Devex CheckUp: The global health boy’s club

As the Commission on the Status of Women kicks off this week, we’re reminded that efforts toward gender equity exist on increasingly shaky grounds.

I co-moderated an event on Monday, hosted by Women in Global Health, looking at the status of women’s leadership in the sector. The verdict? It’s a very mixed bag. Some areas have seen much progress — with women leading at the highest echelons of power, and others have inexcusable gaps.

One prominent example is the experience of WGH’s interim executive director, Dr. Magda Robalo. In 2023, Robalo was the highest-ranked candidate for the top job at Africa CDC. But after an opaque process, without debate or board involvement, a man was chosen instead — with no explanation.

“I’m sure you followed the nomination of the director-general for Africa CDC, where a blatant situation of a mix of women’s leadership, politics, etc., came into play,” Robalo said during the event. “You have a first-ranked woman for a position — then the system comes and tells you that it does not work that way.”

This was the first time I’ve heard Robalo speak about the situation — and the timing felt particularly fitting given the event’s focus. Women comprise 67% of the global health and social care workforce, but hold only a quarter of leadership positions. 

“You need every single day to give yourself the strength to challenge the norms,” Robalo said. “My message to younger women is: really persist, build your resilience, believe in yourself, and then establish a support network of people who help you navigate the challenging infrastructure that was built to prevent women from leading.”

And it’s not just Africa CDC; other corners of the global health architecture are marred by these practices. Precious Matsoso said she was “quite aggrieved” during the pandemic treaty negotiations, particularly during the early days of setting up the Intergovernmental Negotiating Body bureau.

Matsoso served as cochair of the INB for the treaty and former chair of WHO’s executive board. She’s also the former director-general of South Africa’s National Department of Health.

“In the INB Bureau, I was the only woman,” she said. “In this day and age, one would have expected that in the creation of these structures, there would have been a deliberate and intentional approach.”

Matsoso and others repeatedly pushed back, which ultimately led to gender balance at the bureau when there were rotations. That included two women cochairs at the moment the treaty was adopted.

She noted this problem also existed for the International Health Regulations working group, which at one point had one woman and at another point, no women on it.

But she said she’s also been encouraged by women's leadership across Africa, including Robalo’s tenure as Guinea-Bissau’s minister of health, and noted that in Geneva, most ministerial diplomatic health attachés during the treaty negotiations were women.

“There’s been this conscious effort to bring about the balance — but it’s inconsistent. In some instances, there’s progress, in others, we kind of regress a bit,” she said.

Related op-ed: The lack of women in global health leadership has a cure

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A healthy swap

Speaking of Africa CDC, its director-general, Dr. Jean Kaseya, has his eye on a pot of money that could help fill in the continent’s health financing holes: Debt. More specifically, he wants to see more of Africa’s debt canceled — with that money redirected to health programs. A process known as debt swaps.

To help make that happen, Kaseya has tapped Christoph Benn — director of global health diplomacy at the Joep Lange Institute — as a special adviser.

Benn is a leading expert on this. While working at The Global Fund to Fight AIDS, Tuberculosis and Malaria, he helped establish a mechanism known as Debt2Health. Since then, the Global Fund has executed 14 debt swap agreements, converting $470 million in debt into about $330 million in health funding.

But scaling up these deals is easier said than done. Benn tells me the negotiations can be complex and painfully time-consuming, which can be a heavy lift for already stretched government ministries.

Part of his new role with Africa CDC, he says, is to help smooth out those hurdles.

“What the intention of our collaboration is to make the mechanism as easy as possible and kind of minimize the transaction costs,” Benn says.

Read: Africa CDC eyes debt swaps to plug health financing gaps (Pro)

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Back in the game?

To say the Trump administration has had a rocky relationship with NGOs would be putting it mildly. Administration officials have accused some of operating with “perverse incentives” to “self-perpetuate.” While previous American administrations leaned heavily on funneling health aid through NGOs, the Trump administration has taken a different route in signing bilateral deals instead, leaving many wondering where NGOs will fit in — if at all.

But in recent days, the Department of State has provided some clarity. DOS launched a new platform meant to support projects that reinforce and fill gaps in the implementation of the bilateral agreements. And somewhat surprisingly — given the accusatory rhetoric — NGOs are eligible to apply for the funding of up to $4.5 billion — alongside faith-based organizations, companies, universities, and government entities.

Read: US launches $4.5B platform inviting NGO support for bilateral health deals

ICYMI: US State Department signs first Western Hemisphere bilateral health deal

The fine print

On the topic of those bilateral health deals, one major point of frustration has been the lack of transparency. Details are scarce, which is fueling confusion — and concern — among the public about how their tax dollars will be spent and where their data will go.

Zimbabwe’s government said it ultimately said no to the deal after Washington asked for "comprehensive access” to what it described as “sensitive health data." There’s also been reporting that U.S. negotiators sought access to mineral resources as part of the discussions. 

But I got hold of a U.S. statement provided to local reporters in Zimbabwe last week that tells a different story. According to a U.S. official, Zimbabwe walked away from the negotiating table without warning. “No policy or political concerns were relayed to us. The government then notified us it was ceasing negotiations without stating why,” the official stated.

The American official added the negotiations “did not contain any provisions related to critical minerals, neither explicitly nor implicitly,” and that in line with “standard global practices,” the agreement would have included collection of “anonymous, aggregated health data” — stating it’s the same kind of data Zimbabwe has already been sharing through PEPFAR.

Zimbabwe’s government hasn’t responded to my requests for more information.

Background reading: US template for bilateral health deals bypasses WHO pandemic negotiations

Related: Alarm bells ring as US rolls out transactional strings for health deals (Pro)

Risen from the ashes

One of the many casualties of U.S. President Donald Trump’s second term had been the Demographic and Health Surveys program.

Last year, the global health community was dealt a heavy blow when Washington canceled a $236.8 million contract with ICF, the company that administered the DHS program. For four decades, U.S.-funded DHS surveys have been one of the world’s most important sources of population-level data, helping shape health policies and research.

But now the program is back — with $39 million from the Gates Foundation. I spoke with the ICF team, who told me that while the program is operating again, it won’t look the same. The team is smaller, the budget is tighter, and the focus is narrower. They’re also leaning more heavily on new technologies to create efficiencies.

And there’s another big shift. With USAID dismantled — and no longer serving as the bridge between DHS and country governments — the program now has to do much more of its own outreach. The team is also working to diversify its funding base, hoping to never again be so dependent on a single donor.

Read: Demographic and Health Surveys reemerge with Gates funds after Trump cut (Pro)

What we’re reading

Health experts warn of long-term respiratory and neurological risks from American and Israeli strikes in Iran. [The New York Times]

As flooding ravages Kenya, the government warns of water and vector-borne disease outbreaks. [MSN]

In an opinion article, Gavi, the Vaccine Alliance CEO Dr. Sania Nishtar raised the alarm that AI has “radically lowered” barriers to developing genetically engineered bioweapons. [Project Syndicate]