Ndlovo-Gatsheni, a professor from the global south in the field of Development Studies asks the question: “Why decoloniality in the 21^st century?”.  We unpack what this question could mean for global health today.

What is decoloniality?

When a country gains independence from a colonial power, it does not mean that all the effects of colonialism automatically disappear.  Coloniality is the condition that survives beyond the period of colonialism.  Where decolonisation describes the process through which direct colonial rule was withdrawn, decoloniality is a political, epistemological and economic liberation project aimed at dislodging coloniality and its manifestations including the coloniality of power, and the coloniality of knowledge.

Global health and coloniality of power

Asymmetrical power relationships still exist between actors from the global north and global south. In global health research, control of economic resources has often meant that those who hold the funds, get to set the agenda.  This pattern was echoed in remarks made by Ghanaian President Akufo-Addo to the French President Emmanuel Macron at a press conference in December 2017 where Akufo-Addo outlines how and why African countries need to set their national health agenda (irrespective of the origins of economic resources) in order to “Build a Ghana beyond aid”.

However, it’s not all about economic power, and while this is often easiest to see (and measure), other power asymmetries (for example along gender, race, class, ethnic, age, disability, sexual orientation, and religious lines) also play out between, and within global north and global south contexts.  While patriarchy pre-dates colonialism, an example of how the power asymmetries in gender are starting to shift is demonstrated by the fact that we see far fewer ‘manels’ (all male panels) in our global health conferences.  Importantly, we need to acknowledge that patterns of asymmetrical power play out in many complex ways, and this requires us to take a more intersectional approach to understanding (and disrupting) patterns of power in global health.

Global health and coloniality of knowledge

The patterns of knowledge production, and what knowledge is seen as a legitimate way of understanding the world is key in thinking about the coloniality of knowledge.  In global health we see the manifestations of this as some forms of research are posited as more legitimate than others, for example, the idea of the randomised controlled trial being the ‘gold standard’ in hierarchy of evidence, or the failure to recognise the value of social science perspectives in a field often dominated by clinical, biomedical and epidemiological knowledge.

Another example is the authorship patterns we see in many global health partnerships dubbed as  ‘safari research’ where low- and middle-income-country researchers are recruited but have minimum involvement in studies driven by high-income-country authors. This has significant consequences and influences what research questions are prioritised and why.

A Decolonial Approach to Global Health

Reflecting on the coloniality of power and knowledge allows for a critical questioning of existing structures in global health.

Importantly, the next step should not be a fundamentalist rejection of all things modern or European or Western.  Equally, we must be wary of false binaries (between the global north and global south) that are reductionist or over-simplifications of the very complex ways in which power affects these relationships.  Rather, a more nuanced approach is needed, one that recognises that these inequalities are bad for all of us, and cannot be separated from the broader political economy of global health systems.  Importantly, there is a role for actors from both the global south and the global north to actively participate in the decolonial project to disrupt power and knowledge asymmetries.

Some may say these asymmetrical patterns of power are inevitable while the majority of the funding still comes from the global north. Could power relationships in research partnerships between the global south and north be more equal? Could research consortia be structured differently? Are more horizontal, equal partnerships with true co-production of research possible irrespective of where the research funding comes from? We would argue that the answer is yes.

This could mean, for example, that research partnerships between the global south and north address power imbalances ensuring that resources are allocated to joint sessions allowing for the co-development of research ideas.  Research partnerships should be structured to address power asymmetry moving away from models where fund holders in the global north make resource allocation decisions, and ultimately set the research agenda.  Importantly, this would also require a shift in the mindset of funders, as they would need to value (and fund) the time required to co-develop ideas. The decoloniality of knowledge requires researchers (and funders) to recognise the multiplicities of knowledge through work which moves forward the epistemologies of the south.

Finally, we are not merely theorising about a possible future here, but arguing that our generation “must mobilise itself and confront present structural agential sources of social injustices, asymmetrical power structures, patriarchal ideologies, logics of capitalist exploitation, resilient imperial/colonial reason, and racist articulations and practices”

As EVs from the global south, we intend to do just that.

Nigerian Ibo Proverb

Between 21^st and 23^rd February 2017, the Makerere University School of Public Health (MakSPH) hosted the first International Symposium on Community Health Workers (CHWs) in Kampala, Uganda. This symposium brought together over 450 delegates from over 20 countries across Africa, Asia, Europe and America. Themed “Contribution of Community Health Workers in Attainment of the Sustainable Development Goals”, the event comprised 3 keynote addresses, 5 plenaries, 127 oral presentations, 27 posters, 13 panel discussions, 2 capacity building workshops and a book launch. On the sidelines of this symposium, World Vision in collaboration with CHW Central hosted a blog series on CHW work. Alongside this, Healthcare Information For All (HIFA), with support from the Health System Global (HSG) Thematic Working Group on CHWs hosted an online thematic discussion on CHWs between 16^th January and 24^th February 2017. This editorial synthesizes the debates during the 3-day event in Kampala.

