State of women’s leadership in global health

We began the course with a discussion on the current state of women’s representation in leadership globally and how that affects priority setting in global health. Students were introduced to the concept of the glass cliff—where women tend to be promoted to leadership roles during times of crisis when chance of failure is more likely. Other well-documented barriers to women’s leadership including structural inequities, gender bias and discrimination, sexual harassment, the myth of balance, and reduced access to networks and mentors were also described and discussed [13].

Leadership theories, models, and frameworks

With this background, we explored leadership theories, models, and frameworks and their applications to women’s leadership specifically. Modern theories including authentic leadership and inclusive leadership were discussed in-depth, including drawbacks and critiques of these theories as applied to women in global contexts. Because of the course’s focus on global health, we included content on cross-cultural leadership, and recognized that leadership approaches don’t work well in all contexts and for all types of organizations.

Leadership does not occur in a vacuum, so we believed it was critically important to discuss the role of organizations and enabling environments in supporting (or hindering) women’s leadership globally. We differentiated between organizational culture and climate and discussed examples of organizational segregation and stereotyping (i.e., gender, racial, ethnic). We also introduced two phenomena that affect women’s leadership and careers: the maternal wall—the discrimination mothers face in their jobs and in searching for employment, and the queen bee phenomenon, a derogatory term applied to women leaders who are seen to distance themselves from junior women [14].

Building essential skills

We then tackled three specific ‘essential skills’ for leadership including self-awareness, communication, and negotiation.

1. Self-awareness—In addition to the initial self-reflection assignment, we also spent time in class discussing implicit and explicit biases related to gender and race and the role of awareness in reducing women’s susceptibility to negative effects. Students described personal experience with imposter syndrome (feelings of self-doubt despite evidence of the contrary). We further explored how people rarely have an accurate assessment of their own skills and capability, falling somewhere on a continuum between overconfidence and uncertainty. We also explored biases within self-assessments describing their fallibilities, proposing solutions, and discussing the importance of continuous self-reflection as individuals change over time.
   This domain also explored ‘failure’ as a concept related to leadership growth. We shared stories of our failures, the pivotal lessons learned, and the simultaneous fear associated with failures (in spite of their immense benefits).
2. Communication—Communication was divided into three sections: a) communication about yourself to others, b) team communication (i.e., active listening), and c) communicating as an expert about a specific topic. Language and communications play a role in how we understand gender; gender roles are evolving and changing but traditional roles still persist in communication styles.
   To practice communicating about themselves, students were asked to prepare a short elevator pitch introducing themselves by defining the purpose of their pitch (the why) and describing their value proposition or uniqueness. We encouraged students to use a storytelling approach to align their goals with the goals of their target audience. We also spent time discussing the value of networks and how increased contact, effective communications, and strong relationships can increase the likelihood of being remembered or considered for leadership roles.
   We then explored team building through communications and using communication tools to effectively manage and maneuver diverse teams. Here we focused on active listening, “listening with the goal to develop a clear understanding of the speaker’s concern and to clearly communicate the listener’s interest in the speaker’s message [15].” We discussed barriers to active listening (i.e., presence, perceptions, and verbal communications) and strategies to overcome these barriers. Students were then placed into groups of three and worked together, through active listening, to set a leadership agenda or identify a problem statement. The goal was not to find a solution, but rather to arrive at a better understanding of a core problem.
   Given the ongoing COVID-19 pandemic and onslaught of misinformation we felt it was important to build skills in science communication, considering gender and sociocultural barriers and stereotypes. We discussed power dynamics in global health, the type of knowledge that is valued [16], and how we might elevate the voices of women, BIPOC, non-binary, trans, and marginalized communities within global health. In small groups of three, students were asked to present something related to their current scientific work; teammates then asked questions, using an interview-style approach.
3. Negotiation—We described the benefits of negotiation as a leadership skill in terms of team management, collaboration generation, and salary, and presented core concepts in negotiation (i.e., anchoring). Students were given a case study and assigned specific roles and perspectives (i.e., job applicant or hiring manager). In groups of two, students then negotiated a starting salary and other terms of employment. We collated results from each team, discussed the process, and future negotiation strategies.

Throughout the course, discussion reigned supreme. We used polls, guiding questions, virtual white boards, breakout rooms, and plenary debriefs to give students a range of mechanisms for participation and sharing.

