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Policy provokes me to think and write. I currently work in ivory towers inspiring people to engage in their world. I am a student of the human condition and my classroom is the world. I don't need credentials to have an opinion but I've got paper to prove I know a few things about public health, social welfare and economics. I'm coming out of the tower and taking the words to the people and hope you will send some words back at me.

Wednesday, November 6, 2013

'Partnership' in the Context of Global Health

The word 'partnership' is trending in global health and has been for quite some time. Foundations, NGO's, and universities in the global north and south  'partner' with local communities in Asia and Africa to implement research or programs that will move forward knowledge about what works and what doesn't.

But what does 'partnership' mean in the context of huge power imbalances that come with differences in human, knowledge, institutional and fiscal resources? How do hierarchal institutions that assign power based on title, rank, alma mater, publications, departments etc share power with people who, if they had any, would preferably not be 'partnering' with people they do not know, who do not know them and who view them as in need of assistance?

With good intentions, professors, doctors, nurses, social workers and various sundry 'helping' professions write proposals that say they will listen to the local folks and link with the existing power structures although most do not integrate with public heath providers on the ground but choose to provide parallel services because of distrust of local systems.

But evidence-based practice is also trending in global health which means that helpers must implement what has been shown to work, regardless of the fact that the effective program was proven such in another country in another language or with another ethnic group. So what does partnership mean if one already arrives in-country with plans and cash? How many organizations involve communities in the writing of proposals for programs that will impact their lives?

And what of the products of these partnerships? The grants, the accolades, the publications, the promotions? How do local people get their share.

Granted, there are increased efforts to bring local voices to the mostly useless meetings where unenforceable documents get written and unachievable goals get set. And this is a good thing when the practice has been to sit on stage and tell the story of that mother, that child, that grandmother that foreign expert met in whatever country that moved them, changed their life or is evidence of the need for their program. Those stories get old when told 'on behalf of' instead of in-person. And after a while, one wonders why we need such stories at all. Is it not enough that said community is resource poor? Would we not expect sad stories of non-existent health services that caused death, injury or disability?

So what does partnership mean?

Partnership means equality in the relationship, and given the lack of respect for local knowledge and local intellectual resources, and the mismatch of status and money, partnership has a hollow sound when said in the context of global health. Partnership requires humility. It requires transfer of power. It requires acknowledgment of the legitimacy of existing structures.

Partnership requires that we (those who go to help) accept and acknowledge that we are pretty clueless about if it will work and with who and how. We all can't go around the world doing randomized controlled trials in each community to 'prove' what will work. But starting out by asking for permission, for guidance, for leadership with the communities we hope to change, is a start.

After reading this post, Dr. Joerg Maas, head of DSW in Germany (who is a friend) said the following, "Not sure I agree fully with the article - equality is not a prerequisite for partnership - isn't it more complimentarity and playing roles organizations can play best given their experience which matters?"

In response to his question, I believe that equality is about power and not necessarily about having the same skill set. Complimentarity is ideal but one partner is receiving and one is giving and that is often the key fact that drives this notion. And because the roles are somewhat determined by who is picking the partner, the same roles tend to get played by the same players.

One thing to note is that partnerships are often based on serendipity with regard to people connecting with each other, but also quite often academics and NGOs choose their locations and thus choose their partners by going south. It is rare that communities from the south come seeking a particular partner.

As the phrase goes... he who pays the piper calls the tune.

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