This is not to say that representation is not important. Indeed, the lack of women in leadership is a problem, and the lack of women from the global south is an even bigger problem. Women from the global south, working in the global south, may be more representative than white women from the north, but let us also recognize the reality of post-colonial societies, which have their own share of inequities and hierarchies. In India, where I come from, for instance, medicine, media and indeed the non-profit sector, consists typically of upper caste, upper class men and women, who also represent their own interests. This recognition is important in global health, and indeed for those of us who claim to represent the global south. Ultimately, it is the political positions that we take, and the extent to which we are able to question the structures that prop us up that matter most.

In some sense, this tension is representative of the troubling ambiguities and contradictions that currently exist in the mainstream discourse on inequities in global health, which needs reorienting. The current focus of solutions to address inequities is to find ways to “include” the most vulnerable, but fails to question or even understand these inequities in a meaningful way. Part of this is due to the target driven global agenda, especially since the turn of the century, but actually already before that. Hence the solutions tend to pick low hanging fruit through targeting or financial incentives, which are utilitarian at best and coercive at worst. Inequities cannot be tackled in such a myopic manner – what health systems need is to engage with the causes of inequities themselves, beginning with understanding the pathways through which inequities are produced. The framework(s) that we choose to use, in order to make sense of inequities, is/are where the politics of one’s work lies. Scholars and philosophers representing counter-hegemonic traditions and movements can help in this regard. What can we learn from Ambedkar about caste disparities in health in India, or what can Fanon teach us about mental health, for instance? How do we make sense of the exclusion of indigenous populations without an understanding of their fraught relationship with the state, and indeed their struggles?

I suspect that part of the reason for why we do not ask these questions, is because it cuts to the heart of the privileged positions that we ourselves occupy. Talking about inequity cannot be a conversation just limited to understanding who is “left behind”, but must become a conversation about who is at the front, in the driver’s seat. (The overall SDG agenda has skirted around this problem and avoids addressing wealth inequality, or even government spending on health as an indicator for addressing UHC). Focussing only on those who are left behind does a disservice in two ways:

1) it has a tendency to make little compartments where every excluded group – women, indigenous people, sexual minorities, people with disabilities, migrants, fragile and conflict affected – wants its own corner, thus pitting us against one another even as we often embody more than one of these vulnerabilities, and leaves us fighting for a limited piece of the pie and 2) it exonerates those who actually do get the (much) larger portion of the pie. During the post-MDG discussions, I recall reading a somewhat satirical comic which wondered if we could consider a target like “ending extreme wealth” instead of “ending extreme poverty”. It struck me as particularly relevant to the world in which we live – even as each one of us wants no one to be left behind, it is unclear whether anyone is willing to “give up” anything, for this to actually happen. Even in our own work, we often end up reinforcing social hierarchies – reflected in the asymmetry of power in research collaborations, our complicity in top-down policy making and the preoccupation with influencing policy makers with evidence, without recognizing the power of social movements and communities.

If we are serious about ending inequities, we must therefore start looking at where power lies – either in the form of capital, or in the social hierarchy. Understanding how inequities are produced is critical to ending them, and those who produce and benefit from the inequities need to be held accountable. Otherwise, the project of “leaving no one behind” can become an exercise in targeting, and end up missing the wood for the trees.

The newly launched report “Global Health 50-50” released by the Center for Gender and Global Health at the University College of London, shows that in the Global Health world, this is not unusual at all.The report attempts to assess the extent to which 140 major organizations either working in or influencing global health address gender equality both in their programming as well as at the workplace, by reviewing their gender-related policies.Itexplores seven key domains which examine gender responsive programming in the organizations, and the extent to which they provide a gender equitable workplace.The findings of the report are sobering, to say the least. More than 20 years after Beijing, just over half of the organizations made a stated commitment to gender equality and less than half mentioned gender in their overall programme and strategy documents.Despite overwhelming evidence on the impact of gender on access to programmes, decision making, responsiveness of health care providers and exposure to health risks, two thirds of organizations do not disaggregate their data by sex. Organizations remain blind to queer concerns with just about ten percent recognizing the needs of persons with non-binary gender identities, and only one organization reported on health data of trans-persons. It is striking that among organizations that focus on the health of women and girls, most do so without a clear recognition of gender as a social construct. Many work largely on reproductive and maternal health that – ie, viewing women largely in their roles as mothers. The report rightly flags this as a problem, given that the changing patterns of NCDs clearly show women as a disadvantaged group, and therefore it is critical that women be looked at beyond their reproductive roles.

