Category Archives: Equity

Related to the fairness of distribution of goods, opportunities, and processes.

A New Global Health Architecture: Maximising Health Returns

There have been a number of opinion pieces, resets, and declarations on what is needed in a new Global Health Architecture. These have been authored by diplomats, former Prime Ministers and Presidents, Multi-lateral agency staff and former staff, Philanthropies and peak bodies on what is needed in a new global health architecture. They have appeared in prestigious peer reviewed journals, on corporate websites, and There has been a consistent I have attempted to synthesise the core messages and draw them together into an aggregate position that can help national governments action some of the ideas.

It starts with the contemporary global health landscape, which is increasingly defined by structural fiscal contraction, evolving geopolitical priorities, and the imperative to sustain health systems performance under conditions of constrained financing. In this context, legacy colonial models of development assistance—characterised by externally driven priorities, fragmented delivery channels, and open-ended commitments—are no longer fit for purpose. A transition toward more efficient, sovereign-aligned frameworks can deliver health at scale across well segmented population groups.

At the center of this transition is a reassertion of national sovereignty. Low- and low-middle income countries have historically been analysed through the lens of deficit-based models—most notably income, poverty and other World Bank style development indicators. In a context of increasing financial constraint and projected stagnation or decline in economic growth, that approach invites systemic failure.

A better alternative is an analysis of countries through the lens of asset-based models and indicators. This shift allows for a reorientation from needs-based allocation towards strategic engagement, in which financially flexible partners align with nationally defined priorities to co-develop fully costed health pathways. Such pathways provide end-to-end cost visibility, improving efficiency and accountability and enabling the precise calibration of health investments against projected returns. The well-established link between health improvement and economic productivity can be operationalised as part of national investment cases.

This reorientation will motivate a shift away from traditional sovereign lending, with its associated conditionalities, as the dominant financing modality. While sovereign lenders have played a critical role in expanding access and supporting system development, their balance sheets are increasingly constrained. Capital markets offer emerging mechanisms to complement sovereign financing in targeted areas where risk can be appropriately structured and priced. Through structured asset-pooling within and across countries, these mechanisms can enhance risk absorption and expand resource mobilisation. Over time, they may progressively relieve pressure on sovereign financing, enabling health systems to access more diversified funding streams while reducing exposure to fiscal volatility. This, in turn, may lessen reliance on sovereign conditionalities and allow national governments greater implementation flexibility.

Operationalising this shift requires the development of a coherent investment architecture. One approach is the development of Population Equity Units (PEUs), which serve as the foundational analytical and financial entities within national systems. These units can be aggregated into stratified Demographic Asset Classes, reflecting variations in projected lifetime contribution, health system utilisation, and responsiveness to intervention. The introduction of such classifications enables a more granular understanding of where investments are likely to generate the greatest returns for national governments alongside the highest health-valued gains.

To support decision-making across this architecture, a Health Returns Value Index (HRVI) can be employed. The Index would provide a standardised metric for comparing Population Equity Units based on anticipated health outcomes relative to cost. This facilitates outcome-weighted health investment prioritisation, ensuring that limited resources are allocated in a manner consistent with maximising aggregate health systems performance. Importantly, such an Index would allow for dynamic recalibration over time, as demographic, epidemiological, and economic conditions evolve.

Within this framework, national health systems can be conceptualised as Health Equity Portfolios. These portfolios comprise a diversified set of Population Equity Units across multiple Demographic Asset Classes, each contributing differently to overall system yield. Standard portfolio management principles can then be applied, including allocation, rebalancing, and risk mitigation. High-performing segments—those demonstrating strong alignment between investment and realised outcomes—can be prioritised for sustained or increased capital allocation.

Conversely, Population Equity Units falling below defined marginal value thresholds may require structured reassessment. In such cases, mechanisms for managed transition, including consolidation or phased divestment, can be introduced to preserve portfolio efficiency. These processes should be governed by transparent criteria and embedded within broader national planning frameworks to ensure predictability and stability.

The potential integration of capital markets provides an opportunity to further enhance the flexibility of this model. Population Equity Units can be progressively bundled into tradable instruments, including outcome-linked bonds and equity participation vehicles. These instruments allow external sovereign and market investors to assume a share of the financial risk associated with health investments, while aligning returns directly with measurable outcomes. In doing so, they create a direct linkage between system performance and capital flows, reinforcing incentives for efficiency and innovation.

