April 2021 Nature; Recently there was an announcement1 of a US$30 million grant awarded to the nonprofit health organization PATH by the US government’s President’s Malaria Initiative (PMI). The grant funded a consortium of seven institutions in the USA, the UK and Australia to support African countries in the improved use of data for decision-making in malaria control and elimination.
Not one African institution was named in the press release. The past year has been full of calls from staff and collaborators of various public-health entities for equality and inclusion, so one might imagine that such a partnership to support Africa should be led from Africa by African scientists, partnering with Western institutions where appropriate, especially where capacity has been demonstrated.
We write this letter to the major international funders of science and development in Africa as African scientists, policy analysts, public-health practitioners and academics with a shared mission of improving the health and wellbeing of communities in our continent and beyond. We represent a diverse group of institutions and communities dedicated to achieving the United Nations’ Sustainable Development Goals and to establishing a more equitable world.
Our work is informed by lived experiences and accumulated local knowledge of diseases such as malaria, AIDS, diarrhea, meningitis and polio, which have plagued millions of our families and friends for ages. We are therefore grateful that organizations that fund international health research have long been part of the international efforts to rid the world of these illnesses and their associated inequities. We believe the reason these organizations are financing global health and development is that they share in our dreams and aspirations.
We also believe, just like you, the decision-makers at these major funding organizations, that all humans, regardless of where they are located, are equal, even if opportunities are not. We recognize multiple injustices that have been perpetuated through historical practices, often without due consideration of their negative consequences. The current political climate has amplified the global call to ‘decolonize global health’, a more overt stance against what public-health practitioners in both high-income countries and low-income countries have known all along: that the predominant global health architecture and its business model enable ‘western’ institutions to gain more than, and sometimes at the expense of, the people and institutions in the countries where the actual problems are.
As the ‘decolonize global health’ movement has demonstrated, dismantling structures that perpetuate unequal power over knowledge and influence must support the quest for justice and equality. Global health institutions, especially funding organizations, must therefore examine their own internal policies and practices that impede progress toward justice and equality for populations that they intend to help. We write this letter as a collective, hoping to accelerate, and in some cases initiate, a process toward real fairness.
We believe that there are many issues with this specific consortium focused on malaria, including the fact that there are strong African institutions with excellent capabilities this area, including some already actively engaged on the ground, such as the KEMRI Wellcome Trust Information for Malaria (INFORM) initiative that began in 2014 (http://inform-malaria.org/).
International funding, such as that from the President’s Malaria Initiative, has substantially advanced the goal of improving people’s health and wellbeing in Africa and beyond. However, funding models such as that of the PATH-led initiative are among the reasons that after several decades and billions of dollars spent, the control of diseases such as malaria is still heavily donor dependent, This type of funding has also contributed a model of implementation that puts the delivery of several health interventions directly in the hands of Western non-governmental organizations, which further diminishes the capacities and ownership of national programs to deliver to their populations and ultimately leads to weak health systems and a lack of sufficient local capacity. Decisions about such major funding initiatives should be made in consultation with in-country scientists and researchers involved in this work, alongside ministries of health and national malaria-control programs, to augment national priority research efforts. Such efforts have the best chance of success if they are run by local research agencies and institutions that can work closely with governments and are well positioned to support decision-makers in integrating data into local policies and strategies.
The new ‘high burden to high impact’ initiative2 from the World health Organization rightly recognizes the need for such vital work to be country-owned and country-led to reignite the pace of progress in the global fight against malaria and to increase the likelihood of success in eliminating malaria. Omitting African institutions from leadership roles and relegating them to recipients of ‘capacity strengthening’ ignores the agency these institutions have, their existing capacity, the value of their lived experience and their permanence and close proximity to policy-makers.
In 2017, the USA, UK and Canada collectively spent US$ 1.1 billion on malaria development aid, which includes research funding. When the Institute of Health Metrics and Evaluation data-visualization tool is used (https://vizhub.healthdata.org/fgh/), it appears that once global fund contributions are removed, 81% of funding was used to support institutions in the funding country and 18% went to non-governmental organizations (probably based in high-income countries)—that leaves just 1% of malaria funding available to local in-country research institutions. We recognize that the current funding structures create an imbalance of power and a monopoly that favors Western institutions and is derived in part from the perpetuation of inequities in access to funding with policies that lock out African institutions. These structural inequities must be examined, and they must end.
We know that several decision-makers of these organizations recognize the limitations of the model that you have woefully applied to the issue of which we speak. The New Partnerships Initiative from the US Agency for International Development (https://www.usaid.gov/npi) and the Alliance for Accelerating Excellence in Science in Africa (https://www.aasciences.africa/aesa) are good examples of funding local institutions for impact. The latter is shifting its center of gravity by ensuring its funding is provided directly to African scientists and institutions, which in turn empowers and enables them to shape their research agenda and to conduct research relevant to the continent. But we argue that these are the exceptions. For long-term progress, true partnerships and stronger collaborations, you, the funders, are responsible for totally transforming this model. We believe that in the same way we have to apply innovation in our work to fight diseases, innovation can be applied to the design of sustainable funding models with local researchers and organizations at their center.
We are asking that all major international funders of science and development in Africa commit to finding and implementing short-term and long-term changes to these models with consideration of the points we have listed above and with further consultation with reputable Africa-based institutions and scientists.
There is a way to create equitable and dignified partnerships and to defeat the diseases that threaten everyone. We who authored this Correspondence are few, but we are committed to assisting any organization that is willing to make a substantial change.