With regard to gender equitable work environments, the picture is quite dismal. Only a little over half of the organizations mentioned a stated commitment to gender equality at the workplace, and even among those, not all had specific measures to improve gender equality. As far as representation in decision making bodies and positions goes, it appears to lay heavily in the hands of men. The report points out this striking disparity, because close to 70 percent of those working in global health are women, but they seem to rarely occupy leadership positions.

At first sight, the standards seem rather simple and straightforward. What is striking however, is that even with these relatively “low-bar” indicators, organizations fare quite poorly. One wonders what the picture would look like, if a deeper analysis was carried out to understand the gender impact of the work of these organizations, and the roles that they play in global health policy making. Particularly for northern organizations, a critical question to ask would be – to what extent to they truly represent the needs of women on the ground, especially in the global south? To what extent are the aspirations of women’s resistance movements reflected in organizations’ programmes? And indeed, what actions of global organizations run contrary to women’s interests more broadly? The influence of the global political economy on global health policy making, and the functioning of key actors in that space have implications for gender equality. Previous research for instance has suggested that vertical channeling of resources by Global Health Initiatives has resulted in the fragmentation of the sexual and reproductive health rights agenda, moving the agenda away from comprehensive SRH services towards infectious diseases. This cannot merely be assessed through a review of policies and documents, but warrants a deeper investigation that must be undertaken moving forward, if we are serious about addressing gender equality.

Similarly, the discourse around women’s leadership in global health, although indicative of gender biases, lacks an intersectional lens. It seems to be premised on an assumption that having a greater number of women in leadership positions will improve the lot of women in the health workforce (which is predominantly female), and ultimately the health of women themselves. The assumption seems to be that women in leadership positions will represent interests of other women, irrespective of their relative social positions and leadership styles. But can that really be the case? After all, even Pepsico’s woman CEO Indra Nooyi did try to sell us women-friendly Doritos. Leadership at the top is not sufficient to change organisational culture, especially in organisations with affiliates across the world and in which “masculine” styles of leadership may well be adopted by women as well. Having workplace policies similarly often results in isomporphic mimicry: it might look like the real thing but it is really a fake handbag. Therefore it is crucial that the implementation of these policies, internal monitoring and accountability also be assessed.

Moving forward, however, as the report notes, there is a growing interest and pressure to show a commitment to gender equality and this certainly needs to be capitalized upon. It may be useful to undertake such an exercise periodically, but as the idea of gender equality becomes more mainstream, there is also a danger of dilution – the temptation to turn this into a “box-checking” exercise – when in fact, what is needed is to deepen our understanding of WHY there is no gender parity. Why are certain organizations outliers and what might be the reasons for these.Is it because organisations working on girls education would experience an uncomfortable contrast with workplace policy? Or are organizations blind to these contradictions? How do organizations differ based on their geographic location? How do country offices differ from international headquarters? Perhaps in the future, the authors could considera more theory-driven analysis informed by the myriad theories that are currently out there on crossing inequities (i.e.)intersectionality, post-colonialism, originating in (postmodern) power theories.

Overall, the report is timely and provides much food for thought and action.Ultimately, if we want to “do”gender equality in a substantive rather than tokenistic way, embracing the principles of feminism and intersectionality, the bar will have to be set higher. This report provides a starting point and hopefully will evoke a more nuanced, serious conversation on what it means to be “gender equitable”.