Contextualizing material

Implementation science recognizes “context as king,” noting that an intervention’s content and its process (i.e., how it is delivered, and by whom), must be tailored to specific contexts to meet local needs [21]. We recognize the essential value of context in course material and propose to develop country-specific examples and case studies, use local/national/regional statistics, and invite local guest speakers to share their stories. We also believe it is important to incorporate anti-oppressive teaching principles in course delivery mechanisms to address power differentials and colonialism [22]. This includes co-creation of leadership competencies, materials, and delivery approaches with in-country partners, interactive and equal participation opportunities regardless of social status, regional origin, and culture, as well as opportunities to lead in the local setting. As students noted, it is important to recognize existing systems and the extent of the patriarchy within those systems so that discussions and recommendations are not tone-def. For example, this could include expanding the traditional meaning of “women leaders” as women who lead “over” men, instead developing context for women as leaders in their own right, in their many roles. Additionally, negotiation materials should be tailored to local negotiation cultures and approaches, currencies, and reasonable salaries.

Training Instructors and recruiting students

Local instructors and/or facilitators should be involved in the development and delivery of the course (via a training-the-trainer approach [ToT]) given their intimate knowledge of the local context. In a recent Good Health Research Practice (GHRP) training [23], the organizing committee engaged local facilitators not only to provide assistance more easily, but also to bridge with the instructors and other facilitators from different countries with different backgrounds. Involving local instructors builds capacity to lead courses and hold leadership training independently in the future.

ToT approaches have been widely used in global health but with varying success; while ToT is assumed to be self-sustaining, this is not always the case [24]. Identifying the right candidates, providing long-term resources (i.e., funding), and integrated nurturing/development opportunities are needed to sustain ToT models and support new trainers [24]. We propose that future adaptations plan for long-term partnerships, connect instructors and students to existing networks, and offer a mentorship component. Mentorship has been widely lauded as a valuable tool that can support career growth for women in global health [25, 26]. We propose incorporating a mentorship model for local instructors and students.

The selection of participants from varied backgrounds can help increase awareness of marginalized voices in this classroom, such as women from remote areas and groups with disabilities. Our students reflected on the value of the diversity of voices and range of experiences represented in the classroom, and that networking was therefore inherently built into the course. We note, however, that the student selection process will likely face biases both because of those making the selection and the smaller percentage of women from remote areas who might hear about the course or be able to attend. Some strategies for inclusive recruitment include partnering with other schools, ministries, local organizations, and community health worker groups to advertise as broadly as possible (and in local languages).

There may also be opportunities for programs to formally embed this course into existing global health curricula. This allows students to take the course for credits that can be applied to their degree or certificate program.

Modified and additional approaches

Based on course feedback and our subsequent discussions, we also identified approaches to modifying existing curriculum and activities. This includes ensuring students are paired/grouped from different settings to increase knowledge exchange and to create local communities of practice (CoP) that can foster continuous sharing and storytelling. This CoP can be linked with other existing CoPs locally, regionally, and/or globally to grow students’ networks, and as an open opportunity to recruit future instructors for local courses. Given our own access to a virtual Slack networking space, we also discussed providing dedicated linkages for students to this network. For example, students could be provided dedicated Slack channels for networking or discussing course content, within the larger Slack workspace. This approach sensitizes them to the process of engaging virtually, adds Slack to their arsenal of virtual tools, and provides ongoing connection within classmates beyond the scope of the course.

Coaching is an important part of releasing a leader’s full potential and while we discuss the value of coaching in the course, and practice active listening, there is not yet a formal coaching process. Certified coaches could provide coaching to trainees as part of the curriculum, allowing them to connect their day-to-day experience with the training components. This can support goal setting and establish environments in which emerging leaders are solutions-oriented. The benefits are many: students receive direct benefits from coaching that can be applied to their leadership journeys immediately; local trainers can collate lists of local coaches, establishing a cadre of certified go-to coaches; and course participants can spread coaching values within their own workplace and begin to assist others on their teams.

Studies also support the use of shadowing as a pedagogical approach that helps studies build critical competencies including communication, teamwork, respect for other professions, and introducing new roles (i.e., leadership) [27]. Course participants could be connected with local, regional, and/or national women leaders as part of the course and given an opportunity to shadow their day-to-day activities. This would provide learners unique opportunities to observe critical leadership abilities in action and ask questions.

Many of these suggestions, though, including student recruitment, the community of practice, mentorship, coaching, and shadowing, take remarkable time and financial resources to implement. Senior leaders who participate in the program must be incentivized and appropriately compensated for their time and energy. This is particularly salient for women of color, who are overwhelmingly and historically burdened by expectations of “volunteer” labor or service to their institutions [28].