Global learning: A post-COVID-19 approach to advance health equity

ABSTRACT

The COVID-19 pandemic has accelerated acceptance of learning from other countries, especially for high-income countries to learn from low- and middle-income countries, a practice known as global learning. COVID-19’s rapid disease transmission underscored how connected the globe is as well as revealed stark health inequities which facilitated looking outside of one’s borders for solutions. The Global Learning for Health Equity (GL4HE) Network, supported by Robert Wood Johnson Foundation, held a 3-part webinar series in December 2021 to understand the current state of global learning and explore how global learning can advance health equity in the post-COVID-19 era. This paper reflects on these cutting-edge discussions about the current state of global learning, drawing upon the highlights, perspectives, and conclusions that emerged from these webinars. The paper also comments on best practices for global learning, including adapting for context, addressing biases, funding considerations, ensuring bidirectional partnerships, community engagement, and adopting a multidisciplinary approach.

KEYWORDS:

• Global learning
• health equity
• post-COVID-19
• bidirectional learning
• global health

Introduction

We [in the United States] have a lot to learn from other places.

–Keshia M. Pollack Porter (Johns Hopkins Bloomberg School of Public Health)

The understanding that the United States (US) has a lot to learn from other places is not new: many global and public health stakeholders have been advocating for global learning for years (Morgan & Rau, 1993). This concept has been known by several terms over time, including reverse innovation and frugal innovation, which has contributed to confusion and reduced its widespread uptake. A recent literature review advocated for use of the terminology ‘global learning’ to signify identifying and implementing ideas from other settings for adaptation to US contexts (Ogbolu et al., 2022). Global learning is particularly taking off in the health equity realm, with the premise that interventions designed to eliminate health inequity in other countries may also work in local communities in the US. Global learning for health equity was defined in the same review as, ‘the practice of engaging with, exchanging, and adapting health equity-promoting ideas and interventions between communities in ways that foster implementation benefits that are reciprocal and beneficial to both’ (Ogbolu et al., 2022).

There is evidence, albeit limited, that innovations developed outside the US have had success in US settings (Hiatt et al., 2016; Ogbolu et al., 2022; Shin et al., 2022). An iconic example of global learning is China’s 1960s Barefoot Doctors programme, whereby rural farmers were trained to provide basic health care services in their communities; the success of Barefoot Doctors led to the growth of Community Health Worker (CHW) programmes across the globe (Zhang & Unschuld, 2008). Another example, the Ciclovía programme originated in Colombia in 1974 and promotes physical activity and reduces social isolation by temporarily prohibiting cars on certain streets in order to prioritise biking and walking; this programme has since been successfully adopted to enhance mobility in many US cities including Los Angeles, Portland, and Detroit (Shin et al., 2022).

The COVID-19 pandemic has accelerated acceptance of learning from other countries, especially for high-income countries (HICs) to learn from low- and middle-income countries (LMICs). While the US has struggled with high COVID-19 caseloads and mortality rates that revealed stark health inequities, other countries have had significant success in managing the pandemic in an equitable manner. Several news articles highlighted examples: ‘Is Ghana the model the developing world needs against the virus?’ (Egbejule, 2020), ‘How Brazil’s favelas can teach the world to fight COVID-19’ (Tsavkko Garcia, 2020), and ‘Waiving rent and making masks, Afghans meet Coronavirus with kindness’ (Mashal et al., 2020). Foreign Policy’s ‘COVID-19 Global Response Index’ ranked Senegal as the second-best country for its swift official response to the pandemic (Foreign Policy, 2021).

One US-based group studying and promoting the use of this approach is the Global Learning for Health Equity (GL4HE) Network, supported by Robert Wood Johnson Foundation (RWJF). The Network was established well before the pandemic in 2019 and aims to understand the landscape of global learning and build a framework that will support the adaptation of health equity interventions from overseas to US settings with a strong focus on community engagement and bidirectional learning. The GL4HE Network is led by University of Maryland Baltimore (UMB) and includes collaborating partners at Athens City County Health Department, Corner Health Center (Ypsilanti, Michigan), Montefiore Health System, and Navajo Nation. The GL4HE Network is directed by academic faculty members, advised by a committee of partners in academia, public health, community-based organisations, and hospital settings, and offers free membership to any interested party. The GL4HE Network pursues its mission through webinars, scholarly papers, presentations, and seed funding and technical advice to community-based organisations pursuing global learning.

