10 Fixes for Global Health Consulting Malpractice

Recently, an African researcher I met expressed her frustration about how American “kids” with little or no experience come all the time to “advise” her government on what to do about health.

I have seen this myself, but her rant really hit a nerve. For the want of a better phrase, I am calling this “global health consulting malpractice.”

Now, imagine this scenario. A couple of newly minted MPH graduates from an African university, say in Rwanda, land in Washington DC for a 2-week visit. They visit a few hospitals, speak to a few health care workers and policymakers, read a few reports, and write up a nice assessment of the US health system with several recommendations on how to fix the issues they saw. They submit their manuscript to the American Journal of Public Health. Can you imagine AJPH even sending it out for review? Even if the paper got published somewhere, would US health researchers take it seriously? (They should, I suppose. After all, the broken US health care system needs all the help it can get.)

Clearly, it’s an impossible scenario yet American MD, MPH, or MBA grads land in low-income countries to advise them on global health issues all the time.

American graduates aren’t the only problem. It happens with all high-income country (HIC) folks. And it is not just naïve rookies stepping into advisory roles. The professionalized consulting industry (McKinsey, BCG, Bain, etc.), NGOs (CHAI, PATH, PSI, CARE, etc.) and donor agencies send HIC “experts” to low- and middle-income countries to offer “technical assistance” when they might know little about the countries they are advising or the problems they are trying to fix.

This problem of consulting malpractice is merely one facet of a larger issue of how global health, even today, is still colonial in many ways, and how HIC experts and institutions are valued much more than expertise in LMICs. Analyses of research studies’ authorship show that HIC authors dominate and lead publications even when the work is entirely focused on or done in LMICs. While parachute research is increasingly being discouraged, there is little discussion about parachute global health consulting.

To be clear, I am not against consulting or technical assistance. Nor am I against HIC trainees visiting LMICs for global health—they are mostly well-intentioned and do need to see the reality if they care about global health. But I do believe these can be done better. Based on a recent thread I posted on Twitter and the dozens of responses, here are 10 crowdsourced ideas on how consulting can be improved:

1. Global health courses must discourage global health voluntourism, and guide trainees and graduates on what they must NOT do, when they go to LMICs. How NOT to save the world must be a critical, required component of all global health courses. The principle of do not harm must be reinforced in all training. The recent story of an American woman with no medical training running a center for malnourished Ugandan children is an excellent case study in global health clinical malpractice.

2. Those studying or working in global health must complete a course or book on the colonial history of tropical, international and global health. I recommend Randall Packard’s book, “A History of Global Health.” For a more gut-wrenching account of colonialism, I suggest “King Leopold's Ghost: A Story of Greed, Terror and Heroism in Colonial Africa.” (Other terrific books can be found in this crowdsourced list of global health must-reads.)

3. Predeparture training by global health programs must also include content on cross-cultural effectiveness and cultural humility, bidirectional participatory relationships, local capacity building, long-term sustainability, and respect for local expertise and leadership. Training in allyship and privilege is also critical. Above all, HIC trainees and experts must learn to listen and be humble.

4. Consultants must have lived and worked in LMICs, preferably, in the same countries they will be advising. A 2-week trip to South Africa does not make anyone an “Africa expert.” As Randall Packard put it, “Everyone involved in global health decision-making should be required to work in the countries and see how things look from the ground level.”

5. Consultants should be careful about going beyond their specific content or country expertise. It is perfectly fine to decline consulting invitations that are a poor match with skillsets or country-specific experience.

6. Before technical assistance is offered, ministries of health in LMICs should be consulted on what specific expertise and prior experience/background they need. If there are local experts who are suitable, they could be contracted to provide technical assistance instead of expensive consultants flown in from HICs.

7. Strengthening global health capacity in LMICs and expanding the cadre of national experts is key for weaning LMICs away from the current dependence on HIC experts. This is an opportunity for HIC institutions to demonstrate reciprocity. Schools of public health and research institutions in HICs have an obligation to host, train and send back talented LMIC researchers and experts. The NIH Fogarty International Center could be a model for other HICs. Global health programs in HICs must periodically assess their reciprocity (i.e., how many LMIC folks have they hosted vis-à-vis sending their trainees or faculty to LMICs).

8. There is no reason why good training and capacity development cannot happen in LMICs. Building top-notch schools and institutions in LMICs and developing world-class expertise within them is key. Recent examples include the Public Health Foundation of India, BRAC School of Public Health in Bangladesh, and the University of Global Health Equity in Rwanda. The Africa CDC, Nigeria CDC, and African Society for Laboratory Medicine are examples of technical agencies. Initiatives such as the Emerging Voices in Global Health have empowered researchers from the Global South by providing skills training and facilitating their participation in global health events.

9. The ultimate solution is to challenge the current architecture of global health and work towards “decolonizing global health.” This includes answering uncomfortable questions. Why are global health institutions, donors, and power structures invariably based in HICs or controlled by HIC experts? Why is the flow of funding, people and knowledge unidirectional (North to South)? What colonial practices have led to the heavy dependence of LMICs on aid and technical assistance from their former colonizers? Why are major decisions in global health made in Geneva, Davos, New York or Seattle when those who deal with the real issues and have solutions are not at the table (or struggle to get visas, even when invited)? And why are global health meetings held in HICs when the real problems and expertise are elsewhere?

10. The entire global health consulting industry needs a serious re-think. As Teju Cole wrote, “If we are going to interfere in the lives of others, a little due diligence is a minimum requirement.”

In the end, when strong global health leadership emerges from LMICs, the role of external consultants will need to evolve. HIC experts will have to see themselves as enablers not “fixers.” As Seye Ambimbola eloquently put it, “We can begin to truly decolonize global health by being aware of what we do not know, that people understand their own lives better than we could ever do, that they and only they can truly improve their own circumstances and that those of us who work in global health are only, at best, enablers.”

Pai has also created teaching slides based on this commentary as a companion resource; they are free to use and share for training purposes: 10 Fixes for Global Health Consulting Malpractice: Teaching Slides

Madhukar Pai is a Canada research chair in Epidemiology and Global Health at McGill University in Montreal, the director of McGill Global Health Programs and director of the McGill International TB Centre. He is grateful to a large number of people who responded to his Twitter thread (@paimadhu) or have shared their insights with him in meetings. He says any mistakes and errors are his own.

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