The 30 included articles spanned a wide variety of journals and disciplinary affiliations of authors (e.g., public health, global health, nursing, medicine, dentistry, health systems, anthropology, bioethics, and occupational therapy). GHPs were often described as geographically focused in a single city or region within a global South country. Some were described as multi-country partnerships funded by specific organizations, such as the Geneva University Hospitals (28) or a group of funders, such as one that involved the Bill & Melinda Gates Foundation, the Carlos Slim Foundation and the Spanish Agency for International Development Cooperation (29). Authors reported on various kinds of North-South partnerships, involving universities, NGOs, health professional associations, and large multi-national or public-private partnership platforms. Details of data extracted for each included article are provided in Supplementary Table 1, including type of partnership, methods, authorship, clarity, and content assessed.
How were GHPs assessed?
Roughly half of the included articles (n=16) cited the use of one of twelve different evaluative frameworks. In almost all such cases, authors commented on the difficulty of knowing where to start their evaluation and often justified adaptations. Four articles presented frameworks or sets of considerations intended to guide GHPs broadly, developed through a research or GHP evaluation process (28,30–32) and three proposed discipline-specific frameworks (33–35). Approaches to assessing GHPs included qualitative approaches (30,36); literature reviews (31,37); mixed methods (38); realist syntheses and evaluation (39); grounded theory (40,41); social network analysis (42); and survey research with logistic regression (43). Descriptions of theoretical foundations varied widely, as did methodological approaches and participants (i.e., who was involved in a GHP). Interestingly, despite the shared focus on assessing partnering, articles directed attention to outcomes-based performance of Global South partners more frequently than the functionality of partnerships themselves.
Authorship of articles was of interest to us as a marker of who is granted authority or responsibility for reporting on a GHP. Authorship lists were interdisciplinary in thirteen articles (29,34,35,37,39,42–49) and included Southern partners in sixteen articles (29,34–37,39,41–44,46–51). Where all authors’ primary geographic affiliations could be identified (n= 29 articles, 152 authors), 120 (79%) authors were affiliated with institutions located in the global North - Canada (32,35,37,39,41,44,48,52); Europe (Switzerland, Ireland, the United Kingdom, Germany, the Netherlands) (30,31,38,40,45,50,53,54); the United States (29,33,34,36,49,55–58); Australia (51) - and 32 (21%) were located in the global South (Kenya (46), Nepal (47), Rwanda (43), and Uganda (42)).
How did authors portray the contexts in which their GHPs were situated?
How GHPs were portrayed mattered to our analysis because it exposes assumptions underlying the relationships, structure, and character of the partnership and/or authors’ descriptions about the legitimacy and purpose of GHPs (cf, 11,12). Authors varied widely in how they framed the role and context of their GHPs. GHPs were often situated around a topical focus on research, capacity-building, clinical, or health services issues. Though historical and political North-South dynamics were rarely examined as influential forces in GHPs, they were frequently portrayed as complex and characterized by asymmetries in power and resources (31,32,34,35,37–40,46–48,50,51), as one article stated – “relations between different actors with varying degrees of power and influence" (50). The depth in which such asymmetries were explained also varied. In some cases, Southern deficiencies in resources simply appeared as an unexplained lack of capacity or infrastructure (e.g. India’s scarcity of occupational therapists) (52). Others explicitly identified global health inequities as important considerations in their GHP (32,34,35,37,47,48,52,55), with some arguing that responding to these inequities was central to the work of their GHP.