Methods

To understand the current state of global learning and explore how global learning can advance health equity in the post-COVID-19 era, the GL4HE Network held a 3-part webinar series in December 2021 entitled: ‘A Vision of Global Learning for Health Equity’, ‘Voices of Experience: Learning from Global Learning for Health Equity Practitioners’, and ‘Voices of Experience: Learning from Global Learning for Health Equity Framework Developers and Funders’ (University of Maryland, 2021). A list of all webinar speakers is provided in Table 1. Each webinar lasted 90 minutes, including between 10–20 minutes for audience questions. Approximately 75 individual participants joined each of the three webinars for varying lengths of time. Although no biographical data was collected from audience members, self-identification during breakout sessions and Question and Answer periods revealed that most attendees were public health officials, in academics, or associated with community-based organisations. These webinars were conceived in early 2020 but their timing – they were held at the height of the pandemic – led panellists to consider the impact of the pandemic on global learning.

Table 1. List of Webinar Speakers.

Speaker Name	Speaker Title(s) & Organisation(s)
Karabi Acharya, MHS, ScD	Senior Program Director, Robert Wood Johnson Foundation
Agnes Binagwaho, MD, M(Ped), PhD	Senior Lecturer, Department of Global Health and Social Medicine, Harvard Medical School; Vice Chancellor and Professor of Pediatrics, University of Global Health Equity, Rwanda; Adjunct Clinical Professor of Pediatrics, Dartmouth’s Geisel School of Medicine
James W. Dearing, PhD	Brandt Endowed Professor, Department of Communication, Michigan State University
Kevin Fiori, MD, MPH, MS	Assistant Professor, Department of Pediatrics and Department of Family and Social Medicine, Albert Einstein College of Medicine/Montefiore Medical Center
John Hart, PhD	Senior Research Associate, Restoring Promise, Vera Institute of Justice
Linda Kupfer, PhD	Senior Scientist, Center for Global Health Studies, Fogarty International Center, National Institutes of Health
Yolanda Ogbolu, PhD	Associate Professor; Chair, Department of Partnerships, Professional Education, and Practice; Director, Center for Health Equity and Outcomes Research, University of Maryland School of Nursing
Rev. Alexander Plum, MPH, CHES	Executive Director, Corner Health Center (Formerly with Henry Ford Health)
Keshia M. Pollack Porter, PhD, MPH	Professor of Health Policy and Management and Vice Dean for Faculty, Johns Hopkins Bloomberg School of Public Health
Jennifer Jean Prah, PhD, MSc, MA, MSL	Amartya Sen Professor of Health Equity, Economics and Policy; Faculty Chair, Center for High Impact Philanthropy (CHIP); Director, Health Equity and Policy Lab, University of Pennsylvania
Virginia Rowthorn, JD, LLM	Associate Professor, University of Maryland, Baltimore Graduate School; Assistant Vice President for Global Engagement and Executive Director, Center for Global Engagement, University of Maryland, Baltimore
Umair A. Shah, MD, MPH	Secretary of Health, Washington State Department of Health
Sonya S. Shin, MD, MPH	Associate Physician, Brigham and Women’s Hospital; Associate Professor of Medicine, Harvard Medical School
Jonathan Sugarman, MD, MPH	Senior Advisor, Global to Local; Clinical Professor, Global Health and Clinical Professor, Family Medicine, University of Washington; Senior Program Officer, Washington Global Health Alliance
Shams Syed, MD, MPH	Head of Unit, Quality of Care, World Health Organization
Gretchen Thompson, PhD, MA	Scientist I, Behavioral, Epidemiological, and Clinical Sciences, Global Health and Population Research, FHI360
Krishna Udayakumar, MD, MBA	Associate Professor of Global Health and Medicine, Duke University; Associate Director for Innovation, Duke Global Health Institute; Director, Duke Global Health Innovation Center
Ruth Verhey, PhD	Lead, Researcher, and Clinician, Friendship Bench

