Partnerships for Global Child Health
Child mortality remains a global health challenge and has resulted in demand for expanding the global child health (GCH) workforce over the last 3 decades. Institutional partnerships are the cornerstone of sustainable education, research, clinical service, and advocacy for GCH. When successful, partnerships can become self-sustaining and support development of much-needed training programs in resource-constrained settings. Conversely, poorly conceptualized, constructed, or maintained partnerships may inadvertently contribute to the deterioration of health systems. In this comprehensive, literature-based, expert consensus review we present a definition of partnerships for GCH, review their genesis, evolution, and scope, describe participating organizations, and highlight benefits and challenges associated with GCH partnerships. Additionally, we suggest a framework for applying sound ethical and public health principles for GCH that includes 7 guiding principles and 4 core practices along with a structure for evaluating GCH partnerships. Finally, we highlight current knowledge gaps to stimulate further work in these areas. With awareness of the potential benefits and challenges of GCH partnerships, as well as shared dedication to guiding principles and core practices, GCH partnerships hold vast potential to positively impact child health.
- ACE —
- African Centers of Excellence
- GCH —
- global child health
- GH —
- global health
- HIC —
- high-income country
- LMIC —
- low- and middle-income countries
- M&E —
- monitoring and evaluation
- NGO —
- nongovernmental organization
- TC —
- triangular cooperation
In 2015, 5.9 million children (16 000 daily) died of preventable or treatable conditions.1–5 Increasing awareness of these facts, coupled with an emerging shared global identity, and rising numbers of immigrants and refugees across the world, catapulted global health (GH) into the public eye.6,7 Concurrently, there has been surging interest in GH experiences among medical trainees and practitioners from high-income countries (HICs).8 The concept of GH, defined “as collaborative trans-national research and action for promoting health for all,”9 has emerged as a distinct discipline to address these challenges.6
Pediatricians around the world are increasingly engaged in global child health (GCH) partnerships to improve children’s health. Exemplary GCH partnerships positively impact global development.10 Conversely, poorly constructed or maintained partnerships may inadvertently contribute to inadequate health systems.5,11 This review is intended for use by pediatric GH practitioners from low- and middle-income countries (LMIC) and HICs.
In this article, we present a comprehensive literature-based review of the definition, scope, genesis, evolution, and models of GCH partnerships, including both benefits and challenges, guiding principles and core practices. Current knowledge gaps are highlighted to stimulate future research. In this article, we intentionally focus on GCH partnerships and GCH needs, but, where pertinent, draws from the broader GH literature. Although not written as a guideline, the expert panel intend that this consensus review could serve as a resource to optimize current and future GCH partnerships.
This review was prepared by an expert panel comprising GCH clinicians, educators, and investigators from 6 countries and 3 continents with expertise in general pediatrics, public health, and the pediatric specialties of critical care, emergency medicine, hospital medicine, infectious diseases, and neonatology. Three authors from the American Board of Pediatrics GH Task Force conceptualized the initial framework for the review and invited coauthors from 3 continents based on their broad, multinational expertise in GCH partnerships. The framework for the review (ie, reviewing global child partnerships by using these sections: introduction, methods, definition, genesis, evolution and scope, participants, benefits and challenges, guiding principles, core practices, evaluation, and literature gaps) was decided on through consensus by the expert panel. Each section had 2 assigned authors who independently did a systematic review of the English language literature using PubMed, Google, and book chapters. Data were summarized in a first draft of each section. A third author then did an additional independent literature review, added additional references to the sections, and integrated all draft sections into a manuscript. All authors then reviewed and revised the manuscript. Even with the inclusion of all relevant studies, there were areas in which current evidence was inadequate. When this occurred, recommendations were made on the basis of a consensus of the expert panel. The result is a comprehensive literature-based expert consensus review.
