Increasing Women in Leadership in Global Health

Worldwide, nearly one million young women die each year due to maternal complications, breast cancer, or cervical cancer—deaths mostly preventable in resource-rich settings.1 Women in sub-Saharan Africa have a lifetime maternal mortality risk of 1 in 31, one hundred-fold higher than women in wealthier regions.2 Maternal deaths particularly devastate families: children whose mothers die are three times more likely to die than other children.3 Neglect of women’s health is causally related to discrimination in access to education, employment, and economic opportunities.4 Due to high rates of preventable mortality among women in resource-poor countries, women’s health is a central focus of global health. Of the eight Millennium Development Goals established by the United Nations to eradicate extreme poverty by 2015, two specifically target women’s health.5 We define global health as a multidisciplinary field of service, research, and training that seeks to improve the health of both individuals and populations and to achieve health equity for all people worldwide, especially for the resource-poor.6 Given the importance of women’s health to global health, it is surprising that female leadership in the field is sparse. For instance, women constitute only 25% (14/54) of African ministers of health and 24% (12/50) of directors of global health centers at the top 50 U.S. medical schools. We espouse the principle stated recently by Anne-Marie Slaughter in The Atlantic: “Only when women wield power in sufficient numbers will we create a society that genuinely works for all women.”7 While a gender gap in leadership exists in many fields, including government, business, law, and education, the gap in global health is particularly troubling because women’s health and reducing unjust health inequalities are central to the field. Closing the gender gap in global health leadership will not in itself solve all women’s health problems. But it is an overdue first step. The potential benefits of female leadership have been cogently demonstrated in development work. A recent study in India examined neonatal mortality by district, comparing only districts in which an elected official of one gender defeated a politician of the opposite gender by a margin of <3.5%, based on the assumption that the gender of the elected official in these very close elections is “quasi-random.” Investigators showed that, for every one standard deviation increase in the number of female-held seats in the district council, neonatal mortality dropped by 1.5%.8 Women leaders were also more likely to support health facilities, antenatal care, and immunizations.8 Another study in India exploited the randomization created by a 1993 constitutional amendment that required rural villages, based randomly on a village’s longstanding administrative number, to have or not to have their village councils headed by a female leader. After controlling for multiple confounders, investigators demonstrated that women tended to invest in public works more closely linked to women’s concerns, such as clean drinking water, while men invested in works more aligned with men’s concerns such as irrigation systems for farming.9 Ten years after the implementation of these random leadership assignments, adolescent girls in the villages with female leaders received significantly more education, had higher job aspirations, and spent less time on domestic chores than girls in the villages without female leaders.10 A similar study in rural Afghanistan showed that women living in villages that had been randomly assigned to a program requiring 50% female council representation, compared to women in villages without the requirement, were significantly more likely to generate their own income and to rate their village leaders as acting in the best interest of the entire village.11 These field analyses and others support the principle that leaders’ genders influence both their decisions and the welfare of women in their jurisdictions.12–14 Based on this tenet, we believe that striving for gender parity in global health leadership will affect global health policy and practice. In this article, we investigate reasons for the female leadership shortage in global health and propose solutions. We focus on academic global health as an example, recognizing that global health is a broad field additionally encompassing disciplines such as human rights, development, and politics. We draw on both the literature and our experience in Africa and the United States. The training pathway for academic global health typically begins with an advanced graduate degree (MD, PhD, MPH, etc.) followed by postdoctoral field work and, ultimately, a career in academia, government, multilateral, or nongovernmental organizations. Global health careers for individuals from resource-rich countries usually require a significant time commitment to international field work. Individuals from resource-poor countries frequently must travel abroad long-term to obtain graduate education and advanced training. Additionally, the field of global health necessitates a broad skill set including scientific capability, facility with foreign language, cultural sensitivity, flexibility, diplomacy, leadership, team-building, and physical stamina to work in remote resource-poor areas.