The state of gender equality in global health: A deep dive into the 6th Global Health 50/50 report

Launched earlier this year, the sixth Global Health 50/50 report focussed for the first time on sexual and reproductive health and rights (SRHR) in the workplace ranging from menstruation, abortion and menopause, to antenatal care and caring responsibilities. 

Our guests on this episode are the founders of Global Health 50/50, Professor Sarah Hawkes and Professor Kent Buse.

In this episode, we discuss the latest Global Health 50/50 report, its findings, and where Sarah and Kent have seen a shift over the past six years in commitments to equality and the gender responsiveness of global health programmes.

Global Health 50/50 is an independent, evidence-driven initiative to advance action and accountability for gender equality in global health. You can visit their website here: https://globalhealth5050.org/.

Professor Sarah Hawkes is Director of the Centre for Gender and Global Health and Professor of Global Public Health at University College London and Professor Kent Buse is currently Director of the newly established global Healthier Societies Research Program at the George Institute for Global Health, with an appointment at the Faculty of Medicine at the University of New South Wales.

To read the Global Health 50/50 report visit https://globalhealth5050.org/2023-report/. 

We encourage you to join the conversation on Twitter at @AusAmbRHS.

Transcript

Please note: We provide transcripts for information purposes only. Anyone accessing our transcripts undertake responsibility for assessing the relevance and accuracy of the content. Before using the material contained in a transcript, the permission of the relevant presenter should be obtained.   

The views presented in this podcast are the views of the host and guests. They do not necessarily represent the views or the official position of the Australian Government.

Ms Sarah Goulding 00:31

Hello, and welcome to Contain This. I’m Sarah Goulding, Assistant Secretary for Gender Equality, Disability and Social Inclusion here at Department of Foreign Affairs and Trade in Australia. I'd like to acknowledge the traditional owners and custodians of country throughout Australia and our region, and recognise their continuing connection to land, waters, and community and pay our respects to Elders past and present. Today I’m joined by Professors Kent Buse and Sarah Hawkes, the founders of Global Health 50/50 - an independent, evidence-driven initiative to advance action and accountability for gender equality in global health. Professor Sarah Hawkes is Director of the Centre for Gender and Global Health and Professor of Global Public Health at University College London. Professor Kent Buse is currently Director of the newly established global Healthier Societies Research Program at the George Institute for Global Health, with an appointment at the Faculty of Medicine at the University of New South Wales. In this episode, Kent and Sarah talk about the latest Global Health 50/50 report, its findings, where they have seen a shift over the past six years in commitments to equality, gender responsiveness of global health programmes, and the Global Health 50/50 accountability tool. I hope you enjoy the discussion. 

Well, Sarah, and Kent, it's an absolute privilege to be doing a Contain This podcast with you. I've long been a fan ever since you started doing global health by 50/50 reporting of the type of metrics that you're producing, because it really does do what we talk about a lot in Australia about the need to have advocacy that's grounded in a sense of humility, that you are walking your own talk, you can't talk about shifting gender equality and shifting social norms if you're not actually doing that within your own institutions. And if there's a space where that needs to happen, it's in global health. The report that you've got this year with its bespoke focus on sexual and reproductive health is challenging and confronting, and exciting in the breadth of spaces, where you can see institutions are coming to the fore of the things that there need to be considering to be able to provide safe workplaces for women. So with the questions that I've got, rather than starting off, though, with the sexual and reproductive health one, given that we are still in this space of emerging from those years of lockdown, can I ask you what changes and trends you've seen over the last five years? Like, are there some certain issues that you're seeing where there's been greater impacts or progress than others? And, and why? I'm particularly interested in the sense of those spaces where progress feels possible and does happen and those spaces where there's like a sticky floor or people are stuck under the glass ceiling.

Professor Kent Buse 03:55

To just put this in the context of those for those people that might not know GH 50/50, over the past six years, we've collected data on some core variables. And we've repeated that over six years. And maybe that's a good place to start. Sarah, what exactly have we collected the data on?

Professor Sarah Hawkes 04:15

In terms of the work that we do as an accountability measure, started looking at the global health sector, you know, if we can't get our own house in order as global health professionals working in a range of global health organisations, how can we possibly see start to tell other people that they need to shift the dial if our own dial is stuck. But where we have seen a shift over the six years is actually in commitments to equality, they have increased quite substantially by around 50% across the organisations that we've been measuring for the past six years. We have seen a good increase in the public availability of policies. So transparency has increased, which for us is a core part of accountability. There has been a slower but still measurable shift in outcomes. So in terms of outcomes that we can measure from the outside, we're looking at outcome measures such as the issue of gender parity in senior management, or gender parity in the Board, the aggregate gender of leadership, that has been shifting more slowly. But still, there have been positive changes in the six years.

