Equitable partnerships are crucial for the development of resilient and sustainable pediatric global health programs, as a prudent focus on children has a long-term ripple effect that can ensure a healthy future generation by breaking cycles of poverty and fostering healthy adult members of society. Unfortunately, pediatric global health equity is an often-overlooked concept — children’s relative inability to self-advocate, contribute financially to families, and purchase healthcare services has historically made pediatric interventions a lower priority [1]. Consequently, the benefits from investments in pediatric global health equity have not been fully realized, and many of the needs of children worldwide remain unmet.

By drawing upon the insights and experiences from experts worldwide, this paper underscores the urgency for prioritizing pediatric health equity and the need for an underlying framework for equitable collaboration to conduct this work. Our experience affirms that global health partnerships require trust to be effective, and equity helps build trust. Furthermore, partnerships that are not grounded in equity are not only ineffective but are frequently harmful, further upholding power structures that have historically birthed the inequities seen in our world today. Ultimately, we urge a greater focus on equitable partnerships across the globe with multidisciplinary underpinnings to promote this agenda.

In this review, we compile and disseminate the evidence from collaborators worldwide that demonstrate the detrimental impact of global inequities on child health and development and the benefits of prioritizing pediatric health equity. We assert and provide supporting examples of three collaborations: Human Resources for Health in Rwanda, Global Initiative for Children’s Surgery, and Baylor College of Medicine International Pediatric AIDS Initiative to demonstrate that collaborations between high-income countries (HICs) and low- and middle-income countries (LMICs) in pediatric global health programs, healthcare delivery, research, and policy setting can only be successful through partnerships that are rooted in equity and reciprocity.

Child Health Inequities - a Call to Action

Universally across the globe, adverse outcomes for children are inextricably linked to social determinants of health stemming from inequality and structural violence. Factors that disproportionately exist in LMICs, including lower parental income, lower educational attainment, and other socio-economic factors, are independently associated with poor outcomes for children [2, 3]. The delivery of effective public health interventions is further affected by political factors, weak public health leadership and management, horizontal and vertical inequalities in health systems, and ineffective resource allocation and management [4]. Addressing these inequities is key in children, especially those under the age of 5 years – children who experience adversities early in their childhood may not develop to their full potential, leading to short- and long-term health consequences [5].

On a physiological level, the inequities that stem from structural violence result in dysregulation of the adrenocortical system and brain activity related to cognitive processing in less favorable environments [6, 7]. Prior studies demonstrate how multigenerational impacts of inequities hinder children from accumulating the ‘health capital’ necessary for later educational attainment, peer relationships, and parenting ability [8]. The cumulative nature of disadvantage is illustrated by these observable biological changes and measurable outcome disparities associated with structures embedded in communities, such as poverty, violence, and oppression.

In response to the plethora of data indicating how systemic inequities hinder the full developmental and life potential of children with multigenerational impacts, advocacy groups worldwide have united in a call for action [9]. Regardless of the disease process, the amelioration of structural inequities can alleviate broad causes of morbidity and mortality in children [3, 10, 11]. The United Nations Convention on the Rights of the Child in 1989 was one of the first documents that recognized the rights of children [12]. Subsequently, other groups have followed, including the American Academy of Pediatrics (AAP) in their 2010 policy statement. The AAP’s statement emphasized extra-clinical policy impacts, recognizing that the determinants of children’s health and development are rooted in social, environmental, and behavioral factors beyond the purview of the healthcare system [13]. The pediatric field’s global importance is evident in the response to the 2005 World Health Organization’s establishment of the Commission on Social Determinants of Health, which noted the ubiquity of inequities among children and the high number of touchpoints that pediatricians have with their patients in early life [14]. The pervasive impact of social inequities on child health and its broad impacts underscores the imperative to frame global partnerships aimed at addressing these structural inequities and promoting children’s health globally.

Frameworks in Pediatric Global Health Partnerships: the “How” Being as Important as the “What”

Global health partnerships between HICs and LMICs, particularly those involving academic institutions, are often promoted to enhance healthcare systems with a focus on equity. These partnerships, which may encompass activities such as research and financial support, are seen as facilitating the exchange of knowledge, resources, and ideas over time for global benefit [15, 16]. Traditional conceptions of global health, originating from HICs, trace back to colonial medicine and missionary health initiatives. Advocates argue that these historical legacies perpetuate risks of exploitation and harm within contemporary global health partnerships, potentially exacerbating existing inequities [15, 17]. This highlights the need for efforts in global health partnerships to actively address historical power dynamics and engage in ongoing self-reflection to achieve pediatric health equity.

