Health research is an influential component of improving health outcomes, distributing knowledge, improving technological effectiveness and addressing the conundrum of inequitable health care . In order to advance health research and increase health-systems capacity, it is necessary to develop multi-country collaborative health research networks . Collaborations in global health research, however, while tremendously advantageous, can be demanding and challenging; many partnerships struggle to make the most of collaborative processes to accomplish their stated goals . Capacity strengthening, in terms of global health research, needs to be seen as more than simply the transfer of knowledge, skills and resources, but the ‘global and collective struggle for health and well-being in which we are partners’ , (Page 3). This paper seeks to stimulate insight, discussion and future research to inform successful partnership practice in global health research.
For the purposes of this paper, we define health partnerships as “contextually relevant peer-to-peer collaborations which offer a platform for sharing knowledge and growing expertise globally, working towards a common goal, across disciplines and perspectives”. This admittedly broad definition of partnership is cognisant of the multiple type of partnerships in global health research which exist on a broad spectrum to address health inequalities , improve health care delivery, evaluate health programmes and interventions , develop collaborative approaches to international research , build capacity for health researchers , strengthen public health education , examine health promotion through international collaboration , rethink health research capacity strengthening , sustain social networks for global health research , and to relate inter-organisational and network learning to education partnerships [12, 13], amongst other prominent issues in the discourse of research partnership in global health. A broad definition such as this encompasses the key attributes which form all such partnerships and enables success, and in that sense can be seen as unifying. Hence we consider the framework itself as having the capacity to be a unifying framework.
However, it must be acknowledged that part of the challenge of framing this discussion has come from the diversity within the partnership literature itself, given the myriad of disciplines, perspectives, contexts, and practical applications, knowledge and experiences of partners. The partnership framework we propose here emerges out of primary research and offers a perspective on the core issues as concepts (focus, values, equity, benefit, communication, leadership and resolution) that must be considered when engaging partnership for global health research. Moreover, the framework shows the process most global health partnerships pass through - from their formation, to their implementation, monitoring and evaluation, and, where appropriate, their dissolution - in order to achieve success. The flexibility of this framework is intended to guide politically and socially contextualised , successful research partnerships in global health, along with an appreciation of the cultural realities in which they operate, in order to achieve the desired goals and objectives.
Centre for Global Health, Trinity College Dublin
As an international academic research institution, the Centre for Global Health (CGH), Trinity College Dublin, promotes the collaboration of partnerships towards the realisation of strengthening health systems in lower-middle income-countries (LMIC). We recognise that the functionality of different partnerships in different contexts requires different input which will inevitably produce a diversity of outcomes. Since its establishment in 2005, the CGH has worked across more than 40 countries with an international network of more than 20 third-level academic, civil society, government, private sector and UN partners.
Within this period CGH has engaged in inter-institutional and intra-institutional forms of partnerships with the aim of improving health systems performance. Partnerships have include those focused on capacity-building, implementation research, health policy and systems research, participatory action research, impact orientation, interdisciplinary approaches, and long-term partnerships for health systems strengthening in the global south . One example of the kind of partnership undertaken in recent years is the international doctorate in global health programme (Indigo); a north-south collaboration aimed at building the capacity of southern partner universities through extensive training of selected junior staff. Partners collectively deliver the interdisciplinary international doctorate, focusing on social health science and strengthening health systems. Programme partners are TCD (Ireland), the Mailman School of Public Health at Columbia University, New York City (USA), Harvard School of Public Health, Boston (USA), the Methodology Hub at Queen’s University, Belfast (Northern Ireland), and the Cochrane Centre in Oxford (UK), along with four universities in sub-Saharan Africa: Addis Ababa University (Ethiopia), University of Ibadan (Nigeria), Makerere University (Uganda) and University of Malawi College of Medicine (Malawi). The programme also works collaboratively with the Human Sciences Research Council in South Africa and the Council on Health Research for Development based in Geneva, Switzerland. The Indigo programme emerged from ongoing debates around aid effectiveness, academic collaboration between universities and institutions in low- and middle -income countries and, more specifically, the widely recognised need to strengthen health system research in Africa . A table of selected additional CGH partnerships is shown in Appendix 1.