This paper reflects the highlights and the themes in these cutting-edge discussions about the current state of global learning, drawing upon the insights, perspectives, and conclusions that emerged from these webinars. To the best of the authors’ knowledge, this article is among one of the first descriptions of how a global pandemic accelerated the nascent field of global learning, drawing upon the inclusion of the voices of LMIC experts as well as concrete examples of the nuances, barriers, and benefits of utilising global learning to achieve health equity, in addition to an article by Karabi Acharya which outlines the necessity to search for answers to health equity beyond national borders (Acharya, 2020).

How the COVID-19 pandemic transformed the field of global learning

Throughout the webinar series, it became clear that the shared global experience with the COVID-19 pandemic has accelerated the existing global learning field by elevating the need for learning from other countries and by providing concrete examples of how to engage in global learning.

First, the pandemic underscored how connected the globe is. Individual people move constantly across borders for trade and travel. While the global spread of infectious diseases has been a cause for concern for centuries, the quick spread of the COVID-19 pandemic throughout the world in 2020 provided a dramatic example to both health professionals and laypeople alike on how closely global and domestic health are intertwined and how country-level events and efforts can have far-reaching global impacts.

Very quickly this pandemic has shown us that what happens in one part of the world impacts others across the globe and even here domestically. COVID-19 is just one of many, you go back to HIV, you go back to measles and so many other infectious diseases, there are so many reasons we have to be thinking from the standpoint of protection to assure we have learnings from across the global system and [are] working together.

–Umair A. Shah (Washington State Department of Health)

Further, the pandemic provided unavoidable evidence that the US faces deep health equity challenges, spotlighting that vulnerable and marginalised populations experience significant disparities in health outcomes. The COVID-19 pandemic significantly sharpened the visibility of the inequitable systems and structures that create these disparities (Parke & Adebayo, 2021), and there is a growing recognition that the status quo is not working well. This generates both a need and an opportunity to look elsewhere for other solutions to foster a more equitable health system.

Equity is, I believe, morally important but also economically important because we couldn’t open our schools, we couldn’t open our economy, we couldn’t maintain our jobs and our wages, if we didn’t focus on the entire population in an equitable and just way.

–Jennifer Jean Prah (University of Pennsylvania)

Finally, the pandemic has changed how we think about learning from other countries, especially LMICs, and has increased global communication. Multi-directional global information sharing is easy and fast. A common misconception is that global learning flows only from HICs to LMICs. However, in reality, it is common for global learning to also flow from LMICs to HICs, from LMICs to LMICs, and from HICs to HICs. This is facilitated by the technology and communications infrastructure, which allows multi-directional global information and knowledge to travel quickly, and thus provides easy entry points for substantial global learning. The importance of digitalisation in global learning is an area for future study.

There were terrific ideas from other countries [about COVID-19] that can be applied locally – ranging from specific biomedical treatments to more public health-oriented approaches to make immunizations and testing accessible … . It has demonstrated acceleration of the timeline for moving evidence-based approaches into practice from the oft-quoted 17 years to much shorter times … . When COVID-19 first came to the US, clinicians in ICUs [intensive care units] talked to colleagues in Italy to see how they were dealing with things and then immediately implemented their approaches. It’s been instructive to folks who would not necessarily have looked abroad for solutions to now see unambiguous evidence that great ideas come from elsewhere and can easily be applied domestically.

–Jonathan Sugarman (Global to Local)

Agnes Binagwaho, Vice Chancellor of the University of Global Health Equity, framed this notion well with the following example. Dr. Binagwaho shared that at the time of the webinar series, 90% of the population in Rwanda’s capital city, Kigali, were vaccinated despite Rwanda’s struggles with obtaining vaccine supply. According to Dr. Binagwaho, one reason for this success is due to leadership’s compassion, humility, and willingness to learn from others and engage in global learning. As an example anecdote, after seeing positive evidence from Vietnam, the Minister of Health of Rwanda called the Minster of Health of Vietnam to learn from their successes in managing COVID-19 (Binagwaho, 2020). Another reason for Rwanda’s success in managing COVID-19 is the population’s extremely high levels of trust in the health sector (Wellcome Global Monitor, 2018), which itself is a remarkable cultural healing achievement given the horrific history of genocide. Improving trust in health systems would be an excellent global learning opportunity for the US to study from experts in Rwanda.

