Working Towards a Decolonized, Longitudinal, and Equitable Global Health Training and Partnerships Program

Abstract

OBJECTIVES

Growth of global health education programs has blossomed over the past two decades in the United States; yet many do not address the roots of colonialism and racism in medicine. This paper highlights the Arrupe Global Scholars and Partnerships Program (AGSPP) at Creighton University, a social justice and innovative five-year MD-MPH global health equity and partnership program for medical students, international partners, and the communities impacted by these partnerships.

METHODS

Using the applied social-ecological model as the global health educational framework, AGSPP launched a training and partnership program grounded in decolonized principles and global health equity.

RESULTS

AGSPP developed three pillars of its program and monitoring, learning, and evaluation (MEL) platform to track its indicators and progression towards its goal of working towards eradicating health injustice by promoting equitable access to quality healthcare, especially within communities that are marginalized. The first pillar consists of a five-year MD-MPH and global health equity training program grounded in decolonizing, accompaniment, social justice principles. The second pillar consists of creating equitable and power-balanced international partnerships with four academic medical centers in Rwanda, Nepal, Ecuador, and Dominican Republic. The third pillar implemented was identifying, collaborating, and accompanying local communities listening to their concerns and ideas for solutions.

CONCLUSION

AGSPP's three-pillar framework is built on a foundational ethos of solidarity and justice, intended to deconstruct neocolonialistic processes while advancing health equity, social justice, and pragmatic solidarity. We believe sharing our experiences of creating a program that has an intentional focus on historical context, prioritizing equitable collaboration with partner institutions and communities between the Global South and Global North, will lead to future justice-oriented leaders of tomorrow and serve as an example for additional global health programs who have a similar interest.

Introduction

Global health training programs for students, residents, and fellows in health-related fields in the United States have multiplied rapidly over the last two decades.^1,2 Despite the influx of resources being invested in global health education, there appears to be a less robust transformation of curriculum, often with minimal background on the colonial roots of the field and how that translates into current power imbalances. The decolonizing global health movement critically reflects on the history of colonialism in global health and calls for a change in the current system regarding who holds power, funding, and decision-making authority in global health institutions, policies, research, and education. Global health medical education, which is typically embedded in a biomedical framework, usually does not incorporate teachings on racism or the colonial roots embedded in the healthcare system. Nor does typical medical education incorporate strategies for working towards health equity using social justice frameworks.^3,4 Beyond the suboptimal pre-departure preparation, limited training on cultural humility, insufficient mentorship, and singular, short-term international trips are typical for current global health educational programs. ⁵ It is important to acknowledge that much of the language used in global health is problematic, with phrases such as “First World and Third World,” “developed and underdeveloped,” “high-income and low-income,” reinforcing biases and labeling countries by narrow economic categories, rather than other parameters. Exposure to historical context, knowledge of present-day power dynamics, and awareness of problematic vocabulary are critical for trainees prior to working abroad.

Current academic global health educational programs in the United States are structured in a manner which often perpetuates Eurocentric systems of thinking, with decision-making, leadership, and authorship of projects primarily led by Global North partners with limited opportunities for input or control by the partners in the Global South.^6–8 Short-term trips, if not done thoughtfully and in close partnership with international partners, can potentially reinforce systems of structural violence, by assuming that partners in the Global South benefit from and need trainees from the Global North. These short-term trips are often planned without consideration of the burden it place on local resources or how this model can perpetuate the “savior” complex that exists in global health education.^9,10 This study abroad and training perspective frequently lacks cultural awareness, respect, and appreciation for local community assets and resources.

It is imperative that Global North academic institutions with global health programs work to reverse the legacies of colonialism and racism by working towards the decolonization of their global health programs, train their students to understand the complex framework of global health inequities and deconstruct problematic and inequitable systems.^11,12 When programs promote education on decolonization, racism, and health equity not only through didactics, but also via personal reflection, group discussion, and experiential learning, they have the opportunity for greater impact.^13–15

Goal of intervention

Effective global health educational programs that focus on teaching students how to critically evaluate, examine, and dismantle neocolonialistic educational systems are currently lacking in the Global North medical education system. ⁷ Even with recent decolonizing efforts in medical education, the field still lacks a standardized system to implement a justice-based curriculum aimed at dismantling the current structural violence that operates in global health. ¹⁰ Global health educational programs in the Global North need to be aware of perpetuating a curriculum that indirectly fosters a belittlement of the knowledge and systems in the Global South and reaffirms the superiority of the Global North approaches. Programs should include community stakeholder's recommendations, commit to sustainable partnerships, and create joint work plans to highlight the strengths and needs of both institutions. Securing scholarship funding to make programs accessible, sustainable, and equitable is another step toward improved inclusion and representation.^9,10,16

The goal of the Arrupe Global Scholars and Partnerships Program (AGSPP) at Creighton University is to create a comprehensive educational and academic partnership program for students, international partners, and the communities impacted by these partnerships. By embodying and promoting an ethos of solidarity and justice, the program has been designed to deconstruct neocolonialistic processes while advancing health equity, social justice, and pragmatic solidarity.

