Partnerships for now?

Temporality, capacities, and the durability of outcomes from global health ‘partnerships’

Iruka N. Okeke

15 May 2018


Scientific alliances are typically referred to as ‘collaborations’ but in recent times, those with global health or other development goals are increasingly referred to as ‘partnerships’. I observe that one of the features common to this type of partnership is temporality: flagship programs are frequently initiated but less commonly sustained. Thus the pressure that short-term transnational projects place on African health and educational systems that implement them is sometimes hard to justify. I suggest that one reason for the short life spans of partnerships is inadequate attention to the need to build ‘hard’ and leadership capacities: infrastructure, managerial expertise, administrative capabilities, and the capacity to improvise at African partner institutions.

Introduction: What is a ‘partnership’?

The word ‘collaboration’ may have many connotations but in science it is commonly used to describe different scientists and scientific institutions coming together to address a problem of mutual interest. Collaborators can have similar or radically different expertise and they share the credit associated with their findings. ‘Collaboration’ is the preferred term in the biological and health sciences but ‘partnership’ is increasingly employed to describe transnational efforts between Western and African scientific entities when they have a health or development goal. It is not entirely clear to me why those connections are increasingly being intentionally delineated from the collaborations that have occurred for years among basic science researchers, particularly North-North and South-South connections.[note 1]With the important exception that in South-South health or development-oriented collaborations, including a middle- and a low-income country again evokes the word ‘partnership’.
 While ‘partnership’ is expressly used in health and development projects, basic and applied science alliances – even North-South ones – remain ‘collaborations’. For example, even though ‘partnership’ is used increasingly, the recently launched ‘10,000 Salmonella genomes project’ describes itself as a collaboration, and it is explicitly seeking ‘collaborators’ rather than ‘partners’ from Africa and South America.[note 2]See:
 By contrast, the Connecting Health Research in Africa and Ireland Consortium (ChRAIC) explicitly refers to itself as a ‘partnership’ having very practical health systems development goals and describes itself as a ‘network of action’ (Elmusharaf et al. 2016).

As a biologist who has engaged in laboratory research on Africa-relevant topics in Nigeria, Ghana, the United Kingdom, Germany, and the United States, my entire career has been dependent on international collaborations, most spanning at least two continents. I have therefore watched the influx of the term ‘partnership’ into my workspace with interest, particularly as I principally see it in efforts between African countries and other connections (when not used in the context of public-private partnerships, which are not the subject of this think piece unless transnational). As a more-or-less basic scientist, I continue to work within ‘collaborations’. However, my research has explicit real-world applications and scientific ‘partnerships’ have inched closer in the last decade even though my own research has not become significantly more applied. They are now at my Ibadan doorstep, creating some urgency for me to understand what the term means and how I should participate. Many of my colleagues and mentees are project ‘partners’ or would like to be, and so the questions I raise here are of broader interest than my own career trajectory.

Even when joint North-South efforts are fraught with complications arising from inequities, they remain ‘collaborations’ (Jentsch and Pilley 2003; Geissler and Okwaro 2014; Owusu-Nimo and Boshoff 2017). Thus we cannot suggest that unacknowledged inequities alone are forcing the (mis)use of the word ‘partnership’ even though ‘partnership’ is admittedly often invoked to defensively suggest equity (Brown 2015; Fourie this issue). Whilst I do not in any way dismiss these very real and common inequities, I would like to suggest that the term ‘partnership’ is also a convenient misnomer for transnational scientific endeavors that have other feature(s) in common that distinguish them from straightforward collaboration. International collaborations with development or health outcomes are better supported than ever before. Is the terminology evolving because funders bankroll collaborations whilst donors pay for partnerships? After all, donors are often listed as explicit partners in partnership relationships. Or maybe collaborations yield scientific outcomes whilst partnerships may not? These explanations do not seem likely in global health, where operational partners on both sides are more often than not scientists, and both developmental and scientific funding agencies support partnerships. It is worth noting that in the domestic realm, partners generally cohabit. Does the use of ‘partnership’ imply an expectation of Northern partner presence at the African site (or the less common reverse)? This is something that certainly happens more commonly in global health partnerships than in scientific collaborations. But business partners have no need of cohabitation, and physical proximity does not feature in many other types of partnership. Perhaps we describe global health collaborators as ‘partners’ simply for want of vocabulary? It is increasingly necessary to be careful with language and its associated politics. After Dambisa Moyo (2009) ‘killed aid’ in her brief monograph[note 3]The full title of Moyo’s monograph is Dead Aid: Why Aid Is Not Working and How There Is Another Way for Africa.
, the language to inoffensively describe a connection that should be mutually beneficial but to which one party is more closely connected to the funding source while another expends more cash may not exist. As Janelle Taylor also asks in this issue, the real question is: Is ‘partnership’ just a convenient term or is there more contained in its meaning?

