Global health enabling systems

Accounting and critique in the era of ‘America First’

Johanna T. Crane

15 May 2018


This think piece argues for the importance of administrative and bureaucratic labor –‘mundane’ things – in maintaining US-African global health research partnerships and the power relations within them. The daily work of accounting, compliance, and risk management undertaken by global health ‘enabling systems’ created by US universities contrasts with global health’s heroic self-image and conjures up negative imaginaries of intransigent African bureaucracies, crumbling communication infrastructure, and corruption. These negative imaginaries help to authorize forms of US fiscal and administrative control that may contradict global health’s ethic of partnership and its related goal of ‘building capacity’ in low-income partner nations, as well as feed ‘creative accounting’ practices by both partner entities. Critiquing these inequalities may seem risky in an era of ‘America First’ and threatened cuts to global health funding. In fact, advocating for equity in global health partnerships and prioritizing the building of African institutional capacity are only made more urgent by the current political climate.


Over the past fifteen years, US involvement in ‘global health’ has transformed. Within American universities, the number of institutes, programs, and departments dedicated to global health activities has exploded (Matheson et al. 2014). African countries, in particular, have become sought-after destinations for North American researchers and students seeking global health research or training experiences.[note 1]In this paper, I often refer to ‘Africa’ and contrast ‘US’ perspectives on global health partnerships with ‘African’ ones. By invoking ‘Africa’ generally I mirror the ways in which global health professionals (both Africans and non-Africans) speak about the common partnership challenges faced across low-income countries and institutions on the African continent. At the same time, I recognize that this results in a problematic conflation of differences across African nations.
 In a parallel and related development, the US government’s investment in African health programs has also grown exponentially over this period, most significantly through the President’s Emergency Plan for AIDS Relief (PEPFAR), which allocates billions of dollars towards funding free HIV medications, primarily in low-income African countries.[note 2]PEPFAR was initiated in 2003 by George W. Bush and has been reauthorized every five years since then, most recently in 2013.

As it has risen to prominence as a field, global health has sought to distinguish itself from its older, more paternalistic antecedents of international health and tropical medicine by grounding itself in an ethic of mutual partnership between wealthy and poor nations (Koplan et al. 2009). In this vision, global health is commonly imagined as a heroic scientific collaboration in which ‘partnership’ has the power not only to save lives but also to bridge international resource inequalities and build African research capacity. Take, for example, the words adorning the exterior of Kampala’s Infectious Disease Institute in Uganda: ‘Celebration of Partnership’, a motto that elides more than a decade of negotiations over shared ownership and governance. In 2017, at the University of Washington’s celebration of the tenth anniversary of its Department of Global Health, speakers often invoked ‘partnership’ as a core value with keynote speaker Margaret Chan, director of the World Health Organization, describing the future of global health as ‘all about collaboration and teamwork moving forward: partnership’.

What remains unspoken and invisible in these invocations of partnership are the mundane, bureaucratic, and administrative practices and structures that actually make academic global health partnerships[note 3]As a field, global health encompasses numerous types of partnerships between nations and entities. In this piece, I focus specifically on academic partnerships in global health. These arguments do not necessarily apply to other types of partnerships common within global health, such as humanitarian aid partnerships or public-private partnerships.
 such as these possible. This is where ethnography is revealing: spending even a short time talking or working with people involved in these partnerships very quickly illuminates the volume and importance of administrative labor in maintaining the viability and productivity of global health research on a day-to-day basis. This is what one key informant, a prominent US researcher and former AIDS doctor, described to me as ‘making the sausage’[note 4]This American idiomatic expression refers to the notion that watching sausage get made may reveal unappetizing truths about it, given that sausage is often made from less appealing cuts of meat. The speaker is suggesting that looking into the day-to-day operations of global health work may reveal unglamorous or unpleasant realities.
 in global health. His own global health work, for example, did not involve saving lives or caring for sick people in any direct fashion. Rather, more often than not, for him ‘doing’ global health meant sitting at his desk and ‘making conference calls for ten hours a day’. Although this kind of administrative labor is certainly not unique to global health research, the transnational and multi-institutional nature of global health partnerships escalates the scale and scope of this work. My informant’s comments notwithstanding, most of the administrative ‘grunt’ work required by global health partnerships is carried out not by leading researchers such as himself but by a multinational web of lower level, nonscientist support staff who deal with the nitty-gritty of making global health partnerships like his legal, functional, and able to succeed. This daily work of accounting, compliance, and risk management contrasts sharply with the nonmaterialist, humanitarian, and scientific registers in which ‘global health’ as a field is typically imagined within the United States.