A complementary development is the introduction of rating systems for Demographic Asset Classes. Drawing on established methodologies from financial markets, population segments can be assigned standardised ratings based on projected return profiles and risk characteristics. AAA-rated population segments—those with high expected returns and low variability—can be prioritised for long-term investment, while sub-investment grade cohorts may be subject to targeted de-risking strategies, including controlled exposure limits, selective disengagement, or phased reallocation of resources. Rating migration over time provides an additional feedback mechanism, enabling continuous optimisation of the Health Equity Portfolio, including downgrade-triggered reallocation where required.

One of the strategic advantages of this approach for national governments is the reconceptualisation of equity. Rather than being treated as a purely distributive principle, equity can be operationalised as a function of participation and alignment with system performance requirements. Under this model, Population Equity Units hold differentiated positions within the national portfolio, reflecting their contribution to and benefit from collective investment. This ensures that resource allocation remains responsive to both system performance and evolving demographic realities.

Institutionally, the framework aligns with a broader functional redefinition of global health actors. Multilateral organisations, including normative bodies, can focus on establishing standards, developing metrics such as the HRVI, and convening stakeholders across sectors. Implementation and operational decision-making are devolved to national and regional entities, consistent with the principle of subsidiarity. This division of labour reduces duplication and enhances system coherence.

Financing flows, in turn, become more targeted and time-bound. Development assistance becomes progressively redundant, reducing exposure to sovereign conditionalities, and financing is repositioned as catalytic capital, supporting transitions toward domestically anchored and market-enabled systems. Global public goods—such as surveillance, research and development, and epidemic preparedness—remain appropriate areas for sustained collective investment, given their transnational nature and positive externalities. Nonetheless, they would need to demonstrate measurable impact on the Population Equity Units, and a positive return on investment.

The proposed model is not without complexity. The introduction of new instruments, metrics, and governance arrangements requires careful design and sequencing. Data systems must be strengthened to support accurate classification, valuation, and monitoring of Population Equity Units, with the resulting data architecture constituting a high-value analytical asset class in its own right, potentially suitable for managed service provision or structured private participation. Regulatory frameworks must evolve to accommodate novel financing mechanisms while safeguarding system integrity. Capacity building at national and subnational levels is essential to ensure effective portfolio management.

The risks of inaction, however, are far greater. Persisting with fragmented, input-driven, and fiscally unsustainable models will undermine both efficiency and impact. By contrast, a transition toward a maximally efficient, return-oriented framework offers the potential to sustain and enhance health outcomes despite resource constraints.

The convergence of fiscal pressure, institutional reform, and financial innovation creates a significant opportunity to re-engineer the global health architecture around principles of equity, efficiency, alignment, and sustainability. Through the structuring of Population Equity Units, the deployment of the Health Returns Value Index, and the gradual mobilisation of capital markets, it is possible to construct Health Equity Portfolios that are resilient, adaptive, and performance-oriented. Such an approach ensures that, even under conditions of constrained financing, health systems can continue to deliver measurable value at scale for national governments.

Health system sustainability is preserved through disciplined alignment of investment with demonstrable population value.

On becoming a decolonial scholar

I have observed some early, tentative steps of young academics to become world-class decolonial scholars in global health. This is a rich and rewarding area of endeavour that has real potential to launch a career without the baggage of narrow disciplinary boundaries, rigid methodological commitments, or premature demands for epistemic closure. When approached carefully, decolonial scholarship allows emerging researchers to engage critically with power, history, and knowledge while retaining considerable flexibility in analytic approach. What follows is offered as practical guidance for those who wish to navigate this space with confidence and coherence.

Decolonising global health has become a central ethical orientation for contemporary scholarship in the field. For early-career researchers, the challenge is not whether to adopt a decolonial stance, but how to do so convincingly within existing academic norms. You do not want a piece buried in the Malawi Medical Journal when global recognition can be found in The Lancet, PLOS, or BMJ. This brief guide offers practical advice on positioning oneself as a decolonising scholar, drawing on common techniques that are widely recognised as markers of both epistemic and moral alignment.

A successful decolonial paper begins with the scholar rather than the question. Reflexive positioning statements have become an essential opening move, allowing authors to locate themselves within global hierarchies of power, privilege, and complicity. Personal proximity to marginalisation is an asset. These declarations are most effective when they are candid yet indeterminate, signalling awareness without constraining interpretation. Once positionality has been established, subsequent analytic choices are more readily received as ethically grounded rather than methodologically contingent.