Professor Kent Buse 05:44

We have a metric around what, a third of women on the Board, and that data point has come down by 15%, both in the Boards and senior management teams during that period. So it's, we've seen an increase in commitment, we've seen an increase in policies, including a doubling of the Board diversity policies. We've seen a decrease in male CEOs from 73% to 60%. 

Ms Sarah Goulding 06:17

I mean, it's always heartening to know that there's spaces of good news, you know, when you're tracking this, and I think that's part of what the power of the index and the annual reporting that you're doing is that you are able to track that performance. You know, in seeing that shift, particularly in commitments, and some of those around leadership, are there any particular good news stories that just really go help you go, yes, we're moving in the right direction, change is possible and be a catalyst for further change? 

Professor Kent Buse 06:52

Coming to the issue of catalyst, I think one of the really helpful things for us was the support that we got from your sister agency, the Swedish SIDA. And fairly early on when the report would come out, they would convene the health sector staff, and their gender equality staff, and they’d present the results of the report and that they would encourage their managers to actually write to organisations that they were supporting that hadn't been performing well. And they'd ask for a management response. And they've included a few variables that we track in their assessment criteria. And so they've managed to have that catalytic sort of systemic shift across the sector in terms of the organisations that they support. So I think, you know, I think that's a nice example of donor conditionality. Maybe we shouldn't call it that. But I think that has been quite impactful across a number of organisations, but I think it works the other way as well, that some Boards recognise this is important. And so the Board, for example of PSI, has included in the KPIs of their executive director, progress on the journey that we track organisations on sort of the gender equality. A lot of young women in particular come up to us and say - women that are working in these organisations - and say, wow, you put this evidence in our hands. We can see how our organisation is performing and we can track that relative to other organisations in our sector be they donors or NGOs or the private sector and that has enabled them, they tell us, to demand change.  

Professor Sarah Hawkes 08:49

I think in terms of the positive changes that that we've seen Sarah or, you know, where we've been catalytic, we actually had an evaluation of the work of GH 50/50 undertaken by a great organisation called Gender at Work. And in the organisations they surveyed, about half of the organisation said that, that they found that our annual report helped shift in a positive way responses to equality, diversity, and inclusion inside their organisations. So we know that we are seeing some changes, because of the data, the evidence that's been put out in the, in the public domain. And as Kent has said, you know, that that evidence and data is being used by the two ends of the spectrum that we really hoped it would be used by. By the people with power at the top, who can kind of force change across an entire sector or catalyse change across an entire sector, but also by the young people coming into the workforce or already in the workforce, who are saying I'm not prepared to put up with the way things have been up till now I want things to be better, I want to work for an organisation that supports the equitable progress of my own career. So you we're seeing exactly what we had hoped would happen when we set out our first, without meaning to sound too academic about it, our first theory of change of what data might do.

Ms Sarah Goulding 10:32

Well, I can certainly speak from experience in my role as Vice Chair of the GAVI Board, we do share this report with Board members, we do talk about it at the Board. And it is influential in how we look at our policies around gender equality and diversity at the Board, but also in terms of staff welfare and policies. The thing that I was most struck by when you talked about in this report around sexual and reproductive health and rights, is that it sort of almost gets to that corollary of the good news of catalytic change and that dynamic to where that sticky floor is. Because if there's one element that we know is absolutely fundamental for gender equality, it's being able to control your own body. And then it's the having workplaces that recognise that. I mean, there was such variation in some of those measures. I think I remember looking and was it, Japan introduced menstrual leave in 1947. And then, and but there's Spain in 2023. And they're only some of a handful of countries where it's available at all. With this theme or with other themes, what are the spaces where you're seeing that change is hard, changes is stubborn, changes is slow? It's not moving? 