While global learning is not a new concept, COVID-19 has accelerated and enhanced the global learning conversation.

[It is] critical to understand that learning flows in all directions. … Standing up for that concept is critical. And the time for uni-directional learning is really over.

–Shams Syed (World Health Organization)

Barriers and best practices for global learning

While there are practical challenges and barriers to implementing global learning including limited funding and appropriate adaptation, webinar speakers provided insights to facilitate the achievement of global learning. Further, there are at least 20 existing frameworks that provide guidance and offer best practices for implementing global learning, several of which were presented during the webinar series (Dearing et al., 2019; Sugarman & Reed, 2021; Thompson et al., 2019; Yox, 2019, 2020). These insights will support the development of GL4HE Network recommendations going forward.

Context matters

A conclusion reached during the webinar series is that it is critical in global learning to recognise the historical, political, and cultural context of systems of care and health that exist in different countries. Health systems and health outcomes do not exist in a vacuum; rather, they are impacted by their nation’s history, politics, and societal structures (Oliver, 2006).

[The] times where we have seen ineffective models of adaptation and learning have been when we’ve forgotten that the history and the context matter as to what works where. The same solution that might look fantastic in Singapore might look quite different and fail miserably when it’s brought to a US context because the structure of the health system [and] the historical and cultural context is quite different. Ways that we can systematically understand and learn from and make sure we’re adapting for local context which includes a historical perspective [are] really important if we’re going to get the global learning component right.

–Krishna Udayakumar (Duke University)

While addressing COVID-19 in the US, it became important to recognise the history of racism especially in the health sector (Bailey et al., 2017; Brandt, 1978; Dent et al., 2021; Johnson-Agbakwu et al., 2022). For example, the traumatic history of syphilis experiments among people of colour generated tremendous distrust in the health system, which contributed to higher initial rates of COVID-19 vaccine hesitancy among people of colour (Padamsee et al., 2022). History, racism, and trust are thus important social determinants of health in the US context.

Somebody who doesn’t know his history is handicapped … . I am a doctor in my country, if I don’t know the history of this country, I will not know where to find the people who need me. Let’s take the inequities in the US for example … Black people didn’t get the opportunity [for] centuries to flourish … among the poorest, the most vulnerable, those who will be [affected] more rapidly by the pandemic most, and die the most if infected, are the people who didn’t get the opportunity decades, centuries before to flourish. They’re people who don’t trust the system because the system never did anything for them.

–Agnes Binagwaho (University of Global Health Equity)

The COVID-19 pandemic provided a clear example of the importance of context when addressing health challenges in different settings – something that may have been harder to explain prior to this shared lived experience. Recognising the contexts of both the sites where global learning ideas originated as well as destination sites where global learning ideas are implemented, and adapting appropriately, is key to successful global learning. It can be helpful to employ an implementation science approach which takes context into account when enacting evidence-based practices.

Addressing biases

During the webinar, speakers openly addressed how implicit and explicit biases are often at play when engaging in global health work. One challenge in the US is a cultural belief in American exceptionalism whereby many feel that US systems are so unique that no other system can be better. Because of white supremacy and colonial mentalities, there is a lack of recognition of experts and expertise originating from LMICs. Part of the challenge is combatting this idea that solutions developed in other places are not relevant to the US context.

We [in the US] have a bias towards overvaluing learning that comes from Europe and higher-income countries and undervaluing what low- and middle-income countries have to teach us … We have so much, if not more, to learn about health equity from places like Rwanda, Zimbabwe, or Togo.

–Karabi Acharya (Robert Wood Johnson Foundation)

Fortunately, argued the webinar speakers, COVID-19 has made it more acceptable to acknowledge best practices from other parts of the globe. One must regularly and openly work on one’s biases and approach global learning with humility in order to see ideas succeed irrespective of where they originate. Curiosity, compassion, and respect are key to facilitate this. It is important to understand the social determinants of learning that are culturally embedded, as well as combat the bias in our education and learning systems.

