While many calls have been made to support the development of women leaders in global health [1, 2, 3], and to promote intersectional approaches , few resources have been developed, documented, and evaluated to meet this goal .
Savvy leadership in global health is of great importance now more than ever as we widely grapple with the colonial and patriarchal underpinnings of current global health practice and research . Men continue to hold the majority of leadership roles in global health, while 70% of the global health workforce are women . And in institutes of higher learning, public health (and global health) students continue to be overwhelmingly women. But women recent graduates, in comparison to their peers who are men, are not receiving formal leadership training . Women’s limited representation in leadership is compounded by the intersection with other factors including race, religion, caste, class, and ethnicity ; women leaders of different races are perceived differently, facing racial and gendered biases simultaneously .
As women continue to grow in the global health workforce, we must be better prepared to strengthen their leadership skills in preparation for cadres of women leaders who will propel the field forward.
In 2020, the Johns Hopkins Center for Global Health (CGH) launched a seminar series to explore the lessons learned from women leaders in global health. One clear theme that emerged across these talks was a call for more skills-building for emerging women leaders, particularly in essential skills . This call catalyzed the development of a 3-credit course on “Essential Skills for Women’s Leadership in Global Health” that was first offered at the Johns Hopkins Bloomberg School of Public Health, during its summer institute, in June 2021. This Institute is historically offered only in-person, but the ongoing COVID-19 pandemic provided an opportunity to develop the course for a synchronous online audience (including students from Australia, Thailand, and Ethiopia, who might otherwise not have been able to join).
The development of the course was broadly guided by our speakers’ lessons learned in leadership. These lessons were collated and key themes were extracted to identify critical areas for learning and development, including following a passion, not a plan; building bridges, not dams; and strengthening leadership skills . Existing leadership competencies for global and public health, where available, were reviewed to cross-check curriculum for critical gaps but were not explicitly used to guide the course development. The goal throughout course development was to establish a course that transformed the lessons learned from our seminar speakers into skills-oriented materials and exercises that could promote the growth of leadership skills for women in global health.
The course was designed to limit the amount of time spent on lectures and maximize active participation, skills-building, and reflection; all lectures were accompanied by at least one activity. Efforts were made to diversify the range of voices included in the course—in addition to lectures by core teaching faculty, students were asked to listen to podcasts and webinars given by a diverse and global set of speakers. The final day featured a panel of women leaders from Nigeria and India with experience across Africa and Asia.
The content domains covered in the course included an introduction to the state of women’s leadership in global health; leadership theories, models, and frameworks; self-awareness and implicit biases; communication (about oneself, one’s work, and with others in a team); and negotiation. Table 1 shows the domains, topics covered, and associated activities.
|DOMAIN||DIDACTIC TOPICS||RELATED ACTIVITIES|
|State of GH Leadership and documented barriers for women leaders||Women’s representation in leadership
Priority setting in global health
Gender bias and discrimination
Networks and Mentorship
Case Study—the Glass Cliff
Final day panel of speakers
|Leadership Theories, Models, and Frameworks||Historical leadership theories/styles (i.e., trait, behavioral, contemporary)
|Polls and discussion
Case Study—Inclusive leadership
|Organizations and Enabling Environments||Organizational culture and climate
Segregation and stereotyping
Queen Bee phenomenon
|Identifying leadership values
Group leadership SWOT
Implicit Biases—“Traits” of Women Leaders
Freedom to Fail
Discussion—share a failure and lessons learned
|Communication||Gender and communication
Communicating about ourselves
Developing teams through communication
|Negotiation||Benefits of negotiation
Approaches to negotiation
|Discussion—experiences with negotiation
Case study, practice, and debrief
Prior to the first day of the course, students were asked to complete one or more self-assessment tools and reflect on their results, either individually or with members of their personal and professional networks. We selected both free and paid tools that focused on leadership skills , authenticity , and emotional intelligence  and could prompt students to reflect on their strengths and weaknesses. This self-reflection formed the basis of many subsequent conversations and set a tone for ongoing reflection and awareness.
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 .
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 .
We then tackled three specific ‘essential skills’ for leadership including self-awareness, communication, and negotiation.
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.
The Johns Hopkins School of Public Health sent standard end-of-course surveys to students immediately after the course ended in June. Each student has two weeks to respond, and the data is aggregated to maintain confidentiality. Of the 21 students enrolled in the course, 14 responded to the school’s survey, a response rate of 67%.
The course received excellent ratings overall. The course organization was rated as excellent (n = 11, 78.6%) or good (n = 3, 21.4%). The class assessments (tests, papers, etc.) were rated as excellent (n = 10, 71.4%) or good (n = 4, 28.6%). The other item evaluated through this traditional method included that the course expanded knowledge related to the topic and improved skills (excellent, n = 11, 78.6%, good, n = 3, 21.4%). The respondents also rated the instructor and teaching assistant highly.
