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Blending integrated knowledge translation with global health governance: an approach for advancing action… Plamondon, Katrina M; Pemberton, Julia Mar 4, 2019

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REVIEW Open AccessBlending integrated knowledge translationwith global health governance: anapproach for advancing action on a wickedproblemKatrina Marie Plamondon1,3* and Julia Pemberton2AbstractBackground: The persistence of health inequities is a wicked problem for which there is strong evidence of causalroots in the maldistribution of power, resources and money within and between countries. Though the evidence isclear, the solutions are far from straightforward. Integrated knowledge translation (IKT) ought to be well suited fordesigning evidence-informed solutions, yet current frameworks are limited in their capacity to navigate complexity.Global health governance (GHG) also ought to be well suited to advance action, but a lack of accountability,inclusion and integration of evidence gives rise to politically driven action. Recognising a persistent struggle formeaningful action, we invite contemplation about how blending IKT with GHG could leverage the strengths ofboth processes to advance health equity.Discussion: Action on root causes of health inequities implicates disruption of structures and systems that shapehow society is organised. This infinitely complex work demands sophisticated examination of drivers and disruptersof inequities and a vast imagination for who (and what) should be engaged. Yet, underlying tendencies towardreductionism seem to drive superficial responses. Where IKT models lack consideration of issues of power andprovide little direction for how to support cohesive efforts toward a common goal, recent calls from the field ofGHG may provide insight into these issues. Additionally, though GHG is criticised for its lack of attention to usingevidence, IKT offers approaches and strategies for collaborative processes of generating and refining knowledge.Contemplating the inclusion of governance in IKT requires re-examining roles, responsibilities, power and voice inprocesses of connecting knowledge with action. We argue for expanding IKT models to include GHG as a means ofconsidering the complexity of issues and opening new possibilities for evidence-informed action on wickedproblems.Conclusion: Integrated learning between these two fields, adopting principles of GHG alongside the strategies ofIKT, is a promising opportunity to strengthen leadership for health equity action.Keywords: Integrated knowledge translation, global health governance, health equity, health inequities,knowledge-to-action, wicked problems, complexity* Correspondence: katrina.plamondon@ubc.ca1University of British Columbia, 3333 University Way, Kelowna, BC, Canada3Interior Health, 505 Doyle Avenue, Kelowna, BC, CanadaFull list of author information is available at the end of the article© The Author(s). 2019 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, andreproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link tothe Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.Plamondon and Pemberton Health Research Policy and Systems           (2019) 17:24 https://doi.org/10.1186/s12961-019-0424-3BackgroundProblems described as ‘wicked’ earn the label from their in-herent resistance to resolve; they are convoluted, reactiveproblems entangled in competing social interests andvalues [1, 2]. The persistence of health inequities [3, 4] is awicked problem [5] shaped by systems of power [5–10]and the social and structural determinants of health[11–13]. Robust evidence provides clear insights intotheir socio-political, economic and historic causes [14],and offers actionable policy solutions [15–18], making thepersistence of health inequities a knowledge-to-actionproblem. However, efforts to advance evidence-informedaction unfold in the same systems of social and politicalpower that disproportionately advantage the already privi-leged and are generative of health inequities’ wicked na-ture. Additionally, despite recognition of their wickedness,attempts to respond often reduce health inequities intocomponent parts, examining ‘symptoms’ rather thancauses [19–21] in ways that ‘fit’ with dominant politicalideologies [22–24]. These factors fuel the wickedness andtenacity of health inequities.The purpose of this review article is to explore thecomplementarities of two promising approaches of ap-plied research and practice that might support meaning-ful processes for advancing evidence-informed healthequity action. It began with informal conversation aboutour experiences as doctoral students doing research forhealth equity, where we found ourselves grappling withcontradictions and tensions within our field. Though wewitnessed a broad commitment to ‘good’ equity intentions,we simultaneously observed processes and leadership thatcontradicted the evidence on causes and applauded super-ficial responses to health inequities. Critically examininghow to move beyond good intentions for health equitybecame central to both of us in our doctoral