In current health systems governance thinking (frameworks, interventions and action plans), attention has (rightly) gone to the multiplicity of governing actors and the distributive nature of power between those actors. However, governance does not only concern relationships between institutions, governing actors or power centres, but also relationships between citizens, the state and/or other actors. Health systems governance grounds much of its thinking on principal-agent theory (PAT), which rightly focuses on relationships between actors, institutions and their roles. However, the “principal” (the citizens in the relationship) remains a bit of an anaemic creature. While the onus (locus for change) is on institutions, the principal (i.e. citizens or communities) seems underdeveloped and somewhat instrumental. PAT does not appear to do sufficient justice to the creativity of collective action and the political agency of citizens and communities.

We argue here that a complexity-driven governance practice provides space for more creative, political collective action. Complexity science has been infecting governance research for quite some time and even the neo-institutional economist Elinor Ostrom, in her later work, adopted complexity in her study of adaptive environmental governance in social-ecological systems. More recently, the recent popular book “Doughnut Economics” from Kate Raworth throws old-school economic growth thinking out the window, to propose a complexity-driven economics, cognizant of climate change.

In the practice of governance at the national and sub-national health system levels, if we are to apply complexity thinking we will need to begin by acknowledging context and develop interventions accordingly instead of vice-versa (which is usually the case). This means that we must first begin with an appraisal of actual governance practices (what is actually happening right now) in health systems and communities instead of relying on starter assumptions on what governance should look like from other settings.

None of our health systems is a blank sheet in terms of governance. In fragile settings, people create their own practical governance solutions if there is a legal or a policy void, and in non-fragile settings rules are continuously adapted (or adjusted).  Rules are grounded in social norms. Rightly the World Development Report 2017 on Governance and the Rule of Law points out that it really are the social norms, which give rise to power asymmetries and persistent inequity. Both are at the heart of accountability deficits/gaps.  Therefore the effort should be primarily to influence these norms, which are really the mechanisms generating the “everyday” governance practices. If this is not done, actors will (find a way to) work around the rules.

Starting your intervention with what is actually happening on the ground also means that we will need to be “strategic rather than tactical”: when to use which governance instruments and how to combine them. We will need innovative ways to appraise the effects of our interventions, and to understand how they affect actor positions, which will transform the initial intervention. Much like chess play, strategies will need to be iterative and we will need to foresee and seize windows of opportunity by scanning the broader political and social context.

It does not stop there. If we want to tackle power and politics in the true sense of the word it is also time for a bit of “Global Health community reflexivity”, examining the political economy of our own work and the distribution of power therein. We need to question our own assumptions. Who are we as global health citizens, what are our values? Who do we want to be as (global) health citizens? What are our own incentives and how do we recognize and check those? What are our relative positions of power and how do we engage with differences? We could take our inspiration from radical democratic practice thinker Chantal Mouffe, that “talking truth to power” should also transform our practices as global health citizens – our ways of seeing, framing and working as researchers and practitioners.

Finally, (and central to the SDG endeavor and UHC 2030) is that health systems governance practice must be assessed based on its impact on equity, on “leaving no one behind”. Leaving no one behind in the context of health systems governance means that we will have to: (1) critically question legitimate representation, (2) explore how networked governance & self-organisation would lead to stronger democratic practice and public accountability in health, (3) explore how to enforce accountability towards those groups, (4) promote a more open view of what knowledge consists of in global health, (5) spur more “collaborative intelligence” and(6) a fine-grained representation of diversity.

In our role as researchers, it is also our responsibility to document existing practice – both successes and failures. Rooted governance practice does not necessarily appear in the form of experimentally tested interventions and often involves the work of grassroots activists and social movements over decades. Efforts at documenting these are required. New research and documentation on partnerships is required – what, for instance, do we know about cross-scale networks and responsibility sharing partnerships? Barriers of context and language need to be overcome in order to make those stories heard – and further open up space for learning. We can only be successful political agents in the global health community if (1) we manage to create new models that open up space for constructive dialogue; (2) if we manage to persuade others and link up networks and (3) if we legitimately represent and are accountable to those who are not being heard.

