Symptoms of a broken system: the gender gaps in COVID-19 decision-making

### Summary box

A growing chorus of voices are questioning the glaring lack of women in COVID-19 decision-making bodies. Men dominating leadership positions in global health has long been the default mode of governing. This is a symptom of a broken system where governance is not inclusive of any type of diversity, be it gender, geography, sexual orientation, race, socio-economic status or disciplines within and beyond health – excluding those who offer unique perspectives, expertise and lived realities. This not only reinforces inequitable power structures but undermines an effective COVID-19 response – ultimately costing lives.

By providing quantitative data, we critically assess the gender gap in task …

A growing chorus of voices are questioning the glaring lack of women in COVID-19 decision-making bodies. Men dominating leadership positions in global health has long been the default mode of governing. This is a symptom of a broken system where governance is not inclusive of any type of diversity, be it gender, geography, sexual orientation, race, socio-economic status or disciplines within and beyond health -excluding those who offer unique perspectives, expertise and lived realities. This not only reinforces inequitable power structures but undermines an effective COVID-19 response -ultimately costing lives.
By providing quantitative data, we critically assess the gender gap in task forces organised to prevent, monitor and mitigate COVID-19, and emphasise the paramount exclusion of gender-diverse voices.

RETREATING TO THE NON-INCLUSIVE DEFAULT MODE OF GOVERNANCE
The global community was unprepared as COVID-19 struck. As a result, countries swiftly established expert and decision-making structures through traditional processes: reaching out to government ministry directors, prominent experts and heads of well-known institutions. Most of these positions are typically held by men, as evidenced by our analysis of 115 expert and decision-making COVID-19 task forces from 87 countries: 85.2% of identified national task forces (n=115) contain mostly men, only 11.4% contain predominantly women and a mere 3.5% exhibit gender parity.* Similarly, 81.2% (n=65) of these task forces were headed by men (table 1).
Men were overrepresented in global task forces to a similar extent to that of national task forces (table 2). For instance, the WHO's first, second and third International Health Regulations Emergency committees consisted of 23.8%, 23.8% and 37.5% women, respectively. Expert groups, compared with decision-making committees, more frequently had higher proportions of women or gender parity, reflecting potential societal biases and stereotypes in terms of gender Summary box ► Despite numerous global and national commitments to gender-inclusive global health governance, COVID-19 followed the usual modus operandi -excluding women's voices. A mere 3.5% of 115 identified COVID-19 decision-making and expert task forces have gender parity in their membership while 85.2% are majority men. ► With 87 countries included in this analysis, information regarding task force composition and membership criteria was not easily publicly accessible for the majority of United Nations Member States, impeding the ability to hold countries accountable to previously made commitments. ► Lack of representation is one symptom of a broken system where governance is not inclusive of gender, geography, sexual orientation, race, socio-economic status or disciplines within and beyond health -ultimately excluding those who offer unique perspectives and expertise. ► Functional health systems require radical and systemic change that ensures gender-responsive and intersectional practices are the norm -rather than the exception. ► Open, inclusive and transparent communication and decision-making must be prioritised over closeddoor or traditional forms of governance. ► Data collection and governance policies must include sex and gender data, and strive for an intersectionality approach that includes going beyond binary representation in order to produce results that are inclusive of the full gender spectrum. This analysis was based on a large-scale effort collecting data on COVID-19 global and national decision-making and expert bodies for 193 UN Member States through a crowdsourcing effort, targeted grey literature searches, and outreach to national governments or World Health Organization (WHO) country offices. Data collection was completed June 2020. Gender was determined based on prefixes, pronouns and online bibliographies (table 3). Most information pertaining to task force construction, leadership and membership criteria (eg, expertise) was not easily accessible nor publicly available, impeding research and, ultimately, the ability to hold countries accountable to previously made commitments.

THE DEFAULT GOVERNANCE MODE IS LOSING OUT ON KEY PERSPECTIVES AND EXPERTISE
While current evidence suggests direct COVID-19 severity and mortality is higher for men, women are disproportionately burdened by compounded social and economic impacts. 1 2 Decision-making bodies which are neither inclusive nor diverse can easily overlook the reality that COVID-19 acts as a multiplier of pre-existing gender-based inequities. Many governments established COVID-19 response measures which disregarded women's higher levels of income loss, expanded and unpaid family care responsibilities, and gendered poverty rates. Ignorance of these implications exacerbates (lifetime) poverty and hunger. 3 Response measures often do not account for women's increased exposure to domestic and sexual violence or their loss of access to essential health services. Furthermore, many lockdown policies do not consider maternal and reproductive health service as essential care. [4][5][6] Experiences from Ebola and Zika demonstrated rises in maternal morbidity and mortality, unwanted pregnancies and unsafe abortions. 3 Despite being publicly praised with hollow applause, the majority of COVID-19 frontline health and social workforce are women who are underpaid, unpaid or are not recognised as essential at all. Failure to adequately provide resources and personal protective equipment exacerbates disease transmission and disproportionately harms workers in the health and social care sectors, which are predominated by women. 7 The situation is even more dire for marginalised individuals, such as those identifying as non-binary, transgender or genderqueer, as they are forced to navigate the discriminatory impacts of gender-based quarantine guidelines, which authorise specific days when women or men are allowed in public. As seen in Panama, this often led to harassment, abuse, arrest and fines of transgender people who were wrongfully profiled. 8