‘Partnership’ is of course commonly used in other far-from-perfect contexts. Domestic union partnerships may be the comfortable analogy, connoting consent, family, mutual aspirations, and longevity, all things that we would like to see in international programs working towards African health and development. And of course, commitment: for better, for worse. Aberrant domestic partnerships may include strife, contractual breakdown, and even the dreaded but rarely discussed domestic violence. It is perhaps significant that in global health, African and Northern participants as well as on-lookers use the word ‘partnership’ but this does not necessarily mean that everyone who invokes the term imagines these unions in the same ways. We view domestic partnerships differently, after all. An Ibo person may see a man and the two wives he paid dowry on in eastern Nigeria as a domestic partnership in a way that most Americans would not.[note 4]Somewhat paradoxically, some global health partnerships have been compared to polygamous marriages, with the ‘wives’ being the Northern partners (Brown 2015).
 Similarly, a Californian might take for granted a same-sex domestic union that some Nigerians would not sanction. In all probability, global health partnerships are viewed very differently from different vantage points on either side of the Atlantic, with the viewers politely smothering their disapproval and dissension. Maybe it is best not to talk about these things, but permit me to request a brief airing. In the remainder of this essay, I would like to draw out other features of global health ‘partnerships’, with their many varied goals, which would account for the use of a collective term, irrespective of whether that use was originally intended.

Partnerships for now

In real world partnerships, specifically those built around global health goals, after proposed innovations are tested, community health workers are trained, or an intervention has been piloted, what happens next? A rather too common answer among very different global health partnerships is: little if anything. In sharp contrast to domestic partnerships and even scientific collaborations, one of the uniting characteristics of all but a few very significant global health partnerships is their temporariness. Collaborating biomedical scientists often continue to associate, however informally (and admittedly with fewer administrative and budgetary constraints), but continuity beyond the funded period (or its no-cost extension) is much less common in global health partnerships. Partnerships are for now and not for the distant future.

The most heavily criticized partnerships may be those that are cobbled together as ‘postal’ or ‘parachute’ projects (Costello and Zumla 2000; Wolffers, Adjei, and van der Drift 1998; Ross-Degnan et al. 1992; Fullwiley 2011; Osseo-Asare 2014), but many modern partnerships aspire to an ongoing local presence and mid-term goals (Brown 2015; Crane 2013; Wendland 2016). Implementation science measures sustainability, but in the area of global health, it is less popular and credited than developing and testing brand new interventions (Madon et al. 2007; Geng, Peiris, and Kruk 2017). This may be why comprehensive scientific evidence of the proposition that partnerships preclude the long-term is lacking. Evaluation of partnership projects – in those uncommon instances where it occurs – is typically paid for with project funding, a conflict of interest of sorts. And even when projects do determine weak points and critical issues for longevity, it is difficult to determine which activities are sustained afterwards and for how long (Huttinger et al. 2015). The dearth of data notwithstanding, enough postpartnership debris litters many an African hospital, university, or even curriculum vitae for us to be sure that many are not sustained. Examples even abound in the literature and are particularly common in my own area of laboratory medicine, a highly technical and costly field where expertise is repeatedly lost and regained as the priorities of science and global health alter.

