Decolonizing global health governance through knowledge: a perspective on epistemic governance

Global health has become a major focus of decolonization debates, with scholarship documenting persistent colonial structures in funding, governance, leadership, and institutional practices while proposing pathways for reform (1,2,3). However, less attention has been paid to the epistemic foundations of global health governance specifically, what constitutes valid knowledge, who is authorized to produce it, and whose expertise is considered universally applicable. This article argues that global health governance is fundamentally a knowledge practice, with colonial legacies embedded in the epistemic systems that shape research authorship, guideline development, and technology transfer. Drawing on decolonial theory, the decolonizing global health literature, and STS (4,5,6,4), it contends that decolonizing global health requires transforming not only institutional representation but also the knowledge structures that define health problems, generate evidence, and guide global responses. The article develops the concept of epistemic governance, illustrates it through global health authorship asymmetries and the WHO mRNA vaccine technology transfer programme in South Africa, and concludes by outlining mechanisms, challenges, and future directions for decolonizing knowledge in global health governance.Decolonial theory argues that colonialism persists through enduring structures of power and knowledge rather than ending with political independence. Quijano's concept of the coloniality of power explains how colonial hierarchies continue to shape knowledge production, including the privileging of Eurocentric standards in global health (4). Mignolo further contends that decolonization requires delinking from the assumption that Northern biomedical epistemology is the universal standard for evaluating health knowledge (5). Similarly, Wyse argues that this dominance results in epistemicide, whereby alternative forms of knowledge are marginalized through hierarchies of evidentiary legitimacy that privilege scientific and institutional evidence over local, community, and context-specific knowledge (7).A growing body of literature has documented the persistence of colonial structures in global health institutions, including inequities in funding, research partnerships, workforce composition, and governance, while calling for structural reform (1, 2, 3). Abimbola's work provides a key foundation for the concept of epistemic governance by highlighting systematic inequalities in global health knowledge production. He demonstrates that researchers from high-income countries often dominate first and senior authorship in studies conducted in lowand middle-income countries (LMICs) despite substantial local contributions (6,8). He also argues that global health institutions privilege knowledge generated by those who produce and generalize theory over the context-specific expertise of practitioners and advocates, reinforcing epistemic hierarchies and limiting the recognition of locally grounded knowledge (1).Jasanoff's concept of co-production argues that scientific knowledge and governance are mutually constituted, meaning that global health tools, guidelines, and technologies simultaneously shape knowledge and authority by defining whose expertise is considered legitimate (9). Similarly, Smith's work on decolonizing methodologies highlights how research practices have historically reinforced colonial control and advocates for community-led and reciprocal approaches to knowledge production (10). These principles are reflected in the Ownership, Control, Access, and Possession (OCAP) framework, which emphasizes Indigenous ownership and control of health data (11), and the Collective Benefit, Authority to Control, Responsibility, and Ethics (CARE) Principles, which promote Indigenous data governance based on collective benefit, authority, responsibility, and ethics alongside conventional data-sharing practices (12).While the decolonizing global health literature has documented colonial inequities in authorship, funding, and institutional leadership, it has paid less attention to the underlying epistemic structures that sustain these patterns. Conversely, decolonial theory and STS provide conceptual tools for understanding knowledge hierarchies but have rarely been applied to the institutional mechanisms of global health governance. This article bridges these perspectives through the concept of epistemic governance, linking empirical evidence of global health inequities with a deeper analysis of the epistemological foundations that reproduce them.This section develops four linked concepts, adapted specifically to global health governance: epistemic governance, knowledge regimes of global health, epistemic exclusion, and epistemic pluralism/co-production.Epistemic governance refers to the systems, institutions, and practices that determine what constitutes valid knowledge in global health and who has the authority to define health problems and solutions. It operates through mechanisms such as research authorship, peer review, WHO guideline development, disease metrics, and technology-transfer processes. These epistemic structures shape how health problems are recognized and addressed, reflecting underlying assumptions about whose knowledge is considered legitimate rather than functioning as neutral technical processes.A global health knowledge regime comprises the institutions, funders, academic centers, and journals that shape the production and circulation of global health knowledge. Rather than resulting from deliberate coordination, these regimes are sustained by funding, publication, and credentialing systems that privilege standardized, measurable, and generalizable evidence over context-specific local expertise. Consequently, they systematically favor the knowledge of academics and policy experts over that of practitioners and communities with direct experience of local health systems (6).Epistemic exclusion in global health refers to the systematic marginalization of contextspecific, practice-based, and community knowledge from what is recognized as legitimate evidence. This is reflected in authorship practices that prioritize foreign-led research teams over local researchers and health workers in LMICs, despite their essential contributions (7).Such exclusion is reinforced by publication norms, funding systems, and academic incentives that structurally privilege externally generated knowledge.Epistemic pluralism refers to global health governance that recognizes multiple knowledge systems and producers as equally legitimate rather than hierarchically ranked (9). In practice, this requires treating LMIC researchers, health workers, and communities as equal partners in designing research, developing technical protocols, and defining evidence standards, rather than merely as data providers or implementers. However, as illustrated in Section 4.2, formal commitments to co-production do not necessarily result in meaningful epistemic inclusion.Abimbola's analysis shows that global health research on LMICs is disproportionately led by authors from high-income countries, despite relying heavily on the expertise and contributions of LMIC researchers and