Background
International health collaborations have been steadily increasing since the 1990s [
1], often bringing together stakeholders from high-income countries (HICs) situated in the global North, where most funding sources are located, with stakeholders from lower- and middle-income countries (LMICs) located primarily in the global South. Whilst these collaborations may tackle a range of research questions, they often include questions about conditions that primarily affect people living in the global South [
2,
3]. Driving this growth in collaborations are expectations that such collaborations will play a significant role in mitigating global health disparities [
4‐
9]. Another driving factor is a “desire to be socially responsible” [
10]. International collaboration in health research may have the effect of increasing clinical and research capacity in global South contexts and afford scientists in resource-poorer countries an opportunity to participate in or lead innovative scientific research and to publish [
7,
11,
12].
Notwithstanding these potential benefits and driving factors, a range of critiques has been levelled against international health collaborations. Such collaborative arrangements have been accused of being exploitative of Southern researchers and communities, with some researchers labelling such practices as neo-colonial [
13‐
16]. And while many Northern researchers may not set out to reproduce inequalities based on a colonial past, often collaborations have been seen as paternalistic, creating what Okeke has called, “the little brother effect” [
17].
To address concerns related to international collaborations re-entrenching unequal relations, several bodies of literature have provided guidelines, imperatives and suggestions for equity in international collaboration. These include substantial conceptual accounts about what equity is, why it is imperative, and how it can be achieved [
18,
19]. They draw on rich literature from political philosophy that explores the concept of equity and social justice and identify several components, including avoiding unfair power relations, recognition, inclusion in decision-making, and rights to self-development and adequate levels of well-being. Social justice means reducing unequal power relations such as subordination, exploitation, exclusion and violence [
20‐
22] and includes recognition and affirmation of group difference [
21,
23‐
25]. Three core aspects of misrecognition are: 1) cultural domination, 2) de-valuing and stereotyping social groups, and 3) rendering their knowledge and perspectives invisible [
21,
26‐
28]. Accordingly, recognition encompasses affirmation of group difference, rendering the invisible visible and demonstrating respect. Social justice also means ensuring individuals and social groups, including those considered disadvantaged or marginalized, are included in making decisions that have a significant impact on their well-being [
21,
29,
30]. Efforts should also be made to ensure that dominant power hierarchies are not reinforced, and those considered disadvantaged or marginalized are not included as tokens. Scholars often equate fairness with
consensual and
deliberative decision-making [
21,
31‐
33]. Social justice further calls for ensuring self-development (understood as developing and exercising one’s capacities) and human flourishing (understood as achieving an adequate level of well-being for all) [
21,
29,
34‐
36]. Philosophers argue for giving some priority to bringing disadvantaged or marginalized individuals and groups/communities up to an adequate level of well-being [
34,
37,
38].
Ethics researchers have applied these and other concepts from the philosophy literature on health and social justice to explore what equity means for international research [
39‐
42]. This conceptual work has proposed that international research collaborations should generate new knowledge to improve the health and well-being of LMIC populations, particularly those considered disadvantaged or marginalized; foster their and LMIC researchers’ meaningful participation in decision-making about its conduct; and build research capacity in LMICs [
39,
40,
43]. However, debates continue as to whether international research collaborations even have a responsibility to contribute to justice beyond the micro-level (i.e. achieving a fair balance of burdens and benefits during individual projects). Some scholars have argued that international research collaborations should not be expected to contribute to reducing global health disparities and building research capacity, whereas others strongly disagree [
43‐
45].
Additionally, several guidelines and frameworks have been developed that seek to promote more equitable collaborations. These include the “Responsible Conduct in the Global Research Enterprise” [
46], the Montreal Statement on Research Integrity in Cross-Boundary Research Collaborations [
47], the guidelines developed by the Commission for Research Partnership with Developing Countries [
48] and the COHRED Fairness Index for international collaborative partnerships [
49]. Moreover, there have been several qualitative studies reporting on researcher’s experiences within international collaborations [
4,
50].
While these papers provide necessary empirical evidence for what constitutes both inequity and equity, there has been no systematic attempt to synthesize empirical studies in this domain. The absence of such a synthesized understanding challenges researchers’ ability to pro-actively engage in and understand how equity in research collaboration should be promoted. To address this gap, we conducted a scoping review, mapping and synthesizing research from qualitative studies investigating dimensions of equity in international health collaborations.