research, withKatrina focusing on integrated knowledge translation(IKT) and Julia on global health governance (GHG). Asour dialogue became more purposeful and structured,we discovered that the challenges we encountered inour respective fields were met by strengths in the other.Adopting an intentionally optimistic lens, we explored howthese fields might complement each other and, throughdeeper attentiveness to issues of political power, couldcollectively contribute to more productive health equityaction.We understand both IKT and GHG to be primarily con-cerned with processes. IKT brings together people who doand use research as equal contributors to processes of col-laboratively identifying and responding to knowledge-to-ac-tion challenges [25–28]. Ideally, GHG brings cross-sectoractors together to deliberate and guide mechanisms forresolving complex global issues through intentional collab-oration [29, 30]. Both are promising, yet the strengths ofeach mirror weaknesses in the other. Poor governancesuffers from accountability and administrative failures, anda lack of strategy for integrating evidence-informed, con-textual and tacit knowledges [31–33]. Emerging fromhealth systems settings with clearly defined and con-tained contexts (e.g. clinical practice sites), IKT suffersa lack of attention to power dynamics and complexity indecision-making [27], making it difficult to apply to ‘wicked’knowledge-to-action problems. Further, despite much inter-est in both IKT and GHG within the field of health equity,their respective bodies of literature are disconnected.In this article, we draw on Freire and Shor’s metaphorof a ‘dialogic table’ [34], inviting contemplation of howblending IKT approaches with GHG principles couldsupport meaningful health equity action. Below, we lay afoundation for deeper, critically reflective consider-ation of the complementarities of IKT and GHG. Weare inspired by the potential of critical pedagogy as anepistemological guide for ‘how’ we (society, scientists,practitioners, decision-makers, etc.) might collectivelyinspire transformative possibilities. In their reflective con-versation about learning, Freire and Shor described a ‘dia-logic table’ as an enabler of transformative co-learning.They suggested an “object to be known is put on the tablebetween subjects…[who] meet around it and through it formutual inquiry” ([34], p. 14). The “object to be known” inthis dialogue is evidence-informed health equity action.The ‘subjects of knowing’, each with their own insights,knowledges (e.g. tacit, institutional, professional knowl-edges), evidences and epistemologies, are people situatedwithin the fields of IKT and GHG. We set this dialogictable by discussing the wickedness of health inequities, thestrengths and limitations of IKT and GHG, and how toleverage their mutually beneficial characteristics.Unpacking the wickedness of health inequitiesHealth inequities are systematic differences in healthrooted in socioeconomic and political injustices [14]. TheWHO Commission on Social Determinants of Health de-scribed health inequities as avoidable, arising from “…theconditions of daily life in which people are born, grow, live,work, and age” shaped by social, political and economicforces, and requiring response from the “whole of govern-ment” [14]. Evidence shows that the greater the gap be-tween a population’s richest and poorest, the greater thedifferences in health between them [3, 35, 36]. Unequaland unfair systems of power between and within nationstates are widely recognised as driving forces in the cre-ation of structures that disproportionately advantage somelives at the cost of others [8, 14, 37]. Though the evidenceabout causal roots is clear, and a robust suite of tested pol-icy recommendations widely available [15–18], the imple-mentation of policy solutions is far from straightforward.Calls for social policy reform to improve health have beendocumented for more than 160 years [38, 39], revealingPlamondon and Pemberton Health Research Policy and Systems           (2019) 17:24 Page 2 of 10deep resistance to resolve. Indeed, the causes of healthinequities are tenacious because they are rooted socio-pol-itical systems and structures designed to reinforce the sta-tus quo of power distribution, locally and globally.Connecting knowledge to action on root causes ofhealth inequities implicates a reconstruction of the sys-tems and structures that shape how society is organised.This infinitely complex work demands sophisticatedexamination of drivers and disrupters of inequities and avast imagination for who (and what) should be engaged.This work is challenging for many reasons, not the leastof which is a fundamental clash between health inequities’inherent complexity and the dominant lens through whichthe world is observed and responded to in the field of healthand science generally. This lens involves linear, reductionistand hierarchical assumptions (Table 1) stemming fromseventeenth-century mechanistic suppositions about reality[20]. A repercussion of these assumptions is a persistentWestern habit of understanding “the world as a collection ofseparable and thus independent units and