health workers-a phenomenon described as the "foreign gaze" (6,7). Beyond professional recognition, authorship serves as a mechanism of epistemic governance, conferring intellectual authority, career advancement, and influence over guideline development and policy-making. As a result, inequities in authorship reinforce broader patterns of epistemic exclusion within global health institutions. Abimbola further argues that global health systems privilege the theoretical and systems-oriented knowledge of "professors" and "engineers" over the practical and justice-oriented knowledge of "plumbers" and "emancipators," thereby sustaining knowledge hierarchies through the field's own evaluative standards rather than explicit discrimination (6, 7).The WHO-Medicines Patent Pool mRNA vaccine technology transfer programme, established in 2021 in response to global COVID-19 vaccine inequities, aimed to strengthen LMIC manufacturing through a South African hub led by Afrigen Biologics and Vaccines and partner institutions (13)(14)(15)(16). Although the initiative expanded technology sharing and supported vaccine production capacity across multiple countries, evidence suggests that governance and decision-making authority remained largely centralized within WHO and MPP. As a result, while technical knowledge was transferred, Southern partners had limited influence over priorities, commercialization, and independent decision-making (13). This case highlights the distinction between technology transfer and epistemic co-production, demonstrating that genuine decolonization requires not only sharing technical expertise but also redistributing authority over knowledge production, governance, and health priorities (13-16).Building on the contrast above, this section outlines four mechanisms through which global health governance might move from epistemic exclusion toward genuine epistemic pluralism.Journals, funders, and universities can promote more equitable global health research by adopting authorship policies that recognize contextual expertise and local leadership alongside traditional academic contributions. Measures such as mandatory local co-authorship, revised promotion criteria that encourage equitable authorship, and more diverse editorial boards can help reduce authorship inequities. However, as Abimbola cautions, these reforms must address the underlying "foreign gaze" rather than becoming symbolic solutions that leave deeper epistemic inequalities unchanged (7).The mRNA technology transfer case demonstrates that decolonizing global health requires transferring not only technical knowledge but also decision-making authority over its prioritization, commercialization, and implementation. Achieving this demands stronger commitments to affordability, public health priorities, and greater autonomy for Southern manufacturing hubs within technology-transfer programmes (13).The OCAP principles (10) and the CARE Principles for Indigenous Data Governance (12) provide practical frameworks for ensuring community authority over health data. Applied to global health governance, these principles support giving LMIC institutions and communities a formal role in governing how health data are collected, shared, integrated into global metrics, and used to guide research, funding, and policy decisions (10,12).The WHO guideline-development processes and global health evidence synthesis could be strengthened by formally recognizing practice-based and context-specific knowledge alongside traditional sources such as randomized trials and large-scale surveys. This would elevate the contributions of Abimbola's (7) "plumbers" and "emancipators" and require reforming existing evidentiary hierarchies, including frameworks used to evaluate evidence for global health recommendations.Decolonizing global health also requires investment in knowledge infrastructures that are owned, governed, and operated by researchers and institutions in LMICs. Rather than relying exclusively on established journals, research networks, conferences, and policy platforms headquartered in high-income countries, LMIC researchers, universities, professional associations, and public agencies can establish and strengthen journals, scholarly societies, research consortia, repositories, conferences, and policy platforms under local and regional leadership. Such infrastructures can create spaces in which LMIC researchers and practitioners set research agendas, determine publication priorities, develop contextually relevant standards of evidence, and disseminate knowledge without having to pass exclusively through Northern institutional gatekeepers. Importantly, intellectual contribution and scholarly capacity should not be judged primarily through publication in journals with high citation-based impact factors or through other metrics that disproportionately reflect established Northern publishing systems. LMIC researchers who publish in LMIC-led or regionally governed journals should receive full recognition for their intellectual contributions, particularly when these platforms enable locally grounded knowledge, methodological innovation, and context-specific scholarship that may be undervalued by conventional citation metrics. Universities, funders, and promotion committees should therefore broaden criteria for academic recognition to value the quality, relevance, leadership, and societal contribution of research rather than treating journal prestige or impact factor as a proxy for intellectual capacity. This should not mean creating isolated parallel systems; rather, LMIC-led platforms should be connected to international scholarly networks while retaining meaningful local ownership, editorial independence, and decision-making authority. Funders and international organizations can support this process through sustained investment in locally governed publishing infrastructure, open-access dissemination, editorial capacity, research communication, and regional knowledge networks. Building such infrastructures would help shift LMIC researchers from being primarily producers of data for externally defined research agendas to becoming agenda-setters, knowledge producers, editors, reviewers, and institutional stewards of global health knowledge.Three key objections require consideration. First, valuing contextual and practice-based knowledge does not mean rejecting rigorous scientific evidence; rather, it challenges the assumption that a single evidentiary model should dominate and argues for recognizing diverse forms of valid knowledge while maintaining standards of reliability and effectiveness. Second, although the WHO mRNA technology transfer programme represents meaningful progress in technical knowledge-sharing, it demonstrates that formal co-production arrangements do not necessarily transform underlying decision-making and epistemic hierarchies (13). Third, authorship reform is not merely an issue of academic recognition; because authorship influences access to expert networks, advisory roles, and policy-making spaces, inequities in authorship can shape whose knowledge informs global health governance (7).This article argues that decolonizing global health governance requires addressing the knowledge architectures through which health problems are defined, measured, and addressed,