In one example I have chronicled before (Okeke 2011), a partnership between the US Centers for Disease Control and Prevention and health care providers at Kenema Hospital in Sierra Leone resulted in the development of a rapid and sensitive diagnostic test for Lassa fever (Bausch et al. 2000). With on-site testing, Lassa fever patients could rapidly be identified and placed on the expensive disease-specific drug ribavirin and health care workers could use valuable barrier protection so that they did not contract the disease. Yet, only four years after the test was published, during a devastating 2004 Lassa fever outbreak, results of laboratory confirmation of a few infections were only obtained after specimens were flown to South Africa. Most patients were never tested at all. Initiatives put in place after the 2004 outbreak rebuilt laboratory testing at Kenema but only after all of the early capacity was lost. In 2010, a new initiative to revamp diagnosis at Kenema Hospital and elsewhere was initiated, and present attempts to rebuild broader hemorrhagic viral disease laboratory testing capacity after the recent devastating Ebola outbreak can be seen as a continuation of that effort by a wider range of actors. Intermittent laboratory access to hemorrhagic fever testing is highly undesirable but better than no access at all; still, sustained access would be so much better (Yozwiak et al. 2016; Okeke 2011). Every one of the laboratory enhancement initiatives at Kenema Hospital, each of which has been beneficial, would fit the present-day description of a partnership, yet almost all of them have produced outcomes that subsequently disappeared.

When an Ebola outbreak began in nearby Guinea in 2014, one of the reasons why the response was delayed was that international experts that could have been called in were training scientists in Democratic Republic of the Congo on blood collection in Ebola epidemics (Tomori 2015). This sounds completely reasonable and perhaps even well timed, until one recalls that DRC has had the misfortune of having numerically more documented Ebola outbreaks than any other country, beginning with the first one in 1976 (CDC). Prior to the West Africa epidemic, almost all non-African clinical and epidemiological Ebola researchers in the world had visited DRC for assistance or with partnerships. So, why did capacity building in blood collection techniques appear to be starting from scratch in 2014? And if indeed it may not have been necessary, as has been suggested (Tomori 2015), why was it taking place? In other words, why was it presumed that blood sample collection training would be required in a country that offers technical assistance to African countries with less experience of Ebola?

The hemorrhagic viral fever examples illustrate in different ways how the temporality of partnerships can lead to essential resources being absent at the most pressing times of need. Short-term transnational projects benefit African scientists and Africans in general but have also been disparaged by Africa-based scientists (Yozwiak et al. 2016; Tomori 2015). But beyond the disruptions brought by presences and absences, we must question the value of temporary linkages that are created by all but a few partnerships. For less life-threatening conditions, a benefit from temporary capacity may not always exist because, irrespective of what they may build, partnerships also strain capabilities. Indeed, in spite of their pristine intentions, global health interventions are in some sense violent. And as Mahatma Gandhi once said, violence can do temporary good but permanent evil (Gandhi and Dalton 1996, 43).[note 5]This is a paraphrase of Gandhi’s original quote, ‘I object to violence because when it appears to do good, the good is only temporary; the evil it does is permanent’.

What strains do partnerships produce? In global health partnerships, both sets of partners add on travel and transnational activities to their normal academic responsibilities. In particular, whilst there is currently an oversupply of PhDs in academia in the United States who could be recruited to participate in partnership activities, there are scarce highly trained African individuals who can take on critical but mundane project tasks along with the scientific partnership responsibilities. This takes away time from teaching, research, and innovation. Partnerships go on to strain their institutions, for example creating long queues for proposal review at institutional review boards, demanding scarce office and desk space, plugging extra freezers and other equipment into overextended electricity supply networks, and overwhelming laboratory services by their need to test healthy control research subjects along with the diseased.

African health systems have the unfortunate reputation of lacking the resilience that will permit them to withstand shocks such as disease outbreaks (Kruk et al. 2017). These same systems can be battered by partnership-driven intervention testing and reforms that can be shocking as well (Gilson et al. 2017). Overworked health systems or institutions make enormous adjustments to accommodate temporary projects (Pfeiffer and Chapman 2015). Partners, their ideas, funders, and materials must be accommodated, additional data collection and reporting is required (Gimbel et al. this issue), and staffing has to be adjusted to implement partnership goals. Often inefficient public services – such as water, electricity, and security – are overloaded, and artificial cadres and silos of staff and patients are created and must be managed (Brown 2015), all to test interventions that communities may or may not ever receive. We must therefore accept that the valuable immediate offerings made by partnerships could delay more permanent solutions. So whilst they may enhance creativity overall and deliver much needed services, we need to ask whether partnerships bring a net gain to African knowledge creation.