Like the inequities present in HICs among their Black, Indigenous, People of Color, and other marginalized communities, inequities in LMICs are rooted in colonial histories and reinforced by neoliberal economic policies [18]. While strides have been made in redefining terminologies and structures within academic global health, colonial origins still influence the landscape, with leadership imbalances favoring HICs [19]. For example, research partnerships with LMICs in Africa frequently are skewed to benefit the HIC partners through defining the research priorities and where findings are published, limiting the local impact of the research [20]. Discussions now underscore the need to challenge dominant systems of knowledge production and dissemination that privilege HIC perspectives [17]. Equity, diversity, and inclusion are paramount to enabling stakeholders from LMICs to equitably contribute to global pediatric health, as experts from these contexts offer invaluable insights shaped by their unique experiences [21].

In academic partnerships, the prevailing structure of global health research funding often favors institutions in the HICs over those in LMICs. This power asymmetry leads to LMICs agreeing to research agendas that may not align with their specific needs or priorities [22, 23]. Efforts to foster equitable partnerships necessitate collaboration with local organizations and adherence to principles of inclusivity and mutual respect to support local ownership [24]. The chances of sustainability in global health partnerships are enhanced when specific strategies that rectify historical imbalances are taken, such as emphasizing local leadership and ensuring the prioritization of local goals. Addressing the perpetuation of imbalances, such as those highlighted by the Teju Cole’s White Savior Industrial Complex, where Western stakeholders prioritize emotional validation over systemic justice while also perpetuating stereotypes and reinforcing power imbalances, requires critical examination of historical contexts and interdisciplinary approaches within global health education [25]. Embracing a culture of shared power is essential for correcting imbalances in research, practice, and governance, ultimately advancing equity in global health partnerships. Doing so may require HIC partners to relinquish power that they previously held, overtly and more subtly, and refrain from pushing their own agendas and/or timelines.

In a specific, pediatrics-oriented context, prior literature has delineated directional principles and key tenets in the derivation, scope, and maintenance of pediatric global health partnerships [26]. They emphasize that a successful global child health program should adhere to a set of practices that prioritize and respect the perspectives of partners and communities. This approach is crucial to ultimately ensure that global child health partnerships between LMICs and HICs are positioned to succeed by ensuring that operations are led by an LMIC pediatric leader who directs projects and collaborations, thereby increasing the probability of grassroots-style growth. Additionally, collaborators from HICs should receive cultural competence training to better engage with stakeholders in LMICs.

Examples of Successful PartnershipsRwanda’s Human Resources for Health (HRH): Breaking the Hegemony of Funding

Following the genocide in the mid-1990s, the Rwandan government, alongside its Ministry of Health, sought to radically reconstruct the country’s healthcare system. In pursuit of this goal, they implemented the Rwandan Human Resources for Health Program (HRH), a long-term strategy that redirected global health funding from sources like the US President’s Emergency Plan for AIDS Relief (PEPFAR) and the Global Fund to Fight AIDS, Tuberculosis, and Malaria. Unlike traditional approaches, where funds were typically awarded to external entities, the Rwandan government negotiated direct control over these resources. This allowed them to build a robust healthcare workforce internally, subcontracting with international partner organizations and agencies chosen by Rwandan leadership [27].

Through this approach, visiting faculty brought specialized expertise to establish training programs and enhance academic capacity across nursing, medical, and surgical specialties. The objective was to increase the number of Rwandan health professionals completing specialty training, eventually replacing visiting faculty with locally trained staff. This restructuring aimed at ensuring long-term sustainability, marking a departure from conventional global health funding models [28]. Remarkable health outcomes, including near-universal vaccination coverage and the development of specialized healthcare services, now position Rwanda as a regional healthcare destination. The Rwandan HRH program illustrates the potential of reshaping global health funding systems and program leadership to ensure local ownership.

Global Initiative for Children’s Surgery (GICS): Novel Partnership Structures

Stakeholders in global health equity increasingly recognize the value of novel partnership structures in academic relationships that differ from traditional structures embedded in unequal power dynamics. The Global Initiative for Children’s Surgery (GICS), formed in 2016, exemplifies this trend. It facilitates ongoing dialogue and expertise exchange between surgical and anesthetic providers primarily in LMICs with participation and input from HICs [29]. Central to their approach is prioritizing input from diverse stakeholders in LMICs, both medical and non-medical, to ensure initiatives are LMIC-focused and adaptable. By discouraging one-way educational exchanges to HICs, these structures aim to ensure reciprocity and mutual benefit in global health collaborations.

To address this challenge, the group advocates for partnerships between countries with similar healthcare resources or regional training collaborations. This approach fosters equitable collaboration by ensuring balanced educational exchanges between providers from LMICs with sponsorships for travel and accommodation, promoting shared gains. GICS encourages LMIC-led research and publishing to break the academic dominance of HIC-led research in global health. The prioritization towards LMICs has significant career and healthcare system impacts [8].

