Exploring Factors Associated with the Prioritization of South-to-South Partnerships by International Global Health Institutions in the Southern Hemisphere

INTRODUCTION

Academic global health programs in North America have proliferated substantially since the turn of the century. Recent studies have sought to better understand the sustainability and impact of these programs and to evaluate the extent to which partnerships between global health academic institutions in North America and international institutions were mutually developed and are mutually beneficial, and to identify determinants of equity, benefit, harm, and sustainability. Of primary interest, at the conclusion of our 2016 study of North American Academic Institutions and their International partners, we reported that roughly 40% of international partnering institutions intend to prioritize South-to-South over South-to-North partnerships in the future. In this cross-sectional study, the UW researcher explored factors that may be associated with future prioritization of academic global health partnerships

METHODS

A cross-sectional study was used to explore factors that may be associated with South-to-South partnership prioritization and to test three different hypotheses: 1. Dissatisfaction Hypothesis: dissatisfaction with partnership collaboration and/or performance with institutions in the Northern Hemisphere is associated with an increased probability for international partners reporting future South-to-South partnership prioritization (SSPP) as opposed to South-to-North partnership prioritization (SNPP). 2. Diversification Hypothesis: having a predominance of current global health partnerships with North American academic institutions results in a desire to develop a more balanced global health partnership portfolio and thus prompts international partners to pursue future SSPP as opposed to SNPP. 3. Maturation Hypothesis: having a higher number of global health partnerships (total), is an indicator of an institution’s higher level of global health development/maturity and creates capacity for future SSPP as opposed to continued SNPP. Data were collected using surveys that included quantitative and semi-quantitative questions in the form of Likert scales. Surveys were disseminated through the use of Survey Gizmo, an online survey tool, and an electronic version (Microsoft Word) was disseminated via email. Original data collection took place from June 8 to October 15, 2015. Additional data collection took place from June 12th to August 11th of 2017. Overall, 87 international partnering institutions named by US academic institutions were invited to participate in the study, which achieved a 59% response rate. To test the Diversification Hypothesis, the variable “North American Partnership Number-Proportion Matrix” was created as a composite indicator with 6 categories that reflected the number of North American partnerships that each international institution reported, coded dichotomously so that greater than or equal to 5 partnership with North American academic institutions = 1, and North American partnership proportion, coded such that North American partnerships represented less than 67% = 1, greater than or equal to 67% and less than 100% = 2, and 100% = 3. To test the Maturation Hypothesis, “Total Partnerships” was coded as an ordinal level variable in which 1 to 3 partnerships = 1, 4 to 9 partnerships = 2, and 10 or more partnerships = 3. In the analyses, this variable was broken down into dummy variables with 1 to 3 partnerships serving as the reference group. Testing the Dissatisfaction Hypothesis included four sets of independent variables. First, “Collaborations and Investment Expectations Not Met,” was coded into a dichotomous variable such that 1 = Meets Minimum or No Expectations. Second, five indicators were used to assess the extent to which international institutions perceived poor performance of their collaborations with North American academic institutions with respect to: assessing institutional needs; establishing mutual goals; addressing institutional needs; planning, monitoring, and evaluating impact; and providing feedback. These indicators were coded such that 3 = Poor or Not Done, 2 = Well or Fair, and 1 = Excellent or Very Well. Third, seven indicators examined the extent to which international institutions perceived that their needs were not being met by North American academic institutions with respect to: medical training, collaborative research, clinical or public health interventions, health systems development or capacity building, technology exchange, policy development and advocacy, and student learning and practicum experiences. These indicators were coded such that 3 = Poor or Not a Focus Area, 2 = Well or Fair, and 1 = Excellent or Very Well. Finally, “Ranking of Partnership by North American Partner” represented how the partnership between an international institution and a North American academic institution was perceived by the North American academic institution that identified them. The indicator was coded as 1 = High Performing Partnership, 2 = Middle Standing Partnership, 3 = Struggling Partnership. Statistical Analysis Statistical analyses included unadjusted logistic regression models to assess the relationship between the outcome variable Partnership Prioritization and indicators used to test the Dissatisfaction, Diversification, and Maturation hypotheses and multivariate logistic regression models to adjust the associations between the outcome variable Partnership Prioritization and indicators used to test the Dissatisfaction, Diversification, and Maturation hypotheses in order to contextualize these results by geographic region and the type of institutions represented in the data.

RESULTS

Dissatisfaction Hypothesis International institutions reporting higher levels of dissatisfaction with their North American partners with respect to how well their collaborations were assessing the needs of their institution (OR = 0.25 [95% CI = 0.07, 0.87]); planning, evaluating, and monitoring impact (OR = 0.23 [95% CI = 0.60, 0.85]), and providing systematic feedback (OR = 0.27 [95% CI = 0.09, 0.87]) were nonetheless less likely to report South-to-South partnership prioritization. Similarly, international institutions with higher levels of dissatisfaction with their North American partners with respect to having their collaboration and investment expectations met were nonetheless somewhat less likely to report future South-to-South partnership prioritization (OR = 0.34 [95% CI = 0.07, 1.70]). Institutions reporting poor needs fulfillment by their North American partners with respect to research collaboration were less nonetheless likely to report South-to-South partnership prioritization (OR = 0.29 [95% CI = 0.27, 1.00]). Finally, institutions that were reported as being part of a “struggling partnership” by North American academic institutions were nonetheless less likely to report prioritization of South-to-South over South-to-North partnerships in the future (OR = 0.27 [95% CI = 0.09, 0.88]). Diversification Hypothesis Adjusted analyses showed that international institutions having all of their current partnerships represented by partnerships with North American academic institutions and also having less than 5 current partnerships with North American academic institutions were less likely to report future South-to-South partnership prioritization (OR = 0.01 [95% CI = <0.01, 0.85]) than were institutions with a high, but not complete, proportion of their current partnerships with North American academic institutions, but also that had less than 5 partnerships with North American academic institutions. Likewise, international institutions that have all of their current partnerships represented by partnerships with North American academic institutions and have more than 5 partnerships with North American academic institutions were less likely to report future South-to-South partnership prioritization (OR = <0.01 [95% CI = <0.01, 0.74]). Maturation Hypothesis In the adjusted analysis, institutions with 4 to 9 total partners were more likely to report that they anticipate prioritizing South-to-South rather than South-to-North partnerships in the future compared to institutions with only 1 to 3 partners (OR = 2.82 [95% CI = 0.46, 17.24]). Institutions with 10 or more partners were only slightly more likely to report that they anticipate prioritizing South-to-South rather than South-to-North partnerships in the future compared to institutions with only 1 to 3 partners (OR = 1.23 [95% CI = 0.21, 7.20]), suggesting a non-linear association between number of partnerships and prioritization of South-to-South partnerships. 

DISCUSSION

The results are not consistent with the Dissatisfaction Hypothesis, give mixed support for the Diversification Hypothesis, and show some support for the Maturation Hypothesis as explanations for the SSPP phenomenon. Of key importance, these findings provide evidence that prioritization for developing partnerships with other institutions in the Southern Hemisphere rather than with institutions in the Northern Hemisphere is not the result of dissatisfaction on the part of global health institutions in the Southern Hemisphere with past or current partners in the Northern Hemisphere.