The Equity Tool for Valuing Global Health Partnerships

There is a need to more comprehensively identify and respond to equity in global health partnerships. The Equity Tool can support dialogue at any stage of a partnership, by individuals at any level. This assists partnerships to embrace ways of recognizing, understanding, and advancing equity in all their processes.


INTRODUCTION
O ver the past decade, equity has become recognized as a core value guiding the practice of global health. Whether oriented toward research, capacity building, or development, partnerships are often promoted as mechanisms for working in global health, with equity more-or-less centered in the process and practices in global health. Partnerships involve complex relationships between individuals and organizations, each with their particular positions, context, needs, resources, and agendas. In global health, partnerships are common between organizations in high-income countries (HICs) and those in low-and middle-income countries (LMICs). Such partnerships can be difficult to navigate, particularly because issues of power are rooted in complex sociopolitical and economic histories. 1,2 GHPs exist in the ambient context of persistent health and economic inequities between HICs and LMICs and continued calls for the decolonizing of global health. 3 These inequities are caused by the unfair distribution of resources, wealth, and power. 4,5 Addressing (and even discussing) equity considerations and issues of power can be both sensitive and difficult, especially if such discourse is viewed as being outside the immediate goals of the partnership. Indeed, global health has had a long history of not directly talking about these issues. 3 Yet, GHPs that consider issues of equity in their processes and structures hold greater potential for lasting health impact and building local capacity than those that do not. 6,7 Attempts to construct a meaningful guide on what makes GHPs successful are varied and contextspecific, often without clear consideration of issues of equity. [8][9][10] The Canadian Coalition for Global Health Research (CCGHR)* over the past decade has prioritized the promotion of equity in GHPs, resulting in the development of a Partnership Assessment Tool 11,12 and the equity-centered Principles for Global Health Research. 13,14 Another notable effort to amplify attentiveness to equity in GHPs is the Council on Health Research for Development's Research Fairness Initiative. 15 These resources point to the importance of equity in partnering processes yet tend to focus on aspirational ideals or higherlevel considerations rather than on the day-to-day practices of partnering. Extending the scope of these equity-centered aspirational resources, we sought to develop a complementary, practical, user-friendly tool (the EQT) to support ongoing attention to issues of equity in the day-to-day practices of GHPs. In this article, we present the EQT, briefly describe how it was developed, and provide comprehensive and practical guidance on how it may be used. We invite those involved in GHPs to open a productive and relationship-building dialogue about the complex relational processes that lead to more equitycentered partnerships.

METHODS
The development of the EQT was informed by 5 distinct inputs: (1) a scoping review of scientific published peer-reviewed literature; (2) an online survey and follow-up telephone interviews with global health practitioners and researchers; (3) workshops in Canada, Burkina Faso, and Vietnam; (4) a critical interpretive synthesis; and (5) a content validation exercise (Supplement 1 includes a detailed description of these inputs).

Ethics Approval
We obtained ethics approvals from the Institutional Review Board of the Faculty of Medicine at McGill University (IRB # A01-E03-19A) and the University of British Columbia Okanagan (REB#H19-00232-A002). All participants gave their informed consent before participating in the online survey (written consent), telephone interviews (verbal consent), and workshops.

RESULTS
Consolidating the results from the 5 inputs (Supplement 2), the research team mapped what and how issues of equity were either being assessed or considered in GHPs. Guided by the equitycentered CCGHR Principles for Global Health Research, 13 data showing specific and promising ways to practice equity were grouped under 4 different domains of practice (governance and process; procedures and operations; progress and impacts; and power and inclusion, [Table]  . From each of these promising ways to put practices into action, a set of statements for each domain of practice were derived-each intended to illuminate how people engaged in a GHP feel about the ways that equity is functionally working and experienced by themselves, as an individual, and in the partnership overall. The cumulative results from the 5 inputs resulted in a set of 55 statements that form the final EQT (Figure). Because definitions of partnership terms and indicators were rarely defined or used congruently in the literature and to be transparent about the definitions used herein in developing the EQT tool, definitions are included in Supplement 3. The French version of the tool is provided in Supplement 4.
The primary intent of the EQT is to support dialogue that enables people involved in partnering to reflect on their own experiences and to identify how equity is reflected (or not) in partnering practices or processes. It is important to begin conversations using the EQT with shared intention setting that emphasizes the use of the tool as a mechanism to identify equity considerations and support equity-centered practices, working together to learn from each other about how to advance equity in a good way. The tool will spark GHPs that consider issues of equity in their processes and structures hold greater potential for lasting health impact and building local capacity than those that do not. *In July 2021, the CCGHR amalgamated with Canadian Society for International Health to become the Canadian Association for Global Health.
From each of these promising ways to put equity practices into action, a set of statements were derived that were intended to illuminate how people engaged in a GHP feel about the ways in which equity is functionally working.