Defining GCH Partnerships
We adapted Samoff’s definition and defined a GCH partnership as “a collaboration that can reasonably be expected to have mutual (though not necessarily identical) benefits, that will contribute to the development of both institutional and individual capacities to advance child health at both institutions, that respects the sovereignty and autonomy of both institutions, and that is itself empowering.”12
Genesis, Evolution, and Scope of GCH Partnerships
The genesis and evolution of global child partnerships varies. Many are purposive, targeting a specific medical skillset needed in an LMIC, such as the development of a national antiretroviral program funded by the President’s Emergency Plan for AIDS Relief or teaching the initial steps of neonatal resuscitation through Helping Babies Breathe.13,14 Key drivers include LMIC national health priorities coupled with matching strengths of a HIC institution and available funding. Other partnerships are more opportunistic and develop from personal relationships between individuals in LMIC and HICs.15 The agendas of major funders such as the President’s Emergency Plan for AIDS Relief or the UK’s Department for International Development are strong initiators, drivers, sustainers, and modifiers of GCH partnerships. Partnerships evolve in response to LMIC needs, HIC areas of interest and to funding opportunities. Many partnerships that historically concentrated on a specific disease, such as The Center for Infectious Diseases Research in Zambia (CIDRZ),16 which initially focused on HIV, subsequently evolve to focus on broader health system goals of equity, system strengthening, and workforce development.17,18
An example of specific elements required for successful genesis, evolution, and long-term sustainability of programs in LMIC that arise as partnerships with institutions in HICs is described by the St. Jude International Outreach Program.19,20 These are also applicable to GCH partnerships more broadly. Essential components are as follows: (1) financial support for program development and long-term sustainability sought from sources both international and local and public and private; (2) a local LMIC pediatric leader, devoted to the project, directing medical care and collaborations with hospital, governmental, and community leadership and international agencies; (3) nursing expertise (for pediatric subspecialties like oncology, nurses must be trained in pediatric cancer care and able to practice the specialty full-time); (4) developing a grassroots foundation, with members trained to provide pediatric advocacy, fundraising, and, working with the LMIC government, program sustainability; (5) an HIC project mentor to advocate for the project and explore the possibility of collaborative research in the LMIC; and (6) effective relationships between the partnership’s leaders and key stakeholders, which will lay the foundation for productive collaboration and a sustainable pediatric program.
The scope of GCH partnerships varies widely. Activities include education, training, research, clinical service, systems strengthening, public health, and response to international crises.21 Recent surveys of university and pediatric residency program partnerships demonstrate the centrality of research, education, clinical care, health systems strengthening, health interventions, policy development, and technology exchange.7,22 Educational activities may involve a unidirectional or bidirectional exchange of health professionals, undergraduate, or postgraduate learners.22,23 Some relationships are built around short-term GCH experiences for trainees. These are often unidirectional flows of learners from HICs to LMIC that provide questionable benefit to LMIC institutions.18,24,25 Others may involve skilled clinicians, educators, or researchers with a long-term commitment, including building scientific expertise in LMIC, such as the US National Institutes of Health’s Fogarty International Center.26
Who Participates in GCH Partnerships?
A broad range of organizations participate in GCH partnerships. Academic institutions and private and public entities, including foundations, nongovernmental organizations (NGOs), international agencies, community groups, and governments, all participate in various combinations.27,28 Each type of organization offers diverse resources to develop, implement, and sustain GCH partnerships. The principles outlined in this review apply to all.