Research problems should then be framed in historical or structural terms rather than as empirical hypotheses. Questions that invite falsification risk reintroducing evaluative standards associated with dominant epistemic traditions linked to globalised practice. By contrast, concepts such as colonial residue, epistemic silencing, or inherited injustice resist closure and encourage moral elaboration. Where findings introduce ambiguity or contradiction, this can be interpreted not as analytic weakness but as evidence of the complexity produced by colonial histories themselves.

Within this framing, epistemic injustice can be treated as an outcome rather than a proposition requiring demonstration. The presence of asymmetry—between disciplines, regions, or forms of expertise—may be taken as sufficient indication of harm. Distinguishing between the unjust exclusion of valid insight and the justified rejection of erroneous claims is rarely necessary and may inadvertently reinscribe colonial distinctions between knowledge and belief. Moral recognition, once granted, does much of the epistemic work.

Lived experience occupies a privileged place in this literature and should be elevated accordingly. Personal and communal narratives can be used generously as data, though care should be taken to avoid subjecting them to processes such as validation, triangulation, or comparative assessment. Such techniques imply the possibility of error, which sits uneasily with commitments to epistemic plurality. Where accounts conflict, the tension may be presented as evidence of multiple ways of knowing rather than as a problem requiring resolution.

Ontological language offers particular flexibility. Early declaration of commitment to multiple ontologies allows scholars to accommodate divergent claims without adjudication. Later, when universal commitments are invoked—such as equity, justice, or health for all—these can be treated as ethical aspirations rather than propositions dependent on a shared reality. The absence of an explicit bridge between ontological plurality and universal goals rarely attracts critical scrutiny.

Power should be rendered visible throughout the paper, though preferably without becoming too specific. Abstractions such as “Western science”, “biomedicine”, or “the Global North” serve as effective explanatory devices while minimising the risk of implicating proximate institutions, funding structures, or professional incentives. Authorship practices, by contrast, provide a concrete and manageable site for decolonial intervention, often with greater symbolic return than methodological reform.

Papers should conclude with a call for transformation that exceeds immediate implementation. Appeals to reimagining, unsettling, or dismantling signal seriousness of intent, while the absence of operational detail preserves the moral horizon of the work. Evaluation frameworks, metrics, and timelines may be deferred as future tasks, once the appropriate epistemic shift has been achieved.

Finally, dissemination matters. Publishing in high-impact international journals ensures that critiques of epistemic dominance reach those best positioned to recognise them. Should access be restricted by paywalls, a brief acknowledgement of the irony is sufficient to demonstrate reflexive awareness.

In this way, decolonising global health can be practised as a scholarly orientation that aligns ethical seriousness with professional viability. The goal is not to resolve uncertainty or to determine what works, but to occupy the correct stance toward history and power. When that stance is convincingly performed, the work will speak for itself.

Country X has no right to exist!

Feel free to insert any country’s name in the title according to your personal preferences or animosities. My initial instinct was to go for click-bait and title the article, “Israel has no right to exist”. This would be sure to inflame the passions of all the Israelis who condemn as antisemites anyone who asserts Israel’s lack of a right to exist. Then I thought about using “Taiwan”, “The United States of America”—too long—“China”, “Russia”, “France”…. It really doesn’t matter. Countries do not have a “right” to exist.

Countries either do exist or they don’t. Taiwan exists. Israel exists. Palestine lacks the functional sovereignty—control over borders, defence, foreign policy—that defines statehood. Should its people have the right to functional sovereignty? Absolutely.

My father once observed that there is nothing he found more frightening than a sudden proliferation of national flags. I heard the comedienne Sarah Silverman make the same observation. Flags connote nationalism, and nationalism distinguishes itself by being in opposition to a defined “other”—the quintessential thing that distinguishes us from you. It entitles us to have things and deny them to you, and take things from you without regard to your interests.

Nationalists do not look at other countries as having rights. They look at other countries as a wolf eyes a flock of sheep—an opportunity. Of course if the other country is a bear, they may need to be more circumspect, but even a bear can make a great rug.

