Report 2020 – Global Health 50/50

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2020 Global Health 50/50 Report

Power, privilege & priorities

The 2020 report provides an unprecedented birds-eye view of the global health system today. It reveals that the leadership of the 200 most prominent organisations active in global health continues to reflect power and privilege asymmetries along historical, geographic and gender lines. The report further uncovers a distinct disconnect between the organisational priorities and the gendered burdens of disease around the world.

The report warns that these inequalities -- an inequality of opportunity in career pathways inside organisations and an inequality in who benefits from the global health system -- are impeding progress towards health goals.

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Power, privilege and priorities

Foreword

A word from Michelle Bachelet

United Nations High Commissioner for Human Rights, former President of Chile

Inequalities in health deeply touch people’s ability to pursue their life aspirations and to realise their human rights. However, the right to health is not equally realised by all. We can do better. Inequalities in health, and denials of human rights, can be a matter of life and death for women, girls and gender non-conforming individuals. Harmful gender stereotypes continue to exist and directly influence people’s bodily autonomy, risks of ill health and early death. These gender norms also play a critical role in shaping health-seeking behaviours and determine who gets services and when and how they are provided.

Delivering on the right to health without discrimination will simply not be possible without addressing one of the fundamental demands of our era: gender equality.

Gender equality is no different from any other human right, and is a prerequisite for delivering on the transformative agenda of the Sustainable Development Goals (SDGs) and its promise to “leave no one behind.” Respect for gender equality is a necessity and an obligation for everyone, everywhere, always. If we want to have fairness in our societies, inclusion, diversity and gender equality must be a driving force.

Global Health 50/50 has established itself as the world’s leading authority on gender equality in global health. Its annual Gender and Health Index provides a comprehensive, in-depth analysis of the gender-related policies and practices of 200 global health organisations. By putting its data in the public domain, GH5050 provides a mechanism through which to hold these organisations accountable for their progress on gender equality. In so doing, GH5050 provides a unique vehicle to reinforce the operationalisation of the right to health.

This report demonstrates that the current global health system is failing to embrace gender diversity and respond to gender inequalities. I therefore join Global Health 50/50 in calling for gender-responsive health programming as a critical enabler of the right to health-and indeed all human rights-of all people and as a pathway to delivering across the SDGs.

The report forecasts that it could take more than 50 years to see gender parity at the senior levels of these organisations-another half century is too long to wait. I call on leaders of these organisations to heed the report’s call to action and inject more urgency into their efforts to implement commitments made towards gender equality. It is time to truly level the playing field for all staff, transform organisational cultures, ensure equal opportunity and to model behaviour for the international community.

I am encouraged to see this year’s report push the analysis to strengthen our understanding of the relationship between gender and other related systems of power and privilege such as age, nationality and educational background. The intersection of multiple forms of discrimination and inequalities has a devastating impact on opportunities and outcomes in global health and things must change.

We need to mobilise across the world-peacefully and powerfully-to advance on rights, dignity and diversity for everyone. By shining a light on equality- and gender-related practices in global health, Global Health 50/50 reminds us that the health sector needs to lead and advances a powerful incentive for change in this urgent struggle. It is imperative that global health leaders match their words and commitments with action by investing in and delivering gender-transformative health programmes.

Preface

A word from the Global Health 50/50 Collective

“It is time to face up to the entrenched power dynamics at play in global health. We hope that this report fuels collective demand for a more critical, political understanding of the field of global health, and for action to stamp out the causes of health inequities around the world.”

This report reviews the equality- and gender-related policies and practices of 200 global organisations active in health and health policy. The report, and its accompanying Gender and Health Index, provides the single-most comprehensive analysis on gender equality and the distribution of power and privilege in global health. Through these vehicles, we aim to inform, inspire and incite action and accountability towards equality in the workplace and in global health policies and programmes.

Gender has a fundamental bearing on how power and privilege are distributed and maintained, and is a key determinant of everyone’s health and wellbeing. Gender also acts as a gateway to revealing and understanding opportunity, expectations and achievements along a number of structural and social stratifiers, such as class, geography, ethnicity/race, age and (dis)ability.

This report steps through that gateway. It urges actors and organisations to interrogate systems of power-global, national and local, interpersonal and institutional-and how they undermine an equitable and effective global health system. It also urges an assessment of how social and political structures intersect with one another to drive vulnerability and ill-health among those with less power.

It is time to face up to the entrenched power dynamics at play in global health. We find that more than 70% of leaders in our sample are men, more than 80% are nationals of high-income countries and more than 90% were educated in high- income countries. This strikes us as a system that is neither fair nor fit-for-purpose. We believe that the health and well-being of people around the world will benefit from-and require-diverse leadership.

