The ARC-H principle: re-defining global health & shifting the balance.

It is tempting to begin this blog, based on its BMJ Global Health parent paper published in early 2024,  by listing some of the hundreds of definitions of “global health”. Each reader will have their own, slightly different idea of what the term means. And why wouldn’t they? ‘Global’ is so all encompassing that you’ll find some polarising ideas on one hand that it refers to low-resource healthcare settings and on the other that it simply refers to international healthcare collaboration. Who is to say which is right? And you might question why it even matters?

I’d argue it does matter. It matters an awful lot. If we allow ourselves to be carried along in a vague cloud of meaning, we stand to not only dilute its importance but also maintain a very unbalanced status quo.  It is probably fair to say that, despite some meandering to the other end of the spectrum most people’s box of meaning, when it comes to global health, contains:

So that’s it? Job done.

Not quite.

The observant among you will recognise that this box is very high-income-centric. It’s giving off a vibe that global health involves others and takes place elsewhere.

There is a good reason for this. Everything we have come to associate with global health has derived from the time period which bred the speciality of tropical medicine.

The latter half of  the 19th century saw western countries suddenly very excited by infectious diseases endemic to the “tropics”. (1) And the reason? Because it served the direct and indirect needs of colonialism.(2)  Keeping the western coloniser healthy was a primary concern and then later keeping local colonised labourers healthy to serve the needs of the colonisers became a further priority. 

Decades passed and the blurring of this speciality area with its key socio-political determinants of mortality and morbidity, namely poverty, loosened a little its association with its origins.  It collected other facets beyond infectious disease, and aimed to be more inclusive and thus outgrew its title and so the broader term of ‘international health’ emerged.(3)

As the 20th century drew to a close, colleagues within the unhelpfully-termed ‘global south’  were feeling the directionality of ‘international health’ which seemed to be referring to a them versus us paradigm.  One again therefore there was a shift in terminology to ‘global health’.(4)

What could go wrong in the arms of a warm, spherical “global” word-hug? Well, the concept of global health evolved through a myriad of definitions, a common theme centering around transnational universal health inequity.(5) It does sound balanced doesn’t it?

But. There is always a ‘but’…

By the very nature of seeking health equity for all, the definition remains very directional i.e. those with more stable and supposedly equitable healthcare systems indicating the desire to raise up systems elsewhere. 

This has led to a growing expert body in “global health”, the vast majority based in the global north, especially North America.(6)  Expertise, of course, attracts funding. It is therefore no surprise that our image of what global health means in practice retains its colonial flavour.  This has been duly noted in and amongst the decolonisation agenda which, not without its own controversies, has really gained momentum in the past decade.

Ideally, the very nebulous term “global health” which borders on being so vague as to be considered meaningless,  would be replaced entirely. However it is so embedded in academic and practical thinking that until a suitable alternative naming system is found and becomes commonly used for all of its facets, it will remain in use.  Also, it could be argued, why throw the (warm, spherical) baby out with the bathwater?

Instead, the ARC-H principle seeks to redress the balance of thinking around global health by looking at what it has come to mean for the majority – thinking back to that box. 

ARC-H stands for Access-, Resource-, and Context-limited Healthcare.  The order of the words is not relevant, only what they mean – they just happen to spell out a real word. A pretty good word at that.

ARC-H recognises precisely the types of environment and populations which global health has come to concern itself with however it simplifies them and removes directionality.

More importantly, the simplicity re-balances where expertise does and should lie. 