Materials and Methods

Steps taken for development and implementation of innovation

Creighton University launched the Creighton Global Initiative in 2016 to explore new ways of accompanying communities who are marginalized, through justice-centered educational programs, advocacy, and research in effort to confront a globalization of indifference. Creighton's flagship global health program, the Institute of Latin America Concern (ILAC), located in Santiago, Dominican Republic, was launched over 50 years ago and supports rural Dominican communities with health, education, agricultural, water, and sanitization programs. Faculty, staff, nurses, physicians, dentists, physical and occupational therapists, pharmacists, and undergraduate students from Creighton have supported numerous sustainable development programs over this time period. Given the long-term sustainability and success of ILAC, growing interest in global health opportunities, and the launch of the Creighton Global Initiative, Creighton University began exploring more opportunities to participate in Global Health programs.

In January 2021, Creighton received a monetary gift from an anonymous donor to build an innovative 5-year MD/MPH global health training and partnership program. With a vision for the program to be rooted in health equity and justice, it was named the AGSPP, referencing Pedro Arrupe, a Jesuit who committed his life to service and social justice. The program was designed under the guidance of two advisory board committees, international partners, university leaders, and an executive director. The external advisory committee, comprised of experts in global health education and research from the Global South and Global North, was formed to guide the programmatic goals, development of equitable international partnerships, and curriculum. An internal advisory board comprised of Creighton faculty and staff was used to guide internal processes including the MD and MPH curricular and programmatic components, budget, recruitment, and admissions.

International partners contributed significantly to the development of AGSPP. However, to have international partners contribute to the program's development, AGSPP had to first identify potential international partners. One of the first steps AGSPP took was to identify what type of international partnership to explore. Many types of international partnerships were considered including partnerships with non-governmental organizations, community-based organizations, bilateral donor organizations, foundations, Ministries of Health, and academic institutions. AGSPP chose to invest in academic institutions that have undergraduate, masters, and professional degree programs including nursing, medical, and other health professional schools because of the potential synergies of having faculty and student exchanges and joint educational and research programs. AGSPP reviewed Creighton University's previous engagements and networks of universities who work in the Global South and began to reach out to these academic universities via phone and email to see if there was interest in setting up a Zoom call to discuss AGSPP and what an equitable partnership would entail between the universities. If a university from the Global South responded with interest, a series of Zoom meetings were held to learn about each university's vision and mission, the communities they serve and accompany, and ways a partnership could support each institution's educational, research, and service priorities. After these initial discussions, if mutual interest was obtained for a potential partnership, in-person meetings were held to further explore and brainstorm what a partnership would entail for each partner. If both institutions saw promise in establishing a formal partnership, a series of joint workshop sessions were conducted to develop a working definition, agreement, and Memorandum of Understanding (MOU) of what constitutes a power-balanced and equitable working partnership. The MOU outlines activities that AGSPP and international partners are responsible for accomplishing, such as how Creighton would support each international partner in return for the international partner support of the students in the AGSPP. Some examples of international partner requests included opportunity for an international rotation for foreign medical students, scholarship support for international faculty to obtain master's degrees and certificate and professional development programs at Creighton, salary support for international faculty who support AGSPP, funding support for their priority research programs, collaboration on joint health-related research projects, and Creighton faculty support to teach basic science curriculum and clinical education at the international partner site. International partners also assisted in the development of the AGSPP curriculum and content related to the four immersions occurring at their institution where local students from the international partnership institutions also participate as part of the exchange program. To avoid perpetuating colonial research bias and interest by the Global North partners, the international partners requested AGSPP and its students to support their local ongoing research, quality improvement, and educational programs.

Human Resources needed to manage AGSPP was also an important factor to conceptualize and implement during the program's formation. A full-time executive director and program manager support the program. In addition, a part-time curriculum coordinator and part-time Creighton faculty who serve as site directors for each international partnership comprise the rest of the AGSPP team.