Three examples of equity-seeking assessments or approaches to assessing GHPs stood out in our analysis. Herrick et al. examined the complex ‘binds’ inherent to GHPs in contexts marked by deep disparities. In their ethnographic research, they found “many participants felt torn between their belief that working in partnership was the good and right thing to do and their sadness at not being able to effect the kinds of changes that were so obviously needed in such a resource-poor setting” (40). They concluded their article by contrasting the “rosy idea of what a partnership is” (40) against the messy and inequitable realities of GHPs that tend to tolerate or overlook vast and structural inequities between partners. Murphy et al., in response to acknowledging disparities, described in-depth engagement of Southern researchers and research-users in the development of an equity- and power-focused partnership assessment framework (48). Ridde and Capelle (32) situated North-South GHPs for research as a means of addressing issues of equity world-wide, as a response to the 10-90 gap (i.e., the inequitable distribution of 10% of research resources toward problems facing 90% of the world’s population) and the need for capacity building (32). Their results highlighted how such disparities can manifest in GHPs, featuring comments from Southern researcher interviewees on the tendency of Northern researchers to ‘infantilize’ (original text “d’une infantilisation”) their Southern partners and emphasizing the importance of doing work that supports solutions needed by collaborators in the South (32).
GHPs were often portrayed as inherently beneficial and benevolent, with human and financial resources necessarily flowing from the global North toward initiatives carried out in the global South. Leffers and Mitchell (56), for example, introduced their grounded theory study by describing nurses’ “long history of service to the global community,” where nurses provide “direct nursing care to people in global settings or participate in faculty-led service-learning programs” in host settings. ‘Visiting nurses’ and ‘community host partners’ are all named without stating who they were or where they came from, leaving readers to determine (near the end of the article) that the reference to ‘community host partners’ was always in Southern settings.
In addition, the role of corporate power in GHPs was often unquestioned and legitimized, usually through acceptance or endorsement of the private sector’s role in promoting effectiveness in global health. Theissen et al. (51), for example, justified corporate participation in a GHP by asserting that “the reason for partnering is because the private sector can achieve better efficiency through experience and innovative systems”. Problems with public-private partnerships (PPP), such as the potential for conflict-of-interest, were occasionally found (58), although without questioning the legitimacy of the PPP model. One particularly illustrative article highlights the extractive sector’s contributions to solving maternal health challenges in Papua New Guinea (51) without mentioning the same sector’s extraction of massive profits from the country and contributions to widespread environmental destruction, violence and sexual violence (c.f., 59,60).
What did authors assess, or report as important to assess, in GHPs?
The specific features of GHPs that were assessed varied widely, from informally or qualitatively observed interpersonal and relational dynamics, to achievement of quantifiable population health indicators, to reporting logistics (e.g., ability to acquire funds in competitive funding environments). Authors leaned heavily toward reporting on the benefits of GHPs. Many articles reviewed literature on partnership pitfalls or failures before moving on to a success-oriented case study with little emphasis on problems, contradictions, or negative consequences. Most authors assessed aspects of partnership processes (n=23), such as how decisions were made or priorities set, and a portion of these also focused on outcomes (n=8). Common among all thirty articles was at least some attention to the interpersonal experience of being involved in GHPs. Many described relational concepts such as mutual trust (28,36,37,42,45,47,56,57), respect, and understanding (28,36,47,55) as central to their findings. Some authors directly described the value of building personal relationships and friendships in GHPs (28,30,39,41,55). Beyond such cross-cutting relational dynamics, our analysis identified five kinds of things that authors argued were central to ‘good’ GHPs, and therefore worth paying attention to or assessing (discussed in more depth below): (a) early phases of partnering; (b) navigating issues of decision-making, process, or governance; (c) managing the implementation work of GHPs; (d) paying attention to performance and impacts; and (e) attending to issues of inclusion.
Early phases of partnering
Several authors found the early phases of partnering to be critical to the success of GHPs. Authors spoke to the importance of creating formal partnership agreements (e.g., memoranda of understanding) or strategic plans (28,30,34,37,48,51,57). Similarly, many authors described the establishment of shared values, goals, mission, and vision early in the partnership as foundational (31,33,36,39,46,48,55,57). Many authors highlighted the need for priority setting, emphasizing the importance of alignment between the priorities of each GHP partner and local (i.e. Southern) priorities (28–30,36,38,40–42,47,54,56–58). In some cases, this alignment was specifically seen as between GHPs and the national health plans of global South partners (29,51). In the context of GHPs for research, one article recommended feasibility studies (39) during the period of partnership building in order to assess the stakeholders’ priorities, concerns, and willingness to participate in a research partnership. Others spoke to feasibility indirectly, asserting the importance of establishing sustainable (30,37) and sufficient resources and financing to enable the core functions of a GHP (28,30,38,40,56).
