Having studied political sciences and governance, I have always been interested in power. Where are decisions made, who holds veto powers, who has influence?
I have worked in global health and development for over 15 years, and what increasingly bothers me is how divided our community is. There is a small group of „insiders“ who hold immense power over policy-making, funding, and the overall institutional set-up of global health. And then there‘s „the rest“, or the „outsiders“, who debate policy and decisions, and try to influece these.
I have worked on both sides throughout my career, and perhaps surprisingly to some, felt that there was a thought leadership void on the inside, and feel like there is immense thought leadership on the outside. Sadly, these two groups or circles seem to be nearly fully disconnected from each other.
On the „inside“, most discussion and interaction is inward-facing. It‘s an intense and also competitive space, and most people simply lack time to look beyond to see what else is being said and proposed. Interesting artciles are rarely circulated or debated, and very few people have time to follow discussions taking place or points made elsewhere. There‘s also some arrogance involved: having made it to the inside, many people feel more powerful, and „better“. They have insider knowledge, what is being proposed by the outside is dismissed as „ignorant“, and organisations on the outside (eg academia, think tanks, NGOs) are viewed as not as professional or as high in status.
This is not to say that there is no thought leadership inside power houses. But it is limited to the few, and suffers from a lot of yay-saying and lacks richness in diversity and debate. Those few who try quickly get pushed (or crushed) to tow the line of the status quo. I have to admit that I found it quite stifling at times.
Being on the outside again, I‘m in awe how much thought leadership is out there. Think tanks and individual academics are pushing boundaries, and unearthing difficult issues that challenge our impact as a community. There‘s a great deal of discussion and also collaboration, and people build on each others‘ ideas.
Sadly, very few people from the outside are heard or even known of on the inside. Just look at who sits in or provides input to board meetings, who is consulted on policy-making, who sits on panels, and whose articles are shared. Even those 2-3 people I can think of who regularly hob-nob between these spaces, primarily as moderators, are rarely listened to for their own opinions or content. Hence, only a tiny trickle of thought leadership gets through from the outside to the inside. Even less is shared from the inside to the outside, as the pull inside is nearly fully inward-facing.
The consequences of this divide are dire, including:
– Knowledge, experiences, analysis and proposals for change are not heard or taken into account by those who make decisions; a lot of important information is not taken into account
– Discussions and decisions lack diverse perspectives (especially from low-middle-income countries, ie LMICs, as has been well emphasized recently; but also from academia or CSOs), resulting in some unsuitable policies or such that address only narrow issues or needs
– Information on uptake or implementation challenges that could be shared and resolved upstream in policy design are not taken into account, and result in poor outputs and waste
– Top-down policies and decisions fail to get the support of broader communities, who could have played important advocacy, network, legitimacy and support functions
– Many previously learned lessons or experiences from other contexts are ignored, and the wheel is often reinvented.
I am strongly of the opinion that something has to change in the way we work and interact in global health. Inclusion and diversity are important to drive this change. But we also need to look at incentives and how work is structured, especially in „inside“ institutions. If all leadership and staff targets are focused on the organisational level, there is no incentive (or time) to look beyond, or learn from others. There is no incentive to strengthen policy design and decision makig to have real impact.
For the „outsiders“ (and this currently includes myself), we need to go beyond talking about change to truly advocating for it. This requires skills to build bridges to influencers and decision-makers, and build real partnerships for change. We‘re also stuck in our own bubble, but may not yet have fully realized it.
Connecting these two spheres in global health is not easy. Insiders face very different constraints, and are drilled to avoid risk and anything that could provoke funders. Outsiders are not a homogeneous community, and need to organize better to have more influence and access.
But if we fail to connect these spheres, global health policy and decision making, as well as funding, will continue to be a small insider game, and suffer from lack or diversity and intellectual poverty. The cost will be its impact.