Opening speeches given by policy makers – the Honorable Minister of State for Primary Health Care and the Honorable First Deputy Prime Minister – were fairly gung-ho about how committed the government of Uganda is to ensure that CHWs programmes lead to the attainment of the health related SDG goal 3, and other health related SDG targets. These commitments are echoed in most policy statements in low and middle income countries (LMICs). So policy makers came up with flowery statements, as they usually do, but a somewhat different picture was painted in the presentations and panel discussions. Community Health programmes still face pervasive challenges, among others: insufficient supportive supervision, high attrition rates, lack of incentives and essential supplies, low morale. Therein lies the disconnect between the zealous policy statements on CHW programmes and reality in many LMIC settings. In the spirit of the Ibo proverb “If one tells of a place where the rain met him, he is given a place to warm up by the fire”, this symposium provided a platform for researchers and program managers (among others), to bring these issues to the surface and seek solutions.

As Dr Polly Walker – the community health programming advisor at World Vision, UK – aptly stated in her key note address, it’s time to move on from the same old discussions on performance and functionality. We need to get out of the survival mode. She added, “We need to shift focus in this SDGs era from vertical non-governmental organization (NGO) programs to Ministry of Health (MOH) driven multi-sectoral CHWs programs”.

For LMICs to achieve health related SDG targets and Universal Health Coverage (UHC), Professor Francis Omaswa from the African Centre for Global Health and Social Transformation (ACHEST) emphasized: “LMICs have lost ownership and have become cases of global pity needing money and ideas, they need to develop home grown ideas and technical leadership”. A common thread from the discussions was that there’s no need to reinvent the wheel, rather we should strengthen the existing community health structures. It is imperative for policy makers and Ministries of Health to deliberately allocate sufficient resources and political support to ensure the success of community health programmes.

All along, we have asked what community health workers can do for the health system. We feel it’s an opportune time now to ask what the health system is actually doing for the community health workers. We all know what to do, so let’s do it together!

Community health workers

CHWs are human resources for health who are the first contact of the community to the health system, especially in rural and underserved settings. They are usually members of the communities where they work and are selected by the communities based on their ability to read and write (usually in their local language), but also their moral status and integrity. Over time, CHWs have shown their ability to improve the health of the communities they serve by delivering preventive and curative services especially in low and middle income countries. Different countries have different CHWs programmes depending on how they are called, duration of training, and the roles CHWs are involved in. In Uganda, CHWs are known as Village Health Teams (VHTs) and are largely engaged in home visits, health education, mobilizing the community for public health interventions such as immunization, disease surveillance, treatment of children under 5 years under the Integrated Community Case Management of Childhood Illnesses (iCCM), and referring patients to health facilities.

Which SDGs are related to the work of CHWs?

As you know, in September 2015 the UN General Assembly adopted the SDG agenda in a resolution outlining a new framework that established 17 universal goals, 169 targets and 230 indicators. The new framework replaced the Millennium Development Goals (MDGs), substantially broadening the development agenda in the process. Although the international environment looks rather shaky, especially after the election of Trump in the US, the SDG agenda is expected to guide policy formulation among UN member states over the next 15 years (including health policies), and implementation has already started in many countries. Health is a core dimension of the SDGs; goal 3 aims at “ensuring healthy lives and promoting wellbeing for all at all ages”, with 13 targets. “Health-related indicators—ie, indicators directly pertaining to health services, health outcomes, and environmental, occupational, behavioural, or metabolic risks with well-established causal connections to health—are also present in ten of the other 16 goals.” (Lim et al 2016) In addition to the 13 health targets under goal 3, there are 15 other health-related targets within the goals. All in all, across these 11 goals, there are 28 health-related targets with a total of 47 health-related indicators. In many of these, CHWs are expected to play a role (and already do so in many cases in a number of countries).

Who and what to expect at the symposium?

The 3-day symposium in Kampala will bring together academics, researchers, practitioners, funders, policy makers, students, implementers, media and others from all over the world. Over 400 participants (from countries as diverse as the US, UK, Canada, Australia, France, Netherlands, Japan, India, Ethiopia, South Africa, Indonesia, Bangladesh, Nigeria, Ghana, Cameroon, Swaziland, Tanzania, Malawi, Sierra Leone, Kenya and Uganda) will attend the symposium. The likes of USAID, UNICEF, World Vision, Pathfinder International, Amref Health Africa, Healthy Child Uganda, the REACHOUT Consortium, Save the Children, Child Fund, Malaria Consortium, ministries, and research institutes are all expected to attend and showcase their work. Keynote speakers will include Dr. Maryse Kok from the Royal Tropical Institute Amsterdam, the Netherlands and the Reachout consortium; and Dr. Polly Walker from World Vision International. Other keynote speakers from MOH Uganda, Health Systems Global, academic and research institutions will also be presenting at the symposium. The symposium will feature plenary sessions, panel discussions, oral and poster presentations sessions, exhibitions and networking opportunities. The event is mainly sponsored by the UK Department of International Development (DFID) through the Tropical Health & Education Trust’s (THET) health partnership Scheme.

Expected benefits and outcomes of the symposium

The symposium will produce a report highlighting recommendations on how to improve the work of CHWs to help achieve the SDGs. Abstracts presented in the symposium will also be published in BMC Proceedings, a peer reviewed journal. We therefore invite you to attend this symposium and share your experiences, network with other professionals and learn about their work, get ideas for future research and projects, and contribute to the CHWs and SDGs agenda. See you in Kampala!

For more information about the symposium, visit our website: http://chwsymposium.musph.ac.ug/