assumes linearcause-and-effect relationships between these units, and thatthese relationships are reversible” ([21], p. 3). When these as-sumptions are at play, our collective capacity to recognisethe depth and tenacity of root causes remains elusive.Lending to a particularly narrowed and superficial lensthrough which the social determinants of health [20] andhealth inequities are framed [24, 40], mechanistic assump-tions effectively mask complex mechanisms that entrenchinequities. Rather than focusing on the intersecting natureof the social determination of health [41], efforts to advancehealth equity under these assumptions place inordinate at-tention on behavioural interventions and insufficient atten-tion on structural causes [42, 43]. For example, even whenthere is agreement about causes, public health efforts tendto focus on interventions that place responsibility for healthon individual behaviours [23, 44]. Despite the recognisedvalue of upstream and structural interventions, researchshows a predominantly downstream focus in policy andpublic health efforts [24, 45–48]. Behavioural interventionsfor healthy eating, for example, distract attention away fromcomplex issues of affordability and accessibility, whereas amore structural intervention might involve advocacy to ad-vance socially protective policy for living wages.Further, the role of power in establishing systematic ad-vantage and disadvantage, recognised as a pivotal driver ofhealth inequities [14], is only occasionally acknowledgedand infrequently used to guide study goals and objectives[40]. Decades of dominant neoliberal ideology [47] havecontributed to policy environments incompatible with thekinds of social protection known to mitigate health inequi-ties [47, 49, 50]. Compounding these incompatibilities is apreoccupation with individualism and bio-behaviourism inhealth sciences that conflicts with the best available evi-dence and often distracts attention from where it might bemost productive [24, 40, 51, 52]. Whether inadvertent orstrategic, the absence of power analysis in efforts to ad-vance health equity action can undermine possibilities ofuprooting the tenacious systems of power that lead toinequities.The fields of GHG and IKT span practice, policy and re-search outside the confines of a particular topic. Both fieldsbring something important to the table in response tohealth inequities. Further, because of their relational nature,they both offer platforms for the kind of dialogue necessaryto challenge reductionism and mitigate power imbalances.Greater integration across disciplines interested in healthequity is recognised as necessary evidence-informed actionfor health equity [53, 54]. If there is indeed desire and cap-acity to begin unravelling equity-harming structures, powerand policy environments, then there is an urgent need tounderstand how to mobilise knowledge into action – bothin terms of increasing the application of existing knowledgeand informing emerging research. Unpacking these influ-ences could provide a useful means of deconstructingunderlying assumptions that lend themselves to consistentfailures to advance health equity.Table 1 Mechanistic assumptions and their application to social determinants of healthaAssumption Description How the assumption circumvents complexity of health inequitiesReductionism Assumes the whole system can be understood by identifying,describing and analysing all of its constituent partsBreaks social determinants of health into separate, distinct factors(rather than a set of complex intersecting factors)Draws attention to symptoms or expressions of root causes thatare more immediately visible (e.g. considering ‘race’ adeterminant of health instead of ‘racism’)Linearity Assumes that (1) output changes proportionally with input,and (2) the effect of combined inputs can be understoodand predicted by dissecting the input–output relationshipsof individual components, or a direct summative andpredictive cumulation of constituent partsSimplifies interconnectednessJustifies use of proxy indicators that reflect symptoms rather thancauses of health inequities (e.g. monitoring maternal and childmortality rates as indicators of equity)Hierarchy Assumes central power and control, which diffusessystematically from proximal to more distal partsPlaces responsibility for acting on health within individuals orgroups, rather than societyLegitimises a focus on health damaging behaviours rather thanhealth damaging conditions, systems or structuresaAdapted from Jayasinghe, 2011 [20]Plamondon and Pemberton Health Research Policy and Systems           (2019) 17:24 Page 3 of 10What does IKT bring to the table?Efforts to respond to health inequities include explicitcalls for connecting research to action [14, 55]. Thesecalls align with the growing recognition of the import-ance of knowledge translation (KT) [56–59]. IKT offersstrategies for bringing diverse perspectives together tounderstand and respond to problems through processes ofknowledge generation and refinement [25–27]. Inherentlyrelational [60], IKT is non-linear and challenges trad-itional notions of the dispassionate, objective ‘expert