Academic GH partnerships between LMIC and HIC universities are flourishing.15 In 2011, 78 US and Canadian universities had comprehensive GH programs, a 13-fold increase over 10 years.15 In 2013, 42% of US pediatric residency programs had international child health partnerships, spanning 153 countries.7 These partnerships can provide long-lasting, sustainable relationships and impact, especially if younger faculty and students are team members.29 The Makerere University-Johns Hopkins University Research Collaboration based in Kampala, Uganda started in 1988.30 Results from clinical trials conducted by Makerere University-Johns Hopkins University over the last 25 years have impacted both national and international guidelines for prevention of mother-to-child transmission of HIV.31–33 The Consortium of Universities for GH is an academic NGO of over 140 universities globally that collaborate on GH curricula and training materials and foster new partnerships.34
Public–private partnerships combine skills and resources from institutions in the public and private sectors.35 The Baylor International Pediatric AIDS Initiative is an example. This partnership is between Baylor College of Medicine and 10 countries and various private partners that vary by country. The Baylor International Pediatric AIDS Initiative provides pediatric health care, education, and clinical research focusing on HIV/AIDS and other conditions impacting the health and well-being of children.36
Government-to-government GCH partnerships are usually coordinated by the Ministry of Health in each low- or middle-income country. These programs tend to focus on national and GH targets and may involve subcontracts to implementing partners from across the partner spectrum. Examples include HIC government development programs such as the US Agency for International Development, Norwegian Agency for Development Cooperation, and the UK’s Department for International Development.37,38
GH NGOs are classified into 5 groups by the Fogarty International Center39: international organizations, such as the World Health Organization40 and the Global Fund to Fight AIDS, Tuberculosis, and Malaria41; scientific organizations, such as the American Society of Tropical Medicine and Hygiene42; advocacy and policy organizations, such as the Earth Institute at Columbia University43 and the GH Council44; foundations, such as the Open Society Foundations45 and the Wellcome Foundation46; and other resources, such as the Institute for Health Metrics and Evaluation,47 the Web site Gapminder,48 and small NGOs or faith-based NGOs.
South–South partnerships between institutions in 2 or more LMICs are increasingly important to advance shared LMIC institutional or national development goals.22,49–52 South–South partnerships have the potential to spur collaboration between partners who traditionally may have competed for funding.49,53 An example is the African Centers of Excellence (ACE) project.54 The ACE Maternal and Child Health Center at the University of Cheikh Anta Diop in Dakar, Senegal55 partners with other West African universities around education and research in maternal–child health. ACE is also an example of a triangular cooperation (TC). TC involves 2 or more LMICs in collaboration with a third party, typically an HIC government or organization, contributing to the exchanges with its own knowledge and resources.52 TC aims to provide a framework in which partners work together more effectively as equals to jointly develop solutions for global development challenges.56
Common Benefits and Challenges of GH Partnerships
Both benefits and challenges of GH partnerships can be considered at the individual, institutional, and population levels. A healthy GH partnership may accrue mutually shared benefits, benefits specific to the LMIC partner, and/or benefits specific to the HIC partner (Table 1). Many academic partnerships between HIC and LMIC partners provide the opportunity for HIC trainees to hone clinical skills in a setting with limited diagnostics while providing LMIC trainees exposure to different perspectives, such as the University of Washington partnership with the Naivasha District Hospital in Kenya.57
Despite numerous tangible benefits, GH partnerships also face many challenges that could result in serious negative consequences if not anticipated and intentionally planned for (Table 1). Common challenges include inadequate or lack of local engagement, cultural insensitivity, culture shock, unintended adverse impact of the partnership on the LMIC setting (termed “opportunity costs”), lack of continuity, and inadequate funding for intended projects.58 There are also higher stake challenges that may affect the whole health system in a LMIC (frequently LMIC institutions navigate a complex web of multiple partners), which can cause fragmentation of health systems, duplicative processes, and difficulties with absorbing resources and implementing programs.59 Conversely there are also excellent reasons to encourage multiple partnerships and, when well-managed, these can have a catalytic effect on improving health outcomes. Historically, partnerships have been funded by resources from HIC with the balance of power resting with HIC partners, including setting the partnership agenda and priorities, although this is beginning to change.18,60,61
Guiding Principles and Core Practices in GCH Partnerships
A successful, mutually beneficial GCH partnership needs to be both thoughtfully created and diligently nurtured. There are several insightful articles on this topic (Table 2). and are summarized into 7 guiding principles and 4 core practices. The guiding principles are equity, inclusivity, sustainability, mutual benefit, prevention of adverse impact, social justice, and humility. The core practices are communication, leadership, conflict resolution, and evaluation. The interdependence between them is summarized in Fig 1. The overarching objective is that international institutions and individuals work in a way that respects and prioritizes partner and community perspectives and ultimately ensures improved child health. Additionally, the net benefit from program activities conducted in partnership should be greater than what would be expected without partnership involvement.