AGSPP used a variety of resources to build its educational and partnerships program including global health educational frameworks, advice from international partners, literature in the fields of health equity, decolonizing global health educational programs, and recommendations from its advisory committees.

Global health educational framework

To implement a decolonized praxis, expertise is not determined by years of experience alone; rather, expertise is achieved by active listening, coursework, self-reflection, advocacy, and mentorship from non-Eurocentric epistemological frameworks. ¹⁷ Listening to and collaborating with individuals, international partner institutions, and communities with the united vision of the colonial matrix proceeded forward.

AGSPP adopted the applied social-ecological model as its educational framework. Ratner et al highlighted how the applied social-ecological model can be used as a model for learners from both the Global North and Global South to teach about decolonization and global health equity.¹⁷ This model can impact the global health equity praxis and the decolonial movement by structuring its educational programs to “engage with power dynamics and structural advocacy at each level of the model…extending outwards from self (individual) to relationships (interpersonal), through institutions, community, and finally structures, policies, and systems” (see Figure 1).¹⁷

Figure 1.

Adapted social ecological model for levels of learner progression. ¹⁸

AGSPP incorporated the five levels of the social-ecological model into its curriculum and program activities. On the individual level, didactic presentations and discussions were designed to encourage students to question Eurocentric epistemological educational frameworks, to reflect upon their own positions of power within the colonial matrix, and to create change in the world. On the interpersonal and institutional levels, AGSPP and international partners work to establish equitable, bidirectional, power-balanced, and just partnerships to create a sustainable foundation for meaningful work. AGSPP engages with local communities—domestically and internationally—recognizing they are important voices who can inform us of their challenges and teach us the best ways to address those problems. These communities have built trusting relationships with international partners. They conduct and contribute to ongoing needs assessments and projects that address the major social determinants of health of their communities. The projects that AGSPP students and faculty support are identified by the communities and international partners. Lastly, students receive a robust education on policy and structures, understanding how these structures have been influenced by history and by dominating powers. At the same time, students have the chance to understand different health systems and how they respond to a development model of each country and how it influences access to health care and health rights. They are encouraged to advocate through organizing, speaking, or publishing to change injustices they witness. AGSPP is unique in that it addresses each of the levels of the applied social ecological model instead of only focusing on one component (ie, training component for students). By creating a comprehensive program, it is projected that the AGSPP has a greater likelihood of achieving a larger impact as predicted by the model.

Best practices in global health education

AGSPP consulted its advisory boards, international partners, and performed a literature review to determine the best educational practices for designing and implementing a curriculum on global health equity. AGSPP identified five key steps in developing its program and partnerships. First, AGSPP used input from its advisory committees on identifying core components of the program, potential international partnerships, administrative and human resources support, budget, and overall goals of the program.

Second, AGSPP investigated how it could develop a curriculum that supports and works towards decolonization and a global health equity praxis. Curriculum development began with the seven steps to decolonize educational training, as outlined by Banerjee et al ¹⁰

Step 1: Creation of a five-year longitudinal curriculum incorporating the history of global health, and how it influences today's global health systems.

Step 2: Educating students about the global determinants of health and the importance of advocacy.

Step 3: Preparing students to understand that decolonization in global health and medical education is an ongoing process and requires continuing action to dismantle the economic and political structures that keep it in place.

Step 4: Inclusion of articles and lectures from Indigenous and Global South experts who also co-created the educational topics student mentorship from partners in the Global South.

Step 5: Practicing pragmatic solidarity, sustainability, and cultural humility through five international immersions at a defined and consistent location.

Step 6: Building of a “glocal” curriculum, made up of local engagement with communities that are marginalized in Omaha and Phoenix.

Step 7: Creating equitable international and domestic partnerships where equal voice is given to each partner to drive research, educational and training opportunities for members of both partnerships.

Third, we began to work on forming international partnerships. We followed the recommendations by Garba et al and Eichbaum et al on how to build equitable international partnerships whose processes were previously discussed.^5,12 After an MOU was established, AGSPP and its partners began attending standing meetings where joint work plans, strategy on building equitable partnerships, challenges, and feedback are discussed. AGSPP also hosted a four-day Global Health Partnership summit in October 2024 in Omaha, Nebraska with all of the international partners present. It was the first time the partners from the Global South and at Creighton gathered together in-person. Key discussions including forming cross-site future collaborations, joint educational and research opportunities, and building equitable partnerships were discussed. As a result of these conversations, Creighton University offers a variety of professional development and educational opportunities to its international partners based on the specific requests of those partners including offering scholarships for Master's degree programs. AGSPP also supports its international partners’ research projects and priorities with logistical, monetary, and HR support. In addition, it is working to develop an international rotation for medical students at our partner sites and sends Creighton faculty abroad to teach basic sciences and clinical education.

