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Who Gets to Govern in Global Health?: The prevailing status quo threatens ‘Health for All’

By guest contributors Shashika Bandara, Mohammad Yasir Essar, Ramya Kumar, Malvikha Manoj and Afifah Rahman-Shepherd (All authors contributed equally to this piece.)

A week ago, 24 youth in global health gave a critical report on how global health leaders are tackling current crises. The latest Global Health 50/50 report underscores our cries for reform, signaling an alarming lack of representation in the ‘corridors of power’.

Since 2018, GH50/50’s landmark reports have revealed the extent to which the global health system has been shaped by systemic patriarchal, colonial, and imperial fault lines. This year’s report assesses the gender and geographic diversity of 2,033 board members across 147 influential global health organizations, highlighting the gaps and inequalities that continue to pervade the field. As emerging professionals in global health, we must critically analyze, demand reform, and ensure those in spheres of influence are more representative of the global population.

A Dismal Report Card for Global Health Boardrooms

Boardrooms are the fulcrum of governance and power. They shape decisions regarding the leadership, strategy, and value-systems that underpin the organizations’ efforts, which have an impact on populations globally. Yet, within these loci of power, the GH50/50 findings show a heavy skew in favor of men and nationals of high-income countries (HICs) — where only 16% of the world’s population resides.

Where are all the women?

Gender disparity, layered with lack of representation of women from low-and-middle income countries (LMICs), highlight the deep inequalities within these governing bodies. Women held only 40% of board seats across the 147 global health organizations and women from LMICs held only 9% of these seats. In the non-profit sector, merely 1% (17) of board seats were held by women from low-income countries (LICs) and in the for-profit sector, there are no women from LICs on the board. Within funding bodies, only 1 seat is held by a woman from LICs, with overall representation of women at 37%. This lack of representation remains a crucial weakness across sectors and raises questions about organizational ability to truly consider and address global health challenges faced by women globally. Having women and women of color as leaders adds immeasurable value, as Anuradha Gupta, Deputy Chief Executive Officer of Gavi the Vaccine Alliance, says, “The few women leaders from lower-income countries who are on global health governing boards exude exemplary confidence and capabilities. Seeing them in action can be hugely inspirational for staff, setting off a virtuous cycle of women inspiring women… [they] have the domino effect of dismantling gender stereotypes”.


Where does the power to govern reside?

HICs have not lost their strong hold on the governance of global health; for every 1 seat held by a LIC national, 30 are held by HIC nationals. With 73% of global health organizations’ headquarters located in the U.S., U.K, and Switzerland, decision-making power is concentrated in just three countries. Nationals from the U.S and U.K. dominate across governing boards and together occupy 51% of all board seats. As global health and humanitarian crises disrupt our world, these exclusionary decision-making spaces lack the contextual knowledge and lived experiences required to set an equitable global health agenda and risk leaving behind those in need. As Nyovani Madise, Director of Development Policy and Head of the Malawi office of the African Institute for Development Policy highlights “If we are going to have people making decisions about issues in LMICs, we must listen to the people who see the reality on the ground. We need to have that voice in board meetings.”

Where is the sense of urgency?

Calls for reform have been sounding for a while. Global health experts continue to highlight organizational barriers to better governance in global health, but progress remains slow. The GH50/50 report finds that one in four (48/198) organizations publish policies with specific measures to advance gender equality, diversity and inclusion on their boards, meanwhile 17% (32/198) have published a commitment to diversity and representation but lack a strategy and specific measures to achieve said commitments. Out of the 111 organizations that have publicly available data on governing boards, just 2% have dedicated seats or targets related to race and ethnic diversity and just 3% related to youth. Urgency is key, but sustainability is vital as Devaki Nambiar, Program Head of Health Systems and Equity at the George Institute for Global Health, points out “I don’t think there’s a single point where boards become representative, inclusive, and so on. It’s a direction in which we have to travel. It means being open to unlearning, to discomfort, to being at the back, and, for people who are new on the block, claiming the room and claiming that space.”


Can we re-imagine the status quo?

Global health organizations only stand to benefit from more equitable boardroom diversity. Elhadj As Sy, Chair of the Board of the Kofi Annan Foundation highlights this saying, “[..] boards that are rich in diversity – social diversity and idea diversity – are better problem solvers. But equally important is an organization that fosters an egalitarian board culture – one that elevates different voices and perspectives and welcomes conversations about diversity.” Re-imagining representation in positions of power requires organizational transformation to build an environment that fosters inclusivity, belonging, and empowerment, but this is only achievable through collective willingness and a sustained commitment to action.

Ultimately, there cannot be ‘health for all’ without leadership reflective of all. So, how can we get there? The report asks if change is a question of men from HIC relinquishing power, or of an increasingly diverse set of actors seizing power and ‘claiming the room.’ There is a strong case to be made for a multi-pronged pathway. For example, an approach that builds on allyship efforts from those in positions of power collaborating with the under-represented in their efforts to ‘claim the room.’ Yet, as we continue to witness leadership failures to improve the status quo, it is also worth asking, can we solve global health challenges by waiting for those in power to realize their privilege and relinquish their power? Or, can we do more to start claiming the room? As emerging professionals in global health, we are not prepared to stand by and inherit this status quo.

Authors (All authors contributed equally to this piece.):

Shashika Bandara is a Sri Lankan doctoral student focusing on global health policy at McGill University. He holds a masters in global health from Duke University and is formerly a policy associate at the Center for Policy Impact in Global Health at the Duke Global Health Institute. His prior experiences include medical research, human rights policy advocacy and humanitarian support work. He tweets at @shashikaLB.

Mohammad Yasir Essar is a global health advocate from Afghanistan. He is a visiting academic at The Clinical Informatic Research Unit at University of Southampton. His research interest entails public health, infectious disease, and climate change. Yasir’s work has been published in various journals, including The Lancet. Yasir also has a keen interest in mentorship, and leadership. He tweets at @EssarYasir.

Ramya Kumar is a doctoral student University of Washington’s School of Public Health. For nearly a decade, she has lived and worked as an infectious disease epidemiologist in Zambia where she has provided leadership, vision, execution, and oversight of public health workforce strengthening. Ramya has multiple marginalized identities which drive her interests in social justice, research on services for marginalized populations, and equitable global health collaborations. She tweets at @idlidosa2.

Malvikha Manoj, MSPH, is an Indian-born, and UAE-Raised health systems and policy practitioner. She focuses on child and adolescent mental health and well-being, by addressing systemic factors – including representative leadership and governance –  to explore how young people can claim space and convene towards reform.  Malvikha serves as Chair at the International Working Group for Health Systems Strengthening (IWG), a global collaborative of emerging professionals committed to health systems reform. She tweets at @MalvikhaM.

Afifah Rahman-Shepherd is a Research Fellow at the London School of Hygiene and Tropical Medicine, focusing on health policy and systems research to improve infectious disease control. She is a member of the Action to Decolonize Global Health (ActDGH) collective and is increasingly active in processes and discourses to redefine equitable partnerships and collaborations in global health.  She tweets at @AfifahRahShep.

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