In 2020, Seye Abimbola and Madhukar Pai published a short comment in The Lancet with a provocative title: “Will global health survive its decolonisation?” Their definition was deliberately broad. To decolonise global health, they wrote, is to remove all forms of supremacy within all spaces of global health practice, within countries, between countries and at the global level.
Their title implied a question most of the field has avoided since. If global health as we know it were actually decolonised, would it still look like global health as we know it?
The honest answer is probably not. And that is the point this piece wants to press. “Decolonizing global health” has become a phrase that institutions adopt easily, precisely because in practice it has so often cost them nothing. Real decolonisation requires someone to give something up: money, authorship, authority, location or the right to define the problem.
Where the imbalance shows up
It is easy to talk about decolonisation in abstract terms. It is more useful to look at where power actually sits.
Authorship is one place. A 2021 analysis in BMJ Global Health by Michelle Dimitris, Matthew Gittings and Nicholas King examined nearly 787,000 publications on global health from 2000 to 2017. Across all low- and middle-income countries, representation looked reasonable: 86 percent of papers had at least one author affiliated with a low- or middle-income country. But for research about low-income countries specifically, only 36.8 percent had a first author from a low- or middle-income country, and only 29.1 percent had one as last author. Representation was lowest in research funded by high-income countries.
In other words, the poorest countries are often the subject of research led by someone else.
Governance is another. Global Health 50/50’s 2022 report found that about three-quarters of board seats in the global health organisations it examined were held by nationals of high-income countries, with nationals of low-income countries holding 2.5 percent.
These numbers are not a moral accusation. They are a description of who decides.
Three practices that look decolonial and often aren’t
Because the language of decolonisation is now widespread, it is worth naming practices that adopt the language without changing the structure.
- Adding a local co-author. Including a researcher from the study country is better than not doing so. But if the question, design, funding and analysis were all set elsewhere, the byline is decoration.
- “Capacity building.” The phrase often implies that expertise flows one way. Much of the relevant knowledge about a health system sits with the people who work in it. Treating them as trainees rather than colleagues reproduces the hierarchy it claims to reduce.
- Diversity panels. Inviting speakers from the Global South to conferences and events is welcome. It does not change who funds the programmes, sets the research agenda or approves the budgets.
Each of these can be done sincerely. Each can also let an institution feel it has addressed the problem while leaving power where it was.
What decolonisation means in practice
If the phrase is to mean anything operational, it has to translate into specific changes. Here are some that would register.
- Fund institutions in the Global South directly, with control over how money is spent, rather than routing funds through Northern intermediaries that take overhead and set conditions.
- Let the question come from the place. Research priorities should be set, or at least co-set, by the institutions and communities where research happens.
- Share authorship according to real contribution, including first and last authorship for researchers who led the work locally.
- Locate institutions differently. Headquarters, data hubs and technical agencies based in the Global South shift who is close to decisions.
- Accept local standards of evidence and practice where they are sound, rather than treating every approach developed elsewhere as the default.
Abimbola has also written about what he calls “the foreign gaze,” the tendency for global health work to be designed, written and judged for audiences outside the countries it concerns. A practical test follows: who is this paper, programme or report actually written for?
The trade-off nobody wants to name
Here is the uncomfortable part, and it applies to organisations like conferences, journals, universities and funders in high-income countries.
Decolonisation is not free for those institutions. It means less control over budgets, fewer first-author papers for their staff, fewer headquarters jobs, and less authority to define what counts as good evidence. Many of the people who genuinely support decolonisation work inside institutions whose business models depend on the current arrangement.
That tension does not make them hypocrites. It does mean that commitments should be judged by what they cost, not by what they say. A statement is cheap. A shift in budget control is not.
It also means that some things currently called global health might, after decolonisation, simply become national health, led and defined by national institutions, with international partners in a supporting role. That would be a success, not a loss.
A research partnership, examined step by step
It helps to look at how a typical research collaboration distributes power, step by step. The example is a composite, not a specific project.
A research team at a university in a high-income country wins a grant to study a health problem in a low-income country. The grant was written in the funder’s language, to the funder’s priorities, by the team that will hold the budget. A partner institution in the study country is named. It will recruit participants, collect data and manage fieldwork.
The budget flows through the lead institution, which retains overhead. The partner receives a subcontract, often with restrictions and delays in payment. Data is transferred to the lead institution for analysis. The main papers are written there, with the partner’s researchers listed in the middle of the author list. The lead team presents the findings at international conferences. The next grant, building on this work, is again led from the high-income institution, now with a stronger track record in the field.
