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“The idea that one should only be given an ear if they have Harvard MBAs or CVs as long as the Dead Sea Scrolls is one of the reasons innovations and accelerated change for the better never take place in any environment.” – John Kagaruki
Who gets to define what counts as a good idea in global health? Whose solutions are taken seriously, and whose are quietly ignored?
Too often, it isn’t the people closest to the problem. Not the patients rationing HIV medication. Not the health workers in overcrowded public hospitals. Not the small-town entrepreneurs building apps to reach remote communities.
In many development and health spaces, legitimacy is reserved for those with “accepted” profiles: staff from international NGOs, global health consultants, economists with Oxford or Harvard affiliations, or researchers from Western think tanks. These are the people invited to panels, commissioned to draft policy frameworks, and funded to test “innovative” models. In contrast, the community health worker who designs a low-tech reporting tool that actually works in her region? She’s invited to the workshop, not the strategy meeting.
The exclusion isn’t always intentional. But it’s structural. To qualify for most international funding, proposals must pass technical and bureaucratic thresholds – requiring grant-writing skills, English fluency, statistical validation, and in many cases, partnership with a “reputable” organization based outside the region. This system rewards familiarity, not necessarily relevance or originality.
As a result, some of the most transformative ideas never make it past the front gate. They’re dismissed as “unscalable”, “insufficiently evidenced”, or “not aligned with current donor priorities”. And yet, when we look back, many of the greatest innovations in global health came from outside the system. It’s not just exclusion – it’s a failure of imagination.
Consider Tanzania’s Bus Rapid Transit (BRT) system. My friend John Kagaruki, a Tanzanian business leader, raised early concerns about its inefficient procurement processes and unsustainable ownership model. He proposed a practical alternative: allow private bus owners to buy into an IPO, creating broad-based ownership and public buy-in. But Kagaruki’s ideas were dismissed – not because they lacked merit, but because they didn’t come from the usual circle of global consultants and donor-approved firms. The system stalled. The problems remained. influences both local health and global development. It improves access to care, reduces pollution, connects people to jobs and healthy food, and combats social isolation. That’s public health – yet decisions about it are still left to well-paid consultants.
This isn’t an isolated story. It’s a pattern. When ideas come from outside traditional institutions, they are too often treated as fringe experiments – until, of course, they succeed.
The Grameen Bank model, once dismissed as utopian, is now part of the global banking mainstream; there is no place in the world today where microfinance is not practised, it has lifted millions out of poverty. The Aravind Eye Care System in India scaled cataract surgery by adapting an assembly-line model, allowing their surgeons to perform up to eight procedures an hour and over 400,000 procedures a year while maintaining lower complication rates than many Western systems. This idea too was met with scepticism – until it worked so well it could no longer be ignored, now it is a case study used to teach innovation at Harvard University.
Narayana Health, founded by Dr Devi Shetty, applies similar efficiency principles to cardiac care – delivering world-class open-heart surgeries for under US$2,000 through a cross-subsidy pricing model. In traditional Western healthcare models, heart surgery can cost well over US$100,000. These innovations didn’t come from Geneva or Boston. They came from people solving urgent problems with limited resources.
So why do we still struggle to hear those voices in Africa?
Rwanda’s community health worker and national insurance system is one of the most effective examples of locally led universal health coverage. Health workers are trusted, integrated into the system, and compensated through government and community-based schemes. The result? Over 90 per cent of Rwandans now have access to basic healthcare. Yet this model is rarely held up as the global gold standard, and even more rarely exported through formal donor-funded channels.
In Uganda, Dr Robert Opoka and his team at Makerere University pioneered a low-cost bubble CPAP (Continuous Positive Airway Pressure) system to treat premature infants with respiratory distress. Using basic materials like water bottles and tubing, they created a device that saved lives and dramatically reduced neonatal mortality. Yet despite strong early outcomes, the innovation struggled to attract the kind of funding that new “tech-enabled” devices from the Global North routinely receive.
These stories reflect a deeper truth: innovation from low-income and middle-income countries (LMICs), especially in sub-Saharan Africa, is often treated as “anecdotal” until a Western institution validates it.
Meanwhile, foreign pilot programmes – some barely past prototype – are often funded, scaled, and praised before a single outcome is achieved. It’s not that Africa lacks innovation. It’s that too few are looking for it here.
Who holds the microphone – and who pays the price?
The recent USAID funding freeze offered a brutal case study. In Kenya, over US$34 million worth of antiretroviral (ARV) drugs were stranded in warehouses due to halted distribution funding. 1.4 million people living with HIV, many of them dependent on this support, were left uncertain and afraid. “We are now living in fear,” one patient told Reuters, “because we don’t know when the drugs will be available again.”
But in the conversations that followed – among donors, policymakers, and media outlets – how many of those affected were given a platform? How many patients, pharmacists, or frontline responders were consulted for solutions? The silencing is as harmful as the shortfall.
If the goal is to improve lives, shouldn’t the first step be listening to those who are living them?
