Governance of Transnational Global Health Research Consortia and Health Equity

Abstract

Global health research partnerships are increasingly taking the form of consortia of institutions from high-income countries and low- and middle-income countries that undertake programs of research. These partnerships differ from collaborations that carry out single projects in the multiplicity of their goals, scope of their activities, and nature of their management. Although such consortia typically aim to reduce health disparities between and within countries, what is required for them to do so has not been clearly defined. This article takes a conceptual approach to explore how the governance of transnational global health research consortia should be structured to advance health equity. To do so, it applies an account called shared health governance to derive procedural and substantive guidance. A checklist based on this guidance is proposed to assist research consortia determine where their governance practices strongly promote equity and where they may fall short.

Keywords:

• ethics
• global justice
• health equity
• research collaboration
• research consortia
• shared health governance

Notes

1. Identified ethical issues include the disproportionate influence of high-income country partners in setting the research agenda, selecting research methods, and managing joint projects; the unidirectional interpretation of capacity building; the utilization of LMIC partners to collect and analyze data without their receiving authorship in publications; the inequitable distribution of benefits between sponsor and host countries; and there being an overarching semicolonial approach to conducting research through such partnerships (Costello and Zumla 2000, 827; Jentsch and Pilley 2003; Jentsch 2004; Bradley 2007). Broad ethical principles that are grounded in practice have been proposed for the achievement of truly cooperative and equal transnational health research partnerships. They include mutual trust and shared decision making, national ownership (ensuring that research programs are owned and managed by nationals, with foreign inputs technical and advisory in nature), early planning for the translation of research findings into policy and practice, and development of national research capacity (Costello and Zumla 2000; Commission for Research Partnership with Developing Countries 1998).

2. A small amount of work looks at how research partnerships between parties from high-income countries and LMICs can promote health equity at the project level (London 2005; Pratt and Loff 2013).

3. Global actors are public or private entities from outside a particular state and include multilaterals, bilaterals, global health institutions, governments, nongovernmental organisations, businesses, foundations, families, and individuals (Ruger 2009).

4. Pogge argues that external actors are obligated to reform institutional orders that cause harm and/or to promote alternative institutional arrangements that mitigate the particular deprivation(s) to which they have contributed. Specific institutional reforms to address the huge burden of avoidable morbidity and mortality in LMICs include those to eradicate severe poverty (global resource dividend) and to improve access to medicines (health impact fund) (Pogge 2008).

5. Gostin identifies five values of good governance—honesty, transparency, deliberative decision making, efficiency, and accountability (Gostin 2014). To some degree, these values overlap with shared health governance, as it calls for a specific form of accountability (mutual collective accountability) and deliberative decision making is one aspect of shared sovereignty. Yet the values proposed by Gostin do not emphasize the shared or collaborative nature of, for example, decision making or accountability.

6. These accounts do not focus on governance or health governance but rather pertain to specific aspects of shared health governance such as shared sovereignty or shared resources.

7. Aside from the health capability paradigm, Venkatapuram's work on capability and Daniels' extension of Rawls's theory address health justice in depth (Venkatapuram 2011; Daniels 2008). However, Daniels' work mainly focuses on the domestic context and has not extensively described what health justice demands be secured for parties outside one's own state. Nussbaum's discussion of capabilities and Powers and Faden's theory of justice also delve into health capability and health as a core dimension of well-being respectively but in less detail than the theorists previously mentioned (Nussbaum 2001; Powers and Faden 2006; Venkatapuram 2011). Theorists such as Rawls and Shue identify subsistence rights, which include a basic minimum of health care, as being owed to individuals, but their work does not describe what health justice requires beyond that (Shue 1996; Beitz 1999).

8. Health functionings or achievements map directly on to health capabilities, so individuals' health statuses can be used as a rough proxy indicator of their health capabilities (Ruger 2010a).

9. In this article, subsequent references to the worst off refer to those who are worst off in terms of their health.

10. Shue's theory supports an obligation for new or existing international institutions to strengthen the capacity of weak states to make basic public health care accessible to their populations. This is described in detail in Pratt, Zion, and Loff (2012).

11. Young's concept of justice encompasses self-development; injustice arises when people are deprived of the means to develop and exercise their capacities (Young 1990). Young also contends that obligations of global justice are established based on social connectedness (Young 2006). Thus, her work could support a role for global actors in promoting capacity development of individuals in LMICs as a matter of justice.

12. Health systems research has been defined as the production of new knowledge to improve the performance of health systems (WHO 2009). Such research may describe health system components and the complex interactions between them; explore the causes of poor performance; and/or develop and evaluate interventions to improve health systems' functioning. Health systems research methods are determined by the nature of the research question under study and can encompass a wide range of quantitative and qualitative methods (Gilson 2012). Randomized-controlled trials are not typically employed in health systems research. Interventions to improve health system performance might consist of a novel delivery mechanism for existing health services, a new method of creating demand for existing health services, an output-based payment mechanism to boost staff productivity at health facilities, or a community-based health insurance mechanism (Hyder et al. 2014).

13. Ruger and Daniels' accounts of just health systems define equal access and equitable financing in somewhat different ways.

14. In some cases, a stronger focus on the global level may be appropriate if national policy on a specific topic in a given LMIC has been shown to be significantly influenced by particular global policies in the past.

15. Where consortia perform clinical research, poststudy access to new medical interventions proven successful is owed to trial participants (Pratt, Zion, and Loff 2012). Where health systems research is undertaken, poststudy implementation is owed because health system interventions typically consist of new policies and programs/initiatives or changes to existing policy and practice (Pratt and Hyder 2015a).

16. In accordance with the health capability paradigm's functional requirements principle, consortia members are not obligated to conduct research and to deliver interventions proven successful poststudy. Actors acquire their obligations based on their functions, which is why researchers and research institutions are obligated to perform studies and organizations focused on access to medicines or health programming and their staff members are obligated to make new medical products available and to implement new health system strengthening interventions poststudy (Pratt and Hyder 2015a).

17. Here, the article is not suggesting that capacity building cannot or should not be performed for consortia partners from high-income countries. Instead, it is arguing that high-income country partners have an obligation to strengthen the capacity of LMIC partners as a matter of justice.

18. This could mean specifically targeting stakeholders who are vital to ensuring poststudy access or implementation of successful study interventions.

19. Other categories of roles, which the article does not consider but acknowledges would have function-related obligations, include financial managers, research managers, capacity-building or research translation managers, and field staff (i.e., research implementers).