Confronting the 70-80-90 ‘glass border’ in global health: more than 70% of leaders in our sample are men, 80% are nationals of high-income countries and 90% were educated in high-income countries.

Activists and their allies have compelled decision makers and organisations to confront discrimination, inequity and the historical underrepresentation of some groups in the field of global health. A primary aim of this report is to catalyse faster progress in this journey by enabling a degree of enhanced accountability through rigorous evidence.

A second aim of this report is to recognise the role that gender plays in driving health outcomes in everybody-men, women, and people with non-binary gender identities. In our male-default world, gender as a driver of everyone’s health, including men and boys, often remains under-appreciated and under-addressed. Our report captures the extent to which the global health system is addressing and acknowledging gender as a universal health determinant.

Our third aim is to unite the fragmented and sometimes competing global health world around a fair, relational understanding of gender. In 2020, the very concepts of gender and gender equality, and those who dare to promote it, are under attack worldwide. Given the highly politicised and contested environment in which many concerned with gender work, we recognise that some organisations are suffering financially and in other ways from their position on gender and gender equality. Now is the time for the global health ecosystem to be clear and resolute in both what gender means and that gender equality benefits everyone-in line with leaving no one behind and the right to health for all.

At Global Health 50/50, we recognise our own shortcomings in diversity and access to opportunity. Our collective is built of people who are primarily women at the start of their careers and who are in the privileged position of being able to work flexibly and not rely on this work as a primary source of income. We commit to reflecting on the biases and limitations within our own collective, and introducing more inclusive ways of identifying people who wish to work and partner with us-representing a greater variety of genders, social classes, geographies, nationalities and career stages.

To date, our focus has been the global operations of organisations active in health. This was a strategic decision. Organisations must get their own houses in order if they are to be credible gender and equality champions in countries. Real impact, however, lies in so-called grassroots mobilisation to demand that government health policies and programmes are gender-responsive-only this approach will ensure the sustainable generation of equitable health outcomes for all. As such, GH5050 intends to enter into partnerships with advocates and organisations that seek to advance evidence-informed advocacy on gender equality and diversity in health in select countries.

We close with a thank you to those people who are using the power and privileges at their disposal to push for gender equality, including our Advisory Council. We are also grateful to colleagues that challenged us to expand our lens beyond gender. May this report further fuel the collective demand for a more critical, political understanding of the field of global health, and for action to stamp out the causes of health inequities around the world.

About the report

The third Global Health 50/50 report reviews the gender-related policies and practices of 200 organisations. These are global organisations (operational in more than three countries), that aim to promote health and/or influence global health policy.

The 2020 report deepens GH5050’s annual analysis by adding new variables on power and privilege within organisations. These variables include: workplace diversity and inclusion policies, board diversity policies and additional demographic information about executive leaders and board chairs. It also compares the health priorities of 150 organisations against the health-related targets of the SDGs and the global burden of disease, to identify which issues and populations aren’t getting sufficient attention.

Find out more about the report

Power

The ability to influence and control material, human, intellectual and financial resources to achieve a desired outcome. Power is dynamic, played out in social, economic and political relations between individuals and groups.

Privilege

A set of typically unearned, exclusive benefits given to people who belong to specific social groups.

Priorities

Those issues and populations towards which political and financial resources are allocated

Our findings

Commitments to redistribute power

Policies to tackle workplace power & privilege imbalances

The gender and geography of global health leadership

Addressing the gendered power dynamics driving health outcomes

The global health agenda: which priorities and for whom?

Gender & Health Index: performance of 200 organisations

Global health and the long shadow of colonialism

A map of global health today: how global?

High scorers

Stories of progress: Case studies of gender-equitable policies and programmes

Commitments to redistribute power

Public commitment to gender equality

Organisations report a fast-growing commitment to gender equality and social justice

GH5050 reviewed the visions, missions and core strategy documents of organisations to identify commitments to gender equality and to social justice more broadly.

Findings

75% (149/200) of organisations publicly state their commitment to gender equality in their mission, vision or major strategies.

Are organisations publicly committing to gender equality?

While 75% of organisations commit to gender equality, some sectors perform better than others…

One-fifth are silent on gender

The perception that gender is not relevant to organisations’ core work, regardless of their field or industry, appears to be shifting: from 2018 to 2020, the proportion of organisations that are silent on gender decreased from 32% to 17%. However, nearly one out of five organisations in our 2020 sample have yet to publicly state their commitment to gender equality.