Aim
To develop, through synthesizing evidence from published articles, key areas considered critical to fostering equity in collaborations identified by stakeholders involved in international collaborations.
Discussion
This scoping review synthetized empirical evidence about the experiences and understanding of equity in international research collaborations. Our review identified 10 dimensions of international scientific collaborations that were considered to be important in promoting equity. At the level of structural aspects of the collaboration, issues relating to where funding is held and control over funding, authorship arrangements, two-way capacity building, sample ownership and export were described as important in fostering equity. Also essential were fair research agreements negotiated at the outset of the collaboration, with LMIC researchers being able to ensure that study benefits are aligned to local health priorities. The review also highlighted more relational aspects of research collaborations that underpin equity such as explicitly acknowledging and discussing the impact of existing inequality, and ensuring recognition of the work of all stakeholders in the research endeavour – including the contributions for instance of the people organizing sample collection efforts. Moreover, trust was critical to fostering equity, alongside the need for researchers to be able to communicate openly and transparently. Structural and relational dimensions were interrelated in the sense that the articles revealed that to achieve equity with regards to a relational aspect, also requires attention to be given to a structural dimension. For example, in our reporting, we noted that while trust-building is a key relational dimension, it was often influenced or determined by funding arrangements, a structural element.
Beyond the structural and relational, we also draw attention to the fact that the identified domains map onto five components of social justice identified in the political philosophy literature. Funding location and control over funding issues are consistent with unfair power relations of subordination, where a privileged few get to determine the rules and make decisions that apply to many others [
20]. Subordination encompasses an unfair division of labour in the workplace between those who plan and those who execute [
21]. This has been a feature of HIC-LMIC international research collaborations [
3,
63]. Acknowledging inequities, recognition, and authorship domains are consistent with social justice as recognition, which entails affirming group differences and valuing others, especially those who have been marginalized by social institutions and norms [
21,
23,
24]. In the international research context, LMIC researchers have been marginalized by funding institutions and collaboration norms. Sample ownership issues were connected to unfair power relations (i.e., subordination or control by others) and recognition. Capacity building and trust speak to rights of self-development and achieving adequate well-being, specifically relational aspects of well-being: affiliation and commune. Commune refers to relations of harmony with others [
65]. Where research collaborations are characterized by relations of discord (i.e. ill will, us versus them), they can negatively affect members’ well-being. Finally, open communication and research agreements that are characterized by fair terms and transparency are consistent with norms of fair decision-making and deliberation. Inherent in existing accounts of deliberative democracy are norms such as inclusion, reciprocity, reasonableness, and publicity [
29,
31]. We thus propose that these five components of social justice – namely avoiding unequal power relations, group recognition and affirmation, inclusive decision-making, promoting everyone’s well-being and ensuring self-development – (at least) are relevant for equity in international collaborations. Future conceptual work should explore what upholding particular components of social justice means for the relevant domains of equity in international research collaborations identified in this paper, i.e. what reducing unfair power relations calls for in terms of funding. How each domain should be defined can draw on rich work from political philosophy.
In comparing our findings to the (limited) ethics literature that has applied theories of health and social justice to develop guidance on equity in international research collaborations, we note that relational matters such as recognition, communication, trust, and acknowledging inequities are largely not discussed. This paper’s findings, however, indicate that relational aspects of equity in international research collaborations are important, and we suggest they, therefore, require further consideration and exploration. Matters of building research capacity, inclusive decision-making throughout the research process, and ensuring collaborations are responsive to the health care and system needs of LMIC populations are discussed. However, the implications of inclusive decision-making for developing research agreements have not been specifically focused upon [
39,
41,
66].
Fair funding arrangements was a key theme which emerged as critical in promoting more equitable collaborations. A key criticism of funding arrangements was that funding originates in the North, and Northern partners often have control over how and where money is spent, which severely restricts Southern researchers’ power in collaborations. Although there appeared to be a perception that funders tend to prefer Northern partners to oversee funding activities, it is not clear if this is indeed the case. For example, funding from national government agencies is more likely to require that the funds be held at an institution in that country, irrespective of where the research is carried out. This may differ in cases where the primary focus is research in LMICs. The dynamics of funding have recently started to be explored, though the issue of control identified in this paper does not always feature. For example, Pierson and Millum explore what individual health research funders are ethically obligated to do to help reduce global health disparities [
67]. However, they are more focused on how funders should allocate their resources to various illnesses than to how resources should be allocated amongst researchers to reduce relations of subordination. Pratt and Hyder, in contrast, argue that equity means funders should incentivize LMIC ownership of international research agendas by restricting lead applicant eligibility to LMIC institutions [
68]. An example of where that was the case is the H3Africa Consortium [
69].