Who are the experts in resource-limited healthcare?  Of course the answer is those who deliver it – not just those who study it, explore it or seek it. Experts absolutely and predominantly include those whose entire professional practice is devoted to delivering resource-limited healthcare – and very many of those will be born, bred and based in that setting for the majority of their professional lives. (7)

Beirut port explosion, 2020 –  Creative Commons Attribution 4.0 International Tasnim News Agency

But global health stretches beyond resource-poor countries. In richer countries there are pockets of access-limited healthcare which mirror similar challenges e.g. the Northern Territories of Australia, some areas of rural South Africa.  There are countries, like Lebanon, teetering on the edge of an economic step down for whom a catastrophic industrial explosion has tipped the balance to the point of no return.(8) Similarly there are countries like Türkiye whose upper-middle income status cannot entirely mitigate the devastation and healthcare access-limitation of a large scale earthquake such as was seen in 2023.(9)

Furthermore the ARC-H principle reminds us of those who are context-limited, especially by geo-politics: our asylum-seeking, refugee and displaced populations whose circumstance often represents an even deeper dive into poor health than in the setting they left behind.(10)

In higher resource settings, the ARC-H principle refreshingly shines a spotlight on our previously side-lined global health colleagues i.e. diaspora of low and middle income countries.(11)  These often overlooked colleagues, whose lived experience, training, childhood, emotional burden may well be utterly entwined with a country from which the notion of “global health” has disconnected them in favour of the eager young UK/US/Australia-born trainee planning their year out of training.  The latter is most definitely not to be discouraged from responsible and sustainable engagement in global health, however the value placed on the potential contribution of former needs significant development.  In doing so, opportunities open up to gain deeper understanding of the societal fabric and socio-political context such that supporting healthcare systems can be approached from a position and in a way which is most likely to have long-lasting and progressive impact. 

The ARC-H principle presents nothing new, but it shakes off some colonial cobwebs and hopefully goes some way to empowering all experts in global health to take their rightful seat at the table.

The article at the heart of this blog can be found here.

With thanks to Shama Patel, Rob Mitchell and Tony Redmond for their word wizardry in helping turn an idea into a paper. Worth pointing out that it was a face-to-face international conference (ICEM) in Amsterdam which introduced me to Shama and Rob less than a year ago. Proof, if it was ever needed, of the critical value of being together in a room with colleagues. Creating these opportunities for all of our colleagues must continue to be a priority, with opportunities created at every chance e.g. AFEM’s Supadel. Technology can manage the rest, but that chance for even one-off human connection and conversation creates magic.


Anisa Jafar



1.         Wood C. Tropical Medicine: From Romance to Reality. 1st ed: Academic Press Inc; 1979.

2.         Worboys M.  Disease, medicine and empire. 1st ed: Routledge; 1988.

3.         Bradley D. Change and continuity in tropical medical science and international health. Trop Med Int Health. 1996;1(1):1-2.

4.         Beaglehole R, Bonita R. What is global health? Glob Health Action. 2010;3.

5.         Holst J. Global Health – emergence, hegemonic trends and biomedical reductionism. Global Health. 2020;16(1):42.

6.         Macfarlane SB, Jacobs M, Kaaya EE. In the name of global health: trends in academic institutions. J Public Health Policy. 2008;29(4):383-401.

7.         Jafar AJN, Patel S, Mitchell R, Redmond A. Redefining global health and shifting the balance: the ARC-H principle. BMJ Glob Health. 2024;9(2).

8.         Abouzeid M, Habib RR, Jabbour S, Mokdad AH, Nuwayhid I. Lebanon’s humanitarian crisis escalates after the Beirut blast. Lancet. 2020;396(10260):1380-2.

9.         Cinar EN, Abbara A, Yilmaz E. Earthquakes in Turkey and Syria-collaboration is needed to mitigate longer terms risks to health. BMJ. 2023;380:559.

10.       Procter NG, Kenny MA, Eaton H, Grech C. Lethal hopelessness: Understanding and responding to asylum seeker distress and mental deterioration. Int J Ment Health Nurs. 2018;27(1):448-54.

11.       Taslakian EN, Garber K, Shekherdimian S. Diaspora engagement: a scoping review of diaspora involvement with strengthening health systems of their origin country. Glob Health Action. 2022;15(1):2009165.

Cite this article as: Anisa Jafar, "The ARC-H principle: re-defining global health & shifting the balance.," in St.Emlyn's, April 2, 2024,

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