The 3C Framework: Toward a Dignified Definition of Global Health

Shadrack Frimpong; Bernadette Lim

doi:10.20944/preprints202412.0353.v1

Submitted:

04 December 2024

Posted:

04 December 2024

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Abstract

The field of global health has evolved, yet stakeholders lack contemporary frameworks that emphasize collaborative and community-centered principles. Current definitions of global health still depend on outdated and misclassified notions of global health as a “science of LMICs” and/or a metonym for health disparities. Such definitions denigrate the dignity of communities in low- and middle-income countries and limit the field’s full potential of leveraging cross-national insights to transform public health impact in underserved communities in high-income countries. Herein, we build on existing definitions of global health leaders and experts and propose the 3C Definition of Global Health as a collaborative, cross-national, and community-centered framework for global health endeavors. We apply this framework to the global health efforts and collaborative partnership of Freedom Community Clinic in Oakland, California, and Cocoa360 in Tarkwa Breman, Ghana, to demonstrate the power of shared partnership in uplifting the health and well-being of their respective communities.

Keywords:

global health

;

public health

;

community health

Subject:

Public Health and Healthcare - Public Health and Health Services

Introduction

Global health continues to necessitate sharpened and critical dialogue about its evolving definition and practice. Various definitions of global health currently exist, yet few to none encompass the current needs and landscape of the field and its evolving stakeholders. Though the field has evolved in name over time (e.g. colonial health, international health, etc), global health continues to carry on its historical legacy of saviorism, limiting the “global” component of global health to engagement with LMIC countries and/or diasporic communities associated with the Global South.

In particular, the field of global health significantly lacks examples of collaborative and community-centered frameworks that emphasize mutual respect and partnership. Contemporary global health efforts and initiatives continue to enact initiatives that are limited in scope at best and voyeuristic at worst, favoring Western interests and leadership above community contexts. Current global health efforts continue to scale and inappropriately apply models to diverse geographic regions that fail to respect the unique contexts of local communities. Even in our own studies and journeys as global health academic-practitioners, we have been taught ahistorical, misguided frameworks and definitions and hence have become passionate about the right definition for future leaders and practitioners of the field. Without critical reexamination and reflection of what truly constitutes global health, the field will fail to have clear direction and purpose. We simply cannot manage, measure, and improve what we cannot define.

A clear definition for the field is critical now more than ever in order for us to re-define and expand global health as what it is: globally-applicable public health. Current definitions of global health do not encompass the incredible opportunities of cross-national sharing of lessons and best practices. For example, many hospital and health systems in the West have adapted the community health worker model from Africa and the Global South, a framework that has saved the U.S. health system $4.5 billion annually and reduced hospital readmissions by 35% [1,2]. In addition, innovations of low-cost products, technologies, and innovations in limited-resource settings of the Global South have the potential to reduce healthcare costs and associated inequities in the United States [3]. A renewed framework for global health has the potential to transform the field beyond its historical past into a future that emphasizes mutual collaboration, respect, and partnership across geopolitical boundaries.

In this paper, we review existing definitions of global health and remark on their strengths and limitations. We then comment on two popular trends in contemporary global health efforts and their limitations, namely global health being misclassified as a “science of the poor” and a substitute for health disparities. Next, we offer an updated, refined definition of global health based on our academic and field experiences working in global health. Lastly, we offer applied case studies on our proposed refined framework of global health through the work of Freedom Community Clinic in the San Francisco Bay Area and Cocoa360 in Tarkwa Breman, Ghana.

Current State of Chaos: Today’s Definitions of Global Health

Hiat et al. (2016) defines global health as: “improving conditions particularly in poorer parts of the world, often by exporting expertise and resources from better-off areas like the United States and Europe.”[4] Though this definition imparts good intentions, it continues to operate under historical frameworks of colonial medicine that view middle- and low- income countries as charity recipients rather than equal and shared thought partners and collaborators.

