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A critical assessment of the ideological
underpinnings of current practice in global health
and their historical origins
Hani Kim, Uros Novakovic, Carles Muntaner & Michael T. Hawkes
To cite this article: Hani Kim, Uros Novakovic, Carles Muntaner & Michael T. Hawkes (2019) A
critical assessment of the ideological underpinnings of current practice in global health and their
historical origins, Global Health Action, 12:1, 1651017, DOI: 10.1080/16549716.2019.1651017
To link to this article: https://doi.org/10.1080/16549716.2019.1651017
© 2019 The Author(s). Published by Informa
UK Limited, trading as Taylor & Francis
Published online: 21 Aug 2019.
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A critical assessment of the ideological underpinnings of current practice in
global health and their historical origins
, Uros Novakovic
, Carles Muntaner
and Michael T. Hawkes
Bill & Melinda Gates Foundation, Global Health, Seattle, WA, USA;
Department of Interdisciplinary Research, Office OU, Toronto,
Dalla Lana School of Public Health, University of Toronto, Toronto, Canada;
Faculty of Medicine, University of Alberta,
Background: The current approach to global health has significantly contributed to
improving it, as evidenced by the progress made toward the Millennium Development
Goals (MDGs). However, the health gains achieved are often highly unequitable, and the
current approach is expected to be insufficient to meet the future health equity chal-
lenges. There is an urgent need to re-think and expand the scope of research and
Objective: This paper aims to assess the ideological underpinnings of the currently dominant
norms in global health, with the goal of highlighting the research and programmatic areas
that are marginalized and warrant greater efforts in order to resolve persistent health inequity
and achieve the UN Sustainable Development Goals (SDGs).
Methods: We have conducted a critical review of the literature that traces the historical
origins of global health to the period between the mid-19th century and the end of the 20th
Results: Critical review of the historical origins of global health reveals a set of dominant
norms in global health that are ideological in character, and profoundly shape the current
practice. We identified key manifestations of the ideological underpinnings as 1) Democratic
deficit, 2) Depoliticization of the discourse, 3) Marginalization of the scholarship that inter-
rogates the relations of power.
Conclusion: Examination of the dominant norms that shape the foundation of our knowledge and
action in global health is required to solve persistent health inequity challenges and meet the SDGs.
Inversion of the key manifestations of the dominant norms can serve as guiding principles to
elaborate alternative frameworks that have the theoretical and programmatic potential for
a fundamental rather than an incremental change in the practice of global health.
Received 19 March 2019
Accepted 27 July 2019
Peter Byass, Umeå
Global health; ideology;
political origins; health
equity; social determinants
The current approach and its merits
The global health field has been grappling with defining
the term ‘global health’, which may reflect the multi-
faceted path by which the field has been evolving. For our
discussion in this paper, we define it as ‘collaborative
trans-national research and action for promoting health
for all’, as proposed by Beaglehole and Bonita .
Insights into the predominant approach pursued in glo-
bal health can be gleaned from the interventions used to
achieve the health-related Millennium Development
Goals (MDGs) between 2000 and 2015 (Figure 1). The
MDGs focus on child health, maternal health and pre-
vention and control of malaria, tuberculosis (TB) and
HIV/AIDS. The declaration of the MDGs in 2000 recog-
nized that extreme poverty is unacceptable and that
eradicating it is a collective responsibility . This was
a normative shift in the way international development
was viewed, away from a narrowly defined economic
growth and toward a broader development agenda that
encompasses poverty reduction, education, gender
equality, and environmental sustainability . Despite
the broad scope of its initial aspirations, the implementa-
tion of the MDGs focused largely on targeting primarily
individual-level biological causes of specific infectious
diseases, such as malaria, TB and HIV/AIDS (Figure 1).
Several focused interventions were identified to have
contributed to achieving against the MDGs. They
include immunization, insecticide treated bed-nets, anti-
biotics, anti-retroviral therapy, and the Directly
Observed Treatment, Short-course (DOTS) for TB .
In addition to improved living conditions such as sanita-
tion and access to water, these interventions have con-
tributed significantly to improving the under-5 infant
mortality, maternal mortality, and deaths due to malaria,
The approaches reflected in the efforts to achieve the
MDGs can be characterized by targeting, primarily, the
biological causes of disease at the individual level to
CONTACT Hani Kim firstname.lastname@example.org Bill & Melinda Gates Foundation, 500 5th Ave. North, Seattle, WA 98109, U.S.A
Views expressed in the paper are those of the authors alone, and do not represent the views or funded work of the Bill & Melinda Gates Foundation.