Baylor College of Medicine International Pediatrics AIDS Initiative: a Seat for all at the Table

Baylor College of Medicine International Pediatrics AIDS Initiative (BIPAI) at Texas Children’s Hospital is a large, multi-institutional care and treatment network based at an academic institution dedicated to supporting programs for children living with HIV. BIPAI provides technical assistance and clinical resources to address pediatric HIV and related issues through public-private partnerships with respective Ministries of Health and its affiliated Foundations. These affiliated BIPAI Foundations, each of which are locally registered, governed, managed, and staffed in each country, serve as the organizational frameworks for implementation, delivery, administration, and evaluation of integrated programs and services within the local health sector, supplanting the initial facilitation role of Baylor College of Medicine [30].

Upholding a set of core values that prioritize collaboration and resource redistribution, these themes are exemplified in initiatives like the Texas Children’s Global Health Corps, which emerged in 2006 as the Pediatric AIDS Corps to address the critical shortage of pediatricians in Africa and Latin America [9]. Through the deployment of nearly 200 physicians and extensive capacity-building efforts to construct personnel and physical infrastructure, over 100,000 healthcare workers have been trained and a global forum that emphasizes input from LMIC stakeholders has emerged.

In Tanzania alone, where BIPAI’s affiliated Baylor College of Medicine Children’s Foundation-Tanzania has operated in Mbeya and Mwanza since 2009, the impact is substantial. With an annual budget of $3.3 million and a team of 121 dedicated professionals, Baylor Foundation-Tanzania has provided care to over 26,000 patients and trained over 1,200 healthcare workers, demonstrating a steadfast commitment to bolstering the local healthcare infrastructure through a long-term relationship [31]. This global collaboration serves as an example where specialists from HICs and LMICs converge to share best practices and resources, driving forward crucial research and clinical initiatives focused not only on HIV/AIDS but also on tackling a spectrum of health challenges impacting the well-being of children and families worldwide.

Enhancing Equity in Pediatric Global Health Partnerships

Given the interplay of political, social, and economic forces that influence health disparities in children, achieving the goal of pediatric health equity requires partnerships that are innovative in their approaches. Because of their self-critical and dynamic nature, academic partnerships have a distinctive potential to tackle structural injustices in the global system and the associated silos and barriers [32]. In these relationships, educational components can be the most impactful for those in learner roles, as actively incorporating antiracist and anticolonial curricular aspects, especially in HICs, fosters a future generation of global health stakeholders with an equity-oriented mindset [33]. In a qualitative study assessing the viewpoints of stakeholders across HICs and LMICs regarding persistent inequities and legacies of colonialism in global health, key themes that emerged included persistent power imbalances in terms of resource allocation and decision-making in HIC institutions [34]. The results call for a deliberate overhaul of the legacy system with a focus on transferring power and resources to LMICs to increase innovative capacity on their part. Experienced authors in the global health equity field write how regimented methods utilizing checklists are some of the most effective ways to ensure that equity components are enshrined into the structures of global health partnerships [35]. In reciprocating the benefits of global health partnerships that LMIC institutions once conferred onto HIC institutions, these deliberate, new approaches are needed to embed accountability and shift power contributing to the broader goal of dismantling structural inequities in global health and development, ensuring that institutions and individuals in LMICs receive at least the same, if not more, benefit from academic global partnerships as those from HICs.

As shown in the three examples above, these goals can be achieved by promoting collaborations that break the mold in how global health partnerships function. A corroborating, large body of literature now delineates the importance of thoughtfully designed academic global health partnerships between institutions and organizations in HICs and LMICs, at risk of perpetuating legacies of exploitation and oppression. Certain aspects shared between HRH, GICS, and BIPAI shown in Table 1, highlight examples of intentional design [26].

Table 1 Innovative aspects in the academic global health partnership design of HRH, GICS, and BIPAI that center health equity

In pivoting from a mindset of saviorism to solidarity, one tangible tool for all partnerships that aim to be inherently equitable and justice-oriented is the Douala Equity Checklist by Hodson and Colleagues (Fig. 1) [36]. This list was created in response to a need to formulate a tangible guideline embodying the decolonial theories needed in global health partnerships. Comprising a 20-item list, these recommendations are based on four key principles: prioritizing locally relevant solutions, involving teams from both HICs and LMICs at various levels, ensuring equitable funding for all participating countries, and establishing clear roles and responsibilities that leverage the strengths of each team member and institution [21]. The same amount of resources and attention traditionally given to faculty and learners from HICs to pursue global health should be equal, if not more, to their peers at LMIC partner institutions, with their expertise guiding research, policy, and other implementation, as their lived experiences are more contextually fitting.

Fig. 1

The Douala Equity Checklist by Hodson and colleagues, distributed under the terms of the creative commons attribution license