Nobody in this story needs to act in bad faith. Each step follows the rules of how research is funded and published. But the cumulative effect is that expertise, reputation and future funding flow to the institution that was already strong, while the partner remains a partner.
That is the structural problem decolonisation is meant to address. It is not mainly about individual attitudes. It is about how rules distribute advantage.
The strongest counterargument
There are serious critiques of the decolonisation agenda, including from people in the Global South, and they deserve a fair hearing.
One is that the term itself can obscure more than it reveals. Colonialism was a specific historical system, and applying the word to funding arrangements or authorship can seem imprecise. Some argue that the more useful frames are equity, justice or power, which point more directly to what needs to change.
A second is that the agenda has been captured by the institutions it criticises. Universities and organisations in high-income countries now run decolonisation seminars, fund decolonisation projects and publish decolonisation papers, sometimes gaining prestige from the critique of their own position.
A third is practical. Some institutions in low-income countries are not yet in a position to manage large grants or lead complex research, and transferring control too quickly could lead to failed projects.
Each of these holds in part. The language debate is real, and many scholars prefer to talk about equity or power. The risk of capture is real, and the irony of well-resourced institutions leading the conversation is not lost on people in the Global South. And capacity gaps exist in some places.
But none of these critiques argues for leaving the current system unchanged. Whatever the terminology, the imbalances in authorship, funding and governance are documented. The response to capture is to shift resources, not to abandon the goal. And capacity gaps are partly the product of the current system, which has kept money and leadership in a few institutions. They close when institutions are given the chance to lead, with support, not when leadership is perpetually postponed.
Second-order effects
Evidence quality improves. Research led by people who understand the context is more likely to ask relevant questions, design feasible interventions and interpret findings accurately.
Retention of talent. When researchers in the Global South can lead well-funded work at home, fewer need to move abroad to build careers.
Policy uptake. Evidence generated by national institutions is often more trusted by national policymakers and more likely to influence decisions.
Uncomfortable transitions. Shifting power will create friction. Some high-income institutions will lose funding, staff and status in global health. Some partnerships will fail during the transition. That is a cost, and it should be acknowledged rather than wished away.
What this means for different decision-makers
For funders, the most direct levers are to fund institutions in low- and middle-income countries as lead grantees, to cap overhead taken by intermediaries, and to require equitable authorship and data-sharing agreements as a condition of funding.
For universities in high-income countries, the question is whether they are willing to take supporting roles in partnerships, with budgets, authorship and intellectual property shared accordingly. Promotion criteria that reward first-author papers and grant income will need to recognise supporting roles too, or incentives will not change.
For journals, editorial boards, reviewers and authorship policies can be examined for geographic balance, and papers based on research in a country can be expected to include meaningful local authorship.
For global health practitioners, the most useful habit may be to ask, in every project: who defined this problem, who controls the budget, and who will get credit? If the answers all point to the same place, something needs to change.
What to watch next
Watch whether funders publish data on the share of grants awarded directly to institutions in low- and middle-income countries. Watch for journals that adopt enforceable authorship equity policies. And watch whether the growing number of Global South-led research institutions and networks attract direct, long-term funding. The rhetoric of decolonisation is now widespread. The budget lines will show whether anything has moved.
Where the Global South is already leading
It would be a mistake to write about decolonisation only as something that high-income institutions must do. Much of the most important change is being led from the Global South itself, through regional institutions, national public health institutes, research networks and scholars who have been making these arguments for far longer than the recent wave of attention.
The appropriate response from high-income institutions is not to lead this agenda but to follow and support it: funding it on terms set by those leading it, citing and publishing their work, and stepping back from roles that others are ready to take. The measure of success is not how many decolonisation initiatives Northern institutions launch. It is how many decisions they no longer make alone.
Seen this way, decolonisation is less a destination than a direction of travel, measured in concrete shifts: a grant awarded directly rather than through an intermediary, a first authorship that reflects who did the work, a headquarters that moved, a priority set by the people it concerns. Each is small. Together they change who global health belongs to.
The takeaway
Decolonizing global health is not mainly a matter of language, representation or goodwill. It is a matter of who holds money, authority and the power to define the problem. Until those move, the rest is decoration.
The most useful question for any institution claiming to support decolonisation is simple: what have you given up?
What would a genuinely decolonised global health partnership look like where you work? Tell us in the comments.