Senegal, 2017

list of provincial governors department Foundiougne in Senegal, 2017

women talking in a community, Niger (2007)

The GPW is clearly ambitious, and it appears that Tedros is urgently looking to restore faith in the WHO. In his opening remarks, he reminded Member States that WHO cannot continue with “business as usual” – there is a need for a paradigm shift if the organization is to remain relevant in the new global health landscape. In the GPW this is reflected in both strategic shifts (stepping up global leadership, driving impact in every country and focusing global public goods on impact) and organizational shifts (measuring impact, transforming partnerships communications and financing, reshaping the operating model to drive country, regional and global impacts, building critical processes and tools and fostering a culture change in the WHO). While the document was received positively by most member states, who appreciated the transparent, consultative and swift process that was undertaken in its development, there were also concerns raised by some regarding deviation from WHO’s core functions of setting normative standards and providing strategic and technical support, into a more operational role. However, Tedros reassured States that the WHO would be operational only in a handful of 15 countries with fragile settings, and that the core functions of WHO would not be jeopardized. In other countries, WHO will continue to engage via policy dialogue, strategic support and technical assistance, depending on the scale of maturity of the health system.

A critical concern over costs and financing was flagged repeatedly by member states as well as non state actors, however no clear indication was provided on how to address potential funding gaps for a budget covering an ambitious GPW, and it appears that one will have to wait for the investment case which will be presented early next year, ahead of the Executive Board meeting end of January. However, it is pertinent to note that even as Tedros called for more unearmarked funding from Member states, he assured them that signing off on the GPW did not (necessarily) imply they would have to fund it all themselves. This seems to suggest that voluntary donors & private partners will even more become part of the financing strategy (Tedros was also hinting at an ‘innovative’ funding approach). Along with this, the commitment to “partnerships and multi-stakeholder participation” raises concerns around WHO’s independence and integrity, which calls for (more) scrutiny of the implementation of the Framework of Engagement with Non State Actors (an issue raised by both CSOs and some Member States); however no substantive discussion on this issue took place. As IBFAN pointed out in its statement to the EB, it appears that FENSA is perceived to “enable partnerships rather than manage them in order to safeguard the WHO.”

It is noteworthy that, in response to questions raised over WHO’s accountability and impact, the GPW looks to demonstrate impact and hence prove itself to be a “good investment”. A detailed  impact framework and “Triple billion” targets have been set up, and were elaborated upon by the secretariat team. However concerns were raised about their alignment with the SDG targets, as well as on the challenges of data availability. Moreover, there is a danger that setting such targets could foster a tendency to pick the lowest hanging fruit; as some countries pointed out,  regional and country disaggregation is required so that the focus will not only be on big countries, as there’s a danger that the “billion targets” would focus attention first on the latter, with bigger populations. Further, one wonders whether the setting of such “marketable” targets erroneously puts WHO at par with other global health partnerships, turning the organization into just another player in the global health ecosystem, rather than a leader. This trend, known as “Trojan Multilateralism”, implies that WHO might be redirected by specific incentives and bilateral control (by its funders) hence deepening the democratic deficit of global health governance.

While Tedros’ responses to Member States concerns seemed to be in line with his claim that he and his team are listening, to what extent he provides (and will provide) space for CSOs to engage in the policy debate and formulation remains to be seen. Although CSOs concerns regarding the exclusion of certain issues from the draft (ageing, disability, violence against children, sexual and reproductive health, alcohol abuse, palliative care, solid waste management) were acknowledged and assurances made to include them, more contentious debates around conflicts of interest, democratic governance and financing by private players did not take place. One wonders therefore if the participation of CSOs will remain tokenistic or become more substantive in the future.

