Exploring equity in global health collaborations: a qualitative study of donor and recipient power dynamics in Liberia.

IntroductionGlobal health collaborations between individuals from high-resource and low-resource settings are complex and often built on hierarchical structures and power differentials that are difficult to change. There have been many calls and frameworks developed to facilitate more equity within these collaborations, yet little is known about the lived experiences of global health donors and recipients working within such collaborations and how those experiences can facilitate more equitable collaboration. Liberia, a postconflict, post-Ebola country, provides an ideal setting to study lived experiences of global health collaborations.MethodsOur qualitative analysis used key informant interviews representing the perspectives of those working on behalf of the Liberian government, Liberian academics, foreign donors and non-governmental organisations and implementing partners. Thematic analysis guided this analysis to explore topics such as financial control, accountability and decision making.ResultsThe first phase of the analysis mapped the existing patterns of priority setting. Priority-setting power was most strongly held by those with financial control (donors), and implementation plans tended to be built on metrics that aim to meet donor expectations. The second phase of the analysis explored the interplay between underlying factors that we identified in our data associated with driving collaborative inequity: history of prior of engagement, level of transparency and patterns of accountability.ConclusionsOur findings highlight that global health collaborations in Liberia are structured to hinder equitable partnerships. The power structure tied to financial ownership offers little space for recipients to have an equitable role in collaborations, which maintains dependence on external aid and ensures that weak systems remain weak. While our study is limited to Liberia, we anticipate that these dynamics are common elsewhere and reinforce the importance of intentional efforts to ensure equitable decision making and power structures in similar settings worldwide.

Seeking and reaching emergency care: A cross sectional household survey across two Liberian counties.

The overwhelming burden of morbidity and mortality from injury and medical conditions requiring acute care are borne by low- and middle-income countries lacking accessible, quality care systems. Current evidence suggests the lack of prehospital care systems likely contributes to this disproportionate burden. As an initial step in a longitudinal, collaborative effort to strengthen the chain of survival for emergency conditions in Liberia, baseline attitudes and behaviors in accessing and utilizing emergency care were characterized. A multistage, proportional, cluster sampling frame was employed to conduct a cross-sectional, community-based survey of 800 households across rural Lofa County and the greater capital (Monrovia) metropolitan area. The primary outcome was facility-based utilization of emergency care within the 12 months prior to survey administration. 43.9% of individuals surveyed reported a visit to an emergency unit in the last year. Multivariable logistic regression revealed increased adjusted odds of facility-based emergency care utilization in households that were low-income, non-English-speaking, lacking electricity, or had a non-durable roof. Among these individuals, 23.6% had sought care from a community health worker, family/friend, clinic, pharmacy, or traditional healer prior. The majority of persons seeking care do so without ambulance services. 34.8% of all households have called a community member for a medical emergency, but 88.9% of survey respondents report no first aid training and cite barriers to rendering aid. This represents the first household survey to assess the perceptions and utilization of emergency care in Liberia. Formal pre-hospital care provision is limited and substantial barriers to emergency care access exist. First aid training and acceptance is lacking, despite frequent reliance on community-based aid during emergencies.