We designed a qualitative follow-up survey via Google Forms to obtain more feedback from students about their experience with the course and its content. This survey included six open-ended questions (included in Table 2), was designed to take less than 15 minutes to complete and was circulated six months after the course, in December. This study was approved by the Johns Hopkins Bloomberg School of Public Health Institutional Review Board. Twelve students (57%) responded to this survey.
|1.||Please tell us where you are in your career, and how this course was applicable to this stage of your career.|
|2.||What elements of the course surprised you and your understanding of leadership, and yourself?|
|3.||Overall, what did you get out of the course?|
|4.||What else might you have needed from the course, in terms of skills, ability to implement the material, and any other forms of application?|
|5.||What are ways in which you are envisioning applying the content you have learned in the course?|
|6.||What recommendations do you have for us if we were to offer this course in other settings and contexts (in-country and globally)? Specifically, in an international context (outside of the USA), which elements of the course would be applicable; which ones do you think would not be applicable?|
We reviewed the data using a qualitative content analysis approach . Responses were analyzed into meaning units, condensed meaning units, codes and then finally themes. The themes were grouped to reflect the number and types of comments. As the themes were reviewed, a number of strong thematic elements emerged across all of the questions.
Unsurprisingly, the most common theme was related to leadership skills, competency, and the use of introspection to better understand the student’s innate leadership style. The class enjoyed learning new leadership skills and understanding how their own leadership has an impact on their relationships at work.
I’m in senior leadership, and the class asked me to re-examine leadership styles in context of gender--it was really helpful in thinking through how much I have been socialized to behave in certain ways.
I have 3 years of experience, and was thankful to have this insight at the beginning of my career. I immediately tried negotiating my salary after the class ended, and am excited to see the impact play out in the rest of my career.
Just being aware of the glass cliff has helped me more critically reflect on opportunities that I have been presented and those that I see other women tackling.
Another common theme involved relationships with more senior women; the class identified a need for mentoring in their own careers and in the context of negotiations. Networking and interacting with other people during the course was valuable to participants. They found the course content around negotiations, glass ceilings, and maternal cliffs compelling and one student commented that the course was “life-changing.”
I am in a leadership position in my organization and unfortunately experienced a “maternal wall” situation. This course helped me understand my value and how to better negotiate and navigate as a woman in the field for myself personally, as well as to better mentor those I work with under these same learnings.
Another important theme was related to storytelling and learning new skills to share knowledge and information in the workplace. Learning to tell their own stories from a new perspective and in the context of gender and leadership was meaningful to students.
The coaching portions were insightful. It was nice to be able to mentor others and I did not realize I had as much as I did to offer, like helping others negotiate, or sharing my story.
Some students indicated they would like more information about global contexts and international work communities. They had concerns about strong patriarchal societies around the globe and wanted strategies for working within those communities. They also wanted more time in the course to explore these complex interpersonal dynamics and would have enjoyed role-playing some scenarios. They also desired additional time with self-reflection, networking and having more access to mentors, formally assigned as part of the course.
The course was great. I think it would have been nice to have more networking within the group, but it was challenging not being in person to do so.
After the course was completed, students were asked to consider the ways in which the course would impact their professional lives. Students expressed gratitude for the information and expressed interest in sharing their new perspectives with others in their fields and countries.
I am constantly applying the coaching and communication techniques we learned in my daily life professionally, academically, and personally. The course was also timely in that I learned negotiation skills several days before receiving my new job offer and attempting to negotiate. While I was not able to gain additional compensation due to HR policies, I felt comfortable advocating for myself and asking for more than was offered.
One student answered that the class had value in demonstrating “that I wasn’t the only one thinking about certain issues, that it is up to ourselves to stand up for us, that sexism prevails in a bigger way than once thought.”
We have seen growing global interest in promoting women’s leadership in global health, and organizations such as WGH and WomenLift Health have gathered large followings. Our own virtual network for emerging women leaders, established in Slack, has gathered 780+ members in the past year alone. We also know that women leaders in different contexts are facing similar challenges. We have an opportunity to respond to this interest to meet the needs of emerging women leaders globally.
Existing leadership programs in global health focus broadly on the many competencies needed to succeed in global health, from “essential skills” to “technical skills [18, 19].” This course recognizes that opportunities for gaining content expertise and technical skills are more widely available (i.e., through degree programs and online training) than leadership training . Long-term global health fellowship programs that incorporate leadership components (i.e., Fogarty Fellowships, Global Health Corps, Sustaining Technical and Analytic Resources [STAR], and Afya Bora) can also require long time commitments and may be less widely accessible for individuals in various stages of their careers. A recent assessment of the STAR training also identified an important skills gap among participants related to gender equity, ethics, and health equity and social justice . This course represents an opportunity to offer a gender equity-oriented leadership curriculum to those who may need it most and in early stages of the leadership journey.
Moving forward, we seek to adapt this course to other settings to serve as a resource for emerging women leaders in global health to gain skills relevant to their career paths. Based on the evaluations, engagement with the literature on best practices, and our own discussions, we propose approaches for future iterations and adaptations.
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 . 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 . 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.
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 , 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 . 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 . 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.
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) . 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 .
Resources to advance women leaders in global health are sorely lacking and this course on essential leadership skills provides one training model for institutions to support emerging women leaders. Participants discussed the value of having a diverse set of voices participate in the course and enjoyed the emphasis on discussion, reflection, and skills-building. Future iterations, even if offered in specific countries, should maintain the incorporation of diversity, sharing, and storytelling.
The authors would like to acknowledge the course participants, our guest speakers, and panelists, all of whom contributed to the diversity of voices that made this a unique and valuable experience.
Johns Hopkins University PhD Professional Development Initiative.
The authors have no competing interests to declare.
All authors had access to the data and a role in writing the manuscript.
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