re-searcher’ [61] whose work, once released into the worldthrough scholarly publication, carries de facto impact. Itinvolves participatory, inclusive processes where peoplewho ‘use’ research work alongside people who ‘do’ re-search [62]. Recognising a ‘social contract’ between societyand science, IKT brings stakeholders into a social processof problem solving through research [63] emphasisingknowledge co-production in partnership [27]. By virtue ofthis collaborative approach to knowledge production, re-finement and use, an IKT approach necessitates dialogueand trust building [64–66]. These characteristics are wellsuited to overcoming mechanistic assumptions by foster-ing ‘change from within’; however, the application of IKTto wicked problems is constrained by underlying assump-tions that limit the scope and scale of contexts for whichit was originally envisioned.Frameworks for IKT consistently describe it as a way ofcollaboratively leveraging the research processes as a meansfor generating context-sensitive, complexity-embracing,real-life solutions grounded in evidence. Among evolvingmodels for IKT are encouraging innovations, such as theuse of critical realism and arts in KT [67], systems thinking[68], and even reflexive frameworks for equity-focused KT[69]. Common among these models is a recognition that“both communities [of knowledge users and producers]hold distinct norms and values but they also bring valuableknowledge to the problem; and the work of knowledge gener-ation is done collaboratively” ([27], p. 620). A distinguishingfeature of IKT is, however, that “knowledge users usuallyhave the authority to invoke change in the practice or policysetting” [27]. This presumes that knowledge users are indi-vidual ‘stakeholders’ who represent particular portfolioswithin a health system or community setting. When thecontext and knowledge-to-action problem implicates socialorganisation and structure, however, the idea of includingeveryone, or even of finding just one set of stakeholderswho may have authority to invoke change over some aspectof policy or practice relevant to health equity can be para-lysing. The need for engaging people who can be part ofdecision-making mechanisms that lead to action opens aquestion of governance.Although IKT models demonstrate promise for micro-(e.g. clinical practice unit) and meso- (e.g. health sys-tems) contexts [70], their utility is limited when appliedto the multiple, complex actors that contribute to shap-ing political, social and cultural environments that eitherdrive, do nothing or disrupt wicked problems like healthinequities. This is, in part, due to the difficulty of navi-gating meaningful engagement within the vastness ofpotential actors to include. Rather than focusing stake-holder analysis [71] in a defined setting, the range of po-tential actors implicated in wicked problems extends tonetworks of knowledge producers and knowledge users,many of which are not single entities, but conglomeratesthat also produce multiple competing interests and values.Identifying the ‘right’ actors to engage could become inand of itself a wicked problem, resistant to resolve andsurely beyond the scope of any individual study orprogramme of research. Further, these models lack direc-tion for how to achieve cohesiveness toward a commongoal. Additionally, despite a need for evidence-informedpolicy and practice for health [14, 17], there are few exam-ples of using IKT approaches to respond to wicked prob-lems. These features that constrain the application of IKTin the face of wicked problems could be redressed throughadoption of the principles of GHG, particularly its mecha-nisms of legitimacy and collaboration between multi-sectortransnational actors, with an emphasis on civil society.What does GHG bring to the table?As a reaction to the intensifying wickedness of health prob-lems that defy state borders, governance processes consistof stakeholders working through formal international insti-tutions both within and across borders. Heavily influencedby major globalisation events such as HIV/AIDS andSARS, current mechanisms and processes for GHG stemfrom the disciplines of political science, health economicsand health policy [72, 73]. In the absence of a singularglobal government, GHG platforms convene a plurality ofmajor actors to define shared values, establish standardsand regulatory frameworks, set priorities, mobilise andalign resources, and promote research. GHG often requiresindividual governments to forgo aspects of their individualsovereignty in order to collaborate and participate withinternational agencies such as WHO [74]. For example, theWHO International Health Regulations establishes stan-dards for how individual countries respond to internationalhealth risks [75]. These regulations refer to the need forthe Director-General of WHO to consider scientific evi-dence, but do not provide recommendations for how thisevidence could inform decision-making.Ultimately, GHG is a polycentric system that provides amechanism for collective decision-making for improvedhealth through the interplay of different institutionalforms and actors at different levels in pursuit