GLOBAL HEALTH ACTION
2019, VOL. 12, 1651017
© 2019 The Author(s). Published by Informa UK Limited, trading as Taylor & Francis Group.
This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0/), which permits
unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
prevent (e.g. insecticide treated bed-nets to prevent expo-
sure to mosquito bites, vaccines), and treat (e.g. antibio-
tics, anti-retroviral therapy) infection and/or disease.
Implicit in this approach is the assumption that targeting
biological causes of ill health at the individual level,
especially those at an increased risk, will ultimately
improve the health of a population if the individual-
level interventions can be effectively scaled to a large
population. This approach has contributed substantially
to our ability to detect, diagnose and treat and prevent
infectious diseases world-wide. The central role of med-
ical products (e.g. vaccines, drugs, diagnostics) in modern
medicine is emphasized in what can be termed as
a product development paradigm, which can be sum-
marized as 1) discovering, developing and delivering
efficacious biomedical products that target specific indi-
vidual-level etiologic agents and 2) improving manage-
rial efficiency to optimize the process to scale a proven
intervention to a large target population across different
geographical locations. The contribution of these tar-
geted interventions to the MDG health goals must not
be underestimated. Nonetheless, efforts to close the gap
on health equity towards the Sustainable Development
Goals (SDGs) set for 2015–2030 call for critical reflection
on the approaches used to achieve the MDGs (Figure 1).
Limitations of the current approach
A growing body of evidence questions whether targeted
interventions are sufficient to achieve sustainable health
First, the distribution of the gains made in health out-
comes during the last 19 years has proven to be far from
even, with persistent inequalities or, in some cases,
increased inequalities. For example, women, especially
those aged 15–24, still show a disproportionately high
risk of HIV infection in sub-Saharan Africa . Gender
norms and inequalities, insufficient access to education
and sexual and reproductive health services, poverty, food
insecurity and violence lie at the root of the increased HIV
risk of young women and adolescent girls . Childhood
immunization gaps persist between and within countries,
and they have been shown to be associated with house-
hold wealth, geographic location, and mother’s education
. In Vietnam, while the overall level of child malnutri-
tion, measured by stunting and wasting, improved
between 2000 and 2011, the concentration index revealed
a significant increase in inequality in child malnutrition
during the same period. Not only did the poorest quintile
consistently show a greater level of malnutrition, but the
difference between the poorest and richest quintiles also
increased significantly during the study period .
Figure 1. The UN Millennium development goals and sustainable development goals [10,11].
2H. KIM ET AL.
Bendavid et al. recently reported decreasing inequal-
ities in the under-5 mortality between the wealthiest
and poorest tertiles in 54 low- and middle-income
countries (LMICs) (e.g. Colombia, Ghana, Nepal)
. However, the observed convergence was highly
heterogeneous, with some countries (e.g. Cambodia,
Congo, Haiti, and Ukraine) showing a trend of increas-
ing inequalities in under-5 mortality . Furthermore,
the report relied on demographic surveys, which cannot
capture data from people who lie outside government
services or surveys. An increasing number of people
have been dwelling in informal settlements, the result
of multiple interrelated factors, including urban-rural
migration, inadequate housing, economic vulnerability,
weak governance, conflicts, and wars. These people are
socially and economically excluded and lie outside the
reach of municipal services. Thus, the reported differ-
ence in health outcomes between the poorest and the
wealthiest may be underestimated .
Second, lessons from the 2014–2016 Ebola outbreak
in West Africa and the on-going Ebola outbreak in the
Democratic Republic of Congo reveal that the targeted
interventions are often disconnected from the under-
lying historical, political and economic causes and thus
have limited, if any, impact on strengthening the health
system to respond to disease outbreaks [19,20].
Third, the current approach is expected to be insuf-
ficient to meet the looming health inequity challenges
including those associated with climate change and the
crisis of internally displaced persons (IDPs) due to
political or economic reasons. By 2014, 60 million peo-
ple had been forcibly displaced worldwide, the highest
number since World War II (Figure 3)[21,22]. IDPs are
structurally excluded from society and the provision of
public services (e.g. health care, education, clean water).
Thus, they are not only vulnerable to previously con-
trolled diseases but also to new infections and poor
mental health [23,24]. Similarly, worsening conditions
from climate change are predicted to threaten the pro-
grammatic efforts for diseases that have been controlled
and to increase the likelihood of new outbreaks [16,25].
