How Global is Global Health?

Traditional funding streams continue to favor northern institutions. Is it time to change?

NOTE: After publishing, we fixed a small grammatical error on June 22nd.

The term “global health” has become much more familiar to all of us since the emergence of COVID-19 from one city in China to become the biggest pandemic in history. 

Global systems of travel and trade mean that a virus, particularly a respiratory one that spreads via air, can wreak havoc in all countries, no matter where the virus originates. 

In theory, the interconnected nature of global health should mean that the “global north” – where a majority of the world’s wealth lies – should care about and invest in institutions and systems to improve health in the “global south.” An ounce of prevention is worth a pound of cure, or so the saying goes. 

The investments of past decades have certainly been about prevention, but with an eye to national borders and keeping infectious diseases from spreading northward.  That thinking was partially captured in the Millennium Development Goals, which were the development targets for the United Nations and its partners from 2000 to 2015, framing progress in terms of quantifiable, individual health goals of specific populations.

The 2016-2030 Sustainable Development Goals, the current development roadmap of the United Nations, by contrast expressly acknowledges that progress in global development must come about holistically and with an eye to building institutions in all countries.

But have we really changed our approach in global health? One way to answer this question is to see where global health funds are spent.

Last week, colleagues at Devex released an analysis (subscription required) of one of the biggest funders in global health, the Bill and Melinda Gates Foundation. It showed a northern hemisphere-heavy spending pattern. From 1999 to 2022, all of the top 10 recipients were in either the U.S. or Switzerland.

During that time, the Foundation gave 6,666 grants in global health totaling $24.2 billion. But 30% of that generous sum went to the top 10 grantees. The biggest recipient, the non-governmental organization PATH, is based in Seattle, winning 165 grants worth $1.8 billion. For reference, the 2021 national government health budget of Niger, where I lived working on my doctoral work, was approximately $341 million. 

But the situation is not limited to private foundations. The UN itself has an imbalance when it comes to where it spends its funding. The World Health Organization, an institution where I had the privilege to work for 16 years, has had a long-running debate about how to shift more funding from Geneva to its 154 country offices. 

In theory, these offices, if properly supported and staffed, could build national and local partnerships. But despite changes in leadership and active debates on staff mobility, WHO spending remains stuck with roughly two-thirds of the $6.7 billion budget allocated to staff and programs based from its headquarters in Geneva. 

Why are these numbers important?

They reflect a pervasive, nearly unconscious, way of working that allows global development needs to be set in the seats of power in the north rather than locally where those needs arise.

The stated rationale for bringing in “outside” experts to global health is that there are not the experts or the institutions to take this leadership in Low- and Middle-Income Countries. At one level, this thinking has deep roots in colonial relationships between countries and institutions -- relationships that organizations like the UN and others struggle to update. An entire movement has arisen around “decolonizing” global health with a focus, among several, of ending the dominance of northern hemisphere institutions in the national and local policymaking of Low- and Middle-Income Countries’ health systems. 

Such socio-cultural changes have been shifting over decades and will continue to take more time. But what can and should be changed far more quickly is the inertia around funding streams for current program in global health.

It is just no longer true that expertise in infectious disease, in immunization, in primary health care, and in health systems financing and management exists only in North American and European institutions. The Africa Centers for Disease Control and the African Union’s African Vaccine Acquisition Trust are two examples that could help guide other regional bodies, such as the Association of Southeast Asian Nations (ASEAN), to establish similar regional centers of excellence.

Even more important than these regional bodies are national and local universities, NGOs and private companies that are increasingly attracting talented young professionals with the promise of rapid career growth and making a difference in their countries’ health. 

It is clear that organizations which have been “grown” locally have to be part of the long-term, sustainable approach to global health. COVID has taught us that the answers to our global health challenges do not come from getting an expert to fly out to the field from Geneva or Seattle or Washington.

Now that travel is possible again, those of us in “global” health have to ask ourselves – whose agenda is being addressed? Who has defined the problem? Have we understood local needs and local delivery challenges? Who is best placed to develop and implement solutions to those challenges? If we are honest, the answer to these questions must include local voices.

The environmental movement has long urged individuals and institutions to “Think globally, act locally.” In the world of global health, the time has come to “Think locally, act globally.”

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GLOBE is an outlet that allows colleagues and friends of the ApiJect Global Initiative to share their thoughts on matters related to global health and their ongoing work. Send questions or responses to media@apijectglobal.com.

To learn more about the ApiJect Global Initiative, visit our website.