GCH Partnership Guiding Principles
Health equity is defined as the absence of systematic disparities in controllable or remediable aspects of health between groups with different levels of underlying social advantage with respect to wealth, power, or prestige.65 Systematic disparities can involve differences in access to health services, interventions, and outcomes. Health equity is different from health equality, which refers to treating everyone the same regardless of the widely varying levels and types of support needed by marginalized, disenfranchised groups.
With regard to GCH partnerships, the principle of equity is the recognition of and sensitivity to the inherent inequities that usually exist between LMIC and HIC GCH partners. Each of the other 6 core principles directly influences partnership equity (Fig 1).
Efforts to address inequities outside of the partnership should include promoting the involvement and participation of all major stakeholders, particularly communities who may be disadvantaged by poverty, low education, race, or other factors. Partnerships in resource-constrained settings can work to recognize and challenge structures that restrict participation of these impacted groups. Practically, this means that every voice is heard, different perspectives are understood, and all partners, regardless of resources, are included in the design of the collaboration with a “real voice” in leadership.18,66–68 Effectively listening to all voices leads to a clear vision with common goals shared by all partners.69
Sustainability refers to building a long-term vision for strengthening child health while working to conduct successful short-term activities. It can be challenging for HIC institutions that may initially be drawn into a 1- to 5-year GH partnership by enticing financial gains, such as grant funding, but the institutions’ commitments may waver as initial funding success proves difficult to replicate given the competitive nature of international partnerships.70 Similarly, frequent leadership changes in LMIC settings may impact sustainability. However, sustained commitment is expected of each partner. There is ample evidence in the literature18,58,71–73 that sustained engagement results in better understanding and trust between the collaborating partners. This in turn leads to the evolution of more opportunities and strategic projects as the needs of both parties become more evident.
Sustainability is possible when it is intentionally designed and incorporated into partnership strategic planning. For example, research-based partnerships may develop study plans to include provisions for access to effective therapeutics in the posttrial phase. Research partnerships may also commit to providing mentorship and research opportunities for LMIC researchers, thereby strengthening the academic infrastructure of child health in LMIC. Education-based partnerships uphold sustainability by ensuring that short-term educational experiences with transient local benefits are nested within long-term partnerships, leading to long-lasting improvements in child health.25 Partnerships focused on service-based activities can support sustainability by coordinating multiple short-term trips in a way that builds successively on relationships and activities over time,63 working within existing health systems rather than creating parallel ones, and shifting responsibility for health services to local groups.