Furthermore, while climate may rarely be a direct cause
of conflicts, it is hypothesized that it contributes to
increased conflicts and forced migration [26,27].
Independent of the merits or limitations of the
current approach in meeting the future health
inequity challenges, a more fundamental problem
relates to the ideological nature of the dominant nar-
rative governing our knowledge and practice in global
health. While a large body of literature has described
the history of global health, few have specifically
articulated the ideological underpinnings of the
Figure 2. Achievements in meeting the health-related MDGs. (a) Trends in the global under-5 (top), infant (middle), and
neonatal (bottom) mortality rates. Adapted from . (b) Maternal deaths per 100,000 live births in women aged 15–49. CEE,
Central and Eastern Europe; CIS, the Commonwealth of independent states. Adapted from . (c) Percentage decrease in
malaria death rate since 2000 (by WHO region) . (d) Mortality associated with TB in the WHO African region between 2000
and 2016 .
GLOBAL HEALTH ACTION 3
current dominant norms and their manifestation. In
its simplest sense, ideology is defined as ‘a system of
ideas and ideals’. As conceptualized by philoso-
phers and sociologists in the past, a system of ideas
and ideals can powerfully shape what we define as
Overcoming the fundamental limitations of the cur-
rent approaches requires making visible the ideological
duce, programmatic actions we take, and the stake-
holders engaged. This paper critically reviews the
historical origins of global health and examines the ideo-
logical undercurrent of the dominant norms and implicit
assumptions that guide our practice in global health.
We have conducted a critical review of the literature
that traces the historical origins of global health to the
period between the mid-19th century and the end of
the 20th century, with a hypothesis that this period
has significantly shaped the ideological underpin-
nings of the current practice in global health.
The initial sources of data at the start of the search
are the two recent, comprehensive textbooks on the
history of global health, Reimagining Global Health
(2014) and Textbook of Global Health (2017) [30,31].
A critical review of the two textbooks led to a refined
search on specific topics to conceptualize our argu-
ment further. Search terms include, but are not lim-
ited to germ theory, cholera, Cold War,
neoliberalism, Alma Ata declaration, Health for All,
Selective Primary Health Care, health inequalities,
health inequity, social class, and social determinants
of health. The search was conducted between
December 2017 and July 2019.
We report the results of our critical review of the histor-
ical origins of global health that significantly shaped the
dominant norms and implicit assumptions underlying
current practice based on 106 sources, as referenced.
Birth of colonial medicine (1851–1920)
Two interrelated phenomena were critical in shaping the
genesis of global health as a field in the late 1800s and the
earliest approaches taken to pursue its goals: 1) the
colonial programs of Europe and the USA and 2) the
attendant advancement of medical science and micro-
biology (reviewed in [32,33]). The expansion of the reach
of the 19th-century European colonial programs, as well
as the rise of U.S. influence in the Americas, increased
trade and commercial activities across colonial posts in
Africa, Asia and South America [32–36]. The increased
trading activities were accompanied by an increased
transmission of infectious diseases, posing a significant
Figure 3. A future health inequity challenge: Forced displacement due to persecution, conflict or generalized violence .
Figure 4. Conceptualization of ideology by Michel Foucault .
4H. KIM ET AL.
threat to the colonial administration and its commercial
interests . For example, Cholera, which was limited
to Asia until 1817, spread globally and caused six pan-
demics between 1817 and 1923 often following trade
routes or the movements of the army troops throughout
the world [37,38]. Curbing the threat of infectious dis-
eases required the colonial nations to generate knowl-
edge about the causes of the diseases, and to establish
institutional frameworks to coordinate efforts to prevent
and control disease transmission across colonial
The desire to understand better and control the
transmission of infectious diseases provided the
impetus to advance our knowledge about pathogens
and treatments, and gave rise to seminal discoveries of
the etiologic agents and vectors of the major infectious
disease of the time, including cholera (1854), malaria
(1880), tuberculosis (1882), and Aedes mosquitos for
Yellow Fever (1882), as well as the earliest examples of
targeted treatments (e.g. quinine to treat malaria in
1897) [39–42]. The success of these scientific discov-
eries served as a powerful precedent to shape the way in
which we were to define the ‘causes of diseases’,as
expounded in the germ theory and the Koch
Postulates (1890); it also paved the way to the paradigm
of pathogen-specific chemotherapy seeded in Paul
Ehrlich’s‘magic bullet’(1894–1915), the notion that it
is possible to identify and specifically target disease-
causing microorganisms without causing harm to the
host [43,44]. Contemporaneously, the earliest research
institutes of tropical medicine were established, includ-
ing the Liverpool School of Tropical Medicine (1893),
London School of Hygiene and Tropical Medicine
(1894), and the Walter Reed Army Institute of
Research (1893), with their ‘field sites’set up across
sub-Saharan Africa, South East Asia and Latin
America [45–47]. They remain leading institutes in
global health research today.
