The limitations of expert-led fellowships for global health

How to overcome limitations of expert-led fellowships for global health

Reda SadkiGlobal health, Theory

Coaching and mentoring programs sometimes called “fellowships” have been upheld as the gold standard for developing leaders in global health.

For example, a fellowship in the field of immunization was recently advertised in the following manner.

  • Develop your skills and become an advocate and leader: The fellowship will begin with two months of weekly mandatory live engagements led by [global] staff and immunization experts around topics relating to rebuilding routine immunization, including catch-up vaccination, integration and life course immunization. […]
  • Craft an implementation plan: Throughout the live engagement series, fellows will develop, revise and submit a COVID-19 recovery strategic plan.
  • Receive individualized mentoring: Participants with strong plans will be considered for a mentorship program to work 1:1 with experts in the field to further develop and implement their strategies and potentially publish their case studies.

We will not dwell here on the ‘live engagements’, which are expert-led presentations of technical knowledge. We already know that such ‘webinars’ have very limited learning efficacy, and unlikely impact on outcomes. (This may seem like a harsh statement to global health practitioners who have grown comfortable with webinars, but it is substantiated by decades of evidence from learning science research.)

On the surface, the rest of the model sounds highly effective, promising personalized attention and expert guidance.

The use of a project-based learning approach is promising, but it is unclear what support is provided once the implementation plan has been crafted.

It is when you consider the logistical aspects that the cracks begin to show.

The essence of traditional coaching lies in the quality of the one-to-one interaction, making it an inherently limited resource.

Take, for example, a fellowship programme where interest outstrips availability—say, 1,600 aspiring global health leaders are interested, but only 30 will be selected for one-on-one mentoring.

Tailored, one-on-one coaching can be incredibly effective in small, controlled environments.

While these 30 may receive an invaluable experience, what happens to those left behind?

There is an ‘elitist spiral’.

Coaching and mentoring, while intensive, remain exclusive by design, limited to the select few.

This not only restricts scale but also concentrates knowledge among the selected group, perpetuating hierarchies.

Those chosen gain invaluable support.

The majority left out are denied access and implicitly viewed as passive recipients rather than partners in a collective solution.

Doubling the number of ‘fellows’ only marginally improves this situation.

Even if the mentor pool were to grow exponentially, the personalized nature of the engagement limits the rate of diffusion.

When we step back and look at the big picture, we realize there is a problem: these programs are expensive and difficult to scale.

And, in global health, if it does not scale, it is not solving the problem.

How does the scalability of peer learning compare to expert-led coaching ‘fellowships’?

Calculating the relative effectiveness of expert coaching, peer learning, and cascade training

So while these programs can make a real difference for a small group of people, they are unlikely to move the needle on a global scale.

That is like trying to fill a swimming pool with a teaspoon—you might make some progress, but you will never get the job done.

The model creates a paradox: the attributes making it effective for individuals intrinsically limit systemic impact.

There is another paradox related to complexity.

Global health issues are inextricably tied to cultural, political and economic factors unique to each country and community.

Complex problems require nuanced solutions.

Yet coaching promotes generalized expertise from a few global, centralized institutions rather than fostering context-specific knowledge.

Even the most brilliant, experienced coach or mentor cannot single-handedly impart the multifaceted understanding needed to drive impact across diverse settings.

A ‘fellowship’ structure also subtly perpetuates the existing hierarchies within global health.

It operates on the tacit assumption that the necessary knowledge and expertise reside in certain centralized locations and among a select cadre of experts.

This sends an implicit message that knowledge flows unidirectionally—from the seasoned experts to the less-experienced practitioners who are perceived as needing to be “coached.”

Learn more: How does peer learning compare to expert-led coaching ‘fellowships’?

Peer learning: Collective wisdom, collective progress

In global health, no one individual or institution can be expected to possess solutions for all settings.

Sustainable change requires mobilizing collective intelligence, not just centralized expertise.

Learn more: The COVID-19 Peer Hub as an example of Collective Intelligence (CI) in practice

This means transitioning from hierarchical, top-down development models to flexible platforms amplifying practitioners’ contextual insights.

The gap between need and availability of quality training in global health is too vast for conventional approaches to ever bridge alone.

Instead of desperately chasing an asymptote of expanding elite access, we stand to gain more by embracing approaches that democratize development.

Complex challenges demand platforms unleashing collective wisdom through collaboration. The technologies exist.

In the “fellowship” example, less than five percent of participants were selected to receive feedback from global experts.

A peer learning platform can provide high-quality peer feedback for everyone.

  • Such a platform democratizes access to knowledge and disrupts traditional hierarchies.
  • It also moves away from the outdated notion that expertise is concentrated in specific geographical or institutional locations.

What learning science underpins peer learning for global health? Watch this 14-minute presentation at the 2023 annual meeting of the American Society for Tropical Medicine and Hygiene (ASTMH).

What about the perceived trade-off between quality and scale?

Effective digital peer learning platforms negate this zero-sum game.

Research on MOOCs (massive open online courses) has conclusively demonstrated that giving and receiving feedback to and from three peers through structured, rubric-based peer review, achieves reliability comparable, when properly supported, to that of expert feedback alone.

If we are going to make a dent in the global health crises we face, we have to shift from a model that relies on the expertise of the few to one that harnesses the collective wisdom of the many.

  • Peer learning isn’t a Band-Aid. It is an innovative leap forward that disrupts the status quo, and it’s exactly what the global health sector needs.
  • Peer learning is not just an incremental improvement. It is a seismic shift in the way we think about learning and capacity-building in global health.
  • Peer learning is not a compromise. It is an upgrade. We move from a model of scarcity, bound by the limits of individual expertise, to one of collective wisdom.
  • Peer learning is more than just a useful tool. It is a challenge to the traditional epistemology of global health education.

Read about a practical example: Movement for Immunization Agenda 2030 (IA2030): grounding action in local realities to reach the unreached

As we grapple with urgent issues in global health—from pandemic recovery to routine immunization—it is clear that we need collective intelligence and resource sharing on a massive scale.

And for that, we need to move beyond the selective, top-down models of the past.

The collective challenges we face in global health require collective solutions.

And collective solutions require us to question established norms, particularly when those norms serve to maintain existing hierarchies and power imbalances.

Now it is up to us to seize this opportunity and move beyond outmoded, hierarchical models.

There is a path – now, not tomorrow – to truly democratize knowledge, make meaningful progress, and tackle the global health challenges that confront us all.