Funding for global learning

Webinar speakers acknowledged that limited funding remains a significant barrier to global learning. In a 2020 survey, 73% of US foundations said that their domestic grantmaking was rarely or not at all inspired by ideas from around the globe (Acharya, 2021). Often funders have specific grant-making priorities which may not allow for applicants to tailor global learning approaches to meet priorities identified by communities. To combat this, funders should be receptive to global learning, and can foster this by adding in a design or planning phase into their funding mechanisms so that authentic community engagement processes can be prioritised to test if the global learning project is feasible and make appropriate adaptations.

In philanthropy we’re not doing enough global learning … I do want to invite my philanthropic colleagues to learn with us and to recognise that it’s easier than you might think to learn globally. It doesn’t require travel, it doesn’t require a huge team, it requires having an openness and curiosity about what is happening around the world.

–Karabi Acharya (Robert Wood Johnson Foundation)

Two representatives of global learning funders, Fogarty International Center at the National Institutes of Health (NIH) and RWJF, shared their perspectives on how they became invested in global learning.

[At Fogarty, there was a] need to address the question that NIH was frequently asked by senators and congressmen … ‘Why the NIH as a domestic agency is spending taxpayer dollars to improve health around the world, rather than using all their funds to improve health at home?’ And to address this recurring question a colleague suggested that we show how discoveries made elsewhere and anywhere can help people everywhere.

–Linda Kupfer (Fogarty International Center, National Institutes of Health)

Fogarty thus compiled a table of biomedical discoveries originating from outside the US as evidence, included in their Strategic Plan (NIH Fogarty International Center, 2014). For example, research showing that genes associated with high fatality breast cancer in Nigeria play a key role in addressing breast cancer in African American women (NIH Fogarty International Center, 2014). Consequently, Fogarty undertook a project to understand the current landscape of reciprocal innovation research and identify the scientific methods used in this field (Sors et al., 2022).

For RWJF, the impetus came from the realisation that the US was not doing well on health indicators compared to peer countries – for example, life expectancy was lower and infant mortality was higher in the US than in all other Organisation for Economic Cooperation and Development (OECD) countries (Gunja et al., 2023). So RWJF realised, ‘We had something to learn from other places’ and created the Global Ideas for US Solutions team to search beyond geographic borders for ideas and solutions that can be adapted to the US to improve health and wellbeing. When the RWJF team was on a trip to Cuba, they visited a public park which was being used by several groups for different exercise programmes such as yoga and tai chi. A US colleague on the trip commented that she could do a similar programme at the park that is right next to the hospital where she works. This posed the question, ‘Why did it take going to Cuba to “see” a park that was right next door to her hospital?’ Upon reflection, the answer revealed itself as blue marble thinking – in 1972 the first photo of planet Earth taken from space helped humans see Earth in a very different way.

I think that is the idea behind global learning, that sometimes you have to travel, you have to leave your home either literally or figuratively, to look back and see your home in a different way. And that’s what we call blue marble thinking, this idea that global learning opens up your imagination and helps you to see very differently.

–Karabi Acharya (Robert Wood Johnson Foundation)

Bidirectional partnerships

Webinar speakers agreed that having a strong partnership with the site where the global learning idea originated is critically important throughout the phases of implementing a global learning project. It is important to ensure bidirectional learning so that the partnership is mutually beneficial and there are opportunities for both communities to advance in their own work. For example, in the Brazil to Baltimore global learning programme, the Baltimore team learned how to enhance health equity in the community by adopting a family-centered intervention to encourage social inclusion and address social determinants of health of vulnerable populations in local communities of Baltimore, while the partners in Brazil learned lessons from UMB’s experience implementing the programme and were able to strengthen some of their evaluation measures. Another example shared was the bidirectional partnership built between the teams in Northern Togo and Bronx, New York to learn how to best localise current community health worker programmes. The partners involved were able to witness different co-created programmes and implemented easy-to-use tools in the existing CHW programmes.