The growing recognition of the need for interna-
tional health cooperation resulted in efforts to lay out
institutional frameworks that could enable cooperation
among nations to harmonize and reduce the conflicting
and costly maritime quarantine requirements of differ-
ent colonial nations. These efforts took the form of the
first international conferences, with the inaugural meet-
ing taking place in Paris in 1851 and 11 additional
conventions held between 1851 and 1903 . As
a result, the nascent forms of international health agen-
cies were established, including the Pan American
Sanitation Bureau (1902), a predecessor to the Pan
American Health Organization; the Office
International d’Hygiène Publique (OIHP, 1907); the
League of Red Cross Societies (1919); and Save the
Children (1920) .
The need to protect the commercial interests of
the colonial nations in the 19th century from the
increasing threat of infectious diseases provided an
impetus to harness the field of microbiology and
medicine, on the one hand, and to build institutions
of international health governance on the other. The
desire to protect the interests of the colonizers from
the colonized, the infectious, placed the field of tropi-
cal medicine on a distinct trajectory from that of the
public health programs of nation-states, which have
a vested interest in protecting their public at large
from infectious diseases. The ideas and enthusiasm
espoused in the early successes in the discovery of
etiologic agents and treatments during this period
‘validated’the strategy of identifying and specifically
targeting pathologic agents. The context of colonial-
ism and the rise of modern medicine were to shape
profoundly the knowledge to be generated and the
programmatic strategies to be pursued, as well as the
power dynamics among the stakeholders (e.g. coloni-
zers vs. colonized, investigators vs. investigated)
throughout the history of global health.
Competing visions of international health
World War II (1939–1945), and the subsequent con-
text of the Cold War (1946–1989) represent yet
another defining moment for the fledgling field of
international health. The world emerged from the
war deeply divided along ideological fault lines: the
U.S.-led capitalist bloc (Western bloc), the Soviet-led
communist bloc (Eastern bloc) and a group of non-
aligned countries (also called at the time ‘the Third
World’) under the Non-Aligned Movement (NAM),
established in 1961 . The NAM gained significant
traction among the majority of LMICs at the time,
with many of them emerging as nations independent
from the colonial powers [50–52]. The non-aligned
countries not only sought to remain independent
from the influence of the USA or the Soviet Union
but also proposed a distinct vision for a ‘new system
of international economic relations based on equity,
sovereign equality and interdependence of the inter-
ests of developed and developing countries’, as articu-
lated in the New International Economic Order .
The Cold War ideologies espoused by the three blocs
exerted a powerful influence in shaping the strategies
and policies of post-war reconstruction, as well as inter-
national development efforts, including health, with the
USA and the Soviet Union often competing to gain
influence over the non-aligned countries . The ideo-
logical divide manifested itself in competing visions to
achieve health and health equity: 1) the market-deliv-
ered health services championed by the USA, 2) the
centralized, state-led provision of primary health care
(PHC) championed by the Soviet Union, and 3) the
community-driven, government-led ‘health for all’
approach aspired mainly by the LMICs. These compet-
ing visions were most evident in two historical
GLOBAL HEALTH ACTION 5
moments during the Cold War: the small pox eradica-
tion campaign and the Alma Ata Declaration to achieve
Health for All by 2020.
Nearly a decade after the failure of the global
malaria eradication campaign of 1955–1969, the
World Health Organization (WHO) declared the suc-
cess of the smallpox eradication campaign with the
last case of smallpox detected in 1978 . The two
global disease eradication campaigns drew critical
reflections on disease eradication campaigns within
the field, with concerns about the significant financial
burden placed on the governments of LMICs and
their tendency to divert the health expenditure of
local governments away from other basic health
infrastructure (e.g. water, sanitation, safe housing,
education) [52,55,56]. Nonetheless, the contested suc-
cess of smallpox eradication at the time was later to
be heralded as the success of a technologically-based,
disease-focused intervention [33,57–59].