Navigating issues of decision-making, process, or governance
Features described as worthy of attention in GHP assessments consistently involved governance processes, which we considered to involve decision making, authority, and accountability processes within partnerships. Herrick et al (40) described the governance and partnering processes of GHPs as inherently complex and full of contradictions. They noted that the historical shift in international cooperation for health from a focus on specific infectious diseases toward good governance and partnership was envisioned as a way to render "all sides of the relationship accountable, empowered, and responsible", where "partnership is envisaged as both means and ends to achieving a more resilient health workforce in southern countries as well as conferring benefits on northern (or increasingly southern) partners" (40). They examined intense conundrums, or ‘binds’, presented by the inequitable distribution of resources between the global North and South, noting, for example, that Northern funding policies and norms led via budget constraints to overlooked contextual realities, limited sustainability, and lack of responsiveness to Southern partners’ needs. Their study documented Northern partners encountering constant disappointment and frustration, as efforts in Sierra Leone were constrained by structural factors that deeply influenced partnering process and work:
…the busy and politically delicate work of trying to bind partners together around common goals—often involving endless meetings, memos, phone calls, report writing—is often far easier to articulate than the higher order and fleeting moment when everyone is bound to a shared vision and working toward promised change. When efforts to achieve means or ends fall short, as they invariably do in the Sierra Leonean context, partnership working (and especially this “busy work”) becomes experienced and enacted in ways that create a perpetual bind, a source of angst and frustration for those involved (40).
Most authors emphasized governance as central to the function and experience of partnering, with decision-making, accountability and authority tied to relational interactions. Authors consistently drew attention to the importance of clear and effective communication practices (28,36–38,55,58), decision making practices (28,38,42,54), role clarity (29,39,41,54), and determining lines of authority, accountability, and responsibility (28,30,33,36,37,40,42,47,50,58,61). Such terms were frequently named but rarely defined. One exception offered an in-depth exploration of accountability, defined as a participatory, ongoing process of holding power-holders to account (30). In some cases, authors spoke to the importance of understanding (33,48,56), clarifying (32,39,43), or managing (40,58) the expectations of organizations and individuals involved in partnering. Others emphasized the need for well-nurtured relationships, patience, and shared leadership (28,39,54,55,57). Some highlighted the importance of evidence-informed decision-making and policies of GHPs (29,30,62). Shared ownership (39,57) and authenticity (38,41,48) in partnering were both mentioned in the context of discussions relevant to equity in GHPs. Sandwell et al. (44) for example, strongly emphasized the importance of relationships, reciprocity, humility, shared learning, and responsiveness to pressing healthcare services and workforce needs. Similarly, Steenhoff et al. (34) proposed that GHPs pay careful consideration to why, when, and how to partner, and who benefits from partnering. These authors, among others, found that the day-to-day behaviours, attitudes, and practices of the people involved in GHPs were instrumental in how well they worked (32,35,39,41,45,48,51,52,56,57,63).
Managing operational aspects of GHPs
Many authors assessed or emphasized the need to pay attention to the day-to-day operational work of GHPs. Authors highlighted, for example, the importance of transparency in daily communications (32,55,58) and in the distribution of resources (28,33,47,52,54). Authors were attentive to management practices, such as having developed workplans, with evaluation and reporting mechanisms (30,42,50,57) and a clear understanding of the day-to-day priorities (37). Another important operational issue raised by authors was the need for fair and reasonable compensation that recognizes the contributions of staff and partners. In one study, authors emphasized the need for transparent discussion about per diems for capacity building events, identifying an uncomfortable conundrum. They argued that, while Southern partners may lose wages to participate, professional obligations to continuing competency and not expectations of per diems should motivate participation (40).