Why the system rewards the familiar
To understand why this keeps happening, we must go beyond superficial exclusion and interrogate the deeper structures that decide who gets funded, who gets cited, and who gets heard.
Donor institutions are often risk-averse. They prefer to fund what’s been funded before. That means organizations that have the resources and reputational capital to package ideas in ways that appeal to donor templates – well-styled decks, branded metrics, and fluency in bureaucratic language.
Procurement systems, designed to prevent corruption, can exclude local vendors who lack the scale or paperwork to qualify – even if their solution is better suited. A local developer with a low-cost maternal health app may be ineligible, while a multinational tech vendor offering a more complex, less practical solution gets the contract.
Academic and publication ecosystems also reinforce this gatekeeping. A Lancet Global Health study found that researchers from the Global South are significantly underrepresented in authorship, even in studies focused on their own regions. In many cases, African researchers provide the data while Northern researchers write the narrative – and receive the credit.
This is what philosophers term epistemic injustice – when someone’s knowledge is undervalued because of who they are or where they’re from. In global health, this is not a rare glitch – it is a core feature. In many cases, African researchers provide the data while Northern researchers write the narrative – and receive the credit. The pipeline is unequal by design – who gets to generate data, who gets to publish it, and who gets cited defines not just careers, but which ideas are deemed credible in global health.
What listening could look like
But change is possible. And it’s already happening – if we’re willing to pay attention.
In Garissa County, Kenya, ambulance services are coordinated through WhatsApp groups that link paramedics, nurses, and health administrators across vast rural spaces. The system is cost-effective, fast, and built with existing tools.
In rural areas, WhatsApp is also used for community health worker supervision, where supervisors provide feedback, coordinate field visits, and share real-time challenges. These innovations didn’t come from Silicon Valley – they came from necessity and proximity.
The WHO’s NCD Lab is beginning to recognize this. It now highlights grassroots responses to diabetes, cancer, and cardiovascular disease – from youth-led campaigns to low-cost diagnostic innovations. These are early steps, but they signal an opening.
In Rwanda, Health Tech Hub Africa supports local AI-powered health startups. It has so far helped 98 startups scale up, created 1,781 new local jobs with 4.5 million direct beneficiaries of the projects and engaged with 69 policymakers.
I’m proud to be a part of the Global Surgery Advocacy Fellowship. It centres African professionals in the design of policy and practice solutions. From redesigning cancer referral pathways to advocating for surgical infrastructure in low-resource settings, it provides proof that those who navigate broken systems are often best equipped to fix them. Its fellows aren’t just surgeons – because surgical problems don’t exist in surgical silos. They require engineers, data scientists, economists, and patients working together. There must be collaborative efforts by people from various sectors to achieve lasting solutions to the world’s surgical crisis. Surgical care remains one of the most neglected areas in global health, yet it is essential for meeting a wide range of health needs – from injuries and birth complications to cancer treatment. The World Bank estimates that expanding essential surgical services could prevent 1.5 million deaths per year at a cost of just $3 billion – in low- and middle-income countries.
These aren’t exceptions – they are models. The problem is not the absence of innovation. It’s that we still have to justify its existence when it comes from the Global South.
What needs to change
If we are serious about equity, we must move beyond symbolic inclusion. We need structural reform.
For donors, invest in early-stage local innovation. Create funding pathways for ideas that come without a Western partner. Accept contextual evidence. Value narrative case studies alongside RCTs.
For multilateral agencies, share authorship. Rotate convening power. Let local experts set the agenda – and then stay in the room when the decisions are made.
For governments, fund your own universities. Trust your clinicians to lead. Create procurement frameworks that favour practical, local solutions – not just foreign logos.
For everyone in the global health ecosystem, redefine expertise. Stop equating fluency in donor language with strategic insight. And start asking whose voice is missing every time a decision is made.
We need fewer global panels without local voices – and more local panels with global reach. And for all of us, it means seeing expertise not just in degrees, but in lived reality. It means knowing that legitimacy can flow from results on the ground – not just a logo on a report.
One metaphor comes to mind: if global health remains a gated community, then no matter how well designed the mansion is, it will never reflect the lives of the people outside the fence.
Why I’m writing this
As a surgeon and health advocate in Kenya, I have spent time in operating rooms, hospital boardrooms, and donor-funded working groups. I’ve watched brilliant ideas die – not because they failed patients, but because they didn’t speak the right institutional dialect.
I’ve also seen what happens when we let the right voices lead. I’ve seen mothers in rural counties access care they were once told was too expensive. I’ve watched junior health workers transform systems because someone believed in their solution.
The future of global health is not in the next innovation summit or white paper. It’s in WhatsApp threads, village clinics, nurse-led cooperatives, and startup founders working from internet cafés.
The question is not whether these ideas exist. The question is whether we’re finally ready to listen to where they come from. Because the problem isn’t that we lack innovation.
It’s a refusal to believe it can come from us – from a rural Kenyan village, from the community health worker with no degree, from the HIV patient now receiving only a week’s dose of life-saving medication, from the young tech student raised in Kibera…
It’s that we still think it needs a PhD and a podium to be real.