In a document on the role of the United States government with global health in 2022, the Kaiser Family Foundation outlined “U.S. global health efforts aim to help improve the health of people in developing countries while also contributing to broader U.S. global development goals… foreign policy priorities… and national security concerns.”[5] Though improvements in health outcomes are included, this definition similarly articulates a motive for global health initiatives that favors Western interests with little partnership or mutual collaboration with other countries.

Of the many active, circulating frameworks of global health, we resonate most with two definitions. Beaglehole and Bonita (2010) of The Lancet NCD Action Group defines global health as a “collaborative transnational research and action for promoting health for all”[6]. Similarly, the framework illustrated in Chen et al. (2020), generated from the Editorial Board Meeting of Global Health Research and Policy Journal, likens global health to “thinking globally and acting locally [as a] means to learn from each other in understanding and solving local health problems with the broadest perspective possible”[7]. The emphasis on collaboration and being action-oriented in both definitions is particularly profound compared to previously mentioned definitions of global health.

Removing the Blurred Lines: What Global Health Is Not

Before defining the current state of global health, we must name outdated concepts of global health that operate under ahistorical conditions and misguided frameworks. Namely, global health is not: (1) a science of the poor in LMICs and (2) a metonym for health disparities.

Despite its name, global health continues to be seen as a field solely in countries outside of the West. Exotified experiences of caring for the Other continue to be the public imagery of global health, in which motivations of white saviorism continue to be perpetuated in contemporary contexts[8]. The field fails to recognize that global health must include collaborative engagement with Western countries not merely as a donor or conferrer of knowledge, but also as a mutual recipient and partner. We argue that the term “global health organization” only applies if an organization works collaboratively in multiple countries – not simply because it works in an African, Asian, or LMIC country with pronounced health disparities. Similarly, to practice global health goes beyond a foreign-funded organization that engages locals in another country. Global health simply cannot be an isolated geographical endeavor. Contemporary definitions of global health require cross-national collaboration involving more than one country.

Additionally, we refute the contemporary trend of associating global health with “health disparities”, “immigrant or refugee health”, or “non-US public health”. In particular, the term “domestic global health,” popularly touted as “global health at home,”⁴ must be retired. This terminology perpetuates legacies of colonial medicine, such that the narrow definition of domestic global health refers to healthcare in urban settings, of which “exoticism of global health terminology [is] needed to make the urban United States respectable”[8]. Professional societies such as the American Academy of Family Physicians continue to offer “domestic global health opportunities” that racialize clinical care for immigrants, refugees, and asylum seekers [9]. This outdated practice reinforces the colonial hierarchies laden in the history of global health and fails to be a productive dialogue. It’s almost as though citizens of LMICs can’t catch a break - even after they’ve left their countries of birth and moved to the U.S., the care they receive must still be categorized as “global health.” What does the “domestic” qualifier seek to achieve? Is the United States not part of the “globe”?

The 3C Definition of Global Health: Collaborative, Cross-National, Community-Centered

In re-defining global health, our proposed definition underscores that global health must be defined only by the “how” (the approach), rather than the “who” and “what” (type of issues, disparities, population, demographic). Global health’s dependency on narrowly focusing on the latter has driven chaos and confusion in the field, favoring Western interests and resulting in cycles of voyeurism and unequal power hierarchies with health partners. We build on the foundations of Beaglehole and Bonita (2010) and Chen et al. (2020) and emphasize community voices and participation as essentials to present-day and future global health endeavors. Drawing on the definitions from these expert leaders and scholars in the field alongside our own combined two decades as expert scholars and practitioners of global health, we propose the following framework to be used in global health literature.

Our proposed definition of global health is according to the principles of the 3Cs:

Collaborative - must involve an equal and mutually-respected partnership between organizations in two or more countries,
Cross-national - must involve more than one country, be globally applicable, and
Community-centered - must prioritize community voices and active participation in activities.

Each of these principles can be applied to core domains of global health work, such as:

Research - Must look at cross-national determinants of health. Issues must transcend, even if effects are felt within. Shared co-authorship and shared cross-setting lessons.
Action - Research/evidence must be applied to work in all partner settings, not just one. In the collaborative process, one partner cannot apply the research while the other doesn’t.
Partnerships - The available strategies and networks must be used to improve public health in all partner settings involved. Partners in both settings must commit to delivering an impact that leverages the broadest reach of private partnerships possible.