Some authors spoke specifically to the value of financial accountability and transparency (50). Authors in this and comparable articles largely focused on the recipients of aid (i.e., Southern partners), implying a tendency toward unbalanced scrutiny of the outputs or performance of one set of partners. Bruen et al. (50) offered interesting insights about issues of accountability in GHPs involving relationships and actors "with varying degrees of power and influence". They described accountability in GHPs as a participatory, ongoing process of holding power-holders to account, where power was often overlooked:
…the national and international actors who make or influence policy are largely neglected here, as are the asymmetric relations between actors that may lead to modes of accountability that are skewed to favour the interests of more powerful actors. It is necessary to also ask questions regarding who gets to decide on or design accountability interventions, to set the benchmarks or targets against which interventions or decisions should be evaluated, and whether or not efforts to improve accountability actually achieve their purported aims (50).
Generating greater accountability and equity in the context of power imbalances, they argued, requires an examination of the behaviours, influences, and actions of the power-wielders (50). Some authors also emphasized adaptability, flexibility, and responsiveness in the implementation of GHPs (47,57,58), particularly in relation to on-the-ground realities of Southern settings (30,37). Reciprocity (e.g., in student exchanges, in resource sharing, in benefits) was an issue of significant concern for many authors (33,36,42,47,55,57), with one large mixed-methods study reporting GHPs that have greater reciprocity tend to be of high value (46). Several authors argued that high-value GHPs pay attention to training(56), capacity building (38,39,54), and mentoring (34,38,46).
Paying attention to the performance and impacts
Partnership performance and impacts were often vaguely described, without distinction between performance and benefits, or definitions of what should ‘count’ as success. No universal benchmarks or signals of ‘good’ or ‘successful’ GHPs were identified. Only one article (31) provided an explicit definition for what they believed was indicative of a good GHP, stating that "we understand ‘performance’, ‘success,’ and ‘effectiveness’ in terms of problem-solving capacity of partnerships to address the issue they have set out to solve". Yarmoshuk et al. (46) argued that the “analysis of partnerships themselves, and their limitations, is often lacking in detail". They questioned the legitimacy of having implementers writing about their own GHPs for the very question of competing interest and positivity biases inherent in the academic literature, “especially in an era when the use of positive adjectives such as “innovative” in academic papers has increased significantly, likely in response to the pressure to publish and need to sell results”. Though no common definition of success emerged, this literature generally inferred ‘success’ to involve benefits to individuals, organizations, and communities and offered insights about what makes GHPs work well. Most articles presented difficulties, tensions or conundrums in GHPs, with few structured mechanisms identified to support their navigation.
Overall, we found that authors paid less attention to how relationships between the Northern and Southern partners were working than on how the Southern initiative and its multiple local stakeholders were performing. For example, some authors flatly excluded the perspectives of their Southern partners, stating that “unfortunately, interviews with nurses outside the United States were limited by logistics” (56). Without assessing the North-South partnership, authors in another article presented in-depth case study assessments of seven countries funded through the GHP, focusing exclusively on the implementation of different projects and the partnerships within each case (58). More subtly, authors’ assumptions that GHPs involve a flow of resources from North to South seemed to coincide with affording greater attention to the functional activities of the partnership as carried out in and by the Southern partners. In another article (28) using a collaborative governance framework to guide their evaluation of a GHP, authors presented their analysis from the “Northern” perspective, describing relationships and relational concepts (e.g., 'trust') without including the Southern partners (who are identified as the primary beneficiaries of the partnership) in their assessment. They defend the focus on Northern voices as an effort to "further engage ‘Northern’ institutions in seeing the value of such collaborations".