of commongoals [29, 73, 76]. The imperfect decision-making pro-cesses of GHG are, however, embedded in historical andsocio-political contexts of colonialism and heavilyPlamondon and Pemberton Health Research Policy and Systems           (2019) 17:24 Page 4 of 10influenced by power relationships, values, norms, organ-isational structures and resources. GHG is political; it canserve to reinforce or challenge existing institutional exclu-sion and power inequalities and has direct impacts onhealth system equity whereby the decisions made throughGHG processes shape who accesses benefits and whosevoices are heard [77]. Continued processes of globalisationand increasing influence of private sector actors in globalhealth bring new layers of political power to the govern-ance scene [78], while innovations in technology, data,communications and networks open possibilities for reim-agining the mechanisms and processes relied upon postWorld War II [79]. The time is ripe for reimagining howGHG might better support collective responses to globalproblems.At the turn of the twenty-first century, health sectorsworldwide were acutely aware of their limited capacityto deal with emerging challenges in isolation. Globalvulnerability to pandemics, climate change and politicalinstability all contribute to a growing recognition of aneed for multi-sectorial action and broad public and pri-vate partnerships at national and international levels[74]. Further, civil society and political leaders are chal-lenging notions of an isolated, technocratic health sectorand call for more unified attention to issues of equityand human rights [73]. Society writ large voiced a desireto be part of the political sphere that shapes their lifecircumstances, opportunities and experiences of healthand healthcare. In response to a confluence of heightenedawareness of the globalised nature of health issues andgrowing demand for collective responses, complex net-works of international agencies and philanthropic founda-tions collaborated to set global targets for progress towarda more equitable word through the Millennium Develop-ment Goals and the more recent Sustainable DevelopmentGoals [33, 80]. These and other examples of governancefor health equity (e.g. the WHO Commission on SocialDeterminants of Health) are key demonstrations of thekinds of platforms and mechanisms GHG offers. Import-antly, these mechanisms also demonstrate how the legacyof colonialism contributes to health equity failures.Global health crises exemplify how health equity is tiedup to socio-political and economic contexts, including thehistories of colonisation. The 2014–2016 Ebola epidemicis an important example of the consequences of govern-ance failures. As outbreaks emerged, the world witnessedvulnerabilities and fragmentation in public service sectorsthat became determinants of who lived and who died –revealing intense inequities between and within countries[81–83]. Leaders in health systems and governments alikerecognised the need for strong global institutions, mecha-nisms and funding for development of global public goodsthat contribute to resolving global health threats. In thecase of the Ebola crisis, GHG leadership (e.g. WHO) failedto respond in a timely manner, which lead to other key ac-tors stepping up to fill the leadership gap. The responsewas openly criticised as “too little too late” to halt an epi-demic reflective of the “pathology of society and the globaland political architecture” [84]. Like many contemporaryGHG challenges, this crisis unfolded through the legacy ofcolonialism [85] that holds the roots of inequities in place.By revealing the differential value placed on human lifeglobally, these failures illuminated the tenacious nature ofhealth inequities and the lack of political will to uproottheir causes.While GHG provides a platform for responding towicked problems through global collaboration, cooperationand leadership among a diverse set of actors, GHG deliver-ables still lack strategies to ensure evidence- [86] andequity-informed [87] policy, practice and decision-making.The 2014 Lancet–University of Oslo Commission on Glo-bal Governance for Health also pushed for evidence- andequity-informed GHG, recommending mandatory healthequity impact assessments for all global institutions andstrengthened sanctions against non-state actors for rightsviolations [88]. Surprisingly, there are few examples oflooking to IKT to support processes for the same [89].Shared governance and public dialogue about our socialand economic architecture is needed [90], where publicmoral norms can be re-constructed and internalised (e.g.recreating constructs of health equity as a public good).IKT approaches and strategies could support this kind ofdialogue in engaged, inclusive ways that support connect-ing this kind of evidence and other knowledges with ac-tion. In Table 2, we offer an overview of recognized stepsin the knowledge-to-action cycle [25] alongside comple-mentary GHG processes and mechanisms. This blendedIKT–GHG approach, done alongside a critical examinationof power, presents a promising pathway toward healthequity action.Additional ‘objects’ of consideration