The concerns around temporariness extend beyond technical issues to include those of institutional capacity building and viability. In this issue, Johanna Crane writes about how the bureaucratic challenges associated with working with many African universities, health systems, and hospitals have led Western institutions to often look towards ‘shell NGOs’, not-for-profit virtual institutions that exist to administer the sorts of projects that are implemented in partnerships. Shell NGOs efficaciously circumvent the challenges posed by inexperienced finance departments, semi-functional research management offices, and rapidly changing research administrators, which are the hallmark of many African public institutions, and the recurring nightmare of anyone who struggles to do research within them. By operating ‘parallel ministr[ies]’ (Brown 2015, 343) and administrations they also make it unnecessary for the massive swell in international, extramural-funded activity in Africa to force development of administrative infrastructure. Unlike African universities, health ministries, and hospitals, whose onward existence, however skeletal or inefficient, is mandated by the state and assured by clientele, shell NGOs – with their entire administrative frameworks – can come and go and even reformulate themselves for new projects. Successes tend to be reported in journals and books but in the uncommon instances that failures are ever recorded, they are usually burrowed into institutional archives (Linde 2009). Graboyes and Carr (2016) extended our understanding of Linde’s (2009) work on institutional memories, illustrating how mistakes can be made because failures are not documented, archived, or retrievable. When projects work through temporary shell institutions, the option of archiving institutional records, however obscurely, does not exist. By eliminating the institutions within which they work, many partnerships institutionalize the impossibility of a future.

A final way that the temporariness of partnerships has the capacity to cause harm is through impacts on individuals and organizations that were never partners in the first place. One example points to the continued difficulty of obtaining service and repair for many sophisticated pieces of equipment in West Africa, which persists even though the number of laboratories using such equipment has increased exponentially in the last two decades. At a scientific conference I attended, when asked how he kept a molecular diagnosis program for Neisseria meningitis going in the meningitis belt of northern West Africa, an investigator with a US-based partner mentioned that the project had a couple of extra thermocyclers.[note 6]A thermocycler is the key, and most expensive, piece of equipment needed to perform the polymerase chain reaction or PCR, which is central to many biomedical operations that require DNA to be amplified, including those for diagnostic testing.
 If a thermocycler broke down at a participating African site, a substitute one would be flown in and the broken machine would be repatriated to the United States, where it would be sent back to the manufacturer for repair. For the most part, thermocyclers were carried by investigating partners in their personal luggage. This was a perfect solution for the partnership project. However, it also explains why the main manufacturer of thermocyclers refused to provide service to customers across West Africa, even when they owned a warrantied machine that was purchased from the company’s ‘Africa office’, located in Paris. The company, which would never dream of offering machines without service in Europe or North America for risk of losing market share, claimed that there were not enough clients in West Africa to make the offer of service cost effective. The number of domestic laboratories requiring service remains too small to effectively negotiate or demand service they deserve because West African laboratories within partnerships are effectively US or European clients rather than African ones. Therefore, all labs run the risk of losing access to service when partnerships terminate, and labs that are set up by domestic African initiatives lack the service and repair agreements that are routine in the North.

Partnership capacities

The South African minister of science and technology, Naledi Pandor, has been quoted as saying that scientific ‘partnerships’ (her word) offer very little permanence, describing some as little more than ‘visits’ and emphasizing that these initiatives do little if anything to build sustained capacity (Elmes 2017). This policy impression of partnerships is a disappointment on all sides because even though temporariness is a typically acknowledged limitation, many partnerships have a stated goal of ‘building capacity’. Capacity is something that temporary partnerships hope to leave behind. Claire Wendland’s (2016, 416–17) observation is that partnerships with a capacity-building component are rarely concerned with building infrastructure, which is the main capacity gap in African health care, and instead focus on ‘soft capacities that reside in people’s heads’: skills, techniques, and specialized knowledge. The capacity building I have seen in Africa commonly involves supplying Western equipment (for which in-country servicing cannot be secured), delivering short-term training programs to enable African staff to work towards meeting project goals, and implementing exacting evaluation and reporting schedules that could never be sustained even if core partnership activities were to continue.