Fourth, AGSPP and its partners learned it is important to obtain ongoing feedback and communication when building equitable partnerships. Therefore, key faculty were appointed from each international partner and from Creighton University to represent their university's interest and to serve as stewards of the partnerships. One of the goals of this network is to brainstorm how the university can create bi-directional student and faculty exchanges, while working not to strain local resources. A yearly survey is being developed for each international partner and Creighton University to complete to grade the effectiveness and equity of the partnership. Results will be shared with all partners and a dedicated review session of the survey results is being planned to learn how to improve the partnerships. Furthermore, pre-departure orientations for students focus on cultural humility and strategies to build effective collaborations with international partners. Fifth, we reviewed and incorporated all 11 competencies from the second edition of the Consortium of Universities for Global Health (CUGH) competencies took-kit into AGSPP. ¹⁹ These competencies are woven into various components of the AGSPP including MD, MPH, and Arrupe-specific program curricula, practicum, and capstone projects, and the five international immersions.

Overall, we learned that these processes take time (up to a year or longer) to develop. Plenty of lead time is needed to develop and organize a similar global health program. A potential tension in this process is funding the cost of this program. AGSPP is fortunate to have an anonymous donor but acknowledges many universities may not have the same available funding. Finding unrestricted funding to support international partner’s priorities as well as the educational components and immersions of AGSPP can be challenging. However, there are opportunities to incorporate some of these key steps without producing much financial burden. First, bringing together key personnel at one's university who are interested in creating a decolonized global health program and/or partnership can be conducted. This group can identify core components of a global health program, course, or partnership considering its financial resources. Second, if curriculum development is a priority, the seven steps outlined by Banerjee et al can be used as a guide to create a decolonized educational training. Third, if forming international partnerships is of interest, following recommendations by Garba et al and Eichbaum et al is a good starting point to evaluate how one's institution can be an equitable partner.^5,12 Lastly, reviewing CUGH's global health competencies toolkit is a helpful tool when developing a global health curriculum. It provides a guide on what topics should be addressed for each global health competency and is free to access.

Monitoring, evaluation, and learning (MEL)

Given the complexity of developing a new global health equity training program, AGSPP invested early in its MEL platform. AGSPP partnered with a global health MEL consulting firm to remove potential institutional bias and to assist in the strategic planning and development of AGSPP's MEL platform. Given the importance of developing equitable and power-balanced partnerships of AGSPP, the consulting firm conducted multiple workshops with international partners and Creighton University using “The Equity Tool for Valuing Global Health Partnership” to identify best practices in governance and process, procedures and operations, progress and impact, and power and inclusion to guide the creation of indicators and data collection tools to monitor equitable partnerships. ²⁰ These agreed-upon best practices were incorporated into the joint work plan and discussed during partnership meetings.

Results

Using the identified frameworks and best practices in global health education, AGSPP developed its own strategy framework with a vision of working towards eradicating health injustice by promoting equitable access to quality healthcare, especially within communities who are marginalized and living in poverty. AGSPP developed three pillars and associated MEL platform to track indicators to achieve this goal: (a) Developing mindful global health professionals; (b) Equitable Institutional partnerships; (c) Impactful community partnerships.

The first pillar consists of training and educating medical students through a five-year MD-MPH and global health equity training program. In addition to completing an MD and MPH with a global health concentration, students participate in a five-year longitudinal global health equity curriculum taught by experts in the Global South, Global North, and Indigenous peoples. Critical themes such as structural racism, history of global health and colonialism, decolonization of global health, liberation medicine, global determinants of health, pragmatic solidarity, leadership and management, and careers in global health are explored through didactic presentations, large and small group discussions, service-learning activities, and personal reflection. Students receive funding for five international immersion experiences over a five-year program. Four of those immersions require students to return to the same international site to learn the importance of pragmatic solidarity, cultural humility, and building long-term partnerships. Students also participate in projects collaborating with marginalized communities in the local communities where Creighton University has campuses.

The second pillar consists of creating equitable international partnerships. AGSPP partners with academic medical centers that share a common vision of health equity, social justice, and access to care for populations who are marginalized. The strengths of the respective institutions are explored, and discussions ensue regarding how we can work synergistically to address social determinants of health. Shared decision-making and bidirectional participation are foundational to these partnerships. As previously highlighted, partners play a pivotal role in identifying, teaching, and mentoring AGSPP students on key global and local health topics embedded in the AGSPP curriculum. In return, AGSPP supports partners students and faculty with multiple programs supporting educational and research programs. In addition, some international partners have found opportunities for their students and AGSPP students to attend classes together on global and public health topics as well as work on joint projects such as scoping reviews, community assessment, and educational activities.

