The regional level is actually ideally placed to act as a platform for exchange as countries share some commonalities shaping their respective health systems, alongside unique characteristics in terms of pathways of change. Moreover, a regional perspective allows for exchange and mutual learning, developing collective intelligence on cross-border challenges affecting health systems.

The countries of the Region have taken the lead in exploring and adopting innovative governance solutions, with a view to achieving UHC and other challenges,  such as: the “dialogue sociétal” in Tunisia,  accountability and coordination in Sudan, clinical governance and hospital management in Egypt, intersectoral action to achieve UHC in Iran, devolution following the 18th Amendment in Pakistan, the “régionalisation avancée” in Morocco, emergency preparedness and response in Oman…

The Regional Collaborative shares a common vision on health system governance, starting from the complex and dynamic nature of the health system. Challenges facing the health system in the EMR call for a) a focus on ‘actionable governance’ to promote dialogue and inclusiveness and b) exploring progressive ‘best-fit’ approaches to health system governance, adapted to the context to address barriers and look into opportunities to expand UHC in the EMR.

The Regional Collaborative is an independent network that invites all stakeholders in health systems to share their perspectives and aspirations by offering a safe, open and apolitical environment for stakeholders to discuss all health system governance issues, even the most sensitive.

The Regional Health Systems Governance Collaborative Chapter aims to support Eastern Mediterranean countries in developing country-led, actionable and best-fit approaches to health system governance through the following:

Following the Action Plan 2018-2020, the Regional Collaborative will support country-initiated work on collaborative governance and health stewardship in Lebanon, decentralization in Jordan, a legal and institutional review to implement social health insurance legislation in Egypt, and accountability assessment in Oman and the launching of country platforms in Iraq, Jordan, Morocco and Oman.

(sources: action plan, report of the consultation and TOR of the consultation)

The best statements collected (see also on Twitter hashtag #WLGH18):

“Our ceiling must be the floor of those who come after us”.

“If you don’t get a seat at the table, pull up a folding chair and if they won’t let you, just sit on the table”

“When a man interrupts you, keep talking. Don’t make an eye contact & pretend you didn’t hear anything. Just keep talking”

‘Women don’t have to break through a glass ceiling, they have to get through a big fat layer of men’

These and other creatively disruptive statements (the best coming from the fearless Nigerian humanitarian coordinator Ayoyade Alakija –“we are in dangerous times if we do not understand better leadership”) made it all worth to take my (slightly bruised) ego to London for some collective therapy, which is sorely needed. Lately, I realize even more how much pressure there is on some of us, to combine, and have it all. That’s why I think the mentoring and networking was one of the highs of this annual gathering. I attended a mentoring breakfast meet as a mentor where all those things were discussed that you normally do not admit to, and useful tips were exchanged. The WLGH has set in motion a number of country and regional chapters where networking events will be organized, lists of women in global health compiled,…(I think that women engineers also did something similar – might be worth checking out!)

I also noted the intervention of aid worker Lucy O’Donoghue who spoke about her facebook group bringing together moms in global health (see Aidmamas and Humanitarian Women Network)…helping each other how to combine far flung travelling, 24h social media presence, …and standing at the school gate at 3:30 pm.

Therapy and personal mentoring & networking aside, some thorny issues still remain. Despite the huge step of including mentoring to the conference, I am still waiting for those major advancements or that maverick organisation that cracked the puzzle. I belong to those that are not convinced things will just evolve organically. Waiting for generations to change, seems like a light years-approach compared to today’s fast paced, everything-happing-now environment (cfr: maybe we will land on Mars earlier than…). Just waiting is losing out, or, in another twitterable statement heard at WLGH18, “we need a gender shift, not just a drift”.

There also seems to be something still very masculine (“on the front stage, loud mouth, heroic, aggressive”) about our standard perception of leadership that we have not come to grips with. As leaders, following the panel on “a cultural lens on gender & organisational leadership”, we need to foremost acknowledge that we have the privilege of position and need to acknowledge who brought us there and who we are intended to serve. This kind of humility, recognizing that we cannot do it alone (see also H. Clinton’s “it takes a village”) recognizes that we are only as strong as our communities, it counters that fabulous “lone hero” image…

What does this mean for women working in global health? They should avoid pointing the finger to other women (labelling someone “bad mom”) and try to be supportive instead…all too often, some “ladder-kicking” happens in the rush to get ahead. It also means you are speaking for the frontline providers, the grassroots organisations and communities… In Kigali WLGH2019, I hope we can reverse the image /perception that the objective is (to get more) women in leadership positions, while it is much more than that, encompassing a shift in values, discourse/voice, ways of doing, of working, which is much more inclusive and egalitarian than what we have today.