It is not just the predominantly cerebral location of the built capacity that erodes the possibility of permanence but also its very nature. Geissler and Tousignant (2016) recognize two major types of capacity that can be built: capacities to perform certain tasks (such as ‘provide therapy’) and capacities to ‘make knowledge’. To have more than a temporary impact, a skill-based project must continue to deliver services after it has wrapped up or leave behind the capacity to innovate. While most partnerships focus on building capacity for service provision, knowledge is more likely to persist beyond the life of the project when it has worked to bolster local capacity for knowledge making. One barrier to building such knowledge-making capacity (and a possible reason for the short-term impact of global health partnerships) may be that very little ‘articulation work’ (Fujimura 1988) is centered in the African country. Fujimura (1988) describes articulation work as those scientific activities necessary for acquiring resources and generating publications, such as project planning and decision making, reviewing existing literature, communicating with other scientists, and writing articles, the sort of work that does not directly generate data but builds careers. It is what the most successful US principal investigators grumble about keeping them from their lab benches, but also what gives them access to most of the funding available for research, more publications in top journals, and more patents (Katz and Matter 2017). Articulation work includes some, but far from all, of the knowledge that is produced in a project. Not everyone engaged in scientific endeavors performs articulation work, but scientific leaders must, and thus the unequal division of this labor in partnerships has negative implications for African scientific leadership. Because partnerships are goal oriented, the reality that essential tasks towards the goal (such as data collection) must be performed by those ‘on the ground’ in Africa may be one reason why remote Northern partners are primarily tasked with worries about proposals, reports, communications, and audits. However it also means that by their very nature, global health partnerships create articulation responsibilities for Northern partners that would not exist without the partnership and that are not available to African partners (Owusu-Nimo and Boshoff 2017). Articulation tasks often appear burdensome and bureaucratic but they are much of what Northern partners contribute and, in part through them, how Northern careers are enhanced (Blom, Lan, and Adil 2016).

Moreover, irrespective of uneven benefits to career development, the temporariness of partnerships is more or less guaranteed when responsibilities are split along geographical lines. In my analysis of contributions to collaborations in international bacterial genomics, I found that investigators from most parts of the world made a range of different types of contributions, ranging from study design and wet or computational experimentation to project management and writing leadership. However, with the exception of South African scientists, who lead their own projects in this area, collaborators based in Africa invariably contributed only samples (Okeke 2016). This is dismal for collaborations with purely scientific objectives but potentially devastating for those with global health objectives: if implementation is walled off from articulation, project aims will not be accomplishable beyond the life of the partnership (Wendland 2016). Whole institutes have crumbled when foreign scientists have ‘handed over’ responsibilities to skill-trained but articulation-naïve Africans (Geissler et al. 2016). In other words, articulation work is essential for longevity and memory. A short-term partnership cannot expect a better fate if capacity building does not include building capacity to manage. Many a potential African project outcome has been stalled at the end of a partnership because of supposedly simple but pivotal issues such as fundraising, procurement, or human resource management (Gibbs, Campbell, and Maimane 2014).

Health care training and academic training are enacted mainly through apprenticeships, and capacity building partnerships that do not address the systems in which care is given and practitioners are trained are unlikely to have longevity. Nor can people trained very narrowly in specific tasks automatically run a system in which those tasks are normally implemented (Geissler et al. 2016). Geissler and Tousignant (2016, 350) have explicitly divided the world into the ‘capacity-rich’ and ‘capacity-poor’, proposing that capacity is a form of power. Capacity is indeed power, but only certain types of capacity truly fit this description. A capacity lens focused on skills and protocols equips individuals, rather than the milieu in which they operate, and does not empower (Wendland 2016) or bode well for longevity. Attempts at building capacity that rarely build truly empowering articulation and knowledge-making capacities may be the key problem.