The third pillar surveys the power and necessity of community partnerships, whether domestically or internationally. AGSPP has been designed to listen to and learn from the local communities about their needs and concerns, as well as their ideas for solutions. The program works collaboratively and intentionally with international and local partners on needs assessments, program evaluations, and implementation projects designed to improve the health of the community.

Early successes

Curriculum

AGSPP launched its program in July 2022 with its first cohort of 12 students followed by a second cohort of 12 students in July 2023, and a third cohort of 12 students in July 2024. Students apply to Creighton's AGSPP MPH program at the same time as they apply to the School of Medicine. Once accepted into the School of Medicine, applicants complete additional essays, letters of recommendations, and participate in AGSPP-specific interviews with current AGSPP students and faculty. If accepted into AGSPP, students enroll into AGSPP at the start of their first year of medical school. Curriculum development included formalizing a 5-year AGSPP global health equity curriculum consisting of monthly 90 min didactic lectures, large and small group discussions, service-learning activities, and personal reflection including the following general topics:

Year 1: Structural Racism and Racism in Medicine

Year 2: Decolonizing Global Health and Liberation Medicine

Year 3: Global Determinants of Health

Year 4: Careers in Global Health

Year 5: Leadership and Management

To measure student satisfaction, student's annual growth of global health knowledge and skills, cultural humility, advocacy skills, personal development, and well-being, AGSPP's MEL consulting partner created and administers annual surveys to the students. To track student progression over the course of 5 years, students are asked to submit their student ID number to the MEL partner but is not shared with the AGSPP administration or Creighton University in order to keep responses anonymous. These surveys are tracked by student ID but are de-identified. The majority of the results from the annual surveys show high satisfaction with the program, growth of global health knowledge and skills, personal development, and wellbeing.

Additionally, Creighton's Master of Public Health program was re-imagined with new asynchronous courses and an addition of a global health concentration, which allows students to take additional global health-oriented courses to better prepare them for a career in global health.

International partnerships

AGSPP currently has four established international partnerships with academic medical centers in Ecuador, Dominican Republic, Rwanda, and Nepal. Of the four current partners, three were newly established while the Dominican Republic had a 50-year longstanding partnership with the University. Relationships with academic medical centers in Ecuador, Rwanda, and Nepal were initially explored due to individual connections between Creighton faculty and partners at those locations. Only after numerous Zoom meetings, in-person site visits, and follow-up in-depth discussions of each institution's mission and priorities, was a MOU created and signed for each international partner. The MOU contains information highlighting the expectations, roles, responsibilities, and budget of each institution with the overall goal of forming an equitable partnership. Faculty members from the Global South and Global North institutions have dedicated sessions discussing what decolonizing global health means to each institution and the partnership, power dynamics within the partnership, and addressing cultural expectations with an emphasis on cultural humility. For example, we have conducted numerous sessions and working groups on defining, assessing, and creating equitable power-balanced partnership using a lens of decolonization.

First, in February 2024, we held an equitable partnership panel where we invited partners to participate as panel members with the primary audience open to students. Panel members and the Q&A that followed focused on key elements for building and sustaining equitable partnerships, best and worst practices encountered in partnerships, and ways students can engage in culturally appropriate ways when supporting international projects.

Second, in March 2024, the partners and AGSPP conducted a 2 h long partner working session where the partners gathered on Zoom and worked on creating a formal definition of “equitable and power-balanced” partnership. In addition, we defined partnership values and agreed on priorities taking inspiration from The Equity Tool for Valuing Global Health Partnerships. ²⁰ The partnership values identified included (a) trust among all partners, (b) shared leadership that fosters teamwork and prioritizes co-creation, (c) Humility, honesty, and mutual respect that elevates all voices and experiences, (d) transparency in decision-making, and (e) ethical behavior from each partner. The agreed-upon priorities were divided into four domains: (1) governance, (2) operations, (3) impact, and (4) power and inclusion (see Table 1 for agreed-upon priorities).

Table 1.

Domains and agreed-upon partnership priorities.

