforms that negatively impact healthcare.

Structural adjustment programmes restrict public sector spending, making it difficult for governments to invest in foundational health systems infrastructure while user fees and deregulation of the private sector undermine access to quality and affordable healthcare and amplify social determinants of health like income and food.

As LMICs take on more debts to weather the economic blows of Covid-19, this may deepen the vulnerability of health systems to questionable international policy impositions. African countries face a $115 billion collective financial loss from the Covid-19 pandemic, which will push 40 million people into extreme poverty.

Lockdowns and disrupted health care will lead to rising cases of and deaths from other infectious diseases and unmanaged non-communicable diseases as the differential access to Covid-19 vaccines globally continues to amplify these health disparities.

To decolonise global health, all forms of supremacy within all spaces of global health practice, within countries, between countries, and at the global level must be removed through a radical disruption of the global axis of power and the time is now.

The author is an implementation scientist who comments on global health matters of public interest