This essay asks questions about the importance of administrative and bureaucratic labor in enabling and maintaining global health research partnerships and the power relations within them. Specifically, I speak here of academic global health partnerships between US and African universities. Although many types of partnerships exist within global health as a field (including many outside academia, the United States, and Africa), the partnerships I discuss here are typical of those that dominate the North American academic global health landscape and its representative professional organization, the US-based Consortium of Universities for Global Health. Following other social scientists who have called for ethnographic attention to mundane infrastructures and bureaucratic practices (Lampland and Star 2009; Gupta 2012; Graeber 2015; Brown, Reed, and Yarrow 2017), I argue that understanding what ‘partnership’ is and what it does in US global health science requires an examination of the transnational administrative infrastructures, practices, and relationships that allow these partnerships to form and persist.

Global health partnerships necessitate a great deal of administrative labor: the negotiation and management of legal status in a foreign country; human resources, payroll, and tax compliance across multiple national and international bureaucracies and currencies; constant attention to the vagaries of cash flow, exchange rates, and ‘money on the ground’; and daily vigilance regarding legal liability, financial risk, and the safety of staff and patients. Not only is this work mundane in comparison to global health’s heroic narratives but it also often conjures up alternative, negative imaginaries associated with global health work: intransigent foreign bureaucracies, crumbling communication infrastructure, and the specter of corruption. These anxieties, I suggest, can serve to authorize forms of US administrative control that at times seem to directly contradict global health’s ethic of partnership and its related goal of ‘building capacity’ in low-income partner nations (Chu et al. 2014; Geissler and Tousignant 2016; Wendland 2016). Understanding these colliding imaginaries of administration requires a closer examination of the administrative nuts and bolts of global health research partnerships.

Enabling systems

In the early years of the 2000s, when ‘global health’ activities within US universities were newly expanding, partnerships operated with little direct legal or fiscal oversight. American researchers ran their studies in Africa (and elsewhere) out of personal or petty cash bank accounts that they opened in the countries where they were conducting research. Foreign staff were hired on a contract basis and local tax laws were largely off the radar. But as international AIDS funding materialized and the volume of global health work grew, this informal approach soon became untenable. Large research universities with significant federal grant revenue, such as the University of California San Francisco, the University of Washington, and Harvard University, found that growing numbers of their faculty and students were traveling and working in African countries, and an increasing volume of grant money was being spent on health research in African locations. Much of this work was high profile – cutting-edge science with the potential for real improvements to health, particularly in relation to the ‘big three’ diseases of global health: AIDS, tuberculosis, and malaria. It was also prestigious. For all these reasons, universities set about to develop systems that would better support the transnational administration of global health work, as well as ensure compliance with both local laws and US federal accounting standards. 

The result is what are now commonly called ‘enabling systems’: administrative structures intended to facilitate, or enable, institutional partnerships between wealthy and poor nations by smoothing and monitoring the flow of money and other resources to American staff and their local collaborators in poor countries. These systems, designed by administrators at US universities and promoted by the US-based Consortium of Universities for Global Health, are also intended to protect US institutions from the legal and financial risks inherent in transnational partnership.

How do enabling systems work in practice, and why do they matter? Enabling systems can take many forms, but one common approach entails creating a nonprofit corporation or ‘shell NGO’ to act on behalf of the US partner. This NGO registers as a legal entity within the host country, opens a local bank account, manages the grant money, and conducts the hiring, firing, payment, and benefits management of local research staff. The University of Washington, for example, has established several such local nonprofits under the umbrella organization of ‘UWorld’, which the university has used to manage projects in Kenya, Ethiopia, and Botswana, as well as in several locations outside Africa. Although the US administrators who organize enabling systems such as UWorld see them as practical rather than political entities, such bodies do have an impact on global health governance. Their existence and practices raise important political questions about the ability and responsibility of funders, partner institutions, and African states to organize and deliver the resources that partnerships bring, what Hannah Brown (2015, 341) calls a ‘politics of sovereign responsibility’.

From the perspective of a US university, these systems have two major benefits. First, they avoid the problem of US principal investigators running their studies more or less on an ad hoc basis out of personal bank accounts and hence avoiding local tax and labor regulations. Secondly, they allow US universities to avoid administering grants directly through their African partner institutions, which are often seen as having insufficient, inefficient, and/or untrustworthy systems for administering grant money (see also Kenworthy, this issue). However, from the perspective of African partners, such systems may understandably raise sentiments of ‘managerial disenfranchisement’ (Brown 2015, 343).

‘Enabling’ is traditionally defined as ‘making possible or easy’, and since legal, fiscal, and administrative problems all pose barriers to getting research done, it can be argued that these systems live up to their name of enabling global health.At the same time, they work to monitor and ensure compliance – but not entanglement – with the laws and regulations of partner countries (Appel 2012). In this way, these systems enable partnership, but they also enable forms of control with deep and tenacious roots in the history of colonialism (see also Boum, this issue and Fouad, this issue). Notably, in recent years the concept of ‘enabling’ has taken on an alternate meaning in certain subfields of psychology, where it is used to refer to the facilitation of self-destructive behavior by another (Merriam-Webster 2017). Might these administrative enabling systems be facilitating arrangements that are harmful to African institution building, even as they make the logistics of partnership easier (Okeke, this issue)?