on thisdialogic tableIn addition to our interest in leveraging the relational-dia-logic nature of GHG and IKT to counter reductionism andmitigate power imbalances, we propose placing a few add-itional objects on this dialogic table, namely accountability,leadership and inclusion. It is beyond the scope of this dis-cussion to resolve the intricacies of any of these issues,but we hope that they serve as sparks for continued dia-logue and reflection. In GHG, the lack of accountability ofmajor global health organisations (i.e. WHO), and its rela-tionship to systems of power, has been a significant chal-lenge [74]. Unclear accountabilities, particularly forleadership, can play a role in legitimising investments inresearch, IKT, or policy in ways that overlook evidenceabout causal roots or reinforce inequitable power dy-namics. Without frank acknowledgement of the legaciesPlamondon and Pemberton Health Research Policy and Systems           (2019) 17:24 Page 5 of 10of colonisation, and particularly at a time when neo-liberal reason and monetisation of socio-political pro-cesses undermine democratic governance [85, 91], it isinsufficient to assume health equity is the responsibility ofgovernments, government agencies or civil society, nor ofinternational institutions, such as WHO or UnitedNations, whose political leverage falls under the shadowof powerful financial bodies such as the World TradeOrganization, International Monetary Fund, World Bankand, more recently, influential and well-endowed philan-thropic foundations such as the Bill & Melinda GatesFoundation [78, 79]. Neither can the roles, responsibilitiesTable 2 Blending processes and mechanisms for a blended integrated knowledge translation (IKT) – global health governance(GHG) approachMoments in the IKT cycle Complementary GHG processes and mechanisms Examining Power in an IKT–GHG ApproachIdentify problem and identify, review,select knowledge↓Adapt knowledge to local context↓Governance bodies that work together to identifyproblems and knowledgeConsideration of the composition of non-traditionalactors, such as civil society and private sector, ingovernance bodiesGuidance for meaningful engagement betweenactors, particularly in shared governance modelsPromising example: GAVI mitigates known globalpower imbalances through the composition oftheir Board, which includes 9 neutral individualswho speak to public interests, 5 governmentrepresentatives each from donor and recipientcountries, 1 expert in research and technology,1 industry representative each from the globalSouth and global North, 1 civil societyrepresentative, and 1 representative each fromWHO, UNICEF, World Bank and Bill & MelindaGates FoundationTaking steps to balance power between globalNorth and global SouthPromoting transparency and accountability indecision-making about the composition ofgovernance bodiesAttentiveness to how particular ways of framinghealth and governance influences how a‘problem’ is being understoodAttentiveness to how historical conditions andpower dynamics privilege particular assumptionsAssess barriers to knowledge use↓Select, tailor, implement interventions↓Guidance on how to resolve discrepant normsand values between engaged actorsGuidance on how to ensure legitimacy ofleadershipGuidance on how political will and power influencethis processPlatforms for coordinating global-level responses towicked problemsPromising example: The Lancet Commission on GHGoffered specific recommendations for governancemechanisms and processes, with detailed calls tomake the examination of issues of power an explicitresponsibility of GHG. They called for attention todemocratic deficit, institutional and structuralinflexibility, strengthened accountability, identificationand involvement of missing institutions and voices,and to create a policy space for health. Their reportoffers specific guidance on how to do so. Amongthe Commission’s recommendations were specificmechanisms, including a proposed UNMulti-stakeholder Platform on Global Governancefor HealthAttentiveness to how historical conditions andpower dynamics give rise to inequities ininclusion and voiceExploration of how processes of historicalexclusion (e.g. due to race, class, gender,Indigeneity, etc.) can be mitigatedMonitor knowledge use↓Evaluate outcomes↓Sustain knowledge useGeneration and maintenance of mechanisms provideinfrastructure for monitoring and evaluationNorms and expectations for transparency indecision-makingPromising example: Two advisory bodies, theTechnical Review Panel and a Technical EvaluationReference Group, provide independent audit andmonitoring of programmes funded by the GFATM.Their reports highlight lessons learned from fundingrequests and reviews, including perspectives ofapplicants, technical partners, the Secretariat andthe Board. They consist of external experts in HIV,TB and malaria as well as experts in human rights,gender, health systems and sustainable financing.Their reports are made publicly available throughthe GFATM websiteAttentiveness to who decides what knowledgecount as legitimateAttentiveness to who decides what outcomescount as legitimateConsideration of who owns