In the same year of the smallpox eradication (1978),
aspirations to achieve ‘health for all by 2020’culminated
in the signing of the Alma Ata Declaration by 134
countries at the International Health Conference on
Primary Health Care, convened by the WHO and
UNICEF and hosted by the Soviet Union in Alma Ata,
Kazakhstan (then part of the Soviet Union) . The
Alma Ata Declaration defines PHC as ‘essential health
care based on practical, scientifically sound and socially
acceptable methods and technology made accessible to
individuals and families’as part of ‘a comprehensive
national health system’. The Alma Ata Declaration
reflects the vision of the NAM, and it was distinct from
the centralist, state-led PHC advocated by the Soviet
Union or the market-delivered PHC advocated by the
USA. Instead, it emphasizes ‘maximum community and
individual self-reliance and participation’while
acknowledging governments’responsibility for the pro-
vision of adequate health care . It further empha-
sizes delivery of Health For All in alignment with the
‘economic and social development based on the New
International Economic Order’[53,60].
The Alma Ata Declaration is perceived as
a victory in international health for the LMICs in
its quest for a transformation in the power struc-
tures to achieve health equity [61–63]. On the other
hand, critics argued that it hadfailedtoarticulate
how the PHC scale-up would be financed and
implemented worldwide, and that ‘its very scope
makes it unattainable because of the cost and num-
bers of trained personnel required’. However, in
the face of the billions of dollars of military spend-
ing by high-income countries during this period, as
noted by Ted Kennedy, a U.S. senator at the time
financing plans or lack of political will that under-
mined the efforts to materialize the vision of the
Between 1946 and1979, different visions to achieve
health were articulated, each with its legitimacy sup-
ported by its own success . The global context
after World War II meant that the differences
between the visions were deeply ideological in nature,
and thus, were arguably irreconcilable from the start.
The subsequent trajectories of the competing visions
were largely to be determined by the battle for hege-
mony between the USA and the Soviet Union.
The rise of neoliberalism (1979–2000)
By virtue of their association with the configuration of
power during the Cold War, the competing visions to
achieve health and their relative power to influence the
direction and strategies of international health were
not on an equal plane: the community-oriented PHC
movement, largely promulgated by the non-aligned
countries, was sidelined in the battle for hegemony
between the Soviet Union and the USA. In the years
following the Alma Ata Declaration, two closely
related political currents were to turn the tide decisi-
vely against the vision of Alma Ata: the collapse of the
Soviet Union and the Eastern bloc (1989–1991), and
the ascendancy of a set of economic and political ideas
known as neoliberalism.
Dating back to at least 1946, advocated chiefly by
two Nobel laureate economists, Friedrich von Hayek
and Milton Freedman, neoliberal values emphasize
individual freedom, with the freedom of the market
and the entrepreneurial spirit of individuals as central
to ensuring it . Human welfare can thus, be best
advanced by ‘liberating individual entrepreneurial
freedoms and skills by strong private property rights,
free markets and free trade’. It follows, the social
good, including health, would be best achieved by
maximizing the reach and efficiency of market trans-
actions. The collapse of the Eastern bloc signified the
triumph of the West’s liberal democracy and the
values embedded in it, to which the ideal of indivi-
dual liberty is deeply tied.
Aside from the shifting configuration of power, with
the USA emerging as the world’s biggest superpower,
the economic recession for the industrialized countries
in the 1970s (including the USA and the UK) further
legitimated the neoliberal values [66,67]. Characterized
by stagnation in economic growth and high level of
inflation and unemployment, this period of ‘stagflation’
challenged the principles of Keynesianism which advo-
cate for government interventions to stabilize the econ-
omy against the boom-bust cycle by actively regulating
fiscal and monetary policies and opened the way for
neoliberal theories to come to the fore as the main
alternative. By 1978, Deng Xiaoping took the first for-
mal steps to liberalizing China’s economy; Margaret
Thatcher and Ronald Reagan, elected in 1979 and
1980 respectively, brought in broad sets of policies to
6H. KIM ET AL.
deregulate and privatize the economy and reduce the
role of the state in the areas of social provision.