Organisations are increasingly committing to gender equality 55% in 2018 76% in 2020

Definition of Gender

Organisations report a fast-growing commitment to gender equality and social justice

Defining gender in a way that is consistent with global norms is a political act. It confronts efforts around the world that try to manipulate the term, hijack it or erase it entirely. Anti-gender movements are visible across most regions. Their core assertions-particularly that the very concept of gender sows confusion and destabilises the traditional family and the natural order of society-have been embraced and recited by leaders and political parties at the highest levels of power.

In this contested environment, organisations active in global health or health policy must be clear and consistent in their definition of gender as a social construct rooted in culture, societal norms and individual behaviours.

Understanding gender as a social construction (rather than a biological trait, for example) allows us to see the ways in which gendered power relations permeate structures and institutions, and thus begin to address the distribution of power across and within societies, institutions and organisations. A gender lens transforms technical agendas into political ones.

Findings

While we see a growing commitment to gender equality, the meaning of gender remains undefined by the majority of organisations under review.

Just 35% of organisations (70/200) define gender in a way that is consistent with global norms (see glossary for definition). This proportion has changed little since 2018. An additional 11% of organisations define gender-related terms (e.g. “gender diversity”) but do not provide a definition of gender in their work. Only 18 organisations have definitions that are explicitly inclusive of non-binary gender identities, including transgender people.

Among the organisations reviewed since 2018, a slight increase of 6% in those that define gender has been registered: 9 organisations have added a definition of gender to their policies or websites.

Too few organisations are providing a definition of gender

Of those defining gender, how do different sectors perform?

No funding agencies publicly define gender

Key takeaways from our findings

Commitment to gender equality is on the rise, with substantial year-on-year increases. In contrast, use of global norms around the definition of gender remains low. The evidence suggests that commitment and definition are mutually reinforcing. A definition provides specificity to commitments that can otherwise be misinterpreted or misunderstood.

Given the contested understanding of gender in many societies, we believe that now is the time for clear commitments to gender equality.

Gender equality yet to be prioritised. There is a continued lack of commitment to gender equality from almost one-fifth of our sample. This includes organisations from all sectors, but is particularly pronounced among funding agencies, of which just 50% have stated a commitment to gender equality.

Time to define. Organisations should be clear about what they mean by gender. Currently only one-third define gender in a way which is consistent with global norms.

Funders need to show the way. Funding agencies exert a powerful influence on the sector, but fail to define gender. No funders offer a definition.

Gender and health equity. Our analysis shows those organisations that define gender are also more likely to also be committed to addressing the underlying gendered determinants of ill-health i.e. tackling the inequalities in power and privilege that are associated with an increased risk of illness or lack of access to care.

Policies to tackle power & privilege imbalances

Policies to promote gender-equality in the workplace

60% of organisations have workplace gender equality plans

Gender plays an important role in career trajectories. Organisations in the global health sector ought to lead on justice and fairness, but male privilege pervades. This leads to a paucity of women in senior roles. Support for gender equality in the workplace means fostering a supportive organisational culture for all staff and requires corporate commitment, clear policies, specific measures particularly at times of career transition points, and accountability for redressing structural barriers to women’s advancement.

GH5050 assessed which organisations are translating their commitments to gender equality into practice through action-oriented, publicly available workplace policies. It identifies which organisations go beyond minimum legal requirements and implement affirmative policies and programmes with specific measures to actively advance and correct for historical inequalities.

Findings

Do organisations have workplace policies in place that promote gender equality?

Certain sectors perform much better than others on having policies in place

Nearly 60% of organisations reviewed have workplace gender equality policies which contain explicit targets, strategies and/or plans. One-quarter of organisations had no commitments or policies of any kind.

Among the sample of organisations reviewed over three years, progress has been made. In 2020, 69% had workplace gender equality policies (up from 57% in 2019, and 44% in 2018). Thirty-one organisations appear to have adopted, enhanced and/or publicly released their workplace gender equality policies in the past two years.

Workplace diversity and inclusion policies

At the intersection: workplace gender equality policies outnumber broader diversity and inclusion policies

Gender provides one lens through which to understand inequalities in who wields power and enjoys privilege. Gender is always in interaction with other social identities and stratifiers. Privilege and disadvantage in the workplace filters through these intersectional identities. Building a diverse workforce means recognising these intersections and developing solutions that benefit all people.

Advancing diversity and inclusion requires clear policies, deliberate focus and sustained action. GH5050 assessed which organisations had publicly available policies that committed to advancing diversity and inclusion in the workplace-alongside and beyond gender equality-and had specific measures in place to guide and monitor progress.