Wendland (2016) has made a specific suggestion for how partnerships could become more relevant in Africa, and in my opinion, more sustained: global health partnerships should enhance the capacity to improvise. Whilst the directness of her proposal is unusual, the idea is by no means unique, being articulated in the works of Livingston (2012) and Feierman (2011), and other studies of health in Africa (Wendland 2010; Falola and Heaton 2007; Whyte, Geest, and Hardon 2002). In clinical science and laboratory medicine, improvisation is generally at odds with notions of standardized scientific practice. In these fields, working protocols must be outlined clearly and completely so that they are implemented the same way by different operators at different times. As a result, many capacity-building workshops in Africa are focused on training laboratory staff to perform internationally standardized protocols. Yet, improvisation, that dreaded departure from ‘standard operating procedures’ (SOPs), is an almost inevitable feature in life after partnerships, when implementers may tinker with practices and protocols to meet local needs and circumstances. Improvisation can represent a failure to conform, but it also illustrates unusual capacity to articulate. (Interestingly, even if it does not feature in the science, the administration of partnerships is often improvised – for example shell NGOs and ‘creative accounting’ (Crane 2017) are both improvisations.) While it might appear counter to ‘build’ capacity by depreciating a validated protocol in order to better suit its new implementation environment, working during a partnership to ensure that improvisation in health and science is both effective and safe may be one way to ensure that its gains continue to accrue. In this view, a partnership can often offer the uncommon scientific opportunity to compare an improvised protocol to SOPs under controlled conditions, the standard mechanism used to develop and validate medical evidence. The result would be a new validated SOP, rather than a cut corner.

In reality, departure from SOPs is rarely codified and generally frowned upon, and therefore successes through improvisation are difficult to curate. However there are several instances for which there is no other explanation for success. It is perhaps easiest again to draw examples from hemorrhagic fever outbreaks, not because the partnerships that contain them are necessarily much different from other laboratory projects but because the high and immediate death tolls that often result provoke circumspective reflection on what happened and why. A much-reflected positive example is the Nigeria chain of the 2013–16 West Africa Ebola outbreak. Nigeria’s outbreak began when the index case, who had just disembarked a plane from Sierra Leone, checked himself into a private hospital in Lagos on 20 July 2014. Why did entry of this patient into Nigeria’s convoluted health system, in Africa’s most populous city, at a time when public hospitals were closed due to strikes not lead to an outbreak larger than those in Guinea, Sierra Leone, and Liberia? Among the reasons given were a ‘combination of fortuitous circumstances and the institution of a rapid and aggressive public health and infection control measures’ (Tomori 2015, 2). Nigeria – like the other affected West African countries – had no prior experience with Ebola hemorrhagic fever, even though it may have had more epidemiology capacity and forewarning from outbreaks in Guinea, Sierra Leone, and Liberia. Nigeria did, however, have expertise in the laboratory diagnosis of other viral infections, including Lassa fever that could be adapted to detect Ebola. One of Africa’s most vociferous critics of African undercapacitization in the Ebola epidemic, Oyewale Tomori, said: ‘But within 2 to 3 days of [index case] coming in, we knew it was Ebola from laboratory tests done in two of our university laboratories, and then action was taken. I praise Nigeria for that’ (quoted in Kupferschmidt 2014).

Existing laboratory capacity is often taken for granted in chronicles of the Nigeria outbreak, but it was the essential foundation on which the much-commended public health response was built (Shuaib et al. 2014; Fasina et al. 2014). That lab expertise was built on international collaborations that the African participants described as ‘rooted’ (Yozwiak et al. 2016). It is important to emphasize that until the sixth week of the Nigerian outbreak, laboratory-verified cases had not been double-checked in purpose-built facilities or verified by WHO and so, even though the whole world knew that Ebola had entered the Nigerian health system, all cases from Nigeria were nonetheless reported as ‘probable’. Probable cases at other locations were those that had not been verified by laboratory tests. Without in-country expertise in virology and the capacity to improvise by adapting to a new disease, laboratory diagnosis of Ebola in Nigeria might have been delayed until the external assistance that verified testing protocols was available. A six-week (or even one-week) delay would have been devastating, but immediate in-country testing guided the public health response. The outbreak was contained within two months with twenty cases and eight deaths, a very small fraction of the overall reported 28,646 cases and 11,323 fatalities in the region (Dudas et al. 2017). The interventions that spared Nigeria considerable losses were undeniably, carefully informed and implemented, laboratory improvisations.

Systematically growing the capacity for improvisation will require the knowledge, expertise, and innovation of African researchers who have performed (or failed to perform) the desired operation before the partnership began. Where applicable, rather than being a dirty secret, testing and validating improvisations could be the basis for a truly balanced partnership of minds, a collaboration so to speak, of those who must improvise or do nothing and those who have expertise and resources for ‘best practices’ for another place. Is ‘partnership’ the right word to describe such a collaborative endeavor? Perhaps not, because it lacks the lopsidedness and ephemerality of ‘partnerships’ common in global health today. In a rooted collaboration (Yozwiak et al. 2016), by contrast, it is probable that improvisation would be better tolerated. And in what global health aspires to be (Koplan et al. 2009), this level of collaboration would be required.