Finally, Tedros’ leadership style at the meeting was collective and open. He was candid about the challenges of WHO’s own work culture, stating that even as he was proud of having the most gender-equitable senior management in the organization so far, he also feared pushback because “mindsets are perhaps not ready for it”. He repeatedly invoked the participation of his senior leadership and regional directors, and called for greater ownership from Member States. While appreciating feedback from States on the draft, he appealed to them at the same time, to provide unearmarked funding which would allow for greater independence and true prioritization. Ultimately, the extent to which Tedros’ GPW will translate into real action will depend to a large extent on how it will be financed. Overall, discussions on the draft GPW appear to be positive and criticisms by member states and non-state actors appear to have been taken note of by the secretariat, if not explicitly discussed. A revised (final) draft and the investment case is expected early next year, which will be discussed once again in the EB meeting in January 2018, and then agreed upon at the World Health Assembly next year.

Special Session of the WHO Executive Board on the draft thirteenth general programme of work, 22^nd– 23^rd November 2017.

Acknowledgment: With inputs from Remco Van de Pas & Kristof Decoster.

It is undeniable that our society is driven by economic interests. The era of “good” or “bad” ideas was left behind with Hegel. Can an idea be good in itself, taking primacy over human life and reigning upon it almighty? No. Ideas are born in the brain of men who themselves are born in a social and economic context one cannot ignore. It is precisely this context that matters. So when an old all-white panel calls for spreading ideas – some prefer the term ‘best practices’, but in many cases, they mean more or less the same – among the political and intellectual elites of a developing country, as was the case in a pre-event  before the #ECTMIH2017 conference, not only do they reproduce a neocolonialist approach to cooperation called aid, they also reproduce a philosophical school driven by 18th century young German thinkers. But guys. We’ve hit the 21st century for a couple of years now, time to get an update. Given Mr. Stadler seems to think we’re back in the 19th century, you might want to call upon a 19th century German thinker to do just that.

So if society is driven by economic interests and even ideas are born from these economic relations (not to mention the powerlessness of a good idea in a young researcher when he/she becomes appointed ministry of health and has to deal with political and economic interests), why are we not analysing society in terms of these economic relations? The poor and the rich – that’s where the discourse seems to be stuck; at an individual-level analysis of people living in poverty versus those living in abundance. Yet these people come as a coherent whole. They share the same relation to property and ownership. They are the deprived. The masses. The working class. Or as our favorite bearded old man would say: the proletariat. It is not enough to acknowledge that people are poor. One needs to analyse why they are poor. And Marx did it for us.

If you’re not fond of dear Karl, Anne-Emanuelle Birn in her textbook on Global Health  emphasizes the importance for health researchers of analysing society in terms of classes. The Black Report in the UK did just that. The National Health Service was not designed according to social classes but the reports analysis was and it demonstrated increasing inequities and hence the (partial) inefficiency of the NHS : health inequities sparkle from living and working inequities and hence social class. It is this class we need to address. The problem is structural, but that’s too big a truth for governments to be willing to sort data by classes  and for most researchers to wander into analysing them. And why is that? Perhaps because we reject radical ideas as not scientific enough ? Or just because it is not in our interest? As the intellectual elite, the “petit bourgeois” of this capitalist society, we profit from this system. Or at least most of us, ECTMIH participants, still profit more from the system than we are being hit and hammered by it. I am not saying we don’t want to save lives. Everyday around the planet millions of people make admirable efforts into making the lives of their people better. But we have no interest in changing larger systems, in truly ‘transformative’ ways if you want – even if we can’t shut up about the latter.

Yet the system is the problem. Journalist Florence Aubenas decided to delve into the poorest strata of French society, pretending she didn’t have a diploma or work experience. And what she saw was terrible. Her most poignant example concerns dental care. In France, the poorest among us, the ones who clean the floor of your office while you’re sleeping at home or tidy the plane in 5 minutes before you can board, this proletariat that is largely invisible and is dependent on social security, is letting its entire mouth rot. Why? Because if only one of your tooth is carious, social security does not consider it worth the cost required to fix it. So, you would have to wait until all of your teeth are rotten, after which they will pay for a set of false teeth instead of treating them one by one. We’ve all had dental problems and we know how bad it hurts. Imagine this pain in every square centimeter of your mouth, and still having to get up to do the most exhausting job. Keep in mind, that France has good health facilities and relatively good social security – ironically, a result of the struggle of the same masses that the system now increasingly excludes. We have a pharmacy store around the corner, a hospital not too far away and decent public transport to reach it. And yet, this situation prevails. Is that because our health system is not good enough? Or is it because the market still drives up healthcare costs, thereby making it unaffordable for some people? Even in a wealthy France, 14.3% of citizens were considered poor in 2015 and around 3.4 million workers were in a precarious situation in 2016, not to mention that the Gini index is indeed increasing. Does it make sense, then, to waste time compensating for a system that alienates a whole fragment of society? For a system that keeps generating the gross inequalities that we seek to eliminate ?

