Comment
DRUM and international assistance for greatest impact. the African Union, the G20 hosted by Japan, and UN 
The GFF encourages country leaders to work with all General Assembly. We believe country-led initiatives 
key stakeholders in setting priorities—not only health in mobilising and using domestic resources for health 
ministries but also finance ministries, and not only may ultimately inspire other development sectors. This 
the public sector but also civil society and private matches the Addis Ababa vision, which stressed that 
firms. GFF investment cases are drawing support and cross-sectoral learning and integration are crucial to a 
funds from other global health investors. This means development model in which “no country or person is 
that as countries raise more domestic resources they left behind”.1
can pull in additional global financing, including 
from the International Development Association Roch Marc Christian Kaboré, Erna Solberg, Melinda Gates, 
and the International Bank for Reconstruction and *Jim Yong Kim
Development. Presidence du Faso, Ouagadougou, Burkina Faso (RMCK); Office 
The time to mobilise domestic resources for health of the Prime Minister, Oslo, Norway (ES); Bill & Melinda Gates 
Foundation, Seattle, WA, USA (MG); and Office of the President, 
is now. In the next 4 years, at least 35 low-income and The World Bank Group, Washington, DC 20433, USA (JYK) 
middle-income countries are expected to meet criteria ckurowski@worldbank.org
for graduation or transition from key development RMCK is the President of Burkina Faso. ES is the Prime Minister of Norway. 
assistance for health financing streams like Gavi, the MG is the Co-Chair of the Bill & Melinda Gates Foundation. JYK is the President 
of The World Bank Group. We declare no other competing interests.
Vaccine Alliance and the International Development 
1 UN. United Nations General Assembly resolution 69/13. Addis Ababa 
Association.4 Many of these countries raise relatively Action Agenda of the Third International Conference on Financing for 
little health funding from domestic sources and will Development. A/Res/69/13. July 27, 2015. http://www.un.org/ga/search/view_doc.asp?symbol=A/RES/69/313 (accessed Oct 12, 2018). 
struggle to replace external sources of funding, unless 2 Evans T, Pablos-Mendez A. Shaping of a new era for health financing. 
Lancet 2016; 387: 2482–84.
something changes. 3 WHO, World Bank Group. Tracking universal health coverage: 2017 global 
The GFF replenishment and Oslo DRUM conference monitoring report. Geneva: World Health Organization, 2017.
4 World Bank. Equity on the path to UHC: deliberate decisions for fair 
are platforms for countries to lead this change. We financing. Background report for the 3rd Annual UHC Financing Forum. 
commit ourselves to sharing what we learn in Oslo in Washington, DC: World Bank, 2018.
5 WHO. World Health Report 2010. Health systems financing: the path to 
November so that these lessons contribute to a more universal coverage. Geneva: World Health Organization, 2010.
concerted global response to health finance needs and 6 Kim JY. The human capital gap: getting governments to invest in people. 
Foreign Aff 2018; 97: 92–102. 
the broader SDG financing challenge. We will work 7 World Bank. World Development Report 2019: the changing nature of 
with countries and multilateral bodies to accelerate work. Washington, DC: World Bank, 2018. http://www.worldbank.org/en/publication/wdr2019 (accessed Oct 12, 2018). 
this agenda in 2019, through important events of 
Academic promotion policies and equity in global health 
collaborations
When global health researchers in low-income and partnerships.1 Models for equitable collaborations 
middle-income countries (LMICs) collaborate with differ from country to country and team to team, 
academics in high-income countries (HICs), these depending on the experience and empowerment of 
partnerships often result in disproportionate benefits the LMIC researchers and train ing institutes, research 
for the HIC researchers who gain more opportunities infrastructure, the length of collaborations, and the 
for authorship, more prominent authorship positions, amount of funding available for research and training. 
more opportunities to present at conferences, and However, the absence of an optimal model should not 
more funding for administrative and student support be an excuse for poor collaborative dynamics.
for LMIC colleagues. This inequity gap persists despite HIC and LMIC researchers and institutions, govern-
existing guidelines for good collaborative practice ments, journals, and funders all have parts to play in 
and repeated calls to improve global health research addressing this gap. Yet because the balance of power 
www.thelancet.com   Vol 392   November 3, 2018 1607
Comment
number of conference presentations. This time-
Panel: Challenges and recommendations to HIC 
institutions to facilitate equity in global health research bounded, “up or out” path puts pressure on faculty 
collaborations and can create perverse incentives that undermine 
Embedding strong partnerships in global health research. Here 
HIC institutional policies impede extended residencies in we outline five key areas that need to be addressed by 
LMICs. HIC institutions, particularly during faculty promotion 
• Remove administrative barriers that limit LMIC residencies. review, to foster equity in global health research 
• Extend tenure clocks to reflect the constraints of collaborations. 
embedded research.