DOMAIN	DEFINITION	AGREED-UPON PARTNERSHIP PRIORITIES
Governance	How a partnership is comprised, makes decisions, considers contributions	Clear process for joint decision-making, including setting roles and responsibilities Participatory and dynamic decision-making
Operations	How a partnership functions and implements action on a day-to-day basis	Clear and effective communication, including regular space for dialogue Timelines are designed, implemented, and monitored regularly, with adjustments possible
Impact	The difference a partnership makes for partners and those it serves	Partnership activities are centered around impact for students and communities Shared authorship and established process to do this equitably Bidirectional exchange of knowledge, expertise, and resources Impact is sustainable
Power and inclusion	How a partnership actively embraces diversity and responds to issues of power.	Different types of knowledge are valued and integrated into partnership and program planning Participatory methodologies are used for developing community and program partnerships Striving for a horizontal power dynamic Community representatives participate in program planning, implementation, and evaluation

Third, in April 2025, AGSPP MEL partners held 90 min one-on-one sessions with each individual partner to take a deep-dive into each partner context to understand opportunities and limitations. The objectives of this session were to review output from working the previous working session, discuss partner-specific context, vision for partnership success, approach for partnership assessment, and ways to track and assess the cross-site partnerships as well as the community engagement projects. Examples of guiding questions and select insights can be found in Table 2.

Table 2.

Select insights from MEL partnerships meetings with individual partner institutions.

Guiding questions

Considering the priorities for equitable partnerships defined during the working session, how might they play out in practice? Do you have examples of what an equitable partnership has looked like or should look like from your institution's perspective? What does meaningful, low-burden partnership assessment / data collection look like to you? What are your institution's expectations and goals for the Arrupe partnership? What is important and feasible to track for community projects that are implemented in your country in partnership with Arrupe?

Select insights

Prioritize bi-directional exchange of knowledge and resources (faculty & students), transparency on decision-making, clarity in communications and timelines, shared publications Skewed power dynamic is inevitable, but can strive for participatory processes that are responsive to stated need and mutual interest, not assumed need Short-survey assessment with opportunity for individual and shared reflection Interest in collaborative sessions with other partners to share promising practices, provide opportunity for data collection, and peer-to-peer exchange Important to “stay” with communities, and translate promises into action

Fourth, AGSPP invited all of its international partners to Omaha for a 4-day Global Health Summit in Omaha, Nebraska to strengthen the partnership work and goals in October 2024. Numerous meetings reviewing the data from the partnership panel and sessions were held to solidify the decolonized perspectives, initiatives, equitable partnership building, and partnership priorities. The international partners and AGSPP also established agreed-upon goals regarding each of the five international immersions that students in the AGSPP will accomplish (see Table 3).

Table 3.

AGSPP timeline of five-year immersion trips.

	GH EQUITY ORIENTATION JULY (BEFORE M1 YEAR)	IMMERSION 1 JULY (M2 YEAR)	IMMERSION 2 (MPH FALL)	IMMERSION 3 (MPH SPRING)	IMMERSION 4 JULY (M4)
Timeline	10 days	3 weeks	4 weeks	4 weeks	4 weeks
Purpose	-Introduction to global health equity orientation in the DR	-Cultural immersion -Introduction to Research Projects and mentors -Intensive language courses	-Identify and begin MPH capstone project; build community relations and trust -Cultural immersion activities	-Continue capstone project -Build community relations and trust	-Capstone project presentation to local community, partners, MoH-Clinical Rotation

Monitoring and evaluating these partnerships are a priority of the partners and AGSPP. Therefore, AGSPP's MEL consultants are currently conducting a survey with input from international partners and AGSPP to measure the satisfaction of the partnerships. Four main components comprise this partnership survey and include using a Likert scale measuring (a) Governance (How the partnership is comprised, makes decisions, considers contributions); (b) Operations (How the partnership functions and implements action on a day-to-day basis); (c) Power & Inclusion (How the partnership actively embraces diversity and responds to issues of power); and (d) Impact (The different the partnership makes for partners and those it serves). This survey is planned to be administered in the spring of 2025. Results will be shared with all partners and followed up with a Zoom meeting with them to review, discuss, and map a way forward to address any challenges identified.

Monitoring, evaluation, and learning platform

AGSPP's partnership with its MEL partner produced a strategic work plan identifying key quantitative and qualitative indicators for each of the three pillars of the program. These indicators were created with input from the international partners, literature searches using published papers on measuring academic equitable partnerships, input from the anonymous donor, Association of American Medical Colleges (AAMC) surveys, and Creighton University administration. Data is collected through surveys that are given to students and partners annually. Additional data is collected during quarterly mentorship sessions between students and AGSPP administration. MEL partners create formal reports for each survey and are openly shared with students, AGSPP and Creighton administrators. Brainstorming sessions are held with AGSPP and Creighton administrators and with students to discuss the results of the annual surveys and form a plan together on how to address challenges as well as to celebrate the successes.