As health researchers, we know that access to healthcare is not only about building the right health facilities at the right place. But even as mainstream development discourse such as that around the Sustainable Development Goals is recognizing the interdependence of goals and the need for inter-sectoral efforts, we are reluctant to dive head on into influencing systems that perpetuate deprivation and ill health. At the EV debate during ECTMIH, we heard young researchers call for greater engagement of the academic community with social movements and communities at large. Perhaps it is time to join hands and extend solidarities with grassroots struggles led by the proletariat and what modern thinkers like to call the precariat. It is time to do our bit to turn the tides of economic domination. To break this class relationship by engaging into a class struggle. Wait. Are we not almost quoting Karl Marx?

Much like all issues related to women’s sexuality and reproduction, family planning and access to contraceptives are also deeply political. While in several countries women are struggling against right wing politico-religious forces to gain access to birth control, others in countries like India face a dual burden; that of trying to negotiate contraceptive use in their intimate relationships on the one hand, and of having contraceptives thrust upon them in the interest of “controlling population” on the other. It is worthwhile to recall that the origins of several family planning programs today are rooted in Malthusian anxiety of “over-population”. In India for instance, the family planning program began in the 1950s, with a population control perspective and there is a dark history of the use of population control during the emergency between 1976-1977, when forced and coerced vasectomies were carried out rampantly. There is, therefore, an aspect of “reproductive wrongs” that deserves our attention.

The International Conference on Population and Development (ICPD), held in Cairo in 1994, signified a shift in the discourse of women’s reproductive health in many ways, one of them being the move from target-based population control to that of reproductive rights and women’s empowerment. It made a call for moving beyond narrowly focused population programmes to look at family planning within a paradigm of reproductive rights. Countries like India, following the Cairo Conference, realigned their policies to promote a “target-free” approach to promote voluntary uptake of contraceptives. Yet, on the ground, targets continue to drive health workers to use pressure tactics in order to achieve their “quotas” even today. Access to safe abortion services may even be made conditional upon acceptance of family planning. Monetary incentives for providers and motivators, although clearly unethical, do not raise any eyebrows (In September 2016, the Government of India announced a new scheme to accelerate access to family planning services in 145 high-priority districts “within a rights-based framework”, but stipulated increases in incentives to not just acceptors of specific methods, but also motivators and providers!). Even as India commits to a rights-based approach to family planning, the government is instituting policies that restrict entitlements like maternity benefits only to one child. Quality of care is abysmally poor, with women being herded into camps to be sterilized. Not long ago, in 2014, 13 women lost their lives after undergoing sterilization operations under hazardous conditions at a camp in the state of Chhattisgarh. While their deaths managed to gain some global attention, several other women who suffer morbidities due to poorly performed sterilization procedures and IUD insertions, continue to suffer in silence.

International agencies and partnerships like FP2020 repeatedly affirm that it is voluntary contraception and family planning which they advocate, but how are these platforms ensuring that this is being adhered to on the ground? Are policies and programmes being examined to ensure that they are free from coercion? With quality of care being such a big concern in India (and many other countries), are social audits being instituted to ensure that quality guidelines are adhered to? Is quality of care being addressed, not in the context of ensuring compliance to contraceptive use, but in the context of rights violations? As we move forward from the Family Planning Summit in London, it is worthwhile to re-examine how we understand and address the challenges that women face in accessing contraception. It is a reality that women need and want contraceptive services, and health systems must be able to provide them. But perhaps we also need to be conscious and aware of alternate grassroots realities, so that what we see as an advancement of reproductive rights does not become a source of injustice for others. This is only possible if family planning programs are monitored closely for quality and governments made accountable for violations. Civil society activists within countries like India are relentlessly drawing attention to these problems and it is time that these voices are amplified at global platforms, to pressurize governments into addressing and preventing violations that women are subject to in the name of reproductive choice.