Governance and process
Practices that have to do with assigning authority, making decisions, and creating accountability as people work together toward an agreed end. Ways in which partnerships set priorities and directions, seek alignment between personal, organizational, and partnership goals; set intentions; and determine who gets to be involved in these processes. Progress and impacts Practices that have to do with determining and setting goals for personal, partner, community, and overall benefits of the partnership and its outputs, outcomes, and products-both actual and potential (e.g., alignment with local priorities), including long-term sustainability of the partnership and/or its benefits. Actively enable people to make meaningful contributions questions that allow people to pause and think about their experiences of partnering. Different people involved in the partnership will experience the partnership and equity within it differently. These differences are expected and provide a foundation for exploring how to better understand how some aspect of partnering is (or is not) working to advance equity. Partnerships may find it useful to use the tool to guide dialogue from the earliest phases of partnering. Specific effort to use the dialogue as a resource in identifying how equity considerations can be integrated into the work of the partnership. Partnerships may choose to revisit the EQT periodically and when they end or transform into something new. Pausing to reflect on equity considerations will support more equitable engagement in future partnerships. Before entering into a GHP, organizations, and staff less familiar with principles of equity and related issues (e.g., cultural humility and issues of

DISCUSSION
Using an iterative, mixed-methods approach, our research culminated in creating a tool to guide practical, equity-centered dialogue about how a GHP is functioning. The literature review identified several GHP assessment tools. These tools reflected the authors' interpretation of what contributes to good partnership practices based on their experiences in GHPs that were created to support capacity building, the delivery of services, and/or research activities. However, the review did not provide tools to support dialogue or practices for navigating complex (and often uncomfortable) issues of equity. It has been suggested that issues of power and equity are unavoidable in partnerships that are situated in contexts that are characterized by inequities. 44 Principles aimed at guiding good partnering practices in global

Add other considerations specific to your situation
About the partnership overall Yes Unsure No 50. Our partnership has effective mechanisms for resolving conflict. 51. My organization or community is well represented in this partnership. 52. Diverse perspectives are represented in our partnership. 53. Our partnership is aware of and actively discusses how to mitigate inherent inequities between partners. 54. All partners are valued and heard, regardless of gender, ethnicity, ability, Indigeneity, class, education, or other social position. 55. Every partner's contribution is recognized and acknowledged in a fair way. Add other considerations specific to your situation health, for example, emphasize the need to pay attention to how equity actions are integrated into the process of partnering itself. 45,46 Equity-centric partnering pays attention to issues of equity as something experienced by people involved in partnerships, and therefore, requires attention to how equity is reflected both in the partnership overall and for each person involved in the partnership.
The EQT is unique and novel in its incorporation of evidence-informed practices for advancing equitable partnerships. It offers a reflective foundation to guide constructive dialogue about experiences of equity. The tool focuses on partnering practices that connect to equity experiences of individuals as well as experiences connected to the function of a partnership as a whole. Importantly, it is not intended to be used as a top-down set of standards or expectations for which people in positions of authority "collect" from others. It purposively does not include a score and ought to be used to support and inform constructive conversations rather than as a framework for evaluation. There may be particular contexts or additional considerations that people engaged in a GHP might want to reflect upon. For this reason, every section has space for additional statements to be added. This may include, for example, consideration of local or national contexts and potential donor obligations that influence equity-centered actions.

