Abstract

Background: Global Health (GH) tries to address worldwide health issues, focusing on universal health solutions and enhanced equity. Its colonial roots in tropical medicine have perpetuated inequalities. This requires the decolonisation of GH to overcome these enduring impacts and Western-dominated principles, often manifested in donor-driven initiatives with insufficient local engagement. This review focuses on critically examining the “Decolonising Global Health” notion, aiming to assess its varied definitions and contribute advance towards a concept.

Subjects and methods: The review promotes a shift from a notion to a practice-oriented concept of GH decolonisation, fostering equitable GH practices. The methodology involved searching PubMed and grey literature using the terms “Global Health” and “Decolonising”. Out of 148 findings, 48 publications met the inclusion criteria based on abstract screening, supplemented by three manually selected publications. The study acknowledges potential publication bias and the impact of language restrictions.

Results: The review indicates that decolonising GH requires redressing power imbalances between the Global North and South, promoting equitable partnerships, and resource distribution. Central to this is the transformation of education to equip GH professionals with a decolonised mindset, alongside individual-level changes emphasising self-assessment and accountability. Efforts also focus on addressing health inequalities by tackling social determinants and advocating for structural changes, including multipolar GH governance, and challenging entrenched socio-economic disparities. These actions underline the necessity for a coordinated, equity-focused approach in reshaping GH paradigms.

Conclusion: The decolonisation of GH demands a multidimensional strategy addressing practices, institutions, policies, education, and power dynamics. This approach is pivotal for dismantling colonial legacies and advancing towards an equitable and inclusive health system, emphasising the necessity for critical reassessment and transformative action within the GH sector.

Keywords: Decolonisation; Global health; Governance; Health equity.

Introduction

The primary objective of Public Health (PH) is to promote health, prevent diseases, and strengthen healthcare systems, aiming at reducing inequalities and protecting the well-being of individuals, communities, and entire populations at global, regional, and national levels.

Global Health (GH) has this same main objective at the global level, focusing its interest on health issues that affect the world population and cannot be dealt with by countries separately. It aims to seek global solutions, promote health for all, and improve health equity while reducing health disparities on a transnational level [1].

From 2020 onwards, a debate on the decolonisation of GH has risen. It is well known that GH structures have evolved from the practices of tropical medicine during colonial times [2]. Back then, tropical medicine primarily served to control and regulate the movement of indigenous populations, often utilising measures like quarantine to contain infections among humans and livestock. This approach was crucial for colonial powers due to their heavy reliance on colonised territories to sustain their economies and labour forces, particularly through the exploitation of enslaved indigenous workers [2]. GH has been characterised by historical subjugation and disrespect, largely attributed to the legacy of medical missionaries. These missionaries often disregarded cultural beliefs and were at times involved in political motives [2].

Finding out how to overcome this legacy is a challenge. If political colonisation under the violent domination of one country over another is no longer generalised today, the colonial influences and inequalities persist in GH practices. Institutions, organisations and partnerships continue to operate according to principles and agendas dominated by Western countries, prioritising their needs [3]. Thus, many aids for health projects remain donor-driven and lack local ownership [4].

In general terms, the notion of decolonising GH focuses on searching for ways out of this legacy. However, to advance the debate and change the practice, there is a need to move from a notion to a concept of decolonising. This review aims to identify how the expression “Decolonising Global Health” has been defined by different authors, trying to contribute to its clarification.

Materials and methods

To conceptualise the definitions of “Decolonising Global Health” within the literature, a systematic search was conducted using the PubMed database and additional grey literature sources. The search terms “Global Health” and “Decolonizing” were applied to titles, abstracts, and full texts. Initial results revealed 148 publications with no restriction on the publication period, which extends from the earliest available data sets to the cut-off date of 6 November 2023. Inclusion criteria were limited to studies published in English that directly address the topic of decolonising GH. Screening of titles and abstracts was performed independently by one reviewer. Following the initial screening, 48 abstracts met the eligibility criteria and were included for definition extraction. Three additional publications were identified through manual searches of reference lists to ensure a comprehensive understanding of the topic. Studies without accessible abstracts or full texts were excluded. Despite the challenges, we maintained the usage of the terms “Global North” and “Global South” due to their widespread adoption, which was crucial for capturing pertinent publications for this review.

Narrative review on decolonising global health practices

Decolonising Global Health represents a relatively recent concept characterised by various approaches and ideas for addressing remaining colonial legacies within healthcare institutions. To understand its diverse applications, 48 definitions from relevant literature were analysed and condensed into seven core themes. These themes reveal the critical aspects of decolonisation efforts, including power realignment, equitable resource distribution, and the integration of local knowledge into healthcare practices.