In contrast, among the authors who more directly explored relationships in GHPs, findings tended to focus on the behaviour and attitudes of Northern partners. Sandwell et al. (44) examined the experience of being in a GHP and emphasized the importance of long-term individual and organizational relationships, identifying ‘interpersonal rapport’ and ‘lightheartedness’ as contributors to a better partnership experience. One group of authors (38) pointed to the tendency of Northern partners to frame the benefits or successes of partnerships in terms of what they gave, whereas Southern partners were more likely to express gratitude for the opportunity (see p. 5-6). In their discussion, they return to this point, noting that Northern partners were “unable to identify many benefits to them", presenting a challenge to sustainability of the partnership. The authors go on to suggest the need to challenge perceptions of benefits in the context of equity (38).
Financial sustainability and partnership expansion were echoed by some as markers of success or reasons for failure (39,54). El Bcheraoui et al. (29) focused on the successful achievement of quantitative indicators of maternal mortality and other health outcomes, as well as process-related “drivers of success”. Although they emphasized the value of evaluation and learning, the article is centered around fostering competition between Latin American countries, arguing that partners’ fear of losing reputational status with neighboring countries could be a novel approach to “increase the effectiveness of global health initiatives” (29). Opportunities for career development, capacity building, and learning were frequently described as characteristic of successful GHPs. In one article, authors argued that an increase in “funds, volunteers, prestige, awards, and international visibility” (40) enabled by the West African Ebola crisis “solidified the partnership”. Visibility was also described as indicative of the value and relevance of a GHP, with authors quoting an interview participant in their large mixed-methods study (46) as saying, “because we were providing care to people with AIDS, our profile went up since we were involved in the construction of the clinics”. Herrick et al. (40) similarly criticized the concept of academic ‘success’, pointing to the visibility generated by the Ebola crisis, and its role in evoking the competitive incentive structures of academia and related institutions, in which a massive human tragedy can in fact provide career-advancing opportunities for researchers and healthcare professionals. One article (36) asserted that “using the sites to advance the U.S.-based researchers’ careers impeded success—further elaborating that “pressures or rules from funding agencies, academic institutions, and other involved parties may work against mutual benefit”.
Attending to issues of inclusion
The actors included as partners in GHPs varied across the thirty articles reviewed, with some authors naming organizations as the partners (e.g., international organizations, foundations and other funders and corporations, health ministries, hospitals, universities or research organizations, NGOs and other civil society organizations) (e.g., 40,50). Some health professions were also identified as members of GHPs, specifically medicine, nursing (33,35,56), midwifery (44), allied health (40), public health (49) and, in one case, health professions involved in ‘child health’(34). Other authors described the actors of GHPs in terms of individuals. Several articles pointed to the importance of including ‘local champions’ (implying a global South person), ‘visionary leaders’, or ‘partnership pioneers’ as key to successful partnerships (30,42,51,57). Importantly, the members of GHPs rarely included people who experienced the health issues motivating the partnership. Grassroots voices of community members or patients were largely absent from assessment of GHPs.
A relatively small number (n=8) of articles explicitly addressed issues of inclusion in their GHP. Yassi et al. (39) for example, described a research partnership involving the health of healthcare workers in South Africa, in which workers’ union representatives participated in research design and planning. Njelesani et al. (41) observed that being White or Black in Zambia mattered, noting that having a name that may read as White or Black can influence relationships and participation. In their conclusion, the authors directly address power and history: "relations between the Global North (which includes countries such as Canada) and the Global South (including countries such as Zambia) are fraught with power imbalances, macroeconomic forces and colonial legacies, the partnership described here is undoubtedly influenced by, and possibly influences, such superstructure". In another article focusing on a Canada-Dominican Republic nursing capacity-building partnership, (35) authors reported “intentionally bringing community members together to utilize their knowledge and expertise…[as] a foundational principle of community engagement”. Another article asserts that leaders of seventeen “completely indigenous” (sic) communities transmitted their priorities to the Ministry of Health (29) but neither these Indigenous leaders nor other community members were interviewed in the evaluation. Another article (57) repeatedly referred to a “vibrant consultative process” involving a range of stakeholders that did not actually include community members. In these examples, consultations by government, civil society or private sector bodies named among the formal partners often took on the role of representing grassroots voices.