Opinion: Lessons from 17 years of trying to change the system

The depoliticization of global health is the equivalent of whitewashing. Global health is inherently political. It is about the value of people’s lives, not the lack of technical solutions.

For more than a decade, there has been a tremendous emphasis on accountability as the key to unlocking progress for the health of women, children, and adolescents. There have been commissions, expert review groups, independent accountability panels, and countless reports and events to bolster “accountability.”

What there has not been is any actual support for citizens to engage with policymakers and leaders of global institutions. Government representatives often refuse to share a global stage or attend an event unless they have prepared remarks from citizen representatives. This is fully backed up — and often created — by the United Nations’ partners in the guise of country ownership, yet it simply maintains the status quo.

More recently, we tried a different tactic. Rather than force our way through closed doors, we mobilized so many voices that leaders would have to listen. With hundreds of partners and community mobilizers, we asked women and girls around the world one open-ended question: What is your biggest priority for quality reproductive and maternal health care? More than a million readily told us “What Women Want.” Their responses should inform how policy, programming, and investment decisions are being made.

As we were preparing to release this gold mine of information, however, we approached important U.N., donor, philanthropic, and global institutions and asked them to commit to listen — and respond — to women and girls. They hedged. “It depends on what they say” was a common refrain. There was fear that the priorities articulated by women and girls may not be in line with the priorities that their learned experts had already decided to fund and operationalize.

We failed, and the system failed us. Grassroots organizations are repeatedly thanked for “grounding” policy discussions in the realities that communities face. And then everyone marches onward, promoting their top-down approaches, then lamenting the lack of needed political attention and investment.

The top-down frameworks that have been the hallmark of the global health and development sector and associated systems are not working. If we believe in accountability and that people know their community’s problems and the best solutions, we must invest in those people, listen to what they need, and fund their solutions. And it will make us successful.

We should begin by taking money that is used to produce performative global events and invest it in meaningful dialogues and people-led solutions. We need to turn the funding model around so that problems and solutions are first identified locally and then funded, rather than making grassroots organizations compete for prescriptive and project-based grant opportunities.

We need the proportionality of funding to shift toward movements pushing for systems-wide change, recognizing the reality that elected officials act when there is pressure from their constituents, not when a new global report is released. And we must truly link rights and health, instead of turning a blind eye to blatant human rights abuses by leaders who do something “good” for health.

Some groups are already making progress on this front. The Young Feminist Fund, for instance, is a grant-making organization that believes in “the collective power of young feminists to lead and transform their own communities.” They support innovative activists working on social justice in their communities in diverse geographies. With an average grant size of less than $6,500 — about what it would cost to send one person to a global event — it is a drop in the bucket of what is needed, but it’s a start.

Similarly, Merck for Mothers' Safer Childbirth Cities initiative supports community-led solutions that will help cities become safer and more equitable places to give birth. They are making this approach international and will be supporting coalitions in different geographies — funding locally generated solutions. Donors should get on board with this approach and finance solutions, even if they haven’t defined them.

And in the eight countries with advocacy efforts focused on What Women Want, more than 15 policy changes have been instituted; approximately $11.7 million in domestic resources were mobilized for reproductive, maternal, newborn and child health; more than 2,000 midwives were hired; and running water installed in 20 health care facilities. The loud demand from women and girls gave decision-makers a clear direction, a direction they knew their constituents fully supported.

At the individual level, meanwhile, each of us can do something — even if it is just one small action — every single day to help dismantle the power structures that are holding us all back. In recent years, I have pledged the following:

• To stop using language that perpetuates inequities and marginalizes people.
• To decline a speaking engagement where I am a “usual suspect” and advocate for someone who has not been heard.
• To listen more than I talk, if I’m in a decision-making role.
• To find and build connections to our work with other sectors, including those advocating for social justice, and actively support movements for the rights of all people.
• To refuse to script or censor advocates or protect those in power from the truth.
• To hold myself and others accountable within my organization.

These are not enough to truly transform our sector. That will take big institutions significantly shifting power and resources. But the chances of changing the system become exponentially higher if we all individually commit within our respective spheres of influence, using our collective power.