Reassessment and transformation of existing structures

A critical reassessment and transformative actions are essential to rectify historical colonial legacies of colonialism, with a focus on redistributing power, and resources and shifting from colonial paradigms towards equitable cooperation. This shift emphasises the need for equitable representation, adherence to universal best practices, and the rejection of neo-colonial assumptions. It further includes moving away from economic growth thinking, critically analysing the political economy dimensions and promoting post-growth strategies. Addressing the brain drain of doctors from Low- and Middle-Income Countries (LMICs) is crucial within this framework, as is ensuring that the voices of indigenous populations are heard in the training of health professionals. The overarching goal is to confront and overcome persistent colonialist structures and ideologies in GH, encompassing the challenge of structural violence and the ideology of white supremacy. This endeavour requires reconceptualising health beyond the influence of high-income countries, examining the ongoing impact of settler colonialism as a structural determinant of health inequality, and challenging Eurocentric paradigms and patriarchal gender norms. This approach advocates for a paradigm shift, believing that consistent economic and social development in countries of the Global South can autonomously address their health problems [2,4-18].

Strengthen inclusivity and participation

Decolonising GH centres on amplifying marginalised voices, particularly from LMICs, to improve their participation, ownership, and leadership in GH initiatives. This process is fundamental to fostering more inclusive collaboration that not only elevate these voices but also address critical issues surrounding participation and ownership. The importance on inclusivity refers to a transformative dialogue that bridges the Global North and South, integrating indigenous cultural values into care practice. It further emphasises the necessity for non-colonising approaches that promote mutual learning and respect for boundaries. As part of this process, there is a call to build a global consensus to remove practices of colonial remnant. It is crucial to highlight the role of countries in the Global North, which are encouraged to actively engage in and facilitate data exchange, supporting national governments in the Global South. This support is envisioned to establish networks among healthcare professionals, enabling them to share their expertise and knowledge seamlessly [4,20-25].

Educational and institutional change

Educational measures and reforms in the medical and health education curricula are prerequisites for promoting a decolonised GH framework. This transformation involves the preparation of healthcare professionals to act as “decolonisers”, focusing on the importance of long-term collaborations and a transdisciplinary education approach that recognises and incorporates diverse knowledge systems. Genuine decolonisation of medical and health education and research necessitates overcoming the prevailing Nordic bias and historical influences. This requires adapting the teaching of GH to embrace a broader spectrum of health challenges and integrate different knowledge bases. In GH programmes, the practical aspect of education is particularly significant. It underscores the need to create field projects in close collaboration with local partners, ensuring that the educational experience is not just immersive but also deeply aligned with the specific context and needs of the communities involved. Simultaneously, there is a pressing demand for robust institutional support that empowers faculty members, enabling them to redesign outdated curricula and guarantee a more updated and relevant approach to global health education [2,3,7,12,13,23,26-28].

Integration of traditional and local knowledge

Incorporating traditional knowledge systems, indigenous practices, and local leaders in the design of health systems is pivotal to ensure culturally sensitive and community-based approaches, thereby respecting and valuing diverse knowledge forms and expertise [29-34].

Equity and redistribution of resources

Ensuring the equitable distribution of resources, funding, and research agendas, along with reducing biases against institutions in LMICs and advocating for a more equitable GH governance framework, are considered essential. This encompasses promoting gender equality in health research, addressing power imbalances, and fostering South-South cooperation. In alignment with these objectives, there is a strong call for transitioning towards a multipolar GH governance structure centred around the World Health Organization [4,35-40].

Social justice and anti-colonial praxis

Decolonising GH focuses on achieving social justice and health sovereignty while addressing the social determinants of health. This includes a critically examining the impact of colonialism on health structures, incorporating anti-racist and anticolonial principles, and engaging in decolonial cycles of practice [14,21,41-44].

Reshaping and reimagining of GH

The call to redesign and reconceptualise GH involves challenging Western-dominated models, embracing decolonial thinking, and developing new epistemologies based on the experiences and insights of the Global South. Prioritising listening to marginalised groups, repositioning control over health data, and focusing on cultural safety require a new conception of GH that includes diverse perspectives and redresses power imbalances. Therefore, it is underscored that individuals from former coloniser nations should actively seek the opinions of people from the Global South and create capacity accordingly [31,45- 48].

Convergences and divergences between definitions of decolonisation of global health

The effort to decolonise GH is complex and covers various priorities, but common key themes connect these diverse approaches, all aiming towards the mutual objective of decolonising GH. A central point across all seven core themes is the recognition of historical and contemporary power imbalances in GH practices between the Global North and South. Decolonising approaches strive to rectify these imbalances by promoting more equitable partnerships, decision-making processes, and resource distribution.

Another shared focus is on education, which is a strong promoter of change. Institutions can prepare the next generation of GH professionals to approach their work with a more decolonised mindset by redesigning curricula, teaching methods, and learning objectives. Approach [2] sheds light on this concept, underscoring education´s crucial influence in shaping the future of GH. It also aims to enable both students and professionals to adopt a more equitable and inclusive perspective in their work.