Creative accounting

Much like the development enterprise before it, global health’s optimistic, public face of ‘partnership’ is shadowed by Western anxieties about African corruption and mismanagement (Smith 2007, 91). I have heard US global health leaders describe African institutions as ‘too difficult’ to work with directly, a fear that is not unfounded given, for example, the two-month closure of Uganda’s national university in 2016 in response to a lecturer strike. Enabling systems work to alleviate such anxieties by keeping the administration of grant money in American hands and out of African university and government bureaucracies.[note 5]Granted, this arrangement is often out of necessity, as many African partner institutions do not have central grants offices, or, if they do, they may not have the training needed to comply with US federal accounting regulations. This points to the need to include administrative infrastructure and grants management training into the research capacity building that is part of the promise of partnership. See also Okeke this issue.
 At the same time, we should be concerned that such arrangements do little to counter African concerns that a great deal of US funding intended for ‘global health’ ends up back in American pockets (Barnhart and Diallo 2016). In this way, the suspicion of corruption cuts both ways.

Suspicions regarding the true beneficiary of US global health funding may be further seeded by US federal granting policies. US institutions that receive grant money from federal agencies such as the National Institutes of Health (NIH) are reimbursed for overhead or ‘indirect’ costs at negotiated rates that regularly exceed 50 percent or more of the direct research budget. In other words, for every research dollar awarded, a US university with a negotiated indirect cost rate of 50 percent will receive an additional 50 cents to put towards overhead expenses.[note 6]These rates are the source of some controversy. Detractors argue that they are overly generous and take money away from science. While a senator, US Attorney General Jeff Sessions requested and received an audit of the NIH’s accounting and criticized the growth in spending on indirect/infrastructural costs, saying it detracted from ‘direct research functions’. Advocates of indirect cost reimbursements see them as essential for maintaining the physical and administrative infrastructure necessary to support science, and for meeting the costs of regulatory oversight such as institutional review boards and conflict-of-interest reporting (Brainard 2005; Basken 2013; Ledford 2014).
 However, for foreign institutions the US government caps this reimbursement rate at 8 percent. This means that if a US university and an African university are ‘partners’ on an NIH global health research grant, the African university will receive 8 cents on the dollar for institutional overhead, while the US university will get its negotiated rate of 50 cents or more. This can sometimes lead to accounting requirements that seem unfair, if not perverse. For example, grants administrators at Uganda’s Infectious Disease Institute – an international hub of global health research and the recipient of significant US federal research funds – must reimburse any American subcontractors at their negotiated US rates but can take no more than 8 percent to support the institute’s own facilities and administration, including, ironically, the costs of managing and administering that very grant. This hardly seems like a ‘celebration of partnership’.

How might we structure such global health partnerships differently? Are there ways to acknowledge and confront the ‘public secret’ of North/South inequalities that so often remain unacknowledged between partners (Geissler 2013; Geissler and Okwaro 2014)? Is it possible to achieve equity, or at least reduce disparities?

Interestingly, on the ground, ‘real’ partnerships reveal small but creative ways of working within and around the rules and regulations that perpetuate inequalities between African and American staff. Many US global health researchers are acutely aware that US grants offer disproportionate reimbursement, both to them personally and to their institutions, whether in the form of generous travel per diems or disparate overhead cost reimbursements. In response to such frustrations, some global health professionals have developed ways to push back against arrangements that they perceive as unfair or unjust. These are the kinds of ‘workarounds’ that I hear about as ethnographic anecdotes, and that enabling systems are designed to discourage. For example, at a dinner I attended at a midwestern US university, the associate director of the university’s global health program mentioned redirecting her generous US$80 per diem meal reimbursement (set by the US government) towards conference costs for a Liberian junior colleague, who had little official access to funding to support attendance. In another example, I have heard both US and Ugandan grants administrators describe the strategic budgeting of African facilities and administrative expenses as ‘direct cost’ line items in order to get around the US government’s restrictions on indirect cost reimbursements to foreign institutions.