A more straightforward definition we propose is “globally applicable public health.” Table 1 below shows this definition in action, drawn from the 3C framework above.

Global Health in Practice: Case Study of Freedom Community Clinic and Cocoa360

Both authors have established global health initiatives in the United States and Ghana that embody the 3C framework. Freedom Community Clinic (FCC) is an integrative medicine clinic for underserved and immigrant populations in the San Francisco Bay Area. Cocoa360 is a community health financing initiative that leverages revenues from community-run farms to improve education and health outcomes in cocoa-growing communities in Ghana.

Following the 3C Definition of Global Health, both Freedom Community Clinic and Cocoa360 embody the tenets in action:

Table 2. Applied Case Study of the 3C Global Health Framework: Freedom Community Clinic and Cocoa360.

The 3C Global Health Framework: Freedom Community Clinic (Oakland, California, USA) and Cocoa360 (Tarkwa Breman, Ghana)
Cross-National	FCC and Cocoa360 center their work on underserved communities in their respective geographic regions in the United States and Ghana. FCC is not a “domestic global health” organization because it cares for immigrant and minority communities. Additionally, Cocoa360 is not a global health organization because it is in Ghana, an LMIC. Instead, their identities as global health organizations pertain to their partnership with other organizations in multiple countries, such as the United States and Ghana. Would Cocoa360 still have been a global health organization had FCC been in Nigeria? Yes, this passes the cross-national rule.
Collaborative	FCC and Cocoa360 collaborate on various research, actions, and partnerships. In 2024, FCC launched its inaugural community research initiative and ongoing study on systemic barriers to integrative health through mentorship and dialogue of research study design with staff and community members of Cocoa360 who have expertly crafted and honed their CBPR model for a decade. In turn, Cocoa360 and FCC share and collaborate on various grant, donor, and fellowship opportunities to strengthen individual efforts and infrastructure.
Community-Centered	FCC and Cocoa360 participate in CBPR to gain community insight and evaluate the effectiveness of their care models for their local communities. Staff at both organizations convene regularly to share best practices related to organizational strategy, growth, and operations. In particular, FCC has learned from and applied Cocoa360’s Community and Implementing Board of Directors framework to promote community leadership at the highest levels of organizational decision-making.

Conclusion

The future of global health necessitates frameworks that emphasize shared partnership, decision-making, and goal-sharing. The 3C Definition of Global Health offers a framework that uplifts collaboration, cross-national, and community-first initiatives to facilitate equal dialogue and purposeful action. Freedom Community Clinic and Cocoa360 exemplify the strengths of sharing best practices, partnerships, and insights to strengthen their local communities. Rather than haphazardly scaling models and inappropriately applying care models to diverse geographic regions, the 3C Definition of Global Health emphasizes the value of sharing best practices, respecting the equal wisdom of all partners, and uplifting community voices in their application according to unique local contexts. By emphasizing community voices and participation as essential to global health initiatives, this ensures that the dynamism and diversity of local contexts are respected while sharing invaluable lessons to settings outside their geographic area. The future of global health necessitates that we tame the chaos: our answer lies in cross-national insights guided by community.

References

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Table 1. The 3C Framework of Global Health.

Feature	Global Health Domain	Definition
Cross-national	Research	Research must have applicability beyond one country.
	Action	Programs and initiatives should be guided by lessons and insights of another organization in a different country.
	Partnerships	Both partners must actively nurture partnerships with peers in another country
Collaborative	Research	There should be shared co-authorship, reflecting the contributions of all partners.
	Action	Must be willing to pass on local experiences that can be generalizable
	Partnerships	Commit to strengthening networks to provide necessary support so others can do their work well.
Community-centered	Research	In both settings, there must be a commitment to applying community-based participatory research (CBPR) principles.
	Action	Both must actively include communities in operations. Hire locally when possible.
	Partnerships	See community as an active partner, not a passive recipient. Shared community wisdom in both settings must drive work

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