Since its launch in 2015 the Women in Global Health (WGH) movement has campaigned for gender parity in the leadership of global health organisations and for going beyond parity to gender equality, through operationalising Gender Transformative Leadership (GTL).
The Sustainable Development Goals (SDGs), with Universal Health Coverage at the centre, set an ambitious agenda for global health to reach by 2030. But progress continues to be held back by the narrow base from which global health leadership is drawn and specifically, widespread exclusion of women from decision making. Buse and Hawkes conclude: “For too many decades the issue of gender and gender inequality in global health has been swept under the carpet” and that applies both to gendered determinants of health and to the health and social care workforce.
In October 2017 400 leaders from 68 countries met at the inaugural Women Leaders in Global Health Conference and called for “a new vision for leadership in global health” to address gender inequity and the gender gap in leadership. In this article we propose Gender Transformative Leadership (GTL) as that vision and outline why it is critical to #healthforall.
Global health: Delivered by Women, Led by Men
Often portrayed as victims in global health, women actually form 70% of the health and social care workforce and are potentially powerful agents of change. But they hold only around 20% of senior posts and are generally segregated into lower status and lower paid or unpaid sectors. Despite decades of global targets on gender equality, including SDG Goal 5 on gender equality and empowering all women and girls, the 2017 Global Health 5050 (GH5050) report found that 45% of 140 global health organisations surveyed had no commitment to gender equality in their strategies or policies. Data from Women in Global Health (WGH) and GH5050 have also shone a light on the gender gap in health leadership. Exclusion of women from the majority of health decision making roles is inequitable, but more than that, it weakens global health since the women workers who know most about health systems have the least say in their design and management. Women from low- and middle-income countries (LMICs) face the greatest barriers accessing senior posts in their home countries and globally. Health policy decisions are not influenced equally by the priorities and experiences of men and women and global health is diminished by lost female ideas, innovation, expertise and talent.
The Roots of Gender Transformative Leadership (GTL)
GTL, used by WGH as the guiding principle for our work, is based on concepts of transformative leadership, feminist leadership and gender transformative approaches. The concept fills critical gaps in current definitions of leadership.
As the name suggests, there are two main constructs in the definition of GTL: ‘gender’ and ‘transformative leadership’:
WGH draws upon WHO’s definition of gender: “ Gender refers to the socially constructed roles, behaviours, activities, attributes and opportunities that any society considers appropriate for men and women, boys and girls and people with non-binary identities. Gender is also formed through the relationships between people and can reflect the distribution of power within those relationships.”
WHO notes that gendered determinants of health are “among the most important social determinants of health inequities” ‘Gender’ refers equally to men and women and to non-binary people, despite it often being misused as a proxy for ‘women’. Gender driven inequities in health are significant both for the health outcomes of women and men and also for the composition and effectiveness of the health and social care workforce. Applying a gender lens to health systems’ policy and delivery is not optional, it is critical if #healthforall targets are to be met.
(ii) Transformative Leadership:
As Stogdill (1974) points out, there are as many definitions of leadership as there are people defining the concept. WGH’s understanding of GTL builds on principles of Transformative Leadership initially described by James MacGregor Burns (1978) as a leadership approach which “raises the level of human conduct and ethical aspirations of both leader and led, and thus it has transforming effect on both.” Transformative leaders inspire followers by setting out a vision for change and challenging power imbalances imbedded in systems, rather than working within an existing set of values and norms.
Gender Transformative Leadership in Global Health
GTL is Transformative Leadership with a gender inclusive lens. In the global health context, GTL addresses the gender inequities in power that undermine health systems’ design and delivery. GTL is driven by the vision of gender equality and women’s rights embodied in international conventions and agreements including SDG 5 and addresses social and cultural norms, conscious and unconscious bias and deep-rooted structures of inequality. Rather than expecting women to ‘lean in’ to professions and organisations that have largely excluded them from leadership and senior roles, GTL addresses discrimination, bias and inequities in the system so women are included on an equal basis to men. The term ‘gender transformative’ can be applied to decision-makers, the institutions they work in and to the health system itself.
GTL takes an intersectional approach, analysing how gender intersects with other facets of identity, such as race, disability, sexual orientation, caste and class, to multiply vulnerability and disadvantage for particular groups. Additional action is needed to identify and address such multiple, intersectional forms of disadvantage that may affect any gender (black men, low caste women etc). In the context of global health, geography is a significant factor with professionals, especially women, from low income countries, facing structural barriers to participation in global health.
GTL applies to all leaders at every level of health system from community to global, regardless of their gender. WGH acknowledges that organisations operate in diverse settings and start from different points so approaches to address gender inequities must be customised to the context. WGH assumes that a gender transformative approach will include gender parity in leadership but will go beyond gender parity to advance gender equality within organisations and in the work of those organisations, resulting in better global health.
Gender Transformative Leadership in Global Health – Ten Headlines
1. It is grounded in a vision of gender equality and women’s rights.
2. It challenges privilege and imbalances in power to eliminate gendered inefficiencies an rights deficiencies that undermine global health.
3. It is intersectional, addressing social and personal characteristics that intersect with gender (race, ethnicity etc.) to create multiple disadvantage. In global health, GTL would drive equal participation of all genders from all geographies.
4. It applies to leaders from any gender, not exclusively to women leaders.
5. It covers leadership at all levels in global health from community to global.
6. It recognizes different forms of leadership, such as thought leadership, which are not based on simple hierarchy and people managed.
7. It can be used to describe individuals, institutions and health systems.
8. It follows the principle of ‘progressive realization’ allowing for different starting points and contexts but prioritizing inclusion of the most marginalized and excluded.
9. It is always ‘work in progress’ since power dynamics are constantly changing.
10. It assumes that gender equality = smarter global health and that GTL is therefore necessary for the achievement of #healthforall.
A final word….
Gender transformative leaders in global health aim to leave no-one behind in access to health and equally, aim to leave no-one behind in leadership and decision making.
 Women in Global Health define Gender Parity as 60/40.
 Jeffrey P Koplan, T Christopher Bond, Michael H Merson, K Srinath Reddy, Mario Henry Rodriguez, Nelson K Sewankambo, et al. Towards a common definition of global health. The Lancet. 2009;373:1993–95.
 Kent Buse, Hawkes S. Gender—global health’s dirty little secret. The BMJ. 2018.
 Michele Barry, Zohray Talib, Ashley Jowell, Kelly Thompson, Cheryl Moyer, Heidi Larson, et al. A new vision for global health leadership. The Lancet. 2017;390.
 ILO. Improving employment and working conditions in health services. 2017.
 Women in Global Health (data unpublished) 2018
 Global Health 50/50 ‘The Global Health 50/50 Report: How gender-responsive are the world’s most influential global health organisations?’, London, UK, 2018
 Burns JM. Leadership. New York: Harper and Row; 1978.
 Batliwala S. Feminist Leadership for Social Transformation: Clearing the Conceptual Cloud. 2010.
 Emily Hillenbrand, Nidal Karim, Pranati Mohanraj, Wu D. Measuring gender-transformative change: A review of literature and promising practices. 2015.
 WHO. Factsheet on Gender and Health. 2018.
 WHO. Factsheet on Gender and Health. 2018.
 Stogdill RM. Handbook of Leadership – A survey of Theory and Research. New York: Free Press; 1974.
 WGH is thankful for the valuable insights provided by Rosemary Morgan at RinGs.
 OHCHR. Fact Sheet 33 – Frequently Asked Questions on Economic, Social and Cultural Rights