Johns Hopkins Researchers Identify Two Distinct Perspectives on Power Imbalances in the Field of Global Health

Connected to decolonizing health, there are current debates in global health concerning power imbalances between the global north and global south. In a series of three articles published in BMJ Global Health, PLOS Global Public Health, and Third World Quarterly, researchers at the Johns Hopkins Bloomberg School of Public Health examined these debates with a focus on understanding differences in how the problems and solutions to redress the power imbalances are understood by different stakeholders. By better understanding these differences in perspectives, global health organizations can more effectively work to improve health outcomes and redress these power imbalances.  

The project was conducted by Yusra Shawar, PhD, MPH, Jeremy Shiffman, PhD, MA, Rachel Neill, PhD ’23, and Malvikha Manoj, MSPH ’21, from the Bloomberg School’s Department of International Health, and Michael Kunnuji, PhD, from the University of Lagos. It was funded by the USAID MOMENTUM project, a program seeking to accelerate reductions in maternal, newborn, and child mortality and morbidity.

The studies investigated debates around how to redress power imbalances and health inequities through an examination of the terms resilience, self-reliance, and increasing country voice—terms used frequently in global health, but interpreted differently by various audiences. Authors examined the origins and evolution of these terms, how actors in global health understand them, and what drives differences in understanding.

Authors found that underlying ideological differences drive differences in how these three terms are understood among global health actors. They conclude that differences in each terms’ meaning are reflective of fundamental disagreements among global health actors on the nature of the problem, the solutions that should be advanced, and which actors should be involved in their redress. The analyses identified two distinct perspectives in global health—reformist and transformational.

• A reformist perspective, which reflects threads of neoliberal and democratic liberal ideologies, conceptualizes global health problems as predominantly downstream and largely addressed through technocratic solutions. Proponents of this perspective embrace market-based and/or democratic orders with a desire to work within existing global and local health systems to make incremental changes.
• A transformational perspective, which reflects undercurrents of neo-Marxist ideology, conceptualizes global health problems as predominantly upstream and necessitating a different system as the solution. Proponents of this perspective reject the existing international order and seek to overhaul existing power structures.

“Differences in the way reformists and transformationalists understand the same term is not merely linguistic. These differences are reflective of distinct ideas that various global health actors have about the way policies should be designed and implemented, the nature of knowledge that should be produced, as well as which actors should be engaged and how in solving problems,” says Shawar.

The authors conclude that while ideological differences among global health actors are unlikely to be eliminated, it is through awareness of their existence and productive deliberation that it may be possible for disagreements to be effectively managed in ways that enable progress in improving population health outcomes and advancing health equity.

Read more below on how proponents of the two perspectives interpret commonly employed global health terms:

• Resilience: A reformist perspective consider the root problem of inadequate health system resilience to be insufficient self-reliance or deficient health security. Reformist solutions are technical in nature—emphasizing ‘hardware’ elements such as finances, infrastructure, hospitals, and surveillance systems.  A transformational perspective sees the root problem to be structural inequalities, such as historical colonial legacies, and current trade tax, health insurance, and aid systems and policies. Transformationalists emphasize software elements as part of the solution, which account for the interests, norms, and power dynamics that shape the relationships among system actors.
• Self-reliance: A reformist perspective attributes country dependence on external resources to national system deficiencies, such as a country’s low domestic spending, inadequate capacity, or a lack of political will.  Reformist solutions work within the existing system and include fostering localization of funding, subawards, domestic resource mobilization, private-sector engagement and commitment from country actors. A transformational perspective attributes country dependence on external resources to global system deficiencies, such as capitalist models of development and structural inequalities in the world economic and political system. Transformationalists advance solutions that are emancipatory in nature, such a redefining trade terms and developing country strategies that focus on national leadership.
• Increasing country voice: A reformist perspective views a lack of inclusiveness and democratic engagement in global health as a problem whose solution includes improving local representation and ownership with engagement by all involved actors to better understand local contexts and ultimately improve program efficiency and health outcomes. A transformational perspective sees the problem rooted in racial hierarchy and capitalism with the solution being transformation of power structures with the most vulnerable voices—recipients of services—fully dictating how to best prioritize human well-being.

Read the articles focused respectively on self-reliance and increasing country voice, as well as the full report and article that examine all three terms comparatively.