Moreover, with regards to structural elements, whilst the articles we reviewed, described the importance of capacity building and fair funding arrangements, these domains were considered almost exclusively between researchers or research groups. What is missing from almost all the papers included in this review are institutional forms of equity. For example, forms of capacity building described in the articles were training in research methods and new techniques, formal graduate training programmes and developing grant writing skills so that Southern-based researchers can attract their own funding. While such forms of capacity building are critical, they are only focussed on capacity building directly related to the research and only consider an individual or group. Only one study in this review reported on the importance of building more structural forms capacity, for instance, strengthening ethics review capacity [
3]. The articles included in this review did not consider broader frameworks for building institutional or structural capacity [
70,
71], or the importance of also building social science expertise [
72].
Similarly, while the articles we included did report on the importance of funding to support research in lower- and middle-income countries, they narrowly focused on direct funding for research. Indirect costs of research funding are critical for institutional capacity building, such administrative and financial offices which provide critical support for research to flourish [
73]. Importantly, the under-funding of institutional capacity, especially at the administrative level, has the potential to erode capacity of Southern researchers and institutions [
73].
Finally, one of the critiques of international research collaborations is that researchers in LMICs often do not lead publications. Bibliometric studies on authorship in global health research reveal that a significant proportion of articles reporting on international health research conducted in LMICs had an author affiliated to the LMIC where the research was carried out [
74,
75]. Overall, less than 15% of publications on global health research did not have a co-author from the LMIC of interest [
75]. The problem seems to lie more with the authorship order, whereby authors from LMICs are less likely to be first or last authors [
76,
77]. This scoping review highlights a desire for authorship parity in international health research collaborations.
Implications
While the 10 dimensions we identified provide overall guidance about what necessary dimensions of equitable collaborations, the findings of this review also underline the highly complex nature of achieving equity in collaborations. This complexity relates, firstly, to the differing perspectives from researchers and other stakeholders about which domains are required to establish equitable relationships. Secondly, there is also a variety of perspectives about what each domain requires to achieve equity in collaboration. For example, capacity building often means different things to researchers depending on their context. While many themes are generally consistent across many studies, such variance presents important challenges to ensuring equity. What this scoping review perhaps suggests is that finding standard ethical arrangements across time and space is difficult, and these aspects should be worked out in different contexts and collaborations. While such variance is important, especially considering multiple contextual factors, having no baseline shared, and standardized understanding of equity may also potentially undermine equity within international collaborations [
78]. While these dimensions cannot be standardized across all collaborations, our findings demonstrate these are the key areas which must be carefully considered for international collaborations to develop more equitable practices.
In addition, what also needs to be considered is that achieving equity often requires both structural and relational obligations to be fulfilled beyond individual researchers and/or institutions. For example, as it relates to matters of authorship or building trust, these could be worked out between researchers and institutions. However, funding practices are often determined by funders, their policies and the constituencies to whom they are accountable, well beyond the control of individual researchers and research institutions.
Limitations
One important limitation of this study was the small number of papers included in the review. This could suggest that our search strategy did not yield adequate results. We developed a comprehensive search strategy that included as many relevant key terms as possible, searching in as many relevant databases as we had access to. The initial search yielded a large number of publications, yet surprisingly few papers were included. To expand our search, we hand-searched the bibliographies of all included studies for any papers that we may have missed in our original search, and we found an additional four papers which met our inclusion criteria. In addition to hand- searches, we also, through Google Scholar and the citation tracking function, checked for papers that had cited the papers included in our study but found none. We think that the relatively low number of papers on this topic suggests that there are simply very few empirical studies which focus on equity within international collaborations – a surprising finding especially considering the growth in collaborative practices in global health. The second limitation of this study is that we did not include normative accounts or other literature focussing on providing framework or guidelines related to equity in international collaboration and this is an equally important analysis that needs to be conducted going forward. The third limitation of this study is that our search was limited to studies in English, and may therefore have missed studies published in other languages.
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