Transforming partnerships through transboundary research

Abstract

Research partnerships are a key entry point for addressing the asymmetries that pervade global health. However, highly competitive and fast-paced science limits the kind of innovation and transformative change needed to reduce the imbalances that undermine the independence and academic freedom of research partners. The goal of this piece is to present a transformative lens for partnerships in which participating research organisations are willing to be mutually influenced through genuine collaborative efforts. In contrast to transactional partnerships, a transformative collaboration identifies a set of goals toward which the partnership wishes to work and agrees on the process for achieving them together. First, reflexivity and awareness of positionality are needed to recognise the power relations embedded in research and how these relations may not serve all people equally. Second, solidarity and togetherness create an interconnected view that transcends differences. Third, collective reflection on how and why the desired changes will occur is needed to guide the planning of 'who will do what, how and when' to advance equity-centred actions. Finally, shared responsibility for actions and outcomes will ensure mutual trust and a productive working relationship among partners. Implementing these principles requires some partners to relinquish control and step back when necessary, others to take ownership and greater leadership, and all partners to act with solidarity, accountability and trust. These complementary attitudes underpin the success of transformative partnerships in realising the full societal value of global health research.

Keywords: Global Health.

Figure 1. Key drivers for transformative partnerships along the working together continuum. Working together can take place at different levels of engagement, ranging from basic interaction to deeper, more integrated forms of collaboration. Cooperation is a relationship between individuals who may not have a common goal but who support each other and their objectives through individual tasks or projects. Collaboration is the process by which a group of individuals work together to achieve a common goal. Partnerships typically reflect a higher level of interdependence, often with shared risks, responsibilities and rewards. All partnerships are a form of collaboration, but not all collaboration is a partnership. As we move from left to right on the continuum, working relationships move from more transactional (focused on short-term goals, compliance and structured procedures) to transformational (built on a shared vision, fostering a culture of autonomy and ownership, and taking a long-term approach to support mutual growth and development). Key drivers of transformative partnerships are positional awareness (introspection to understand individual and institutional positions in relation to different social identities such as gender, race, class, ethnicity and geographical location), togetherness (a sense of interconnectedness and shared responsibility among partners), intentionality (a pragmatic purpose to drive change through action rather than rhetoric) and a vibrant culture of accountability (a willingness to take responsibility for one’s actions).

Figure 2. Common misconceptions in global health research partnerships. The ‘learner-teacher’ misconception, which assumes that researchers from low-income countries lack the capacity to address their country’s health problems, leads to seeing only weaknesses where there are strengths. This emphasis on deficits encourages the formulation of top-down projects dominated by institutions located far from the settings most affected by the health challenge being researched, ultimately reducing agency and perpetuating dependency. The ‘implicit capacity development’ misconception assumes that ad hoc capacity building linked to specific projects is sufficient to address contextual challenges and usually leads to fragmentation of development efforts rather than addressing systemic needs. As knowledge and technology are assumed to be concentrated in high-income countries, it is also wrongly assumed that partnerships only benefit less well-resourced partners (the ‘unidirectional’ misconception). However, high-income institutions also gain much from these collaborations because the health challenges that researchers seek to alleviate are also a professional, knowledge-generating opportunity to be exploited (eg, creation of global health schools and master’s programmes, project overheads, salaries and promotion of researchers). Recognising the benefits of global health research for all institutions involved in the collaboration, while increasing direct funding to institutions located where the health challenge resides, can help to promote more balanced partnerships. Finally, the belief that all differences are inequities (the ‘right-over-duties’ misconception) can encourage charitable roles, complacency and accommodating attitudes that reduce active engagement and ultimately undermine empowerment.

Figure 3. Outcome-driven path for transformative research partnerships. The path begins with the identification of the problem that the collaboration seeks to address, which in the case of global health usually refers to power imbalances and inequalities in relationships, and the changes that the collaboration expects to bring about. The thinking on how to solve the problem can be summarised in a pathway of change that defines (a) the overall strategy; (b) the inputs (resources needed to drive the change); (c) the critical actions that will be required to achieve the strategic goal; and (d) the outputs (tangible, measurable results achieved by the partnership) that will ultimately lead to the joint realisation of the partnership’s outcomes (short-term to medium-term effects) and impacts (long-term effects). Designing this path requires critical reflection on key enablers (the conditions needed to ensure the partnership’s ability to deliver), barriers (potential obstacles that may prevent success) and risks (the likelihood that something will affect the partnership’s ability to achieve its goals). Joint action by partners is required in three main areas: (a) institutional commitment to ensure appropriate governance, leadership and resources; (b) engagement with the context to promote country-owned models by breaking down structural barriers; and (c) effective joint review, monitoring and accountability to ensure the implementation of corrective measures and continuous improvement (feedback loop from the outcomes back to the strategic goal).

Figure 4. Dimensions of accountability in research partnerships. Accountability in the management of funds, the implementation of activities and the use of research results maintains a productive working relationhsip between partners and ensures that tasks are completed as planned. Accountability is experienced individually (and thus depends on personal views and capacities) and implemented institutionally (determined by the way collaborative research is approached). Across these two levels, five inter-related dimensions underpin accountability. First, a set of individual and institutional values such as honesty, fairness and solidarity. Common barriers to this dimension include, at the individual level, arrogance, complacency, lack of motivation to improve or fear (of failure, of making a mistake, of being too hard or too risky) and, at the institutional level, the belief that accountability will just happen, perverse incentives and unfair governance. Second, personal skills and capabilities (such as effective communication to articulate ideas and instructions succinctly, maturity in dealing with disagreement, and time management) and institutional mechanisms to ensure accountability. Barriers include opacity in the institution's accountability standards, lack of resources, underestimating the time needed to get things done due to inexperience in thinking realistically or to make a favourable impression, overestimating one’s own abilities, self-serving bias (attributing past failures only to external factors and not to one’s own abilities and efforts), and memory bias (inability to correctly recall how long similar tasks took in the past). Third, leadership to demonstrate the importance of accountability and to provide clarity about goals, roles, timelines and budgets. Proportionality (ie, balance between scientific ambition and the commitment required to achieve quality and equity-focused outcomes) is essential to avoid over-commitment to too many tasks and projects. Fourth, the style of relationships and work within teams, institutions and partnerships, such as creative and problem-solving thinking, openness to give and receive feedback, speaking up to take responsibility, adherence to rules and regulations, and attention to detail. Poor organisational structure of the teams and institutions involved, skills gaps, last-minute habits and diffusion of responsibilities increase the risk of errors that compromise accountability. Finally, monitoring to ensure the quality, accuracy and completeness of activities, and feedback mechanisms to reflect on shortcomings, failures and missed targets for continuous improvement. Lack of visibility, traceability and objective measures of success, as well as failure to recognise the contributions of team members, are common barriers to this dimension.

Figure 5. Indicator typologies to monitor transformative partnerships. Representative, simple and specific indicators (signs of success) make it possible to monitor the partnership’s activities in relation to the agreed goal and expected outcomes. Success indicators provide a framework to guide and sustain partnerships, ensuring that they remain productive and beneficial for all involved. Well-designed indicators help to set expectations from the outset and to check that all partners understand the aims, roles and responsibilities, enabling accountability. They also allow progress to be monitored, strategies to be adjusted and tangible impacts to be measured, helping to keep the partnership focused on its goals. Finally, and particularly important in equitable partnerships, where success is not just about outcomes for one partner, but for all involved, indicators allow for the establishment of appropriate monitoring mechanisms to ensure that the partnership is beneficial to all, and promote fairness, trust and long-term sustainability.