Guide to Using the EQT
The EQT is a practical means of appreciating the quality of different aspects of a partnership in terms of established equity and promising practices. Each of its 4 domains of practice incorporates statements about an individual's experiences within the partnership: green, yellow, and red colors provide a visual cue for what GHPs might be invited to focus on in their reflection and dialogue about how their partnership is working. It is important for partners to discuss, as early as possible in the partnership, how the EQT will be used. Considerations might include the size of the partnership, the roles and responsibilities of all persons working in the partnership at different levels, and how results will be managed.
Conversations about equity create vulnerabilities and discomfort for many people, requiring facilitation skills and care. Across many disciplines, and even generally in public conversation, conversations about issues of equity are high risk. Everyone in a GHP experiences different positions of power. These experiences, the history of colonization, and ongoing neocolonial practices need to be confronted. Conversations about people's experiences of equity or inequity are welcomed in an inclusive and respectful way that attends to the cultural, emotional, physical, and career safety of all people who contribute. This might mean creating multiple tables of dialogue so that all people who should have a free and active voice can do so in a way that they feel safe. Partners can explore how to accomplish this together, designing an approach that works for them. There are excellent examples of workshops or training initiatives that focus on building awareness of, and responsiveness to, power dynamics, privilege, and equity that can be useful for GHPs that wish to embrace a consistent practice of equity-centric partnering. 16,46 Because a partnership evolves over different phases, a periodic appreciation of equity and other considerations is appropriate at different times between initiation and completion. The EQT is intended to be used by partnering individuals or organizations who are initiating or are currently participating in a GHP. For this reason, the EQT is designed to be efficiently used as often and as strategically as needed to ensure adequate and timely reflection to guide responsiveness. It can also be used by individuals working at different levels within a partnership or by partner organizations as a whole (as represented by one or more of the lead partners). Issues of confidentiality should be discussed and agreed upon beforehand. The EQT can be completed either individually or collaboratively, or both, so that all voices can be heard. Ideally, an action plan should be established to implement recommended actions to mitigate indicators of concern. It needs to be reiterated that the primary intent of the EQT is to flag areas that need attention such that a conversation can follow, ultimately leading to improving the partnership. It doesn't necessarily matter if the tool is used to guide individual or group reflection-if there are areas where people's responses fall in the yellow or red zone or points where partners differ in their perception, the tool invites discussion about equity. The tool is intentionally not scored nor is it to be used to conclude that a partnership is, or is not, equitable. Organizations are encouraged to share their experiences with the EQT.

Limitations
While the EQT benefited from input from different stakeholders during the online survey and workshops both in Canada and in 2 LMICs, there are limitations to its development. These include the use of strict inclusion criteria for the bibliographic The unique and novel EQT should be used to support and inform constructive conversations on equity not as a framework for evaluation.
The EQT's primary intent is to flag areas that need attention such that a conversation can follow, ultimately leading to improving the partnership.

CONCLUSION
The EQT can support people involved in GHPs to advance equity in their actions and relationships, at all levels within the partnership. By engaging in a continuous process of learning and reflection, grounded in an intention of advancing equitable partnerships, GHPs can identify how their partnering can be more responsive and inclusive. By centering equity considerations in their processes, practices, and structure, GHPs can foster a dynamic and respectful culture of practicing equity in global health. Les résultats suggèrent que les partenariats en santé mondiale génèrent des expériences d'équité ou d'iniquité, mais ne fournissent que peu de conseils sur la manière d'identifier et de répondre à ces expériences. L'EQT peut aider les personnes impliquées dans un partenariat à prendre en compte les implications en matière d'équité de toutes leurs actions, du début à la fin d'un partenariat, en passant par sa mise en oeuvre et son achèvement. Lorsqu'il est utilisé pour guider un dialogue réfléchi avec l'intention claire de faire progresser l'équité dans et par le partenariat, cet outil offre une nouvelle approche de valorisation des partenariats en santé mondiale. Les professionnels de la santé mondiale, entre autres, peuvent appliquer l'EQT dans leurs partenariats pour apprendre ensemble comment cultiver l'équité dans leurs contextes uniques, au sein de ce qui devient une communauté de santé mondiale de plus en plus diversifiée, dynamique et réactive.