The most striking way in which neoliberal policies
directly affected health in the LMICs has been through
the structural adjustment programs (SAPs) prescribed
by the international financial institutes (IFIs): the
International Monetary Fund (IMF) and the World
Bank. SAPs were developed by IFIs as a tool to help
governments restructure their economies to control
inflation, repay international debt and stimulate eco-
nomic growth . The IFIs provide loans and debt
relief to target countries under a set of specific condi-
tions that demand 1) the promotion of the free markets,
2) the privatization of state industries, 3) economic
deregulation, and 4) small government . By 1991,
75 of the poorest countries in the world received adjust-
ment loans, 30 in Africa and at least 18 in Latin America
. Conclusive findings on specific population-level
health outcomes have been controversial due to the
inherent challenge of disentangling multiple factors in
a nation’s health system. Nevertheless, a body of litera-
ture has compellingly argued for the negative impact of
structural adjustments on income and social inequal-
ities and on health indicators throughout Africa in the
1990s (Reviewed in [68,71–75]). It is hypothesized that
the adjustment policies harm public health by cuts to
public sector services, such as health care, education,
agriculture, water and public works, and the imposition
of fees for health care services . Growing discontent
with the SAPs and with rising economic inequalities in
the 1980s and the 1990s was among the key drivers for
the declaration of the MDGs in 2000 .
Chronic funding scarcity in international health,
exacerbated by the economic recession in the 1970s
and the 1980s, led to a concern about financing
international development and health. In 1979, as
an alternative to PHC, two researchers at the
Rockefeller Foundation presented ‘Selective Primary
Health Care: An Interim Strategy for Disease Control
in Developing Countries’at a conference held in
Bellagio, Switzerland [64,76]. The role of the
Rockefeller Foundation in unveiling Selective
Primary Health Care (SPHC) is consistent with its
status as the single most influential funder in global
health throughout the early 20
century . Briefly,
the SPHC consisted of four interventions known as
GOBI: 1) Growth monitoring, 2) Oral rehydration, 3)
Breast-feeding, and 4) Immunization [61,64]. The
main rationale for SHPC was the ease of monitoring
and evaluating the results and clear targets [61,64].
The report initially caused a heated debate, polarized
between comprehensive or ‘horizontal’health care vs.
selective or ‘vertical’care . However, by 1984, this
debate was settled in favor of the cost-effectiveness
model embodied by the SPHC. With strong cham-
pions in the U.S. government and the World Bank
(with a former Secretary of the State of the
U.S. government as its president), UNICEF spear-
headed the implementation of the SPHC between
1984 and 1990 [61,78]. Arguably, the appeal of the
cost-effectiveness model to donors was further
enhanced by the looming threat of the new epidemic
of HIV/AIDS, with detection of the first case of AIDS
in 1981 [79,80].
The shifted configuration of power at the end of
the Cold War, the rise of U.S. hegemony and neolib-
eral values combined with chronic funding scarcity
and the threat of the HIV/AIDS to turn the tide
decisively against the vision of Health for All reflected
in the Alma Ata Declaration and in favor of a set of
narrowly focused cost-effective interventions.
Ideological underpinnings of current practice of
A critical review of the historical origins of global
health reveals the shaping of a set of dominant
norms and implicit assumptions that undergird cur-
rent practice in global health. We posit that the
dominant narrative displays three key manifestations
that are ideological in character:1) a democratic def-
icit in the decision-making processes of research and
programmatic actions, 2) the depoliticization of the
discourse in health equity, and 3) the marginalization
of scholarship that interrogates relations of power as
a determinant of health equity. These manifestations
serve as powerful currents to perpetuate the domi-
nant norms and restrict the scope of our thoughts,
strategies, and actions. We closely examine the ideo-
logical underpinnings of these manifestations below.
Arguably, the most far-reaching manifestation of the
dominant norms in the global health field is the demo-
cratic deficit in the processes of making decisions on the
scope of research and programmatic activities . This
profoundly influences the production of knowledge and
practice in the field. Under the neoliberal framework,
the desire to maximize individual liberty and rights is at
odds with governance by majority rule . Thus,
a neoliberal approach favors governance by experts
and elites, whose power is protected in insulated insti-
tutions. In global health, the anti-democratic tendencies
of neoliberalism meet 19th-century colonial legacies,
which inherently privilege the colonizers over the
Significant power disparities exist among and within
different stakeholder groups, such as governments,
researchers, civil society organizations, private philan-
thropies (e.g. the Bill and Melinda Gates Foundation)
and multinational pharmaceutical companies . An
asymmetry in decision-making power is observed not
GLOBAL HEALTH ACTION 7
only between stakeholder groups (e.g. governments vs.