A reciprocal and mutually beneficial relationship is a core component of successful partnership. Transparency of motivation fosters trust, which may involve outlining and reconciling objectives that are not strongly shared while ensuring that objectives are not divergent. A memorandum of understanding or agreement is of great value to many partnerships, ideally is established at the inception of a partnership, and undergoes formal review at regular intervals. A dynamic memorandum of understanding that evolves with GH partnership maturity is essential for transparency and trust between partners; these in turn foster sustainability and additional opportunities for the collaboration. As goals are established, HIC partners are challenged to have the funding, initiative, and skills needed to support clinical care, education, and research that meet the needs of LMIC partners, including alignment of research priorities.70 For example, the HIC institution may wish to conduct biomedical research and publish in high impact journals. By contrast, the LMIC institution may be focused on research in public health and health systems to meet urgent needs in the LMIC setting or on LMIC faculty or trainees visiting the HIC institution for professional development. More recently, some authors have challenged the principle of “mutual benefits,” suggesting that GH partnerships should maximize benefits among all partners but with priority given to those with the fewer resources.66,70
Prevention of Adverse Impact
Several studies demonstrate the importance of taking steps to minimize adverse outcomes to visiting providers, students, and trainees as well as to patients, communities, local providers, and health facilities in LMICs.63,67,74 Also integral to the prevention of unintended adverse impact is the monitoring of true costs of the program to all institutions involved in the partnership. These include administrative costs for coordination of multiple partners, indirect impact on the community from exposure to short-term visitors, and ensuring appropriate reimbursement and steps to alleviate any undue burden.25
The principle of social justice calls for partners to work together to value diversity (including gender, religion, age, race, social class, socioeconomic circumstance or disability, and sexual orientation); recognize social, historical, political, economic, and environmental determinants of health; and seek ways to mitigate inequities.75
GCH partnerships present inherent cultural challenges based on differing perceptions, past experiences, communication styles, and discordant objectives.76 Humility calls on stakeholders to dedicate efforts to understand their own assumptions, biases, and differing values and to center the partnership on the act of learning rather than on knowing.75 Differences in understanding are often based on divergent cultural, economic, and political histories and social realities.72,77 However, when partners come to the table with an attitude of cultural humility and mutual respect, enhanced understanding is possible.78
GCH Partnership Core Practices
Effective communication is crucial for the success of any partnership. Communication challenges faced by GH partnerships include not only language barriers and logistics of telecommunication but also differences in verbal and nonverbal communication styles, notion of time, decision-making processes, assertiveness in interactions, and use of e-mail exchanges. A transparent, open, honest, and unambiguous communication strategy between partners builds a foundation of trust.64 Pretravel preparation for trainees and faculty may improve communication and minimize challenges in this area.
Numerous authors have emphasized that successful GH partnerships depend on good, accountable management of both operations and relationships.64 Others have highlighted that leadership has been neglected in GH.80 Bradley et al80 state that, “strong management enables the achievement of large ends with limited means.” Balance and diplomacy have been identified as essential leadership skills when dealing with collaborators in a GH partnership.64 Securing buy-in and commitment of high-level organizational leadership offers the opportunity for the larger institution and network of experts within to commit to the partnership.81 Partnerships are at risk for failure if leaders are not actively engaged and willing to invest in continued nurturing of trust. Although implementing each principle and practice in every situation is certainly the goal, effective partnerships also depend on wise, shared, and pragmatic leaders to navigate situations in which upholding a principle or practice may appear to infringe on another’s principles or practices.
Partnerships are expected to encounter difficulties. Hence, conflict resolution and mediation may offer solutions to prevent the dissolution of partnerships.25 Additionally, addressing and planning for these challenges can transform them into opportunities to further strengthen the partnership.
Assurance that stakeholders follow the core principles of GCH partnerships and that goals are being reached involves a commitment of effort and time to conduct evaluation. As partnerships are implemented, resources need to be allocated to periodic assessments of outcome measures, research and educational priorities, authorship on publications, and interinstitutional communication and relationships.
Evaluating GCH Partnerships: Current Models and Proposed Frameworks
The US Agency for International Development states that “evaluation is the means through which it obtains systematic, meaningful feedback about the successes and shortcomings of its endeavors. Evaluation provides information and analysis that prevents mistakes from being repeated, and that increases the chance that future investments will yield even more benefits than past investments.”82
Evaluation is fundamental to a GCH partnership’s future strength. Evaluation documents the extent to which a partnership’s objectives are being achieved, including how efficiently and why. We briefly summarize planning and conducting a partnership evaluation and references provide more in-depth descriptions and frameworks.
A useful model for evaluating partnerships is the 2012 collaborative report from the UK-based Tropical Health & Education Trust Partnerships for GH and British Council.83 Figure 2 summarizes steps to conduct a partnership evaluation.84 Initial engagement focuses on partnership stakeholders and those impacted by the partnership. Participants may include: public sector agencies such as the Ministry of Health, the private sector, international or local NGOs, international agencies such as United Nations Children’s Fund, professional associations or societies, community members, and special interest groups. The aim of the initial engagement is to reach consensus on (1) aims of the partnership, (2) criteria for evaluation (including what will be evaluated), and (3) how results will be interpreted, disseminated, and applied. This collaborative process requires skills in evaluation design, cost estimation, selection of measurement tools, data collection, analysis, and dissemination.