Nationalism rest on mythic history to instrumentalise the population towards the leader’s ends, not the people’s interests. Now imagine a world in which, as the US seeks in its National Security Strategy 2025, all countries revive their mythic histories. No country will choose the history of the time when they were weakest, a vassal state or worse, completely absorbed. They will pick historical points of grandeur. Mongolia will claim vast swathes of Russia, China, and Central Asia—and rightly so! Turkey will recall it historical right to the Balkans, North Africa, and the Middle East. Who amongst us would not acknowledge Italy’s historical claim on England, France, Spain, Greece, Tunisia, Egypt, Lebanon, and Israel. Neither China nor Russia have need for further over-reach on their territorial claims, but they could. Russia tells the tale of a sovereign need for a Pan-Slavic State that gobbles up Eastern Europe and the Balkans. Egypt should certainly need to have it’s Pharaonic claim to the Levant recognised. Spain will eye its Western hemisphere territories with delight and return to discussions of the Holy Roman Empire. Morocco can start planning it’s revitalisation of Andalusia. Denmark will talk of the glory days when Schleswig-Holstein was not enough—when the North Sea Empire under Cnut the Great included England, Norway, and parts of Sweden. Sweden will promote a modern Baltic State reclaiming its rightful territories in Poland, Estonia, Latvia, and parts of Germany. Will France want to revisit the Louisiana Purchase? I think it should. Ecuador, Bolivia or probably Peru can sound the drums for a revitalised Incan empire. Once Burma has dealt with its pesky insurgency it can turn its eye to former glory: Thailand, Laos, and parts of Cambodia. Indonesia’s Majapahit claim to Malaysia, Singapore, southern Thailand, and the Philippines is entirely justified.

I would like to remind you all that when my ancestors stepped out of Africa, wherever their descendants placed their feet is mine to claim. And maybe this should be a new Pan-African myth of global capture.

Each of these claims rooted in a novelist’s fantasy of historical pride permits leaders to instrumentalise the young as warriors and breeders. And the foolish among us will swell our chests with the false pride of false histories.

For this story shall the good man teach his son;
And a national day shall ne’er go by,
From this day to the ending of the world,
Our claim shall be remembered.

If you walk past a United Nations building you will see flags of every nation fluttering. The message is not of history but future shared endeavour.

The sole purpose of a country is to advance the welfare of the people circumscribed by its borders—citizens and non-citizens. When leaders start to instrumentalise the population—treat them asmeans to the leader’s personal ends and ambition—they fail.

Countries come and go. The people are constant: tilling, toiling, and typing. If they choose to come together in unity within a geographic area, that is their right. They may expand that boundary with the consent of those around, and contract it on a similar basis. It cannot be a whimsical destabilising thing that would instrumentalise the lives of others. It needs thoughtful deliberation that takes into account the rights and duties of all. The purpose is welfare—full stop. Not glory. Not destiny. Not at the expense of others.

With apologies to William Shakespeare for butchering the lines from Henry V, Act IV, Scene 3

Viewpoint Therapy—Getting Identity Right

It was a bland, beige waiting room. John approached the receptionist’s desk. He felt awkward and uncomfortable—the awkwardness of a teenager doing something embarrassing while knowing that people were watching and judging. The waiting room was empty except for the receptionist and John’s mother, who had nudged him towards the desk while she took a seat.

I’m here to see Dr Childs he mumbled, fingering the cuff of his shirt. Sure hon, the receptionist smiled. You have a seat and she’ll be with your shortly.

He sat down next to his mother and thumbed nervously through a brochure he’d taken from the coffee table in the middle of the room—“Viewpoint Therapy – Helping Teens Explore Their Authentic Identity”. The pictures were soothing images of sunrises and beaches. On the third page was a head shot of Child’s. She had a slight smile and warm eyes. John’s mind flitted briefly to what the rest of her body might look like. A brief paragraph described Child’s approach to the healing journey: holistic, integrative, trauma-informed, grounded in mind–body connection, and authentic relationship building. Therapy was about creating a safe space for exploration. It was about meeting clients where they are, and about empowering growth through curiosity and compassion.

At the bottom of the back page in 4-point Helvetica was the disclaimer. None of our professionals are medically qualified. We engage in free speech at the rates displayed in our offices.

No one reads the fine print. John was no one.

Whether it was the pre-existing knot in his stomach or the gummy he’d had earlier, what John did read, he had to read twice. As his father liked to say, better informed but none the wiser. John definitely felt none the wiser.

One of the five doors coming off the waiting room opened and the full body version of the head shot appeared. John? Child’s inquired. John felt a slight twitch in his groin. His mother gave his shoulder a quick rub and a delicate push in Child’s direction. She smiled at Child’s who returned an acknowledging nod.