The ten year anniversary of the establishment of CGH provided an opportune moment to reflect on, and (re)evaluate, the course of these partnerships. To this end we conducted exploratory research involving current and former partners and staff members, which sought to identify the characteristics of successful research partnerships and to reflect on some of the lessons learned. The results of this research informed the development of a unifying framework for establishing successful research partnerships in global health. This framework, and the process through which it was developed, is presented below.
After a decade of building relationships through a range of partners and operations, practice and research, the CGH recognises the importance of guiding principles. Several useful sets of guidelines have been established (in particular, for example, the Swiss Commission for Research Partnership with Developing Countries (KFPE) principles [15, 16], and the Netherlands Development Assistance Research Council (RAWOO) guidelines ). In response to the inequitable exclusion of Southern partners and voices contributing to written best practices for North-South health research partnerships, the Canadian Coalition for Global Health Research (CCGHR) in collaboration with the International Development Research Centre (IDRC), BRAC (Bangladesh), the Universidad Andina Simon Bolivar (Ecuador), and the Armauer Hansen Research Institute (Ethiopia) developed a Partnership Assessment Tool (PAT) that can be used to improve the ethical conduct and accountability of partners . Helping to navigate questions about authorship and intellectual property as well as discussion points on the development of MOUs, and priorities, PAT’s application is seen through four phases of partnering: inception, implementation, dissemination, and good endings with new beginnings . The CCGHR is currently leading a participatory research process in developing principles for guiding involvement in equitable global health research . More recently, the Council on Health Research for Development (COHRED) released a ‘Fairness Index’ for international collaborative partnerships, an extension of its Fair Research Contracting (FRC) initiative for better global impact . The index provides a certification mechanism for partners engaging in research to encourage and improve upon best-practices within their international collaborations; including the alignment of interests, long term contributions and reduction of inequity to stimulate socio-economic development.
While existing evaluations and studies on Global South-North partnerships, endeavours and networks engaging in academic research, have been instructive and evidence informed, many of the issues that have been recognised warrant further exploration and action . The formation of global health research partnerships requires conceptual explanation to inform future practice and explore the resolution of identified issues.
Neither global health research, nor global health research partnerships, are removed from underlying political inequalities, competition, economic growth or opportunity . Similarly, social, cultural, environmental, and technological realities exist which shape and define successful research partnerships in global health. Understanding these factors will direct and guide partnership formation, and ensure the achievement of desired goals.
While the advancements and benefits to health research arising from global partnerships are undeniable, there are persisting issues around inequality and distribution of these benefits between Northern and Southern partners—a ‘hierarchy of research and research outputs’ [22–24]. Numerous grants and funding regimes incentivise partnerships between high-income countries (HICs) and LMICs, and it is important that donors recognise, and are sensitive towards, the disparity of existing and contributing capacities within this international market. In addition, donor-funded programmes often have a shorter lifespan than that necessary to achieve long-term mutually beneficial and sustaining partnerships . Finding a balance between merit and equitable funding allocation would help to maintain successful working relations and garner the necessary buy-in towards the realization of goals and outcomes , ensuring that all partners benefit equitably.
Various organisational bodies and networks have begun to take action on some of the aforementioned issues, in particular the inequity of roles, responsibilities, power and benefits between Northern and Southern partners [26–28]. According to Costello & Zumla , while the extensive benefits of collaboration in global health research are recognised, there must be equitable balance between local and foreign partners to prioritise objectives and set research agendas in order for partnerships to be mutually beneficial. Their efforts in establishing four, cooperative principles of research partnerships applied to ‘developing countries’ come from a genuine desire for partnerships to promote positive change and were among some of the first to counter structural limits of persisting colonial systems. In recognition of the differing capacities, the costs, benefits and associated risks of partnering, Costello and Zumla  promote accountability of partners themselves, and even suggest that funding agencies need to play a more active role in monitoring the cooperation and equality of research partnerships. While they provide a checklist, it is evident the need for defined methods of applying such principles in the wider governance of partnerships . In applying a clear mechanism for equitable partnering, they also refer to tokenistic and exploitative partnerships formed in sole fulfilment of funding and publication requirements. Such inequities are driven by structural power imbalances engrained within development, donor and research agendas, (Page 11/12). We suggest rather than simply monitoring, the donor-recipient relationship should be considered an equitable partnership, and be guided by this framework in the same way as research partners. In combination with these existing mechanisms, we see our contribution as the development of this unifying framework for successful global health research partnerships