And what about exercises such as the UK’s  Athena SWAN   (a charter established in 2005 to which research institutions commit to advance gender equality and address unequal gender representation) to promote diversity in science ? They might come down to box-ticking exercises, however, their (real) power might lie in reframing the discourse, and gently nudging everyone of us towards a culture change, without too much pain for everyone involved…

Is the private sector doing any better? Compared to other global health gatherings, there were quite some representatives from the private sector and from corporate philanthropy, such as Novartis Foundation & Johnson and Johnson Global Health. Although the private sector portrays the same picture in terms of gender in the 50/50 Report as the UN and the private not for profit, they seem to publicize their initiatives to promote gender equality better. However, nowadays, we should always ask what concrete there is behind the nice tweet. The hard nut to crack, and not stressed enough during this gathering is the importance of vision and of organisational culture, carried by whoever is perceived to be the leader in terms of values in the organisation. In order to have bottom up, distributed, networked, 360-degree leadership and whatever-you-name-it, you will need a turnaround in culture and some concrete action that will (hopefully) set in motion a positive cascade. Maybe bring some organisational culture expertise in next time, so we can take a real deep dive. We need more examples next time from organisations (and why not, organisational research?) and leadership in WLGH19 Kigali on how we can make this happen, next to the very appreciated networking and inspirational therapy.

Trying to do it all / My ceiling is her floor 

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)

Despite the “black swans” (outliers) mentioned above, women, although they make up the majority of the global health workforce, and are in the majority in academia, still do not take up senior leadership positions. (Exceptions are the EVs and Health Systems Global)…What are we doing wrong (and are we doing something wrong, isn’t it typical for a women to think we are doing something wrong?) Women do not make it to top leadership, it was argued, as they focus too much on meticulously executing their work, instead of seeking support for big ideas… Or, women are too modest and rarely state when they have made an unique contribution to their fields. Or, women are not tough enough : we need to realize that “not everyone is going to be in our fan club”.

Others yet again argued that we need to engage men more. And yet others were saying that there can be a bit more solidarity amongst women themselves, coaching and mentoring others (I think the latter is a very powerful strategy). Finally, maybe we should re-think what global health leadership looks like. Is global health leadership really about giving keynote speeches at conferences, writing op-eds in the Lancet and networking during evening receptions (when women would need to go home to put children to bed) ? Or is it about “empowering others, to have greater impact”?

Then again, if we are looking for a new definition of leadership, women’s global health leadership should not only be about the community of women itself. As caregivers, we have a “unique contribution” to focus on vulnerable groups. How can this newly found power or voice be used to advance everyone’s? Vulnerability is not static, and we can argue that in certain settings, due to male stereotypes of strength and machismo, men do not timely access health care. We are indeed in an age of collaborative intelligence : problems cannot be dealt with by one individual with one type of knowledge / expertise and leadership alone as they are far too complex. We thus need to learn to work better in teams and be comfortable with people of different hues and backgrounds.

Furthermore, global health researchers living in the Northern part of the globe all seem to suffer from a form of schizophrenia. On the one hand, global health in the US is apparently undergraduate course choice number 1 and in fact many med school graduates expressed a wish to work in the global south during the conference. However, on the other hand, if you mount a public bus at Stanford, which is in Silicon Valley (where everyone has a car), the inequities fly right into your face. Only the true have-nots use the bus (in this case: the poor, people with disabilities, and older people without a safety net). Isn’t it a flagrant paradox ?

The next conference will take place at the London School of Hygiene and Tropical Medicine next year, and the still outstanding objective will be to really connect to the women’s grassroots organizations across the globe and show some evidence of ideas that really worked.

