Leadership: A Health Determinant Worth Funding?

Leadership and governance is one of six building blocks the World Health Organization uses to define a functioning health system, alongside financing, workforce, service delivery, information systems, and medicines. It is a determinant of health outcomes, in the same technical sense as income, education, or access to care — not a line item to tick once a year in a grant report. Every dollar or rupee a funder puts into a diagnostic platform, a clinical trial, or a delivery program is also a bet on whoever is deciding how that money gets spent. So why don’t we invest in leadership in health as a strategic lever, alongside R&D, policy, and systems delivery?

That bet rarely gets asked, because health investment is evaluated mostly on what it delivers — products approved, services reaching more people — and barely on behavioural competencies such as leadership. Those metrics are real, but they capture only half the story. The deeper question, one investment committees rarely ask, is who decided what the research would study, what the innovation would optimise for, and whom the delivery model would assume it serves. And do we have enough of such responsible leaders to begin with?

That decision is shaped by norms most institutions never examine. Katherine Hay and colleagues argue, in a landmark Lancet analysis, that gender norms permeate health systems in ways rarely acknowledged but regularly reproduced. Left uninterrogated, these norms are present across the value chain of a health system, including the funding decisions that shape which proposal gets resourced in the first place.

The cost shows up in health outcomes. For decades, women of childbearing potential were routinely excluded from early-phase clinical trials — a precaution that hardened into habitual exclusion long after its original justification faded, and medicine continues to treat the male body as default, the female body as variation. What if a funder had decided, instead, to invest in leadership in health — so that downstream health programs were inclusive and responsible from the start? McKinsey Health Institute estimates that closing this gap could add roughly $1 trillion to global GDP by 2040 — a return no funder would leave on the table in any other asset class.

A study at the All India Institute of Medical Sciences, New Delhi, led by Pragyan Acharya, examined sex-based differences in serum creatinine — the marker used to diagnose acute kidney injury in liver failure — and found that men had higher baseline levels, yet women who developed the injury showed sharper rises from their own baseline. Since diagnostic thresholds are mostly uniform, the finding raises an uncomfortable question: when we assume neutrality in diagnostics, are we quietly treating male physiology as the norm?

That question rarely gets asked because so few of the people setting thresholds are women — over 70 percent of the global health workforce, but fewer than 25 percent of its senior leaders. Closing that gap takes leadership on both sides of the funding relationship. For a funder, exercising leadership means treating investment in leadership as the intervention itself: recognising that funding a program or a trial while ignoring who leads it is not a neutral choice. For the leader receiving that investment, responsibility means something more demanding than representation — questioning the status quo a threshold was built on, and redesigning the structures inherited from someone else’s assumptions so they work for the bodies they were never built to see.

That redesign takes Authentic Leadership: leaders who bring their own lived experience into the room and are willing to ask whether a threshold built for one body can really describe two. Representation without that conviction becomes box-ticking in funding documents; authentic leadership is what turns representation into insight, and insight changes outcomes when leaders rewrite protocols rather than sitting at the table where they are written.

None of this works if leadership is treated as a given. It is not a resource that, once funded, keeps producing results on its own, and it erodes the moment a renewal cycle deprioritises it. Most funding committees still treat investing in leadership as a target — a gender marker, a panel quota — rather than a determinant to manage deliberately. Such an approach to funding needs to change, especially when budgets shrink, because that is when responsible decisions matter the most. 

In practice, that means investing in responsible leadership in health as its own budget line; mandating sex-disaggregated data as a condition of the grant, not an optional appendix; funding the validation of diagnostic thresholds for sex-specific performance as part of the research budget, not a separate ask; and treating a pipeline of women leading science and policy as core to the health investment itself, not an adjacent grant competing with the “real” program for funding.

Treating leadership as a determinant of health outcomes takes effort on both sides: funders investing in it as deliberately as they invest in a diagnostic platform or a delivery program, and leaders using it to question inherited assumptions rather than simply occupy the room. When a woman’s symptoms are dismissed or mismeasured, the failure is institutional, and further upstream, a funding one — the result of a portfolio that budgeted for the diagnostic, the trial, and the delivery model, but never for who would lead them. Any investment in health research, innovation, or delivery is already, implicitly, an investment in whoever decides what it studies, optimises for, and assumes. The only real choice left to a funder is whether to make that investment on purpose: to put leadership on the same term sheet as the diagnostic and the delivery program, as a strategic input in its own right, not an afterthought to either.

The above information is the author's own; Outlook India is not involved in the creation of this article.