Findings

44% of organisations have committed to promoting diversity and inclusion in the workplace and have specific measures in place.). One-quarter of organisations reviewed make no public reference to non-discrimination, or diversity and inclusion (D&I).

Do organisations have policies in place to promote diversity and inclusion more broadly than gender?

How do different sectors perform?

Board diversity policies

A fraction of organisations have board diversity policies in the public domain

Advancing diversity in governing bodies is an issue rooted in principles of power, representation and equity.

Boards of directors are arguably the most influential decision-makers in global health. They often nominate an organisation’s leadership. They help to determine goals and strategy. Yet continued lack of diversity in boards means that they are missing the perspectives of key stakeholders, including the communities they are meant to serve.

Globally, gender diversity on boards is increasing. Progress is likely due in part to growing regulation around the world. Some countries have set strict quotas for women’s board representation in public and state-owned organisations.

In general, strict regulation on diversity is associated with more gender-diverse boards. Strong regulations are in place in many of the countries with the highest percentage of female board members. Those with less stringent regulations or no mandates tend to have fewer women on boards [ref]. However, social norms often drive the regulatory framework, and how that regulatory framework is fulfilled-thus societies that are already more gender-equal may be more likely to have stronger regulations in place.

Findings

Just 28 organisations (14%) have policies available in the public domain that state how they seek to advance diversity and representation in their governing bodies.

These 28 organisations are almost four times more likely to have gender parity on their boards compared to the 170 organisations that we understand to have boards, but do not have policies (or do not have them publicly available).

30 organisations in our sample have fewer than 3 women on their governing bodies-despite significant evidence suggesting that it takes a critical mass of at least 3 women to fully reap the benefits of gender diversity.

At the level of the board do organisations have policies to promote diversity and inclusion?

We found four sectors where not a single organisation had a board diversity policy in place.

Key takeaways from our findings

Organisational policies matter. They are the building blocks that provide rules, norms, standards and guidelines for organisational composition, culture and ‘ways of working’. They are also the standards and means through which organisations can be held to account. Policies, however, are ‘words on paper.’ Implementation requires strategies, plans and specific measurable actions to tackle imbalances based on power and privilege in career pathways. Importantly, implementation also requires resources, both human and financial.

We recognise that workplace policies and workplace culture is influenced by more than its leadership. The presence of active trade unions or other mechanisms for representing employees’ rights should also play a crucial role in ensuring that workplace policies are fair and equitable, and that organisations are held to account for the policy promises they make.

We encourage transparency of workplace equality policies. We also recognise that given the contested, sometimes violent, nature of debates surrounding gender in some places, a small number of organisations deliberately keep their gender-related policies internal as a means to protect the organisation and its staff.

Gender equality policies on the rise. The number of organisations with policies to advance gender equality in the workplace appears to be increasing. Organisational policies are equally likely to be in place irrespective of the geographical location of the headquarters or the gender of the CEO or board chair.

Not enough policies are in the public domain. Some organisations may have robust equality and/or diversity policies that were not captured in our report as they are not in the public domain. We believe that a lack of transparency diminishes people’s power to know, demand, benefit and hold organisations to account.

More gender, less diversity. Organisations are more likely to have policies to promote gender equality than diversity/inclusion in the workplace. This is an issue that organisations in global health should be aware of and responding to.

Private sector leads on diversity and inclusion policies. Both the private-for-profit sector and the consultancies perform well across workplace gender and D&I policies-particularly when compared to NGOs or public-private partnerships (PPPs). Building on the principles of SDG 17 (revitalising the partnership for sustainable development), the private sector could bring this capacity to its health partnerships and strengthen workplace policies of organisations that are currently lagging.

Cross-sector learning through partnership. The public-private partnerships, most of which were established in the early 2000s, are the sector most likely to have board diversity policies. This may have historical roots. When these partnerships were established, debates were waged over the legitimacy of private sector involvement and how to share decision-making while controlling for conflicts of interest. These debates resulted in structured board compositions intended to ensure balanced power-and a more robust board policy environment than in other sectors. This provides another opportunity for cross-learning within and across the global health ecosystem.

Gender and geography of global health leadership

Gender parity in senior management and governing bodies

Inching towards gender parity in global organisations

The number of women and men in positions of authority provides a strong measure of equity in career advancement, decision-making and power.

In many ways, the professional world operates at the end of a long pipeline littered with obstacles for many people. But organisations can decide whether to passively reinforce or actively correct historical disadvantage and inequality.

