The global health community embraces and champions gender equality as a guiding principle embedded in policies and processes, yet it has been very hard to translate this paper commitment to real change in people’s lives. While there is growing documentation of the gendered differences of risk to and effects of COVID-19, the pandemic has only highlighted existing gendered realities in risk and in health outcomes, while creating new ones. Gender has long been recognized as a social construct with enormous impact on people’s risk to disease and injury, access to health care, and their ability to follow health care messages and uptake services. To understand why information and knowledge generation continues to be gender-blind, we need to look critically at the global health paradigm that is often funding and providing the “technical know-how” on systems responses.

Most global health organizations espouse a commitment to gender mainstreaming and promoting gender equality. The 2020 Global health 50/50 Report “Power, privilege and priorities” documented that 75% of the 200 global health organizations have a stated commitment to gender equality.  The annual report ranks global health organizations on their commitment to gender equality using 17 indicators that range from work-place gender policies, performance on sexual harassment policies, to gender responsiveness of global health programs. The Global Fund to Fight AIDS, TB and Malaria was ranked amongst one of the 12 “very-high performers”.

The aim of the Global Health 50/50 Report is laudable, and using concrete and defined indicators to hold ourselves and the institutions of global health accountable is important. Having worked for more than 5 years at the Global Fund as a gender advisor to promote strategies that drive investments that address gender inequities and inequalities, I should be thrilled by this rating. It represents real policies, guidance and intent in the Secretariat and our partners for a more gender equal world, starting in our own workplace.

I am troubled, however, because the rating represents a real inconsistency with what I know to be true: we have a long way to go to see investments that are truly gender responsive and addressing gender inequalities in a sustainable way. This has been repeatedly recognized by the mechanisms in place to drive accountability and transparency of the Global Fund. The Technical Evaluation and Review Panel is a body that produces independent evaluations of the Global Fund across a range of thematic areas and in country specific grants. The Strategic Review 2017 raised the question of the “extent to which the Global Fund, as a financing institution can, or cannot, influence the “big picture” that shapes gender and key population contexts in countries remains and there are still challenges in understanding how to most effectively operationalize human rights and gender to support the achievement of the Global Fund’s objectives.” This challenge was echoed in the Strategic Review 2020, a mid-term review of the Global Fund 2017-2021 strategy, released in December 2020 found “limited progress in addressing equity, human rights and gender issues across the Global Fund portfolio, albeit with variation by geography, disease and key and vulnerable populations group. COVID-19 appears likely to reverse some of the gains made.”  The Technical Review Panel, the external body that reviews the Funding Requests from countries to the Global Fund, rated 61 of the largest grants across the different grant components (HIV, HIV/TB, TB, malaria, RSSH) for the 2021-2023 funding cycle as to whether “The funding request ensures that gender-­related barriers to accessing services are adequately analyzed and addressed to achieve the set targets.” The TRP answered “strongly disagree” or “disagree” for 30 grants, (1- strongly disagree, 29 disagree), and “strongly agree” or “agree” for 31 grants (2 – strongly agree, 29 – agree).

If you’re a glass half-full person, this is good news. But for an organization that just received the highest rating for its track record on addressing gender equality in a highly publicized report, it seems more like glass half empty news. It raises the question of why organizations like the Global Fund have been challenged to see more gender responsive or transformative programming even with the best of intentions and technical guidance in place. This discrepancy between guidance and policies to practice is notable given the high accord global health organizations give to evidence-based approaches to inform programmatic decisions.

One reason could be organizational cultural in global health. Often the global, regional, and national leaders and decision makers are dominated by physicians, public health professionals, and economists who may rely on technocratic rather than transformational approaches. The technocratic response may base decisions on an over-reliance on quantitative data that can be transformed into easily read dashboards that point quickly to success or failure. There is often an eschew of qualitative data that explores the reasons and the solutions behind the inequities. Monitoring frameworks are generally based on a linear model of causality from input to output to impact within a time horizon that is palatable to donors. It is difficult to bend programs that address human rights and gender-related risks and barriers to services, that transform community norms and power dynamics, to these log frames and monitoring processes.

But another issue is the willingness and ability of these organizations to truly address the power dynamics that make a person or a community at higher risk to disease or poorer health outcomes due to their gender or other factors. Investments and programs that are truly gender transformative would call for real transformation of power imbalances to address the underlying causes of disease, health risks and poor health outcomes. This is difficult terrain for global health organizations, especially one that has based much of its success on country driven processes. While the ethic of country driven is imperative, investments approaches and strategies must take into consideration how the decision making structures that they support may replicate or rely on the exact power paradigms that create gender-based inequalities in the first place.

As calls for decolonizing public health point out, solutions for power imbalances and equity will not be found in Geneva or New York. However, a real transformation to address the inequalities again revealed by the COVID-19 pandemic may not only impact the countries where donors are working, but also the global health institutional structures and power. Perhaps this is where the immediate opportunity lies for global health institutions. While the Global Health 50/50 report is a big step in the right direction towards more accountability to gender equality in global health, even the high performers need to continue to challenge our institutional cultures and partnerships to translate the metrics on paper to real transformation for the communities we serve.

This would mean global health organizations examining whether the incentives baked into the operational systems promote funding of programs that perpetuate inequities, even if inadvertently. This could challenge organizations to push beyond their current levels of risk tolerance and ways of contracting to support more community-led organizations at significant levels. It might mean adopting more equity-based targets and indicators that look at the multiple ways people are rendered more vulnerable to diseases – gender, sex, location, income level, education, and age. It would likely entail an expectation at all levels of the power structures that staff are expected and equipped to understand how gender interplays with risk, programming approaches, monitoring, and engagement.
The solutions will be myriad – but what is clear is that we need to find the courage and space to move beyond the well-intended gender equality policies on paper and in reports.

Author
 

Heather Doyle
Research Fellow at the Global Health Centre