• Fund extended residencies in LMICs where research is First, we call for promotion criteria to support 
conducted. embedding—ie, the idea that HIC collaborators, 
including principal investigators, spend substantial 
Equitable engagement of LMIC collaborators
Promotion committees do not focus on the nature of the time in the LMIC countries where their research is 
collaboration with LMIC partners. done. Embedding enables nurturing of professional 
• Ask promotion candidates to detail specific efforts to relationships, development of cultural competence, 
promote equitable collaborations. and investment in the collaborative team through 
• Solicit performance feedback from in-country shared training and mentorship. Extended residence 
collaborators and LMIC institutional leaders.
is often discouraged by administrative barriers and 
Authorship that reflects real collaboration pressures of time limits to obtain tenure at HIC 
Academics are evaluated by the number of publications and 
place in authorship order. institutions.
• Value an HIC researcher’s contribution when the LMIC Second, equitable engagement of LMIC collaborators 
collaborator is first or senior author. and unfair research practices, such as parachuting or 
• Raise questions about appropriateness of publications parasitic research,4 should be highlighted. Promotion 
about an LMIC that lack any authors from that country. committees could penalise faculty who do extensive 
Training and mentorship research in an LMIC but have not shown a commitment 
Training and mentoring LMIC students or collaborators is to meaningful and mutually productive partnerships 
often not valued. with local institutions. For example, if an HIC 
• Encourage candidates to teach or mentor in the LMIC.
researcher’s contributions are limited to provision 
Adequate funding for LMIC institutions and of funding or deployment of students or fellows to 
collaborators
Promotion committees value funds brought to the HIC research sites in LMICs, a committee should recognise 
institution but not those obtained for LMIC-related costs. that weakness.
• Value funding jointly obtained by HIC and LMIC Third, authorship that is based on real collaboration 
collaborators, including funds awarded directly to the should be incentivised. While equity in authorship 
LMIC institution. does not necessarily signal an equitable collaboration, 
HICs=high-income countries.LMICs=low-income and middle-income countries. it is often an indicator of respectful team dynamics. 
Promotion committees usually evaluate faculty by 
the number and impact of their publications and their 
and rewards tilt strongly toward HICs,2 it is important positions on authorship lists. This approach can result 
to ask what systemic, structural, and cultural factors in authorship hoarding, particularly in coveted first and 
are at work within HIC institutions that lead to these senior positions, and failure to share the publishing 
persistent problems. Our own experiences and those rewards with LMIC collaborators. We recommend that 
of a group in Kenya3 suggest that the academic promotion committees place value on authorship 
promotion process at HIC institutions is a major cause lists that feature LMIC investigators in first and senior 
of inequitable collaborations (panel). positions and ask faculty members who publish 
In HICs, most academics move along a defined faculty papers with local LMIC data but without local LMIC 
track, from assistant to associate to full professor. collaborators to explain why they did so.