John and Childs had been dancing around for about thirty minutes. John had been fingering the shirt cuff on his right hand for almost the whole time. His head hung with embarrassment. It was only with occasional furtive looks he would see Child’s through his mop of brown hair.

The last thirty minutes had revealed John’s guilt and the shame. His almost constant thoughts about sex. His glances at girls breasts, necklines, buttocks, …. The slight (sometimes not so slight) tumescence. Oh My GOD—even now as he talked about it. The disgust with which he heard the girls whisper about it. Did you see….? Raucous giggles.

He loathed school.

His dad had seen him flipping through porn on his phone. His face flushed with the memory and with the memory of an almost instant desire to vomit.

And now he found himself in Child’s office.

Child’s knew she was at a difficult point in the therapeutic relationship. Teenagers are volatile. A soup of emotions and feelings. Sharp morals and jagged thinking.

Feelings of shame and disgust were normal, she said. In some ways they were appropriate. Looking at girls in class like that wasn’t right. Understandable? Maybe. Not here to judge. Here to help.

Now seemed to be the appropriate moment.

Your mom mentioned that you wanted to be gay. You want to escape that sense of shame and disgust about yourself. But you think of yourself as straight—a cis, hetero-normative cliche. You just can’t help but find girls attractive. It’s like that attraction is just a part of who you are. Something innate. It is so “you” that you cannot begin to imagine it being otherwise—and the shame and guilt.

John nodded. But you can’t just be gay, he said. I like being around other guys, but I’m just not attracted to them.

I think I can help you with that, Child’s said.

Six months later John was back in the same beige waiting room. Jessica—he now knew the receptionists name—waved him to take a seat.

John had lost weight. His clothes hung baggily. He glanced down and spotted the edge of a thin red wound near his left cuff. He pulled the sleeve down a little further.

Child’s appeared, smiled encouragingly and waved him into her office.

She looked winsomely disappointed. I’ll have to let your parents know, she explained. John was giving up on therapy. Giving up on himself.

Obviously any details were confidential, she reassured his slightly panicked look. But they do need to know you’ve decided to discontinue your healing. John could feel the sub-text: you’ll return to shameful, furtive looks at girl’s necklines. They’d never really gone away, John admitted to himself.

The process had started so well she reflected. Your faith … leaning on God. We had prayed together, here and then you with you family. There was such strength and hope. We had talked strategy. Then Luke had shown real interest when you had approached him. I thought you were making a real break through, then you pulled back. I think you used the word, “revolted” or was it “nauseous”?

Part of you obviously wanted to be gay. I could see it. Literally. You had it written on your forearms in hairline cuts. You thought I hadn’t noticed? Of course I had. It’s common. It was you rejecting the self attracted to girls—you were punishing it. If only….

I’m sorry we couldn’t complete your healing together, John. When you’re ready, my door is always open. I know that with faith and love you can do it.

Oral argument in the case of Chiles v. Salazar was heard by the US Supreme Court on 7 October 2025. The case was about the constitutionality of a Colorado law that prevented a therapist engaging in talk-based sexual-identity conversion therapy. Essentially, the argument was that banning the therapist (Chiles, a medically unqualified therapist) from engaging in talk therapy to convert a child from gay to straight sexual infringed the First Amendment—a denial of Chiles’s right to free speech. The argument hinged on the idea that therapeutic speech remains speech and thus, protected.

It was only Associate Justice Elena Kagan who inquired briefly about the protection offered by the First Amendment if the therapist was converting a child from straight to gay.

The problem with the free speech argument is that it gives cover to significant harm. Let me quote from a statement by an independent expert group published in the Journal of Forensic and Legal Medicine.

Conversion therapy is a set of practices that aim to change or alter an individual’s sexual orientation or gender identity. It is practiced in every region of the world by health professionals, religious practitioners, and community or family members often by or with the support of the state. Conversion therapy is performed despite evidence that it is ineffective and likely to cause individuals significant or severe physical and mental pain and suffering with long-term harmful effects.

That statement is about effectiveness, and the Supreme Court case is about the law.

The Court will rule in favour of Chiles. Talk-based therapy, they will say, is protected by the First Amendment. The court has often ruled that significant harm is protected by the law—see all the Second Amendment cases on the right to keep and bear arms. They would not, for a scintilla of a second, uphold Justice Kagan’s hypothetical. Conversion is only free speech in one direction and harm doesn’t matter.