Conclusion: After the ‘partnership’

A utopian partnership of any sort would yield outcomes that might never have been and, in this context, a health or development goal is certainly an appropriate emergent aspiration. Partners can have similar or radically different roles but a partnership ideally includes some degree of interdependence and requires frank communication. Ideal partnerships begin with ownership: each party brings something and each partner stands to lose something if the union breaks down. Ownerships evolve and at the end of the day – unless a partnership is lifelong – each partner should get to keep something. All of these features are aspirations of global health partnerships, irrespective of whether they are achieved (Brown 2015; Abrahamsen 2004; Elmusharaf et al. 2016; Koplan et al. 2009).

The temporality of partnerships that I describe in this essay, and their inability to accommodate managerial capacity development, suggest that a critical look at the motivations behind global health partnerships is necessary and overdue. Ethicists and practitioners alike have criticized the propensity for global health projects to be individualistic (as opposed to focused on the health of populations) and to work in vertical silos instead of building robust systems (Benatar, Daar, and Singer 2003; Farmer 2011). I doubt that such broad-based and lofty goals can be reached in the context of a short-term connection, however ambitious and sincere the participants may be. In the handful of cases where this appears to have happened, a series of interlinked short-term collaborations or a true accompaniment model is more likely to be responsible (Farmer 2011). As has been pointed out to me based on a reading of an earlier version of this piece, in lopsided global health partnerships there is a moral requirement of delayed reciprocity if benefits are to be truly mutual (Bloch 1973). The duration of partnerships has important implications for how they play out. Moral partnerships tolerate more imbalance and would then perhaps be less inclined to cut corners on building indirect capacities that are dispensable for immediate reciprocity but essential for long-term gains.

Currently, most partnerships are supported by three-to-five-year competitive project grant awards. Responsible project leaders must deliver on tangible partnership goals within the proposed period, or at least within its no-cost extension. But rarely are they called to deliver on what happens next. Indeed, many a project carried out by reflective partners ends with a worried discourse about the long-term prospects. It is presumed that someone or something else will be responsible for scale-up, extension, and sustainability, but it is rarely clear whose responsibility this actually is. This should matter to all sides but in particular it should trouble those more closely connected to the health or development outcome that justified the partnership. If ‘partnership’ implies ownership on all sides (Abrahamsen 2004), then African partners should own something when they dissolve. In reality, the fervor and excitement of high-level innovation and teamwork at a partnership ball may leave just a little more than a perishable pumpkin and a single glass slipper behind. We scientists on the African continent are going to have to demand more from partnerships than a full buffet and a quick ballroom whirl. We are in a new digital age in which the ability to make selective, nondurable, health-related change can be delivered with a swish in an app (Kenworthy 2018, this issue). Global health partnerships, whatever we choose to call them, need to aspire to more and figure out how to sustain it.


I am especially grateful to Johanna Crane, Nora Kenworthy, and Lynn M. Thomas for the opportunity to engage in discussions on partnerships with University of Washington faculty, for additional helpful discussions, and for their insightful comments on an earlier draft of this piece. I also thank Tom Widger for helpful comments and El-shama Monu-Nwoko for editorial assistance in preparing the manuscript.

I am a UK Medical Research Council/Department for International Development-supported African Research Leader. I thank the Walter Chapin Simpson Center, University of Washington, Seattle, for support through the Humanistic Perspectives on US Global Health Partnerships in Africa and Beyond project.

About the author

Iruka N. Okeke is Professor of Pharmaceutical Microbiology at the University of Ibadan and an MRC/DfID-supported African Research Leader. Her laboratory studies the molecular epidemiology, pathogenesis, and drug resistance of intestinal bacteria. She also researches laboratory practice in Africa. Okeke received BPharm, MSc, and PhD degrees from Obafemi Awolowo University, in Ife, Nigeria, and postdoctoral training at the University of Maryland in the United States and Uppsala University in Sweden. She is author of Divining without Seeds: The Case for Strengthening Laboratory Medicine in Africa (Cornell, 2011) and coauthor of Genetics: Genes, Genomes and Evolution (Oxford, 2017) as well as numerous articles and chapters.


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