Findings

Decision-making bodies are still disproportionately male

We see indications of progress towards equal representation of women and men in decision-making bodies, albeit slowly. Among the organisations reviewed since 2018, the number of organisations with at least one-third women in these positions has grown from 56% to 65%. Eleven (11) organisations increased the representation of women in senior management from less than one-third (Red) to 35-44% (Amber). While parity (Green) figures haven’t moved substantially, organisations are moving in the right direction.

The proportion of governing bodies with at least ⅓ women has grown from 47% to 51%.

Will we wait for parity until 2074?

At the current rate of change, it will take:
54 years to reach gender parity in senior management and 37 years on governing bodies.

Can we shave a few decades off of that forecast?

View the proportion of women in senior management by sector

Gender of CEOs and board chairs

Parity at the top? Not anytime soon.

Findings

Despite the recent wave in media and public attention to clearing the path for women’s ascent in the workplace, the number of women reaching the top (executive) has barely budged.

CEOs and Board Chairs are still predominantly male

Gender of CEOs and Board Chairs

From 2018 to 2020, the total number of female CEOs increased by 1 (from 41 to 42 out of 139 CEOs total).

This isn’t merely a result of slow turnover at the top. On average, one in five organisations under review welcome a new CEO each year. In 2019, 64% of these new CEOs were male. Simply, men continue to be succeeded by other men.

There may be an indication that progress towards parity is on the horizon: among CEOs under the age of 44 (of which there are only 16), women and men are more equally represented. Whether this is a sign of generational progress, or will turn out to be another example of female attrition along the career pathway, remains to be seen. This finding reinforces growing evidence that the gender pay gap is an age issue. Even in contexts where the gender pay gap is close to zero at early professional stages, gaps widen substantially later in life.

How does the distribution of women in leadership vary by age?

Trends are slightly more encouraging among board chairs. Faster progress is due to more rapid turnover in board chairs: 30% of organisations saw new chairs in 2019.

67% of board chairs are men. Among the organisations reviewed three years in a row, seven outgoing male board chairs were succeeded by women, increasing the percentage of women board chairs from 20% in 2018 to 26% in 2020.

Demographics of CEOs and board chairs

Power in global health remains firmly in the grasp of the Global North

GH5050 gathered publicly available demographic information in addition to gender on the CEOs and board chairs of the 200 organisations in our sample. This information included: nationality, highest educational degree attained, university where that degree was attained and approximate age. These proxy measures provide insights into who runs global health.

Findings: Privilege and nationality

17% of CEOs and board chairs are nationals of low- and middle-income countries (LMICs). These same countries are home to 83% of the global population. An additional six CEOs are dual nationals of a high-income country (HIC) and an LMIC.

Geography of global health leadership

How do power, privilege and education intersect?

Nationality of CEOs and Board Chairs by income level

Key takeaways from our findings

Workplace policies are among the building blocks for equitable career advancement. Who reaches the very highest levels of leadership within any organisation also reflects broader social factors, including legislative, educational and domestic.

We recognise that data on who holds power and enjoys privilege within organisations reflects more than the policies of a single organisation. Nonetheless, such data can provide insights into organisation-level inequalities that can and should be addressed and their commitment and measures to doing so.

The absence of diversity and representation within the upper reaches of global health can no longer remain unchallenged. It is time for global health to reconsider its values and the norms it perpetuates. We must shift the status quo and become more inclusive and better able to represent the diversity of global views and voices.

Gender equality in decision-making bodies is increasing at a snail’s pace. There is some indication of progress towards gender equality at the senior levels of management and governance. Our estimate that it will take 54 years to reach gender parity in senior management however is unacceptable. Among the 60% of organisations with gender equality policies and strategies in the public domain, there is a need for evaluation of whether these strategies are working. For all organisations, the time has come for critical self-reflection.

Stepchange needed to advance towards gender parity at the top. At the very highest levels of leadership (board chair, CEO), progress towards parity has stalled. When women do make it to the top, they are more likely to be running smaller organisations with fewer than 50 employees.

More than a numbers game. Parity in leadership is more than just a ‘numbers game’. It is an opportunity to exercise more inclusive norms and values across the entire organisation. For example, organisations with more gender equality in leadership are also more likely to have workplace policies to support diversity in the workplace and in the board. The time has come to consider more radical and progressive reforms to ensure that women have a fair chance at exercising power in and changing the values and norms of global health.

Lack of diversity and opportunity on the basis of nationality, age and education. Leadership across the global health sector is mainly in the hands of older (> 45 years) men from high-income countries. Within those organisations wielding financial power (i.e. bilateral and multilateral funding agencies, private foundations), the concentration of leadership characteristics (men, over 45, national of and educated in a high-income country) is even more pronounced.