Other scholars of global health have made similar observations regarding the ‘official’ versus ‘unofficial’ economies of global health funding. In his ethnography of a Kenyan trial community, Geissler (2011) shows how transport reimbursement payments to study participants are less about covering travel expenses than they are about the ‘public secret’ of inequality that underlies global health research, and the value that research trial affiliation may hold for community members. Conteh and Kingori (2010) observe that even comparatively small per diem reimbursements for attendance at conferences and workshops may constitute an important salary supplement for underpaid African public sector workers, and that such payments are often dwarfed by those received by Northern colleagues for participation in similar events. Pfeiffer’s (2003) work in Mozambique shows that funders’ authorization of per diems can cut both ways: at times, such payments represent Northern partners’ efforts to redress the financial hardships faced by their Southern colleagues, but they can also be deployed strategically as a means to leverage local support for priorities set by Northern funders. Importantly, all of this quasi-official reimbursement takes place against the backdrop of a global health endeavor that relies heavily upon unpaid ‘volunteer’ labor by people in African partner countries (Prince and Brown 2016; Kalofonos 2014; Biruk and Trapence 2017).

What are we to make of these gestures? Is this creative accounting tantamount to misuse of funds, or even ‘legalized corruption,’ as some have argued (Ridde 2010)? If so, are global health ‘enabling systems’ the solution? At times, this strategic budgeting does resemble the personalization of bureaucracy that Smith (2007, 56) describes as characterizing corruption and that enabling systems seem designed to prevent. Yet, as others have pointed out, ‘corruption’ or ‘mismanagement’ are too often and too easily seen as ‘African’ problems, a framing that perpetuates the American tendency to see corruption as something that happens elsewhere and obscures how many of the practices in question are neither African nor American, but inherently transnationalin nature (McKay 2012; Conteh and Kingori 2010).

An alternative framing could be to imagine these examples as small acts of resistance against the inequalities built into the systems that fund and administer global health partnerships. Much in the way that medical providers and billers in the US learn how to strategically ‘work’ diagnosis coding in order to assure insurance coverage for their patients within an unequal system (Kaufman 2005; van Eijk 2017), we can see that global health professionals learn how to ‘work around’ or ‘creatively comply’ with structures that offend their sense of what is right (Berlinger 2016; Buchbinder et al. 2016). In this reading, we might see such actions as going beyond the sunny promise of ‘partnership’ and engaging in the more complex work of solidarity across inequalities. But this reading is problematic as well. Not only does it mask the ways that incentives can be deployed to ensure patronage (thus reinforcing rather than challenging inequalities), it also maintains a problematic focus on the actions of individuals rather than on the structural conditions that encourage, perpetuate, and sometimes justify these actions.   

America First?

It is not an easy time to critique the global health enterprise. Back in the flush days of the George W. Bush administration, gratitude and amazement in reaction to the sudden bounty of global health programs like PEPFAR could safely be accompanied by justified concerns about the structure and politics of such programs. At time of writing, in 2017, US global health programs and their partners face the prospect of an ‘America First’ federal budget that would cut NIH funding by nearly 20 percent and that proposes the complete elimination of its Fogarty International Center, an agency dedicated to global health research and one of the few US federal bodies that provides direct funding to African researchers. Criticizing global health – whether over enabling systems or creative accounting – seems like a more dangerous game than it was only a few months ago.

What is to become of global health in this era of ‘America First’? Although it feels risky, the current political moment makes careful critique all the more important. Already, well-meaning defenders of global health are advocating for the continuation of US global funding on the grounds that cuts will harm Americans, because ‘80% of federal dollars funding global health research goes to US institutions’ – a defense designed to appeal to ‘America First’ thinking, but also one that will only further confirm African suspicions about the true beneficiaries of US global health funding (Slyker 2017). Instead, we must continue to fight for a global health enterprise that lives up to the field’s aspiration to ‘the mutuality of real partnership’ (Koplan et al. 2009).

The use of ‘enabling systems’ to circumvent African institutional partnership is a small example of a much bigger and long-standing problem of the systematic ‘decapacitating’ of the African public sector by US policies and programs promoting the privatization of health (Pfeiffer and Chapman 2015).The consequences of this hollowing out were made dramatically evident by the West African Ebola outbreak, which was spread and amplified by the lack of adequate public health infrastructure and staffing (Packard 2016). The need to strengthen health systems in Africa remains imperative for both Africans’ health and global health (Pfeiffer and Chapman 2010; Gimbel et al. this issue). Doing so, I argue, should include a commitment to strengthening the African public administrative and educational systems that undergird global health research. Global health should not put ‘America First’, nor should enabling global health partnerships perpetuate the erosion of the African public sector. Given that the current US administration has called for the ‘deconstruction of the administrative state’, critical ethnographic attention to the administrative infrastructure of global health partnerships – and the work that this infrastructure does, both to enable and disable scientific and health capacity in Africa – has never been more important.

About the author

Johanna Tayloe Crane is the author of Scrambling for Africa: AIDS, Expertise, and the Rise of American Global Health Science (Cornell University Press, 2013) and holds a PhD from the UCSF/UC Berkeley Joint Program in Medical Anthropology. She is Associate Professor of Science, Technology, and Society at the University of Washington Bothell and an Adjunct Associate Professor of Anthropology at the University of Washington Seattle.


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