Early challenges

Curriculum

Keeping the AGSPP curriculum up to date with the latest literature, evidence-based interventions, and CUGH's competencies can be challenging. The curriculum is constantly updated to better align with current competencies and based on student feedback. Ensuring we are responding to the interests and knowledge gaps of the students requires us to be nimble and timely in updating curriculum, which is time and labor intensive.

International partnerships

Time zone differences often make it difficult to find mutually agreeable meeting opportunities. In addition, faculty at all sites are busy with existing roles and responsibilities, so finding bandwidth to engage with international partners can sometimes be difficult.

Monitoring and learning platform

The amount of data collected by our MEL consultants from surveys from students and partners can be taxing to analyze. Creating productive and timely responses and changes to the program can be challenging due to the amount of time and bandwidth needed to implement successful changes. We have learned that we needed to invest more time and effort to respond to the surveys to create a stronger program.

Discussion

Creating a decolonized, historically informed, and justice-oriented global health educational and partnerships program takes intentionality and humility. When AGSPP was initially conceptualized, the vision was to create an MD-MPH training program with global health immersions. However, as the process evolved, the leadership intentionally chose to broaden the scope beyond biomedical and public health, and to emphasize historical frameworks, residual structural inequities from colonization that perpetuate health disparities today, and the recognition of unequal power dynamics that often accompany international partnerships. The leadership of AGSPP understood that creating decolonized global health educational programs requires more than training students on concepts and theories but must incorporate equitable approaches to partnership between the Global North and Global South. Having international partners take the lead in teaching Creighton students about the challenges, needs, and social determinants affecting their communities is paramount in recalibrating appropriate power balances. This allows the international partners to not only share their unique expertise but also introduce different perspectives to our Arrupe Scholars. We realized that most literature on decolonizing global health is written by authors from the Global North, displaying another example of the power asymmetry in authorship. Therefore, although many of the recommendations found in the literature review were implemented, we also relied on our partners from the Global South to guide the development of the curriculum and the formation of equitable international partnerships.

As noted earlier, the program drew upon the Adapted Social Ecological model from Ratner et al to ensure students had training for, and opportunities to engage at each level. Indeed, it has been shown that our scholars have ample opportunities for personal reflection, dialogue in small groups, collaboration with international partners and communities, and advocacy through professional organizations, public writing, or organizing. In addition, the program drew upon the 11 competencies from CUGH Decolonizing toolkit. The five-year Arrupe Curriculum touches upon all of the competencies so that they will have a robust and standardized educational experience by the time of graduation.

A federated search conducted by Hawks et al sought to identify theories, frameworks, models, and assessment tools for global health experiential learning. ²¹ Out of 13 articles, several themes emerged as imperative to the decolonizing movement in education: prioritizing interests of host communities, treating local partners as equals in planning and design, compensation to host sites, bidirectional opportunities for local practitioners, inspiring and equipping students to dismantle colonial practices, exposure to local knowledge, participation with local populations, and sufficient self-reflection to facilitate cultural humility. The AGSPP incorporates all of these components into the current program, demonstrating alignment with current recommendations to promote decolonizing.

Beyond simply its close alignment with current frameworks and competencies, the program distinguishes itself in a couple of ways. While other medical schools offer global health tracks, the majority center on the US-based learner. However, in AGSPP, student education is weighted equally with international partnerships. Foreign partners are not seen as a means to an end, or simply a place to send our learners. Equal time, attention, and prioritization are given to nurturing the academic partnership at the professional level. Joint papers, conference posters, joint classes, and panel discussions are examples of some of the outputs from these cross-site relationships. Not only do the international partners have a close partnership with Creighton University, but they have ongoing opportunities to engage cross-site with each other. Building this global network of health professionals benefits not only our learners but our academic institutions as a whole.

Another distinguishing factor of the AGSPP is the early integration and investment in a third-party Monitoring, Evaluation, and Learning (MEL) plan. It is not evident on the websites of other Global Health programs whether they have a rigorous MEL system in place. Choosing to prioritize this demonstrates an authentic desire to be ethical, accountable, and adaptable. Having a third-party vendor also decreases the risk of institutional bias in the evaluation of the program. The fact that the third party gets feedback not only from students but also from international partners shows how Creighton values and respects its international colleagues. Many programs might survey students at the end of the program but may not extend similar opportunities for feedback to partners. The partnership has been instrumental in our strategic planning and formation of the MEL platform.