Run in the global north by the global north. Global health headquarters (HQ) remain firmly rooted in high-income countries. Organisations identified in low- and middle-income countries tend to be led by nationals from the global south. It is time for organisations in global health to look at the redistribution of headquarters functions outside of the global north, e.g. by transferring HQs to the global south, or dispensing with the notion and pursuing a partnership structure across different geographical settings.

One singular truth? The current leadership in global health (irrespective of nationality and gender) have mainly received an education from a relatively limited pool of elite institutions in the global north. Change is a long-term goal, but this finding highlights the need to strengthen the quality, capacity and brand recognition of teaching and research institutions across the breadth of LMICs. This is an essential step to ensuring the redistribution of power, including the power of networks, and privilege in global health leadership in the future.

Do global organisations address the gendered Power dynamics of inequalities in health outcomes?

Gender-responsiveness of global health programmes

Strategies to advance health veer from gender-blind to gender-transformative in our sample

Much of the global health sector agrees that gender norms play a crucial role in perpetuating disparities in the distribution of the burden of ill-health across and within populations, and gender influences how organisations address the problem(s). We would therefore expect that their policies and programmes are fully gender-responsive. We find, however, a broad range in the gender-responsiveness of strategies, from those that address the underlying structural drivers of gender inequality, to those that ignore gender altogether.

Findings

Some organisations in our sample are among the global pioneers in analysing, understanding and working to transform the power dynamics and structures that reinforce gender-related inequalities in health outcomes. A total of 29% of organisations promote transformative strategies to address the systemic inequalities underlying the gendered distribution of power and privilege in health programmes. Around two-fifths of these organisations focus on women and girls as the primary beneficiaries, while the majority address gender norms in both girls and women and boys and men.

20% of organisations reviewed were entirely gender-blind, but no organisations were gender unequal.

Of the 158 total organisations (80%) with strategies found to be gender-responsive, 95 were primarily focused on meeting the needs of women and girls. None focused on primarily meeting the health needs of men. Sixty-three are gender-responsive to meet the needs of both women and men. Only 12 specifically mention the health needs of transgender populations.

Gender-responsiveness of organisational approaches (applying the WHO Gender-Responsiveness Scale)

See the WHO Scale.

Organisational approaches to address underlying gender-related drivers of ill-health, by sector

Sex-disaggregated monitoring and evaluation data

The power of data

In assessing this variable in previous reports, GH5050 deemed the sex-disaggregation of a single data point to be sufficient for an organisation to score positively. This year, we have raised the bar and instead require organisations to show consistent sex-disaggregation of data across core reports, policies and/or strategies in order to score positively.

Findings

Fewer than four out of ten organisations commit to and fully sex-disaggregate data on programmatic delivery.

This includes roughly half of research and surveillance bodies, one-third of NGOs and one-fifth of private funders. No faith-based organisations in our sample disaggregate their M&E data by sex.

Do organisations sex-disaggregate their monitoring and evaluation data?

Of those that do, how do different sectors perform?

Takeaways from our findings

Gender plays a key role in determining health and well-being across the lifecourse. To be ‘gender-transformative’ requires that organisations recognise and address the root causes of gender-based health inequities, rather than simply focusing on the specific gender-related needs of certain groups in the population.

There has been a tendency within global health to equate gender to the needs of women and girls. This risks the perpetuation of the ideas that gender is a ‘problem’ associated only with women and girls. It implies that the gendered norms, behaviours and expectations of men and boys do not carry health-related consequences. Both ideas carry negative implications for the health outcomes of everyone. It is, therefore, both highly consequential and heartening to see that the majority of the norm-setting multilateral agencies apply gender-responsive approaches to address the underlying structural issues for men, women and transgender people.

We understand that men have greater relational power than women in most spheres across most if not all societies. Yet when it comes to their health, they face greater risk exposures. This is in part because of gendered roles, expectations and behaviours in society. An intersectional lens highlights that power disparities among men along other axes, such as socioeconomic status, are equally important determinants of health inequities.

Transforming unhealthy gender norms. Fewer than one-third of organisations in our sample take a gender-transformative approach to their programming. Such approaches embedded in the work of global health organisations have been shown to yield more effective outcomes (the body of published evidence is focused on the health of women and girls). While programmes that are gender-sensitive or gender-specific are a step in the right direction, global health organisations should also be focusing their attention on the structures and norms that lie at the heart of gender inequalities and their impact on health outcomes.