No worries, I’m a social scientist: we do self-reflection and meta-analysis for a living  

For some time now, something in the back of my mind has been nagging me: the feeling that it cannot be sufficient to teach health policy analysis of the UK and US in the 70s, 80s & 90s to students from LMIC, in the year 2017, without a certain (wry?) sense of irony; maybe the same sense of irony that you are displaying when wearing orange 70s bell-bottoms now. True, Lipsky (the one from the “street level bureaucrats”), Kingdon (“window of opportunity”) and Lindblom (“muddling through”) are, what you call, universal theories on implementation, agenda-setting and decision-making. As they are (pretty much) universal, they can be successfully applied anywhere and have thus also been applied to LMIC, with good results in many cases. However, since Gill Walt’s seminal work, Health Policy -An introduction to process and power (1994), there has been (virtually) no successful conceptual translation of good political science theories into health policy. Yes, governance was introduced, and neo-institutionalism also made a few inroads (e.g. political economy, the work of Elinor Ostrom), but that’s about it.

In global health policy research, political science concepts are more widely used, mainly through International Relations scholars who are increasingly interested in global health governance. In environmental studies, political science seems to have found easier inroads as well, see for example the journals Global Environmental Change and Global Environmental Politics. But at national level? Where are the political scientists in national (multi-level) health policy development? In this world of half- (and often half-baked) truths (see Nichols’ book “The death of expertise” (2017)), increasing complexity and acceleration, some recent concepts, methods and tools could actually serve health policy development well, as they explicitly try to manage uncertainty. National LMIC health policies are hardly insulated from the uncertainty and unpredictability we witness in other sectors and  all over the world. This is what causes most of the nagging in the back of mind – many of the theories and concepts currently used were tailored for far more predictable and slower times. Those times are gone, as far as I can tell.

In addition, the role of health policy makers (and the MOH) is also changing rapidly. In the SDG era and far beyond, they will have to seek a more collaborative and interactive role (facilitating networks) e.g. under the umbrella of UHC, embracing new financing arrangements, engaging in inter-sector coordination, negotiating with local governments,…

So this is a call to those policy makers, political scientists and sub-regional practitioner networks out there, interested in LMIC governance, to join forces and consider new tools, fitting the changed role of health policy makers and new policy realities. Anticipatory governance, scenario-planning, realist policy analysis, to name just a few… There is a whole plethora of new tools out there for the benefit of policy makers in LMIC!

Social anthropologists and kindred souls shared (sometimes eerie) stories on doing long term fieldwork during the Ebola epidemic, working for WHO, DFID or other global health actors. For me, it all happened at a distance, being pregnant, but the discussions brought back memories of my stay in Sierra Leone, which I visited a long time ago in the aftermath of the war. There was no electricity at the time, even in the capital, the streets were lit by candlelight. In the rural area I visited, the first line health facilities and the district hospital were in a terrible state, compared to other LIC.

At the event, Dr Sylvain Faye, a rather famous Senegalese sociologist, shared his unease of feeling torn between staying true to his discipline and being “instrumental” in the Ebola response. Anthropologists were mainly deployed as communication specialists to interact with and mobilize the communities for safe burial practices, food distribution and contact tracing. The main objective was to overcome ‘community resistance’ (sic). Faye even used the term ‘resistance-lifting committees’, which tells you all you need to know.

Faye questioned concepts such as ‘community mobilization’ or ‘participation’. According to him, in the Ebola response, one seemed to be at times working with an ‘ideal type’ of community representative (contracted individually by the coordination team), rather than with the real thing – the locally lived experience. Together with Melissa Leach, director of IDS, he called  for a critical anthropology of the Ebola response, analyzing community initiatives, but also the responses of the global health actors themselves. For some anthropologists, the (almost professional ethical) questions they face while doing long term fieldwork become very personal – as (reflexive) engagement is what good anthropological fieldwork requires.

Anthropologists felt fortified by the recognition bestowed on them by the global health community in the aftermath of the Ebola epidemic. The Ebola response Anthropology platform was widely viewed as being instrumental in the UK’s ebola response, for example. But at the same time, the global health praise left a somewhat bitter taste for quite a few.  Some reckoned maybe it is time to reconsider anthropological practice: how to be relevant in a global health rapid response while also staying engaged with locally lived realities – linking local power and wisdom to a swift global response. Faye argued we need to be “co-disciplinary” not “pluri-disciplinary”, Leach called for the building of local social science capacity…

In short, there is work to do.