A final way the program distinguishes itself is through the opportunity for five immersions, which exceeds the time abroad in other programs. This is in part due to the nesting of an MPH year between M2 and M3 year, which allows for two additional immersions. Apart from scheduling constraints, the endowment of the program by the anonymous donor removes the financial constraints which typically limit multiple visits to partner sites. The ability to engage with international sites in person, longitudinally, builds trust and allows for more meaningful work.

From the initial years of this program, an early lesson learned—which could be helpful to the existing theoretical literature on the decolonizing movement—is the nuance of what “equity” and “partnership” mean to different sites. There is not a one-size-fits-all approach to decolonizing. What one academic institution values in a partnership may be different than what another partner values. This suggests that while we should continue to use frameworks to aid us in our ongoing work, one of the most important “tools” is simply honest dialogue between partners.

Successes

AGSPP has found a number of successes in addition to the early successes previously mentioned within the first two years of being launched. The program established four international, power-balanced partnerships with institutions in the Dominican Republic, Ecuador, Rwanda, and Nepal. In conjunction with its MEL partner and international partners, AGSPP created workshops and focus group sessions to define the main values and components of what an equitable partnership looks like between Global South partners and AGSPP (subsequent manuscript will be written on lessons learned on building equitable partnerships). Because of the intentionality for equitable partnerships and honest conversations, we believe AGSPP made positive strides in forming trust with our partners. A final success was the creation of a 5-year global health equity curriculum (refer to Pillar 1 for information) and a Liberation Medicine elective course taught in the School of Medicine. AGSPP has collaborated closely with its international partners to create orientation materials and agendas for the four international immersions. Data from the latest surveys conducted by AGSPP's MEL partner revealed high student satisfaction with program content and learnings as well as program faculty/leadership. The highest gains in knowledge and scores were related to decolonizing global health, racism in medicine, empathy, and ministry of presence.

Challenges

In addition to the aforementioned early challenges, AGSPP encountered several more challenges. First, identifying Creighton and international faculty availability to meet consistently across different time zones has emerged as an obstacle. We have also learned that even though each international partner has identified common values of equitable partnerships, the requests and resources requested by AGSPP vary from partner to partner. AGSPP has learned that it needs to be flexible in how it approaches and supports its international partnerships as a “one-size-fits-all” approach does not work when striving towards forming equitable partnerships. Given the broad array of requests, we have also realized we cannot provide all the services requested by our partners. We have learned to be upfront with our partners noting what requests are and are not feasible for AGSPP. Another challenge we have encountered is that no matter how much AGSPP works towards decolonizing global health education, partnerships, and practices, we carry a long legacy and history that instills distrust, questions our motivation, and has the potential to perpetuate power asymmetries. Overcoming these structural injustices and mistrust takes effort, time, and humility. It is our hope that as we continue to act with humility and work towards building honest and trusting partnerships, these challenges will improve over time. We openly discuss the power asymmetries that exist between Global North and Global South academic institutions and discuss how we will strive to not perpetuate these structural violences. We acknowledge that we are an academic institution in the Global North and have our own implicit biases but will work to address these openly in hopes of creating a trusting partnership. We hope that having open and honest dialogue paired with humility, annual partnership surveys (that are administered by a third party), and ongoing collaborative projects will foster trusting partnerships. Lastly, we have faced domestic challenges running this program across two campuses located in Omaha, NE, and Phoenix, AZ. The logistics, faculty, and staff support, and communication across different time zones needed to make a program run smoothly has been more challenging than anticipated. The majority of the AGSPP administration team is based at one campus, which allows some students to have more in-person access to the leadership team and more direct communication. We have learned to communicate more frequently through a variety of platforms including email list servs, WhatsApp groups, and Canvas course pages created for each cohort of AGSPP. Additionally, in the future we plan to hire a full-time program assistant for the Omaha campus to enhance student support.

Conclusion

The positive potential for this program results from the intentionality and preparation that went into its design. We cannot overstate the importance of having a strong financial foundation to fund such a program. AGSPP is fortunate to have an anonymous donor who committed ten years of funding. These resources provided the latitude to create a robust global health equity training platform that benefits not only our students, through scholarship dollars, but also allows our international partners to partake in bilateral exchanges, professional development opportunities, and ongoing funding to create sustainable projects. It is our hope that this program's intentional focus on historical context, existing structural violence, and importance of equitable collaboration will lead to justice-oriented leaders of tomorrow and meaningful improvements in global healthcare as well as serve as a model for the development of additional programs with a similar interest.