Gender impacts everyone’s health. When organisations state a population focus for their policies and programmes, it is predominantly on improving the health of women and girls. Forty percent of organisations that are responding to gender in some way do so to meet the needs of everyone, whereas 60% are focused on the health of women and girls. Among the organisations that include a focus on men and boys, they tend not to do so in a gender-responsive manner-despite the body of evidence showing the role that gender plays in everyone’s health outcomes.

Failure to recognise and address the role that gender plays in the health of everyone is likely to mean that no one’s health needs are fully met. It is time for the global health system to recognise and address health risks rooted in long-standing social, economic and gender inequalities that impact on the health and well-being of everyone.

Sex-disaggregated data is a minimum requirement. Fewer than half of organisations report sex-disaggregated data. The lack of sex-disaggregated reporting among funders and research and surveillance organisations is particularly concerning. This is a lost opportunity for understanding the distribution of ill-health, who is benefitting from interventions, and who is being left behind.

The global health agenda: Which priorities and for whom?

Are global health organisations aligned with the health agenda established by the SDGs?

To explore the extent to which global health organisations are working across the SDG health agenda, GH5050 reviewed the mission statements and core strategies of 146 organisations in our 2020 sample. We identified organisations’ stated priorities and assessed how they align to the targets of SDG 3 and three targets of SDG 5 (“the gender equality goal”). These latter targets were: 5.2 (elimination of all violence against women and girls); 5.3 (elimination of harmful practices such as child marriage); and 5.6 (universal access to sexual and reproductive health and reproductive rights).

We did not include the 42 private sector companies nor the 10 consultancy companies in this sub-analysis. Many of the private sector companies generally seek to influence global health policy, but do not have global health promotion or action to advance the health-related SDGs as a core function. This means that identification of their priorities in line with SDG targets is difficult to assess from their websites.

Number of organisations (146 in total) that state a focus on each SDG 3 target and health-related SDG 5 target.

What is the burden of disease associated with the SDG health-related targets?

We find that not all health-related SDG targets receive the same amount of attention from global health organisations-ranging from 94 organisations that prioritised work on target 3.3 (infectious diseases) to 8 that prioritised work on target 3.6 (road traffic injuries and deaths).

One explanation for this could be that some targets represent areas that have a lower burden of disease in the global population. We therefore calculated the burden of disease associated with each target in order to compare to the number of organisations focusing on each target.

Are organisational priorities aligned with the distribution of the burden of disease?

The following figure compares the burden of disease and organisational priorities. It presents the organisational focus of two groups: the overall sample of 146 organisations, and a subset of 31 organisations that are classified as exerting financial power.

We found a mismatch between attention paid by organisations (all, and financing subset) to some targets and global burdens of disease associated with those targets. Of note, those health issues that represent a continuation of the MDG agenda- maternal and child mortality and infectious diseases-continue to receive the largest proportion of attention of the global health ecosystem. The newer SDG-era targets, particularly NCDs, do not receive proportional attention from funders or other organisations.

Assessing alignment: global burden of disease compared to organisational priorities

Health issues that represent a continuation of the MDG agenda continue to receive the most attention of the global health system. Newer SDG-era targets, particularly NCDs, do not receive proportional attention.

Which populations do global health organisations target?

Given the differences in the distribution of DALYs between men and women, we also assessed whether organisations mentioned targeting specific populations-i.e. women and girls, men and boys, both or neither-in relation to their programmatic priorities. We found 72 organisations focused on one sex only. We did not find any organisation working solely on men’s health; all organisations with a single-sex/gender focus were concerned with advancing the health of women and girls. The other 74 organisations were either focused on the whole population or did not specify who they were targeting. For the sex-specific SDG targets (3.1, 5.2 and 5.3, i.e. reducing maternal mortality, and eliminating violence and harmful practices suffered by women and girls), a focus on women and girls would seem to be consistent with the aims of the targets. For other targets, however, the rationale for a sex-specific focus is less clear.

A sex-specific focus is not synonymous with being fully gender-responsive. We find that the majority of organisations are not gender- transformative in their policies and programmes. This is despite the role that gender plays in driving risk exposure and health outcomes across all targets.

Organisations that specify a population focus in their programmatic priorities, by SDG target

Key takeaways from our findings

Global health organisations wield power (financial, normative) at both global and national levels. Priorities set by these organisations about which health issues and which populations should be targeted have an impact on who benefits and which conditions receive adequate attention. Measuring the distribution of ill-health within and across populations has been a core function of global health research and surveillance organisations for many years, and the global health sector benefits from having extensive and robust empirical evidence that can contribute to decisions around priority-setting.