knowledge, withefforts to promote publicly owned andaccessible dataAttentiveness to equitable distribution ofresources and benefitsPlamondon and Pemberton Health Research Policy and Systems           (2019) 17:24 Page 6 of 10and accountabilities of ‘researchers’ and ‘research users’in IKT be simply assumed because they agree to worktogether. These are critical considerations in movingtoward evidence-informed, equitable governance forhealth equity action.Systems for enabling accountability and transparencymust be agreed to, which raises questions of meaningfulparticipation and responsibility [30]. Despite intense im-balances in power and interests, the challenge for GHGand IKT strategists alike will be to engage a plurality ofactors in ways that enable collective agreement on a com-mon goal. Accountability extends to issues of inclusionand exclusion and how power is distributed. Though in-clusion is widely recognised as important for GHG andKT, how to achieve it is elusive. Global events exemplifyways in which civil society is pushing back on systems ofexclusion, voicing a desire to transform what are, in es-sence, governance processes. Responses to global healthissues evolve in politicised systems that exclude the voicesof those most burdened by health inequities [92]. TheIdle-No-More [93], Occupy [94], Black Lives Matter [95]and the more recent #metoo movements share a commonoutcry for justice and equity in society, pointing to the in-equities generated by power and policy structures that sys-tematically privilege the wealthy and White. Collectively,these movements reflect a growing public demand for pol-itics of inclusion where government and non-governmentactors are held accountable for the consequences of theiraction (or inaction). They are demonstrative of how intri-cately tied up health inequities are in complex, competingsystems of power within which there is a need for criticalanalysis and mitigation.Further, the likelihood of understanding complexity be-comes much greater by directly fostering balanced repre-sentation that includes a pluralism of voices. On a largerscale, this is reflected in the evolution of the major GHGplayers in the world. Historically, WHO and the WorldBank have been primarily responsible for GHG, but giventhe significant frustration with each of these institutions’poor GHG, two new organisations have risen, namely TheGlobal Fund for AIDS, TB, and Malaria (GFATM) andGlobal Alliance for Vaccines and Immunization (GAVI);what separates these two institutions from their counterparts are their commitment to GHG. These commitmentsinclude a wider, more inclusive, Board of Governors(civil society, the private sector, and philanthropicorganisations), as well as providing clear and transpar-ent (i.e. publicly available) decision-making regardingfunding decisions and priority-setting processes. Bothorganisations rely on external review for their ac-countability for decision-making processes like fund-ing decisions. We believe that theory and practice inboth IKT and GHG would benefit from these new exam-ples of creating organisations that work towardgovernance models based on inclusion, voice, transpar-ency and accountability. Without clear leadership and acommitment to accountability through transparency by allglobal health actors, the current response to health inequi-ties will be ad hoc and exclusive of these civil societyvoices, as well as highly fragmented with little to no for-mal mandate between the players. Importantly, the re-sponse would be at risk of remaining distracted by thetendency to focus on symptoms rather than causes.As the field of IKT evolves, so too do opportunities fortheory and practice refinement. Governance processescould enhance current IKT frameworks to open consider-ations of how to weave evidence into decision-makingwhile acknowledging conflicting norms and values withinthe political sphere under which it operates. Using sharedhealth governance theory to drive this examination cancontribute to more transparent and equity-centred ap-proaches to understanding how these norms and valuesshape health problems [90]. Expanding IKT models to in-clude governance would require re-examining legitimacy,transparency, power and inclusion in the process of con-necting knowledge with action. This broader conceptual-isation extends the application of IKT into a complexpublic sphere, across domains and outside the control orcontext of any one institution or set of actors. We aremuch more likely to approach understanding complexitythrough systems of inclusion that directly engage multiplesocio-political arenas. Systems of inclusion can be expli-citly addressed by adopting principles of GHG alongsidethe strategies of IKT.Exploring a blended IKT–GHG approach could extendinsights from the success of IKT in clinical and health sys-tems settings [70, 96] to wicked problems. This approachcould illuminate new ways of thinking about how we mightinfluence the trajectory of wicked problems to fair, equit-able governance informed by high quality, rigorous andrelevant research. In the example we offer here, of movingtoward health equity, IKT implicates an all-of-society