*The title of this viewpoint borrows from the title of Betsy Hartmann’s book ‘Reproductive Rights and Wrongs’ (1995),  which examines the global politics of population control.

In Bangladesh, some mHealth activities have sought to recognise the roles of men as gatekeepers to women’s health. Instead of only sending SMS messages to pregnant women, they also send them to husbands or other significant men who have been identified by the women. This seems to play two roles: it encourages men to take women’s maternal health seriously and makes it harder for these men to block women from using maternal health services. But does it also play a role engaging men in maternal health?  Does it also give men maternal health information which they find interesting and useful?  Is it helpful at all, or potentially harmful (i.e. does it increase their power over women)?

This leads us to ask: is there an inherent tension in involving men in maternal health – are we in fact increasing male authority in a domain that was at least partly in women’s control? Brazilian feminists have argued for a long time against the ‘maternal infantilisation’ of women, i.e. that women should still have primary authority about what happens to their health and bodies, including when it comes to pregnancy and childbirth. When we seek to engage men in maternal health, we need to ask whether it is done in a way that would be considered unethical or would in fact inhibit women’s autonomy (e.g. encouraging forms of community surveillance that take away women’s right to privacy). Questions that need to be asked include: when is it acceptable to share health records of one person with another and what are the gender dimensions involved? Under what conditions should men be encouraged to actively participate in women’s maternal health?  Are there ways to involve men, to promote gender equality and sustain women’s autonomy? What kind of services and support mechanisms do we need to navigate this?

This is not to say that engaging men is necessarily counterproductive. In India, our experience shows that the framework which guides such engagement is what matters – it should not be instrumental, i.e. we should not engage with men because they are “decision makers”/”gatekeepers” and can affect service uptake, but as partners who have a responsibility to share the burden of contraception, childbearing and rearing, and who have a responsibility and interest in advancing gender equality. Rather, that the basis of engagement aims to foster a recognition of, and discussion around, men as fathers and male privilege. As feminists have long known, men must be involved in the dismantling of structures and harmful social norms that jeopardize women’s well-being – norms such as early marriage, early childbearing, violence, restriction of mobility and so on. Even then, there is a temptation to persuade men to support women’s health and empowerment through an easier route by making utilitarian appeals like “if your daughter is well educated, she will be a good mother”. While this may help to convince the community to not force their girls to drop out of school, will it not further essentialize women’s roles as mothers?

Men and maternal health (UNFPA /Omar Gharzeddine)

What is the role of health systems researchers in addressing this issue? Health system researchers are in a unique position to support policy champions and bridge the gap between research and policy by linking appropriate policy audiences in developing research, disseminating research findings effectively to different stakeholders, and supporting a policy community to work on issues informed by research. A recent review, critically examining the emerging evidence base on interventions that engage men in maternal and newborn health, has found important gaps in how male involvement is conceptualized, and recommends more research to document the gender transformative potential of these interventions.

Building on this, we call on health systems researchers to investigate the context specific gendered determinants of maternal health, and be aware of how interventions interact with these contexts. Such informed investigations would ensure that evidence based approaches to engage men keep gender equality, women’s autonomy and rights at the center, rather than focusing instrumentally on health outcomes alone. We need efforts that engage policy makers and implementers in supporting long lasting change, rather than superficial measures that further involve men in maternal health in ways that may not be helpful and indeed in some instances be harmful.

Note: This blog is based on an online discussion about gender in health systems with 14 members of the new cohort of the Emerging Voices. The blog presents reflections made during those discussion.