Striving towards true equity in global health: A checklist for bilateral research partnerships

The paper interrogates why global health scholarship often reproduces colonial-era inequities, noting increased HIC interest in global health, the heightened visibility of inequities during COVID-19, and persistent power imbalances, racism, and coloniality. The authors highlight manifestations such as HIC-dominated agendas and institutions, funding imbalances, limited LMIC mentorship opportunities, and the dominance of English in scientific literature. They argue that HIC trainee projects can exacerbate structural violence without equitable partnerships. The paper emphasizes that LMIC institutions should assert agency to shape or reject inequitable collaborations. Prior frameworks for ethical partnerships exist but have often lacked optimal LMIC leadership and practical steps for day-to-day implementation, underscoring the need for actionable tools like the proposed checklist.

The authors synthesize prior guidance on equitable global health partnerships, noting numerous frameworks and toolkits: (1) principles for transboundary partnerships (e.g., KFPE’s 11 Principles), (2) ethical tools for research partnerships (Afsana et al.; Murphy et al.; Pratt’s Research for Health Justice and priority-setting toolkit), (3) recommendations on partnership structure and governance (e.g., joint North–South PI models, shared ownership, MOUs, transparent budgeting, conflict resolution), (4) data access and benefit principles (e.g., Gates Foundation Global Health Data Access Principles), and (5) organizational practices to decolonize and promote equity (e.g., Global Health Decolonization Movement in Africa). Table 2 (as described) consolidates practical recommendations including trust-building, clear roles and responsibilities, equitable resourcing, institutional buy-in, reciprocal capacity building, transparent authorship and data policies, inclusion of marginalized perspectives, community engagement and accountability, and funder responsibility in enabling equitable participation of LMIC partners.

This is a narrative review and practice-oriented perspective drawing on published literature and the authors’ multi-country experience building HIC–LMIC collaborations (e.g., Uganda, Burkina Faso, Guinea, Cameroon). The authors structure recommendations across research phases—design, implementation, analysis, and dissemination—guided by four foundational principles: locally relevant solutions, paired collaborations at multiple levels (co-PIs and trainee pairs), paired/bidirectional funding, and clear, shared roles and responsibilities codified via MOUs. They culminate in a practical 20-item Douala Equity Checklist intended for integration into funding screening and project planning by both HIC and LMIC institutions.

• Key problems in global health scholarship: HIC-centric institutions and agendas; scarce direct funding for LMIC investigators and trainees; research priorities set by HIC rather than local needs; dominance of English limiting LMIC participation; inequitable authorship and conference access; exploitation of LMIC collaborators; and overvaluation of quantity over ethical quality.
• Four foundational principles: (1) prioritize locally derived, relevant solutions; (2) foster paired HIC–LMIC collaborations at all levels (co-PIs, trainees, field/lab teams); (3) provide paired funding and benefits for HIC and LMIC team members (travel, stipends, conference attendance, protected time); (4) assign clear roles and responsibilities, with appropriate recognition and authorship.
• Design phase recommendations: co-develop questions and aims through bilateral discussions; emphasize decolonial history and LMIC scholarship in team preparation; ensure access to literature; establish transparent MOUs detailing authorship, IP, data use, and roles; restructure HIC trainee grants to directly fund LMIC trainees and activities; increase direct funding streams to LMIC investigators; encourage LMIC philanthropy to support trainees.
• Implementation phase recommendations: avoid parachute research; conduct analyses locally where possible; invest in bilateral training and capacity building (including technology transfer and hosting exchanges); ensure protected, funded research time for LMIC PIs and fair, regular compensation for field teams; leverage digital platforms for continuous engagement.
• Analysis and dissemination recommendations: ensure LMIC partners drive or co-lead analysis and interpretation; provide access to statistical tools, training, and language support; address English language bias by publishing in multiple languages and supporting interpretation at conferences; pursue equitable authorship models (co-first/co-senior) and broaden contribution definitions; disseminate findings locally through accessible media (radio, TV, social media, community gatherings); create pathways for LMIC collaborators’ future training and employment.
• Quantitative insights cited: Only 46% of African countries list English as an official language; maternal health literature shows a dose–response whereby lower host-country income correlates with a lower proportion of local first authors.
• Output: The Douala Equity Checklist—a 20-item tool to guide ethical, equitable collaborations and inform funding decisions.

By centering locally defined priorities, pairing leadership and training opportunities, and ensuring paired funding and clear roles, the proposed approach directly addresses structural inequities in global health collaborations. Implementing equitable budgeting, transparent MOUs, capacity building, and authorship reforms redistributes power and credit, mitigates parachute practices, and promotes sustainable LMIC-led impact. Addressing language barriers and ensuring local dissemination expands participation in knowledge production and uptake. Conditioning funding on adherence to equity criteria is posited as a lever for systemic change, steering collaborations away from extractive models and toward ethically grounded, mutually beneficial partnerships aligned with community needs.

The Douala Equity Checklist offers a practical, phase-spanning tool for HIC and LMIC institutions to evaluate and improve equity in global health collaborations. The authors argue that proposals failing to address core equity issues should be unfunded or restructured. Embedding equity as a funding prerequisite can catalyze a shift from problem recognition to implementation of solutions, advancing toward truly equitable, sustainable partnerships. They call on donors to prioritize direct funding to LMIC investigators, especially for LMIC-relevant issues, and on academic institutions to adopt transformative, bidirectional models of training, authorship, and dissemination.

As a narrative, experience-informed review, recommendations are not empirically validated across all settings and may face practical and institutional constraints. The authors acknowledge major challenges to implementation, the time required to build trust and capacity, potential unintended burdens on LMIC institutions, and broader structural barriers (e.g., funding flows, language dominance, visa and conference access) that may limit generalizability and pace of change.