ap-proach because the root causes involve all of society. IKTmodels already acknowledge the process of connectingknowledge with action as inherently social, but this is oftenused as a way to describe the processes involved inwell-defined settings. Wicked problems are not confined tosingular contexts. Although attending to social processesare important, they need to be considered in the broadersphere of how society is organised. This means thinkingabout and connecting the best available knowledge about awicked problem to evidence-informed action as a ‘publicgood’, wherein the process is integrated as part of the socialfabric around which communities are organised. We be-lieve broadening the application of approaches to IKTacross multiple layers of complex social interactions cansupport evidence-informed influence and, again, GHG cansupport the achievement of coherency in doing so.Plamondon and Pemberton Health Research Policy and Systems           (2019) 17:24 Page 7 of 10ConclusionIn this article, we set a dialogic table to explore howblending principles of GHG with IKT strategies could le-verage the strengths of both, enhancing the possibilityfor effective and evidence-informed answers to wickedproblems. We situated this table in a global politicaleconomy that unfairly distributes power, resources andmoney. By focusing on explicit examination of powerand overcoming mechanistic assumptions that draw at-tention away from the root causes of health inequities,there is tremendous potential to be leveraged in a com-bined IKT and GHG approach. Such an approach wouldrequire leadership from academic, policy and civil societyarenas wherein existing GHG platforms explicitly embracea commitment to connecting knowledge (evidence aboutcauses) with action. We encourage those pursuing anIKT–GHG approach to engage in bold and inclusive dia-logue about how socio-political histories (e.g. colonisation)are at play in the ways they frame or respond to health in-equities. In contemplating governance-focused IKT, actorsinvolved in advancing health equity can take promisingsteps toward inclusion of a broad spectrum of actors anda pathway for stimulating the collective agency needed toaffect change on this wicked problem.AbbreviationsGHG: global health governance; IKT: integrated knowledge translation;KT: knowledge translationAcknowledgementsWe wish to acknowledge the mentorship, encouragement and scholarlyguidance we receive from our supervisory committees as doctoralcandidates. For KP, at the University of British Columbia, this includes Dr JoanBottorff, Dr Susana Caxaj, Dr Ian Graham, and Dr Michael Burgess. For JP, atMcMaster University, this includes Dr Lisa Schwartz, Dr Susan Jack, Dr ClaudiaEmmerson, and Dr Brian Cameron.FundingThis paper was commissioned by the Integrated Knowledge TranslationNetwork (IKTRN). The IKTRN brings together knowledge users andresearchers to advance the science and practice of IKT and train the nextgeneration of IKT researchers. Honorariums were provided for completedpapers. The IKTRN is funded by a Canadian Institutes of Health ResearchFoundation Grant (FDN#143247). Further, the article emerged from thedoctoral dissertation work of both authors. KP’s doctoral studies are fundedthrough a Banting and Best Canada Research Scholar award from theCanadian Institutes of Health Research. JP’s doctoral studies are fundedthrough Banting and Best Canada Research Scholar and the Douglas KinsellaAward in Bioethics from the Canadian Institutes of Health Research.Availability of data and materialsNot applicable.Authors’ contributionsKP provided coordination and leadership for the preparation of themanuscript. The content for this debate article was generated through aseries of conversations to which KP and JP contributed equally. Both authorsbrought a strong grounding research and science related to health equity.KP provided more content related to integrated knowledge translation, JPprovided more content related to governance. Both authors read andapproved the final manuscript.Authors’ informationKP is a Regional Practice Leader for Research & Knowledge Translation atInterior Health. In her role, she supports IKT through teaching, mentoring,consulting, and leading IKT and equity-centred research.Ethics approval and consent to participateNot applicable.Consent for publicationNot applicable.Competing interestsThe authors declare that they have no competing interests.Publisher’s NoteSpringer Nature remains neutral with regard to jurisdictional claims inpublished maps and institutional affiliations.Author details1University of British Columbia, 3333 University Way, Kelowna, BC, Canada.2McMaster University, 1280 Main Street West, Hamilton, ON, Canada. 3InteriorHealth, 505 Doyle Avenue, Kelowna, BC, Canada.Received: 14 November 2018 Accepted: 6 February 2019References1. Rittel HWJ, Webber MM. Dilemmas in a general theory of planning. PolicySci. 1973;4:155–69.2. Waddock S. The wicked problems of global sustainability need wicked(good) leaders and wicked (good) collaboraative solutions. J Manag GlobSustain. 2013;1:91–111.3. Labonte R, Schrecker T. 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