Monitoring and evaluation (M&E) plans should be defined collaboratively by all partners and be realistic and feasible with regard to workload, resource requirements, and consistency of use. A simple tool useful for facilitating M&E is a logic model, which guides M&E and ultimately identifies a data collection plan.85 This is a quality improvement approach to evaluation. Beginning with an overall objective, a logic model provides measureable parameters (qualitative and quantitative) on which to base an evaluation that includes the following: Inputs → Activities → Outputs → Short and Intermediate Term Outcomes → Ultimate Goal. Figure 3 provides an example of a logic model (intended to illustrate components, not a complete model). Once the model is completed, a monitoring plan is established that identifies which data are required and how, by whom, and when the data will be collected. In health partnerships, attribution of change in practice, behavior, or attitudes is difficult (a useful approach is to use several data collection methods to evaluate different aspects of the partnership aims).
Once available, evaluation results are shared with target stakeholders. Effective dissemination raises awareness of the partnership, its impact, and creates opportunities for stakeholders.87 These references present salient, in-depth approaches to evaluating GCH partnerships.75,82,83,88–91
Although there is a burgeoning literature describing various aspects of partnerships for GCH, significant gaps remain. These include a paucity of rigorous assessments of partnership benefits and challenges, including equal weighting between HIC and LMIC partners, how these vary in different settings, lessons learnt from failed partnerships, and how benefits can be optimized whereas challenges are minimized and overcome. Additionally, an assessment of possible differential impact between partnerships that adhere to the guiding principles and core practices as compared with those who do not is needed. Furthermore, an evidence-based understanding of best practices of partnership evaluation, adjustment, and reevaluation is missing. Membership organizations, such as the American Academy of Pediatrics, are optimally positioned to develop policies pertaining to minimum standards for GH partnerships. Finally, there is an urgent need to prioritize both funding and publication of partnerships for GCH. Additional funding is needed to hasten implementation, education, and research. Peer-reviewed publications will grow the evidence base and inform best practice.
Although initiating GCH partnerships can be challenging, once successfully established and effectively maintained, they can be of tremendous mutual benefit. With long-term commitments from all partners, these initiatives can become self-sustaining and support development of much-needed training programs in resource-constrained settings.92,93 Poorly constructed or maintained GCH partnerships may inadvertently contribute to the further collapse of health systems.5,11 Recent improvements in GCH outcomes are cause for optimism that further improvements in child survival can and will be obtained.5 Strong ethical and public health arguments call us as a pediatric community to commit to building the highest quality GCH partnerships needed to meet these equity-guided goals.
We thank Valerie Haig of the American Board of Pediatrics for exceptional administrative support, Michael Pitt for assistance with figures, and Virginia Moyer and Adriana LaMonte for their thoughtful review of the manuscript.
We would also like to thank the members of the GH Task Force of the American Board of Pediatrics: Christopher A. Cunha, MD, Chandy C. John, MD, Jonathan D. Klein, MD, MPH, David G. Nichols, MD, MBA, Cliff M. O’Callahan, MD, PhD, Nicole E. St Clair, MD.
- Accepted June 26, 2017.
- Address correspondence to Andrew Steenhoff, MBBCh, DCH, Children’s Hospital of Philadelphia GH Center, 3535 Market St, 13th Floor Room 1323, Philadelphia, PA 19104. E-mail:
This paper is one of a series of papers conceptualized and produced by the GH Task Force of the American Board of Pediatrics. The content is solely the responsibility of the authors and does not necessarily represent the official views of the American Board of Pediatrics or the American Board of Pediatrics Foundation.
FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.
FUNDING: This publication was supported in part by the American Board of Pediatrics Foundation.
POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.
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- Copyright © 2017 by the American Academy of Pediatrics