Professor Sarah Hawkes 12:06

Yeah, so it's a really good question, Sarah. And I mean, I think if I put it in the context of some of the core variables, what we have not seen, for example, is that is that in the absence of legal mandates, that organisations do not spontaneously report gender pay gaps, and that speaks to some of what you've just mentioned around a topic like menstrual leave, that this is not about the discretion of an individual organisation to decide whether or not they give you menstrual leave. This is about having a society-wide commitment to supporting and fostering workplaces that work for everybody. Whether that's through a menopause policy, or a menstrual leave policy, or the right to take time off because you need to deal with some other aspect of your sexual and reproductive health, that our position has always been that for, for those kinds of core areas, that this should not be at the discretion of individual employers, that this needs to be supported by a strong legal framework. And the gender pay gap is an area where that really is starkly illustrated for us, that we ended up only being able to report on the gender pay gap for those organisations that are based in countries where there is a legal mandate. And quite honestly, that just boils down to the UK at the moment because other countries don't have the same strength of a legal basis for reporting the pay gap. Some organisations, I mean a good news story is that, you know, some organisations have seen the value of something like a gender pay gap reporting and are now doing it within their organisations, including looking at pay differentials between let's call it headquarters and national offices in other countries. So you know, there is a shift there, there is a positive example there. In terms of sexual and reproductive health in the workplace, I mean, this was the first time that we had done this survey, and we would, I think, what we've shown over the years, is that there is a really important value in coming back to data, measuring it again, you know, we've essentially what we've just put out is a ground zero situation analysis, and we'll come back to it in a few years and say, okay, so what's the progress been? But where we would love to see progress is not just inside organisations, but in wider societies supporting, putting in place the measures to support equality in the workplace, and that that that's a much longer-term shift. 

Professor Kent Buse 15:17

So just coming in with a couple of shocking data points, though, from this year's report on SRHR in the in the workplace across the life course. We look at 200 organisations, all of which have female employees, have women that work for them, and only one of those 200 had a menstrual leave policy and only one out of those 200 had a menopause policy, so the baseline that we're that Sarah is talking about is one that it should be fairly easy to, to shake is the dial on. But I mean, Sarah’s other point is incredibly well taken, we strategically decided to focus on global health organisations. We ultimately would like to see this similar analysis done at country levels in ministries of health. But ultimately, as Sarah says, we’d like to foster demands for legislative change. And so Sarah mentioned the gender pay gap. But the same could be said arguably for paternity leave, that men won't take up that leave and share the caring responsibilities unless there's huge disincentives not to do it. So yeah, the floor is still sticky to use your analogy. 

Ms Sarah Goulding 16:43

Moving on, there was one section in your report, where you talked around the gender responsiveness of global health programmes. I think global health has been on a real gender equality journey. Because if you're doing something about SRHR, it's been very clear for decades, you know, that there's a fundamental relationship between that, and gender equality. You know, feels like, you know, maternal, child health, anything that sort of really around kind of practical needs of women, people have been able to make that connection. Anything a bit more, sort of at the level of the ecosystem, you know, the around sort of medical research, other things, it's been very gender blind. So, I mean, I'm just really interested in your perspective around the gender responsiveness of global health institutions and global health programming, because it does cross that traverse between institutions that are focusing on some very practical needs, but actually the majority of institutions that are looking at much broader, you know, things about engaging a public health system, but you're just as likely to have a conversation around pool procurement, or public financial management, as you are around, you know, their work health and safety conditions available for your employees.

Professor Sarah Hawkes 18:17

Sarah, this, has been the most challenging area for us to measure over the years. In terms of, you know, what do we mean by the gender responsiveness of policies and programmes that every organisation delivers for its beneficiaries? And we included it in there because actually, you know, that was our starting point, our starting point was we wanted to see the global health sector will be much more gender responsive in terms of what it delivers to its beneficiaries. And again, coming back to our conceptual framework, we really operated under the belief that there is a link between the gender responsiveness internally of an organisation and the gender responsiveness of what it's delivering to the outside, and that those two arms of an organisation's ethos are completely interlinked. But how do you measure gender responsiveness of what the organisation is delivering has proved to be very difficult from the outside. And partly because, you know, how do you compare the gender responsiveness of an organisation that's looking at patents, for example, to the gender responsiveness of vaccine delivery? So this year, for the first time, we actually decided just to focus on the question of sex disaggregated data. And we did that because it's the one more specific variable that we can measure across organisations, perhaps not for patents, but certainly for things like vaccine delivery. And that is one of the variables that over the years has been more difficult to shift, is the commitment to sex disaggregate programmatic data has been a very slow shifting dial. But the actual you know, the question of whether, not just are you disaggregating your data by sex and/or gender, but are you also taking a gender responsive approach to what you're delivering? We have found that tricky. And we have been engaging with different stakeholders to think about how we can measure that more specifically, because quite honestly, just applying the WHO Gender Responsiveness Scale, hasn't really proven to be very practical over the five, six years that we've been doing it. So some of the suggestions that have come through to us have been around things like, can we look at gender budgeting, can we look at actual financing and see whether we can actually start to assess programmatic delivery in terms of not just what the words on paper are, but where are organisations actually putting their resources, their financial resources in terms of gender responsive policies and programmes. So that for us is an area that that we really need to explore. 