NGOs, public institutions vs. multinational corporations)
but also within each stakeholder group (e.g. academic
researchers in high income countries vs. those in
LMICs, political and technical elites vs. the working-
class communities within LMICs). These stakeholders
hold vastly different levels of power and thus different
degrees of control and ownership of decision-making
processes, ranging from determining research questions,
programmatic priorities, relative amount of resources to
be allocated, and the stakeholders to be engaged. Indeed,
a recent article reported that the vast majority of PubMed
titles with ‘global health’are from northern institutions
, which raises the question of whether global health is
a concept largely driven and owned by the high-income
countries in the northern hemisphere. The dominant
norms governing the practice of global health tend to
concentrate the control of the decision-making processes
within a group of technical experts and elites. The demo-
cratic deficit in global health governance has stimulated
an animated discussion [12,77,82,84,85] that points to the
importance of ‘bottom up (health) activism’to deepening
the democratic character of global health governance
The deleterious impact of the SAP on health illus-
trates how neoliberal policies can significantly erode
democracy in the practice of global health. In their
pursuit of privatizing public services and weakening
governments and public services, the SAPs redirected
foreign aid from major donors away from the local
governments of LMICs to Nongovernmental
Organizations (NGOs) . Because donors often
bypass national and local health authorities in favor
of international NGOs, they exert undue influence in
shaping national health programs and distort the
health priorities in such a way that they may not
accurately reflect the interests and the wishes of the
local population [19,20,77,86]. By one conservative
estimate, only 11.5% of resources appropriated for
the emergency Ebola response were channeled
through the governments of the three most affected
countries [19,87]. While the frequently cited concerns
with corruption and mismanagement are not invalid,
bypassing the local public health authorities in favor
of international NGOs contributes to a weakening of
the local public health system. Concerted efforts to
collaborate with and support the local governments
are critical, even in times of emergency outbreak
Depoliticization of the discourse
The dominant norms observed in the practice of
global health tend to drive the discourse and action
toward a methodological individualism that focuses
on individual-level biological causes, attributes, or
risk factors, which lend themselves as ‘targets of
intervention’. This view is associated with search for
behavioral or technological interventions, which are
detached from the broader context of political econ-
The depoliticization of the discourse in global
health is also manifested in a disproportionate
emphasis on technological solutions. The roots of
this fetish for commodifiable, product-driven solu-
tions can be found in the neoliberal framework, in
which ‘products of innovation’(i.e. new products,
new production methods, and new organizational
forms) are a desirable consequence of individual
entrepreneurial freedom . Within the neoliberal
framework, the proliferation of products of innova-
tion is deeply tied to its own definition of success in
materializing human welfare. When this notion
becomes implicitly or explicitly dominant, there is
a danger of assuming that there is a technological
fix for everything and of discrediting a theoretical
approach if there is no easy technological fix.
Encouragingly, a recent report from the UK suggests
that the biomedical R&D industry may have reached
the point of diminishing return. The report calls for
a‘radical shift of life sciences funding priorities from
the biomedical bubble and towards the social, beha-
vioural, environmental determinants of health’, and
for a vision of public engagement that can influence
high-level strategies [89,90].
While much of the literature on the social deter-
minants of health treat individual-attributes or risk
factors as a way to contest the assumed primacy of
technological, product-driven solutions to health
epidemiology assumes that it is individuals’respon-
sibility, and therefore simply a matter of exercising
avoid known risk factors regardless of a broader
context within which individuals must exercise
their agency [43,91–93]. This view is consistent
with the neoliberal prioritization of individual lib-
erty and responsibility over the collective responsi-
bility. Whether the focus is on biological causes or
individual-level ‘social, behavioural determinants’,
both approaches represent methodological indivi-
dualism, which treats individual attributes as iso-
lated, apolitical variables that are independent of
the surrounding social and political processes,
thus contributing to depoliticizing the discourse.
Marginalization of the scholarship that
interrogates the relations of power
Depoliticizing health equity problems precludes, con-
sciously or subconsciously, an examination of the poli-
tical and economic contexts within which individuals
exercise their agency. As such, it prioritizes approaches
that generate commodifiable intervention products
and discredits theoretical constructs that are not easily
manipulatable in the current policy space [94–96]. For
8H. KIM ET AL.
example, two individuals of the same sex, the same
level of income and the same level of education can
face vastly different strategies and choices –i.e. differ-
ent scopes within which they can exert their agency, to
survive and flourish –in contexts that differ in
employment condition; access to welfare programs;
exposure to stigmatization, exploitation, or domina-
tion; and degree of control or ownership of all produc-
tive resources relevant to physical and mental
wellbeing. In other words, the depoliticized, individual
attributes (e.g. education, sex, age, race) possess lim-
ited explanatory power for the social mechanisms that
generate health inequalities and offer little guidance
for social policies . In addition to the individual
attributes, concepts such as social class, exploitation,
domination, control and ownership of resources and
decision-making power are valuable constructs
through which one can generate insights about the
social mechanisms underlying health inequalities.
