COMMENTARY Institutionalizing Ethical Review in Global Health Practice: A Modest Proposal

David Ross

Assuring basic human rights for all, seeking social justice, and the ethical implementation of policies to make these goals a reality begins with inspired leaders who have the courage and imagination to challenge established power. Once the social change process has begun, then governance structures and organizational processes must be established if that change is to be made permanent. As countries move toward health equity, this march must be guided by standards of practice that promise ethical treatment of those whose lives we seek to improve. To achieve health equity, Lawrence Gostin et al. call for the World Health Organization’s adoption of a global health framework that is capable of ensuring a well-functioning health system, a full range of public health services, and economic and social conditions conducive to good health.[1] In my role as CEO of the Task Force for Global Health, I am both inspired and challenged by the need to fully integrate systematic ethical review into our organizational structure and programmatic practice. Here, I describe my vision for how ethics can more meaningfully be implemented in global health.

Realizing the vision of the Universal Declaration of Human Rights requires ongoing efforts to make it relevant across many cultural traditions and countries’ diverse governing structures. In our search for health equity, it seems clear that countries need a formal framework to guide the creation and maintenance of essential personal and population-based services. In addition, we must also assure that the services provided by this framework guarantee the ethical treatment of all people. Achieving health equity requires both structure and process. Today, organizations such as the Task Force for Global Health entrust partner nongovernmental organizations and their networks of community health workers and other providers to deliver medicines, nutritional supplements, and other interventions. The populations that these organizations serve have little recourse to redress if the services provided or the outcomes experienced are inadequate or harmful as a result of the work of these organizations. Thus, we must ask: Does the large global health enterprise need an ethics framework that creates jointly held accountability among global health funders, program implementers, and national governments?

The clinical research enterprise has informed consent and institutional review boards to ensure that well-intended researchers make explicit to all affected how they will balance the risk of harm against benefit. Can global health programs learn from the research enterprise by implementing a means by which those affected, those providing direct service, and those promoting social and health benefits can be assured that they have considered at the outset and throughout the work that important ethical lapses have not occurred? The answer to these questions seems obvious. By failing to make explicit how global health programs protect those we seek to benefit, we fail to protect human rights. When we fail to implement ethical reviews by failing to monitor programs for ethical challenges, we risk violating the rights of those we serve.

The three-day symposium on global health ethics held at Agnes Scott College in April 2018 provided numerous examples of ethical challenges confronting the implementation of global health work. The articles in this special section address a wide range of constructs that should guide how we consider ethical issues. All of these issues speak to the need for a routine or standard way in which global health funders, program implementers, and country participants consider, adjudicate, and resolve ethical challenges throughout the life cycle of global health programs.

A modest proposal

Today’s expected practice for proposals submitted to any large global health funder requires that the proposals include clearly stated governance structures, project plans, program management plans, budget controls, and plans for the monitoring and evaluation of processes and outcomes. As demonstrated in the articles in this special section, an emerging body of evidence now points toward adding ethics review as a new dimension to the definition of well-run and -managed global health programs.

Best practice today suggests that when one is creating a new program, the program should have a charter. A comprehensive program or project charter includes a complete statement of purpose (i.e., the goals and impact of a successful project), an evaluation framework showing the metrics of success (i.e., process and outcome measures), a governance structure (i.e., who makes which decisions), a detailed project plan, a communications plan (i.e., which audiences need to know what and when), and a budget and budget narrative. Each of these components is informed by a body of peer-reviewed and practice-based evidence and is supported by professionally trained practitioners in that discipline. For example, professional project managers bring with them a discipline for coordinating interdependent activities over time to enable a smoothly functioning program that achieves its goals on time and within budget. Similarly, evaluation scientists develop feasible and meaningful measures that guide investment in, management of, and interpretation of program work.

A formalized ethics review and monitoring needs to be added and supported by trained global health ethicists. By incorporating such a component into programming, global health practitioners can assure that the noble aspirations of their programs do the good they are intended to do. By incorporating ethics review and monitoring as one of the core global health practice disciplines, we give voice to those we seek to help while also offering assurance to the helpers that they will do no harm. There is much work to be done to establish workable processes through which meaningful ethical review of global health programs can be conducted without hampering creativity in our programmatic solutions to global health problems, where we must often adapt quickly to changing conditions or crises on the ground. However, it is only through initiating this process that we will be able to develop a robust evidence base for ethical practice in the implementation of the right to health.

The time has come to define the components of a global health ethics review and to mandate that review as one of the essential elements demanded of program implementers. All parties—program funders, those who receive our services, those who govern health in countries, and those who implement programs—need to view ethics as one of the essential components of their program charter. Just as the right to health has been discussed and debated by many, the process of including ethics in official project funding awards would spark deeper, meaningful discussion from various viewpoints about what is ethical.

Getting started

At the Task Force for Global Health, we have created a Focus Area on Compassion and Ethics (FACE) to serve as an organizational hub for our thinking about the ethical implementation of our programs, as well as the broader issue of working ethically toward the goal of health as a human right. By formalizing FACE as one component of strong program management, we encourage our program leaders to be aware of ethical dilemmas, ask thorny ethical questions, and seek well-reasoned solutions. Functioning ethically as an organization requires a workforce educated in essential ethical principles. We guide ethical decision making through institutional processes that are measured as part of routine field operational data gathering to assure accountability. We need to see other global health organizations embrace procedural ethics as a means of guaranteeing that we walk the talk of seeking social justice and universal human rights.

David Ross is president and CEO of the Task Force for Global Health, Decatur, USA.

Please address correspondence to the author. Email: dross@taskforce.org.

Competing interests: None declared.

Copyright © 2019 Ross. This is an open access article distributed under the terms of Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licences/by-nc/4.0/), which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original authors and source are credited.

References

[1].             L. O. Gostin, E. A. Friedman, K. Buse, et al., “Towards a framework convention on global health,” Bulletin of the World Health Organization 91 (2013), pp. 790–793.