Ms Sarah Goulding 21:40

I wonder where you think there might be changed for the coming years and about how organisations might change. But I might add to that, how you think the appetite for growing the evidence base is there that you're generating, that you're catalysing by surfacing some of these imbalances in the GH 50/50 reports. I'd love to hear your sense of what the future perspective is where you think you might see change and where that evidence might go.

Professor Kent Buse 22:14

Just following up on or making link between what you and Sarah were just discussing, around evidence, I think that it's true that the global health organisations aren't disaggregating their own data sufficiently, and they could do better. But I think that there is an increasing evidence base around, as you said, the gendered nature of risk factors. And the gendered nature of the health care cascade, if you want to call it that, or the pathway, that that data is available, and that the challenge really is bringing it together in a way that can tell stories that make it clear that there are not just these gendered disparities that you referred to. But there are underlying reasons for those disparities to be in place, including power. And I think that the more that that becomes apparent, that it will then become apparent that there needs to be research into gendered responses and how we can reap the gender dividend that Sarah spoke about. But I think that organisations with power in the sector have come to find that our data is useful. And that they will be able to shift things in a way that we can't, as a couple of academics, running a small outfit. But having said that, we're quite encouraged because a number of institutions have come to us and said, have you pulled together a good baseline in the health sector, and we can run with that now. And we will run with that now. And we'd encourage you to keep going. But can you now do the same thing in the judicial sector? Can you do the same thing in the women's economic empowerment sector? And so I think that we're getting to a place where we can make the evidence available, the evidence has, has been there in some ways, but it doesn't speak for itself, you need a systematic way of, of doing that. Having said that, and I'm going to turn back to Sarah, that the sticky floor, even in the health sector, there's these 25% of organisations that have consistently performed very poorly over six years. We named and shamed last year, for the first time. One of the organisations threatened to sue us. And we thought that that would be good for our cause. They decided not to. But we're hoping that with additional resources, for example, that we'll be able to engage in ways with 25% of the sample that hasn't shifted. So if we could talk to their Board Chairs, if we could talk to their CEOs, we might encourage them to shift as well. What are your thoughts on that Sarah?

Professor Sarah Hawkes 25:20

I mean, it's again, a really good question, Sarah. I think where it hopefully is going is really going back to where we started, which is what we've developed is an accountability tool, that is useful for the health sector, but not unique to the health sector. So as I said, you know, it can definitely be applied across all sectors. But equally, it's a tool that we've used once at national level. And we would really encourage, because we really think that, that where change happens for the vast, vast, vast majority of people is actually at national level or sub national level, it's not within this rather esoteric idea of this global system. So we're hoping to see more rolling out of this kind of evidence gathering at a national level as well. So you know, lots of ways that this tool that we have spent six years honing and developing can be rolled out to have more impact. That's the optimistic side. On the on the sort of slightly more cautionary side, I'd really like to come back to a question that you asked earlier on, it's around, you know, what's stopping us moving forward. And I do think that we're otherwise in danger of creating this notion of workplaces as a beacon of excellence as far as equality and diversity is concerned. Whilst for women in particular, what we know is that one of the biggest restrictions on women's ability to have equitable career opportunities, is what happens in the domestic space. So until we all sign up to also pushing for gender equality across all spaces outside of our employment, particularly when it comes to things like domestic labour, then we were simply not going to see the kinds of outcomes that we're all hoping to see, potentially, within our lifetimes.

Ms Sarah Goulding 27:41

A powerful moment to actually bring this conversation to a close on. Because I think we do all have a level of ambition, about how tools like yours can be catalytic for reform, to shift the sticky floors. And to break those glass ceilings. Not just because it means you get better, more effective, and better performing institutions, but you also have much better outcomes of the work that they do, that progresses global health objectives, and gender equality objectives and sees a health outcome and agenda outcome is actually two sides of the same coin. So I can't thank you enough for letting me have this conversation with you both Kent and Sarah.

Ms Sarah Goulding 28:47

Today we've heard from Professors Kent Buse and Sarah Hawkes, the founders of Global Health 50/50. You can find more information about Global Health 50/50 and the recently released 6th Global Health 50/50 Report in our show notes. During the episode, we talked in depth about the 50/50 report, the changes and trends they’ve seen over the past five years, and what the future holds for gender equality in global health. I hope you enjoyed this conversation. I’m Sarah Goulding. Join us in another fortnight for the next episode of Contain This.


Contain This is produced by the Indo-Pacific Centre for Health Security. You can follow Australia's Ambassador for Regional Health Security, Dr Stephanie Williams, on Twitter at @AusAmbRHS. You can also find that link in the show notes.