While these priorities coincide in many aspects, their manifestations vary across different structural levels. Silberner’s article offers a more detailed look into individual-level principles, reinforcing that foundational change is rooted in personal action - with individuals challenging existing norms and practices. Additionally, focus on self-assessment and accountability highlights the essential task for both individuals and institutions to critically evaluate their contributions to colonial legacies and engage towards meaningful change.

State [49] that the unequal distribution of power and wealth within and between countries is the cause of health inequalities. They argue for comprehensive actions that address the social determinants of health to promote Global Health equity [49]. This call to action signifies the depth of analysis and intervention required to redress entrenched inequities that affect health outcomes globally.

Present [4] a multifaceted approach within a holistic framework, advocating for interventions at multiple levels, from modifying healthcare practices to reimagining GH policies. Notably, the call for a multipolar GH governance, centred by the WHO, emphasises the importance of having an institution responsible for coordinating GH efforts [4]. They advocate for the adoption of consistent definitions and measurements, officially defined by the WHO, in order to better integrate stakeholders and enhance comprehensibility and sustainability in Public and Global Health [3]. Moreover, their approach also acknowledges the necessity of confronting deep-rooted socio-economic inequalities that have been intensified by colonial practices [4], aligning with [50] critique of superficial reforms and advocating for the dismantling of colonial structures within the “Global Health industry”, thereby addressing white supremacy, racism, sexism and capitalism. To truly align with its objectives, they claim that the decolonisation of GH must include conceptual elements of postcolonial theory, particularly notions of power and oppression [50].

To move “from rhetoric to reform” in terms of promoting equity and decolonisation, [51] propose a comprehensive roadmap. These recommendations include (a) ensuring diversity of gender, race/ethnicity, social status and geographical location in the management of international cooperation institutions; (b) the decentralisation of decisions on resource allocation, directly involving the communities served; (c) the selection of leaders with experience of living and working in the country of program beneficiaries; and (d) conditioning financing on the commitment to promote equitable partnerships [51]. These approaches underscore the importance of diverse collaboration across multiple sectors and regions.

Analysis of decolonising global health approaches

There are many ways to approach the multifaceted topic of decolonising GH, each offering unique insights into how health institutions deal with the persistence of colonial legacies. While all these approaches share a fundamental commitment to equity as an ethical principle, the divergence lies in the strategies employed to achieve health equity. There are two primary approaches: (a) transforming current GH organisations (governmental or NGO), research and educational institutions; and (b) advocating for structural changes involving political and economic power, race, and gender.

A central path for addressing health disparities involves ensuring access to high quality healthcare services at both local and global levels [3]. This process involves deep reflection on how various disciplines influence decisions related to funding allocation, research priorities, and the development of research capabilities. This reflection should also consider the power dynamics involved in these processes [3,12]. In addition, decolonisation can be facilitated through educational measures. Curriculum reforms in medical and health education are highlighted as a prerequisite for promoting a decolonised GH framework. By redesigning educational structures, there is an opportunity to instil principles of equity and inclusivity in future healthcare professionals, thus enabling the decolonisation agenda.

The secondary overarching approach focuses on the primary goal of decolonising GH through structural changes, which is to create a future in which all people, regardless of their country of origin, have assured their right to health. This encompasses equal access to quality healthcare and the broader social determinants of health - factors integral to the World Health Organization´s Alma-Ata Declaration of Health for All [52]. Since 2020, debates around decolonisation of GH have intensified. They are increasingly seen as a movement against schemes of domination in which the knowledge and values of specific countries and dominant classes, ethnic groups and genders are often privileged at the expanse of the lived experience of the target populations of health programs. Decolonising GH is not a task for one entity but requires a collective effort involving governments, institutions, professionals, and communities worldwide. At its core, decolonising GH is fundamentally about promoting equity and inclusivity. This entails respecting local cultures, actively engaging with communities, and developing healthcare practices that are culturally sensitive and responsive.

Conclusion

In conclusion, the decolonisation of GH requires a multidimensional approach that strictly addresses practices, institutions, policies, education, and power dynamics. The decolonising GH movement can apply these varied approaches to work towards a more equitable and inclusive future that actively liberates itself from the remnants of colonial legacies. The diverse approaches and critical perspectives underscore the complexity and urgency of the task ahead. Decolonising GH is a challenging process that requires a thorough reassessment of existing structures and systems alongside a committed effort towards transformative change. By integrating these diverse perspectives, the GH community can make significant progress towards a more equitable health system for all.

The potential for publication bias and the exclusion of nonEnglish publications are acknowledged as limitations of this review.

Declarations

Author contributions: ESS: Research, methodology, writing original draft, writing review and editing, final approval.

LES: Conceptualization, methodology, writing review and editing, final approval.

Financial support and sponsorship: This work was not financially supported or sponsored.

Conflict of interest: There are no conflicts of interest.

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