However, these concepts, and scholarship that inter-
rogates relations of power as a determinant of health
inequity, are marginalized in the current discourse of
global health [88,98–103]. Stifling the discourse that
interrogates the relations of power serves to legitimate
and perpetuate the dominant norms and their asso-
ciated manifestations described above. As a notable
example, while the report of the WHO Commission
on Social Determinants of Health  emphasizes
the problem of unequal distribution of power as
a critical determinant of health, it explicitly avoids
the issue of social class and is limited to individual
attributes. As a result, the report offers few insights
into economic and power inequalities and how they
may give rise to health inequity [99,105].
A way forward
Overcoming the persistent health equity challenges and
achieving the SDGs require a radical shift in the way we
view and generate hypotheses about the mechanisms by
which health inequity is generated in specific contexts.
What is needed then is a set of principles that could
guide us on the path of re-examining the dominants
norms governing our practice in a fundamental way
rather than seeking incremental modifications to the
current programs and policies.
We have identified a set of key manifestations of
the dominant norms that undergird current prac-
tice in global health. We propose the inversion of
three manifestations of these norms to serve as
a compass, i.e. a set of guiding principles to design
or evaluate health programs in specific contexts
Situating the problem in the full social and political
context requires analyzing the context of the social
and political processes within which a proposed pro-
gram is to be implemented. Determining the target
outcomes and the hypothesized mechanisms by
which the target outcomes are to be achieved should
be elaborated in this context.
Interrogating the relations of power implies the
importance of an active inquiry into the relations of
power among not just the immediate stakeholders of
the proposed program but also the local population at
large, which the study population is assumed to
represent. Such an inquiry can reveal hidden social
processes that may underlie health and health equity
problems observed in the chosen population, includ-
ing social exclusion of particular social group(s),
domination, and exploitation.
Deepening democracy in decision-making empha-
sizes the need to share decision-making power
among the key stakeholders when setting priorities
for health programs and determining the target out-
comes for the proposed programs, desired
approaches and the hypothesized mechanisms by
which the proposed approaches should achieve the
Figure 5. Proposed principles to guide designing of health programs.
GLOBAL HEALTH ACTION 9
The proposed principles are intended to serve as
acompass, not a blueprint for all health programs in
all contexts. It does not prescribe or preclude specific
requirements, technical or non-technical, for a program
to achieve its target outcomes (e.g. high-quality data on
vaccine effectiveness to guide national policy on routine
immunization programs). Instead, it calls into question
the foundational assumptions and norms that may hin-
der our view as we imagine overarching programmatic
strategies and scope. It will thus help us to elaborate on
proposed health programs’specific contexts in
a manner that is cognizant of the conscious and sub-
conscious undercurrents that tend to keep us in an
intellectual and programmatic ‘business-as-usual’
A radical shift in thinking about programmatic stra-
tegies in global health is possible only when we criti-
cally examine the set of norms and assumptions that
shape the very foundation of what we produce as
‘knowledge’and the programmatic actions that are
developed from such knowledge. Tracing the histor-
ical origins of the global health field illuminates the
arc along which the currently dominant norms in the
field have been shaped since the birth of colonial
medicine since the mid-19th century.
We posit that the manifestations of the dominant
norms identified are ideological in character and pro-
foundly influence (consciously and subconsciously) the
programmatic strategies and scope in global health.
Inverting these manifestations could help us to elabo-
rate alternative approaches and theoretical frameworks
that might help us to re-orient ourselves in
a fundamental rather than an incremental way.
We acknolwedge Editage (www.editage.com) for English
HK conceptualized and wrote the manuscript. UN, MTH,
and CM reviewed and contributed to editing the manuscript.
Views expressed in the paper are those of the authors
alone, and do not represent the views or funded work of
the Bill & Melinda Gates Foundation.
Ethics and consent
Although previous literature has described the history of
global health, narrating historical events is distinct from
dissecting the ideological undercurrents that emerge from
them. To our knowledge, few have specifically articulated
the relationship between the historical origins of global
health and a set of dominant norms and assumptions that
lie at the foundation of current practice. We identified the
key manifestations of the dominant narrative and propose
guiding principles for designing health programs.
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