EFFECTIVE CHANGE CALLS FOR BOLD SOLUTIONS
The exclusion of women and gender minorities stems from a host of factors including inherent conscious and unconscious biases, discrimination, workplace culture and gendered expectations. Unfortunately, this is not new. Although women comprise 70% of the global health workforce, they hold only 25% of senior decisionmaking roles. Women from the Global South are particularly underrepresented at global level holding less than 5% of senior leadership roles. This exclusion creates a vicious cycle where perspectives and knowledge of large segments of the population continue to be excluded. 11 12 One cannot expect a different result by replicating this same broken cycle over and over again. A 'new default' mode of diverse and intersectional governance is sorely needed to face future crises head-on and guide a healthy and equitable COVID-19 recovery. Reaching a critical mass of women in leadership -even as result of intentional selection or quotas -benefits governance processes through the disruption of groupthink, the introduction of novel viewpoints, a higher quality of monitoring and management, more effective risk management and robust deliberation. 13 Interestingly, countries with women leaders have been associated with implementing particularly effective COVID-19 responses and have been better at reducing COVID-19 negative impacts (fewer deaths per capita, a lower peak in daily deaths and lower excess mortality). A recent study indicated that countries with women in positions of leadership suffered six times fewer deaths from COVID-19 as countries with governments led by men. 14 Recognising the effectiveness of countries led by women may help in understanding the underlying prerequisites of effective leadership. Societies who elect female leaders may share a different set of values and perspectives, including gender equality, than more traditional societies. 15 Countries where women lead seem to have political institutions and cultures that have prepared for inclusive governance being practised prior to COVID-19, influencing their COVID-19 response.
Gender quotas can establish a standard to redress inequalities in the public realm and enable more effective decision-making through gender parity. Increasing women's representation is a key step towards addressing inequalities-but it cannot stop there. 16 17 More women in leadership positions does not necessarily lead to changes in social norms nor does it guarantee the genderresponsive, gender-mainstreamed policies needed to mitigate the gendered vulnerabilities of pandemics. Women are not automatically gender-inclusive advocates, nor are men inevitably gender-exclusive. 17 18 Furthermore, gender intersects with additional factors that act as significant barriers to healthcare access and participation. This requires recognising inequities across ability, race, income, ethnicity, class, religion and geography, and intentionally prioritising programmes and resources  20 Claiming to not find any qualified women in global health is ultimately an unjustifiably poor excuse for excluding diverse perspectives. Systemic and cultural change must address traditional norms and attitudes, and embrace holistic gender-mainstreaming practices. This deep-rooted change is critical to ensure that health services and policies mitigate the adverse socio-economic impacts of COVID-19 and adequately meet the needs and safety of all populations. 17 21 GOING FURTHER THAN GENDER BINARIES Despite employing colloquial binary terms such as 'men' and 'women' to denote gender, we reiterate that gender is non-binary, socially produced, self-identified and complex. In a non-pandemic scenario, we would have sought to conduct a survey to self-identify gender, with appropriate ethics review, privacy and data protections in place. By relying on binary definitions of "gender," research initiatives (such as this one) and governance, emphasise the inability of current data to produce results that include the full gender spectrum. This means an entire segment of the population is misrepresented and side-lined from policy decisions that affect them. Promoting and integrating mechanisms that ensure inclusive intersectional data collection is one of the systemic changes needed for fair governance.

INCLUSIVITY AND TRANSPARENCY SHOULD BE AT THE CORE OF THE 'NEW NORMAL'
Our data exhibit what has become a disturbingly accepted pattern in global health governance. Collective efforts in policy-making continue to overlook opportunities to create inclusive and comprehensive decisionmaking, echoing gender inequalities in other areas such as academia and the sciences. 22 The COVID-19 pandemic response requires inclusion of diverse perspectives, experiences and expertise in global health leadership. First, international and national task forces need to ensure diversity, particularly across gender, but also in terms of ethnic, racial, cultural, geographic and disability groups

BMJ Global Health
in decision-making and expert advisory bodies. Increasing representation and gender parity is a first step, but functional health systems require radical and systemic change that ensures gender-inclusive and intersectional practices are the norm -rather than the exception. Second, quick action in emergency scenarios is repeatedly used as a justification to sidestep transparency and restrict communication in the name of health security. Crises are precisely when transparent procedures and clear communication are required the most. Rather than relying on closed-door governance, open and transparent communication and decision-making should become the norm. Third, data collection and governance policies need to go beyond binary representation in order to produce results that are inclusive of the full gender spectrum. A future with resilient health systems depends on radical action to establish decision-making groups that reflect the populations they represent, in the time of COVID-19 and beyond. Leaving these voices unheard today sets a precedent for continued silence in the years to come.