[This is about] having not just health equity, but learning equity … to make sure that if there is exchange of information or concepts that it’s bidirectional, that it’s respectful, and it’s not reappropriating or re-perpetuating patterns of colonial appropriations.

–Sonya S. Shin (Brigham and Women’s Hospital)

The recent Brocher Declaration written by the multisectoral coalition Advocacy for Global Health Partnerships to address concerns related to short-term experiences in global health reiterated ‘mutual partnership with bidirectional input and learning’ as one of its six principles for global health (Prasad et al., 2022). Creating networks to make connections and building relationships with those abroad can lower barriers to sharing information and foster reciprocity.

Community engagement

Webinar speakers stressed that a critical element of global learning is authentic engagement with communities and inclusion of community voice and participation in all stages of programme development and implementation. For example, the Global to Local programme in Washington intended to focus on the community’s poor immunisation rates based on standard epidemiological data; however, when asked, the community instead said their bigger problems were lack of access to healthy food, lack of sidewalks to exercise, and needing modest environments for people from certain cultures to exercise. Responding to the communities’ stated needs resulted in significant success and high levels of community engagement and trust.

Instead of approaching communities based on their own assessment of community needs, anchor institutions [such as universities] … should work with communities to find out what their felt and expressed needs are. That’s one of the lessons from successful programs, particularly in many low- and middle-income countries, that have worked to engage communities.

–Jonathan Sugarman (Global to Local)

Multidisciplinary approach

During the webinar series, speakers noted that global learning must be considered in concert with other well-established approaches to public health and health equity, including the Health in All Policies (HiAP) approach as one example. HiAP is a collaborative approach that involves multiple sectors and systematically takes into account the health implications of decisions to improve population health, well-being, and health equity (Rudolph et al., 2013). HiAP and other public health frameworks emphasise the importance of multidisciplinary, cross-sectoral collaborations and ensuring that all partners consider health and health equity in their work.

There is tremendous potential to impact health by decisions that are made outside of the health sector. For example, decisions made by the housing, transportation, or energy sectors can impact health … So we have to partner … with individuals in other sectors … because it’s possible to advance the goals of their sectors and to advance health goals as well.

–Keshia M. Pollack Porter (Johns Hopkins Bloomberg School of Public Health)

Conclusion

Both health inequities and the approach of global learning existed long before the COVID-19 pandemic. However, COVID-19 helped to illuminate the depth of these inequities in the US as well as the possibilities to learn from other countries, providing general acceptance and momentum to continue the important work of global learning to advance health equity.

Throughout the webinar series, speakers highlighted how the pandemic provided additional rationales and arguments to justify global learning approaches to address health equity. For example,

With COVID, you can talk about the humanitarian disaster that it’s been, you can talk about the need for equity because of the humanitarian perspective, and that’s completely valid, and we should. But when you add to that the fact that it’s in the self-interest of rich countries to approach global equity in a stronger way, that it’s in the economic interest of high-income countries to do so as well – we can strengthen the argument without weakening the primacy of equity.

–Krishna Udayakumar (Duke University)

The authors and webinar speakers have identified global learning as one way to improve health equity in the US by expanding our horizons for health equity initiatives that have had success in other settings and adapting them for use in the US. Global learning is both an orientation and a strategy that needs further study and implementation strategies in order to realise its full promise. It should be noted that the tendency of global learning has been more initiative-based, where the learning from overseas has been adopted to specific locales of the US, rather than adopting the entire system of a country. However, the example of Brazil’s healthcare system shows the possibility of learning lessons from other countries’ structural systems (Gates, 2023). As the global learning field continues to become more visible and advanced, as more evidence is generated, and as more funding becomes available, we will come closer and closer to attaining health equity.

Acknowledgements

We would like to sincerely thank all the speakers of the GL4HE Webinar Series for their invaluable insights and perspectives on global learning. The views expressed here by webinar speakers do not necessarily reflect the views of their respective organizations. Support for this webinar series was provided by the Robert Wood Johnson Foundation. The views expressed here do not necessarily reflect the views of the Foundation.

Disclosure statement

The authors report there are no competing interests to declare.

Additional information

Funding

This work was supported by the Robert Wood Johnson Foundation under Grant # 77717.