Promotions are based on publications, grant funding, Fourth, promotion assessments should consider a 
and reputation, the latter generally assessed by the global health researcher’s contribution to training and 
1608 www.thelancet.com   Vol 392   November 3, 2018
Comment
mentorship in the LMIC where the researcher works. *Bethany Hedt-Gauthier, Collins O Airhihenbuwa, 
Although most promotion criteria require teaching, Ayaga A Bawah, Katherine States Burke, Teena Cherian, 
the focus usually revolves around the training of Maureen T Connelly, Patricia L Hibberd, Louise C Ivers, 
formal learners at the HIC institution; teaching in Jean Gregory Jerome, Fredrick Kateera, Yukari C Manabe, 
LMICs often does not fulfil teaching requirements for Duncan Maru, Megan Murray, Anuraj H Shankar, 
promotion. We recommend that promotional reviews Miriam Shuchman, Jimmy Volmink
recognise the efforts of HIC faculty in global health Department of Global Health and Social Medicine, Harvard 
to build the capacity of collaborative teams in the Medical School, Boston, MA, USA (BHG); Global Research Against 
Noncommunicable Diseases, School of Public Health, Georgia 
LMICs where they work, teach courses, mentor local State University, Atlanta, GA, USA (COA); Regional Institute for 
students, and otherwise support local institutions. Population Studies, University of Ghana, Accra, Ghana (AAB); 
We also recommend that HIC institutions facilitate Center for Innovation in Global Health, Stanford School of 
hosting LMIC collaborators and students for reciprocal Medicine, Stanford, CA, USA (KSB); Department of Global Health 
exchanges and learning. and Social Medicine, Harvard Medical School, Boston, MA, USA 
(TC); Department of Population Medicine, Harvard Pilgrim 
Fifth, promotion committees should consider Health Care Institute, Harvard Medical School, Boston, MA, USA 
their faculty’s efforts to ensure adequate funding (MTC); Kaiser Permanente School of Medicine, Pasadena, CA, 
for collabo rating LMIC institutions and colleagues. USA (MTC); Department of Global Health, Boston University 
Many promotion committees focus on the School of Public Health, Boston, MA, USA (PLH); Center for 
amount of grant funding that faculty members Global Health, Massachusetts General Hospital, Departments of 
Medicine and of Global Health and Social Medicine, Harvard 
bring to the HIC institution. This focus often Medical School, Boston, MA, USA (LCI); Partners In Health, 
means that the LMIC in-country research costs are Port au Prince, Haiti (JGJ); Partners In Health, Kigali, Rwanda 
consistently underfunded, LMIC collaborators’ time (FK); Division of Infectious Diseases, Department of Medicine, 
is not adequately covered, and expenses for LMIC Johns Hopkins School of Medicine, Baltimore, MD, USA (YCM); 
investigators to travel to international conferences Arnhold Institute of Global Health, New York, NY, USA (DM); 
Department of Health Systems Design and Global Health, 
and other collaborative venues are under-budgeted. Department of Pediatrics, and Department of Internal Medicine, 
We recommend that HIC institutions commit to Mount Sinai School of Medicine, New York City, NY, USA (DM); 
budgeting the real costs of global health research done Department of Global Health and Social Medicine, Harvard 
at LMIC sites. Medical School, Boston, MA, USA (MM); Department of 
Moving from talk to action on equitable partner- Nutrition, Harvard Chan School of Public Health, Boston, MA, 
USA (AHS); Summit Institute of Development, Mataram, 
ships requires overhauling long-standing guidance Indonesia (AHS); Department of Psychiatry, Faculty of Medicine, 
for evaluating HIC faculty for promotion and HIC University of Toronto, Toronto, ON, Canada (MS); and 
faculty themselves being more mindful of privilege. Department of Global Health, Faculty of Medicine and Health 
Faculty who consistently do global health research Sciences, Stellenbosch University, Stellenbosch, South Africa (JV)  
without sincere engagement and promotion of LMIC bethany_gauthier@hms.harvard.edu
collaborators should face consequences at their home We declare no competing interests. This Comment resulted from a meeting hosted at and funded by the Radcliffe Institute of Advanced Studies in 
institutions, while promotion committees should February, 2018.
celebrate faculty who take concrete steps towards 1 Walsh A, Brugha R, Byrne E. “The way the country has been carved up by 
researchers”: ethics and power in North–South public health research. 
equity in their research collaborations. HIC institutions Int J Equity Health 2006; 15: 204. 
cannot espouse global health research without 2 Shiffman J. Global health as a field of power relations: a response to recent commentaries. Int J Health Policy Manag 2015; 4: 497–99.
sincerely and constructively grappling with the tensions 3 Nordling L. Kenyan doctors win landmark discrimination case. Nature 2014; 
between long-standing promotion practices and the published online July 22. doi:10.1038/nature.2014.15594.
4 The Lancet Global Health. Closing the door on parachutes and parasites. 
imperative to engage in fair and ethical collaborations. Lancet Glob Health 2018; 6: e593.
The time is now to resolve this disconnect and develop 
best practices to enhance the quality of our global 
partnerships and scholarship. We demand better.
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