Prioritisation and neglect

Some health-related SDG targets get more attention than others, and some with high DALY burdens seem particularly neglected (e.g. NCDs and environmental health). Analysis of the distribution of the burden of disease and corresponding organisational focus across different SDG targets is not intended to pit targets against each other, but, rather, to highlight gaps in attention and funding. While recognising that factors other than the burden of disease are important in setting priorities, we should expect to see greater alignment between burden of disease and the priorities of global health organisations than our report finds.

Our analysis has shown that the global health sector is stuck in the MDG era, failing, for example, to adequately address the rising burden of NCDs. While it is important that the unfinished MDG agenda is addressed, a full five years into the fifteen-year SDG agenda, we believe that global health organisations must also ramp up action on the new SDG elements.

Population-specific focus

Our report has shown that around half of all organisations that state a population focus are targeting attention and resources to women and girls. Much of this is associated with sex-specific reproductive needs, while some programmes also focus on the gendered inequalities that drive violence and harmful practices suffered by women and girls. Our analysis of sex-disaggregated DALYs across SDG targets has shown that for some targets (e.g. alcohol, tobacco, substance use), the burden in men is much greater than in women-but no organisations are focusing specifically on men. Apart from their work addressing sexual and reproductive health and ending violence and harmful practices, the vast majority of organisations make no distinction between the health-related risks and needs of women and men.

As organisations shift towards addressing the full range of SDG health-related targets, we encourage them to not only consider the sex-disaggregated distribution of disease associated with each target (now, and likely future trends), but also to ensure that they integrate a fully gender-transformative approach for each target. Taking a gender lens to the SDG targets will not only promote more equitable outcomes, but is likely to result in more effective policies and programmes that deliver better health for everyone across all health-related targets.

Global health and the long shadow of colonialism

Exposing the patterns of the past to break their hold on the present

Waldemar Mordecai Wolffe Haffkine inoculating a community against cholera in Calcutta, March 1894. Credit: Wellcome Library.

Advancing equality is a defining objective in global health, and a full three-quarters of the organisations reviewed in this report publicly commit to social justice and gender equality. But progress towards equality has been persistently elusive. In part, the challenge of advancing equality is that it depends on broad societal advancement. This is at odds, however, with global health’s lineage of colonial medicine, which focused on single diseases and did not build the systems that broadly protect and promote public health.

A critical element of colonialism itself, colonial medicine was concerned with protecting European health, maintaining military superiority and supporting extractive industries. While colonial physicians and scientists made substantial contributions to medicine, they worked almost entirely on health issues that were unique to the colonies, which in part reflected a competition for knowledge and prestige using material unavailable elsewhere. In doing so, they established a focus on infectious diseases exclusive to the colonies—an interest that has been inherited by global health today.

Accordingly, colonial medicine emphasised malaria, yellow fever, sleeping sickness and other specific diseases, and quickly came to focus on narrow bacteriological approaches to disease control. The emphasis on controlling diseases this way reduced the need to secure cooperation from indigenous people. In the colonial and post-colonial periods, European and American specialist interest groups have followed this pattern, using their leverage to shape a continuing concentration on diseases through, for example, public-private partnerships for drug development. Similarly, virtually all of the major pharmaceutical manufacturers either produced, or have evolved from firms that supplied medicines to sustain colonialism.

Over the same period in the late 19th and early 20th centuries, metropolitan societies developed urban sanitation, municipal water supply, public housing and other public health measures as a complement to advancing knowledge and control of specific infectious agents. These broader interventions were deployed only selectively in the colonies and never as part of an inclusive state-building process. This form of systems-building thus did not enter the heritage of what was to become global health and remains underutilised today.

Post-independence, population control was one of the key elements in the evolution of colonial medicine into international health. While priorities and approaches shifted, international health continued to take on ideas powered by colonial relationships and the economic interests of former colonial powers. Post-independence international health was thus very much linked to concerns with the so-called ‘population explosion’ in the ‘third-world’ and among low-income communities domestically. This focus was to later be situated in more people-centered concerns about reproductive health and rights, but the focus on women’s reproductive health remains prevalent in global health.

Today, alternative approaches and agendas are emerging. While rich and poor countries alike signed on to Agenda 2030, there are many deep disagreements. For example, the G7 (Canada, France, Germany, Italy, Japan, UK and US) and the BRICS (Brazil, Russia, India, China and South Africa) have divergent views of global health priorities. As new regional and global health bodies are established in low- and middle-income countries, and older organisations explore alternative structures to share and shift power, calls to decolonise global health grow louder around the world.