Prof. Agnes Binagwaho

The global health enterprise has contributed to improving the wellbeing of people and increasing access to health services. However, deep structural inequities persist between institutions from high-income countries (HICs) and those in low and middle-income countries (LMICs) in access to resources, training, and knowledge. This results in significant health inequities, lack of ownership, lost opportunities, misguided priorities, and wholly insufficient attempts at achieving the Sustainable Development Goals. Power imbalances are embedded across funding opportunities, research management and coordination, knowledge production and transfer, access to training resources and most technical and political aspects of global health.1 The current pandemic, which has further highlighted these inequities, is an opportunity to acknowledge and rectify these gaps.2 The changes needed include ensuring that partnerships between HIC and LMIC institutions are equitable and that benefits from those arrangements accrue equally to all parties. Collaborations rooted in respect, honesty, equity, as well as commitment to mutual capacity building and health outcomes aligned with the needs of the LMIC partners are essential to reforming global health. Previous attempts have been made to address this imbalance, but there is a lack of accountability. The following reforms are concrete suggestions, particularly for the academic community, to achieve this objective. Overcoming the research to policy gap is critical to addressing health challenges.3 However, knowledge generated and reported in scientific publications is largely inaccessible to LMIC researchers even when they play a significant role in the research process.4 HIC research institutions should provide free access to their academic libraries to their LMIC partners. Moreover, research findings must be shared with equity, fairness, and respect for the work of LMIC and HIC collaborators. Results of global health research should be translated into local languages, with plans drawn at the start to ensure dissemination to all stakeholders including communities which are the subject of the research.

Patterns of marginalization and exclusion of the vulnerable in medicine and public health have become the norm. The vulnerable, especially on the African continent, have been left out of the distribution of life-saving medical and public health interventions. When included, they have always been last in line to receive such interventions. This inequity prevents Africa from stopping the spread of diseases, resulting in preventable deaths. The repercussions of this inequitable distribution are magnified in countries whose health systems have been weakened by centuries of colonization and unfair international policies such as the structural adjustment programs that hollowed out public investment in health systems.1 A prime example that illustrates the historical marginalization of the vulner- able is the distribution of antiretroviral therapy (ART). In the 1990s, powerful administrations such as the U.S. government strongly pushed for ART to be denied to HIV/ AIDS patients in developing countries as it was considered too expensive, too complicated, and not cost-effective.2 Instead, leaders around the world called for prevention as a cheaper means of reducing the spread of the virus, leaving the 40 million infected in Sub-Saharan Africa in 2002 with no treatment options at a time when treatment was available.3 This is just one example of the countless manifestations of injustice that have pervaded our society, leaving Africa to contend with diseases that have become an afterthought on other continents.