NextBillion - An Initiative of the William Davidson Institute at the University of Michigan

There is no denying the fact that access to essential health services has improved in most lower-income countries during the last two decades, leading to a reduction in preventable deaths. However, in order to protect these gains and accelerate progress, we need to move beyond a “one size fits all” approach to global health. And for this to happen, the boardrooms of global health organisations will have to look different than they do today.

“Boards for All?”, a new report from Global Health 50/50, highlights the urgency of this issue. The report details the gender and geographic makeup of the boards of 147 leading organisations that are active in global health – mapping over 2,000 board seats. It shows that while much of global health’s work is concentrated in low- and middle-income countries (LMICs), just a quarter of board seats are held by nationals of these countries (which are home to 84% of the world’s population). Compare this figure to that of American and British nationals, who alone hold over 50% of all board seats.

Perhaps most concerning, while significant global health action continues to focus on women’s health, women from low-income countries are almost entirely excluded from the boardroom. While men from high-income countries hold 44% of board seats, women from low-income countries hold a shameful 1% of all seats – just 17 seats in total! Meanwhile, across 11 philanthropic funders, which distribute over US $16 billion each year and hold huge power in determining global health priorities, there is only one woman board member from a low-income country. If we hope to make a real difference in LMICs’ health outcomes, the board tables at these influential bodies must increasingly seat those whose lives they are aiming to improve.

The Need for Diversity in Global Health Governance

We should all care who is entrusted with governing global health. The boards of leading organisations active in global health wield immense power: By providing strategic direction, oversight and leadership, they play a significant role in determining the priorities, funding and solutions that impact the world’s health. A lack of gender equality and diversity in these bodies means excluding the lived experience and practical insights of those whom these institutions were created to support. As a result, we are seeing a huge disconnect between what is needed and what is offered, limiting the sector’s impact and its ability to protect, transform and enrich the lives of individuals, families and communities.

This disconnect has been clearly highlighted by the COVID-19 pandemic, during which we have seen numerous examples of the lack of consideration of the specific needs of certain populations in healthcare initiatives. For example, a 2021 report from Women in Global Health revealed that just 14% of respondents exclusively used personal protective equipment fitted to women’s sizes – despite the fact that women comprise 70% of health and social care workers globally.

However, the failure to reflect the needs of key stakeholders in health services delivery is not a novel issue. For instance, during the HIV/AIDS crisis of the 1990s, the exclusion of African populations from the design of HIV/AIDS responses bred misconceptions about the feasibility of, and adherence to, drug uptake in the region, leading to policymaking based on false speculation rather than evidence.

These stories are not unique – they’re representative of a decades-long, system-wide failure to ensure diversity in global health decision-making. That’s why the findings of the 2022 “Boards for All?” report leave me disappointed but unsurprised. The report reaffirms the lack of gender equality and diversity that we see not only at the apex of governance structures, but also more generally in the senior leadership positions of global health organisations. But while there has been a lot of discussion and verbal support for changing this status quo, there has been little intentional and deliberate action to make it happen.

Building a More Inclusive Global Health Sector

At Gavi, the Vaccine Alliance, where I serve as Deputy CEO, we are committed to building and nurturing a culture in which inclusiveness is a reflex, not an initiative or afterthought. Our Board, its committees and its advisory committees have gender balance principles in place to ensure there is no more than 60% of any one gender represented. Because Gavi is an alliance, our board structure inherently ensures diverse geographic representation, with specific board seats reserved for lower-income country representatives, both from Gavi-implementing countries, as well as from the pharmaceutical industry in these countries.

This institutionalisation of gender and geographic balance in policies and governance structures is important – but it’s not sufficient on its own. Having diverse voices at the table is not enough: We must also ensure respectful environments, practices and work cultures, so that everyone is listened to, valued, respected and able to contribute meaningfully.

I am a firm believer in the virtuous cycle of representation: When women leaders from lower-income countries claim their rightful space in the room, they inspire others to achieve the same. I have witnessed first-hand how the insights, experience and expertise of people from lower-income countries have transformed health challenges that seemed intractable from the perspective of donor nation decision-makers. I have trust in our ability to transform and rebuild global health governance to work for all of us – and to ensure that our boards mirror the world we serve.

Anuradha Gupta is Deputy Chief Executive Officer of Gavi, the Vaccine Alliance.

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