Kent Buse: Tackling global health policy and gender inequality one paper at a time

Kent Buse is the Chief of Strategic Policy Directions at UNAIDS. Although he calls himself a ‘relative latecomer’ to Twitter, he currently ranks in the Top 20 position on the UN Social 500 Leaderboard for using his personal social media accounts to share the work of the UN with the public.

Emily Robinson asked Mr. Buse to enlighten us about his work with the UN and to share his unique perspective on communicating through social media. A lightly-edited version of the transcript appears below.

1. Tell us a little bit about yourself, Mr. Buse. Where are you from? Where did you go to school?

I grew up in Sudbury, a mining town in the ‘near-north’ of Canada. I never graduated from school as I found myself busy with other pursuits. It is perhaps surprising that even though I was a high school dropout, I managed to get to enjoy such a privileged career, among other things teaching at Yale University.

I was lucky that my parents provided a rich education through books, travel and the company they kept. And after dropping out of high school I spent 8 months on a cultural youth exchange. I had the good fortune to live in a remote village on Flores island in Indonesia, that had neither electricity nor running water. It gave me an appreciation of daily life with a loving family that practiced subsistence agriculture and animism. That experience drove my interest in development; to try to understand why such hard-working people were so materially deprived. I went on to study international development at the University of Toronto and then, after working in Nigeria and founding a composting company, did a Masters degree in health policy and financing offered by the London School of Economics and the London School of Hygiene and Tropical Medicine (LSHTM). Eventually, I returned to the LSHTM for a PhD in policy analysis which examined how power relations between government and donors in the health sector impacted the health sector agenda in Bangladesh.

It just goes to show that curiosity, drive, and serendipity can play a determining role in life and that the idea of a linear and predictable career trajectory is not the only one.

2. You have spent a good amount of your career working in academia, what are your main areas of expertise?

I am a political-economist with an interest in the politics of health policy. I studied a wide range of issues from government-donor interactions, to the governance of public-private partnerships, to the political economy of pro-poor health sector reform to policies and the politics of sexual and reproductive health and rights.

But it is really health policy analysis that I am best known for – thanks in part to my textbook, Making Health Policy, which is widely used in schools of public health around the world. I remain engaged as a co-investigator in a few academic projects, typically providing policy analysis training and advice. I am particularly excited about a six-country study funded by the UK Medical Research Council which is trying to explain the gap between countries’ policies on non-communicable diseases and the World Health Organization’s recommended evidence-informed ‘best buys’ policies.

My academic career has been defined by the synthesis of concepts and ideas into tools that people, whether they are policy-makers or activists, can use to tackle real-world problems; problems that typically have asymmetries of power at their roots.

3. How did you get involved with UNAIDS?

I had long been fascinated by UNAIDS, which was established in response to an understanding that the social determinants of vulnerability to HIV were many and varied. While WHO had a role to play in the AIDS response, so too did a number of other UN agencies. As the UN’s first Joint Programme, UNAIDS represents an experiment for the UN to work in a radically new way, uniting not only multiple UN organisations around a single complex issue but also the formal representation of civil society on its Board, side by side with UN member states. It was a bold idea. So, when Michel Sidibé was appointed to lead the organisation in 2009 and asked me to join him, I jumped at the chance. 

Of course, neither HIV nor the AIDS response is not unique: most diseases require joined-up approaches across sectors, particularly if the goal is to prevent them. But the idea of UNAIDS as a joint programme, and not as a stand-alone agency, was 20 years ahead of its time. One of the things we have been advocating for at UNAIDS is for similar multisector approaches, and engaging civil society, to accelerate progress across the entire Agenda 2030 for sustainable development.

5. Can you tell me a little bit about your work with UNAIDS?

I feel extremely fortunate to serve as an advisor to UNAIDS Executive Director Michel Sidibé. We have worked together on an exciting range of issues across the AIDS response, global health, and social justice more broadly.

Michel pioneered a new and inspiring vision for the global AIDS response: Zero new HIV infections; Zero AIDS-related deaths; and Zero discrimination. Later UNAIDS brought the idea of ending the AIDS epidemic as a public health threat in the context of the Agenda 2030. Such bold and ambitious agenda-setting was different from anything that had come before in the UN and faced considerable resistance. Michel has also advocated for urgent, time-bound people-centred results – like eliminating new HIV infections among children. These kinds of people-oriented goals provide alliances and their leaders a challenging but achievable effort to rally around – working to transform business-as-usual approaches and ultimately people’s lives on the ground.  

Together we have developed two global AIDS Strategies – which involve highly consultative processes to reconcile the latest scientific evidence, programmatic realities, the politics of UN member states and the demands of an activist global civil society movement representing, men who have sex with men, drug users, sex workers and especially people living with HIV. UNAIDS really is at the center of rights-based approaches to development, which makes the work particularly rewarding. I have supported Michel Sidibé to lead in the negotiations of two UN political declarations on AIDS, as well as processes to adapt our UNAIDS Joint Programme business model to the evolving development cooperation landscape that transitioned from the MDG to the SDG era.

And the AIDS response has learned lots of lessons that should inspire and inform approaches to tackling and ending other diseases – namely the importance of rights, participation, activism, addressing the social determinants and harnessing science for people.

6. I see you published a paper called ‘Addressing the theoretical, ethical and practical challenges inherent in prospective health policy analysis’ – can you tell me what it is about and why you wrote it?

Retrospective policy analysis tries to understand why an issue got on the agenda and why a policy came to take the particular form it does. Prospective policy analysis uses tools to understand how best to get a policy in place – how to shape it – often in a complex and contested space.  

Too many people still think that evidence speaks for itself and that pro-poor, evidence-informed policy will be adopted once policymakers ‘see the light’. That might be an appealing notion, but it is naïve given the political nature of policy change: those stakeholders with something to lose will work hard to keep the issue off the agenda or develop other policies to maintain and further their interests.

The paper argues that global goals, such as the SDGs, provide the legitimacy to pursue pro-social justice objectives with like-minded groups, and also provides a roadmap for thinking and acting politically to bring about change. In effect, you could argue that it is short-sighted or even counterproductive to encourage countries to set super ambitious targets but fail to help them manage the politics inherent in achieving them.  It is a political science paper in the service of social activism, and as such, in my mind, it is perhaps one of the more important of the 100 or so papers I have published. 

7. You are a co-founder of the organisation Global Health 50/50. What are the main goals of the organisation?

I set up Global Health 50/50 with Professor Sarah Hawkes, the Director of the Gender and Global Health Center at UCL in London, who is also my partner.  We had long attempted to draw attention to both the gender dimensions of health determinants and the fact that global health is staffed by women (think community health workers, midwives, nurses and increasingly female doctors around the world) and governed largely by men (with a smattering of elite women, mainly from the global north).  This message had fallen largely on deaf ears; for decades gender has been the dirty little secret of global health.

With the #SheDecides movement in full force, Sarah and I thought we had a golden opportunity to take our message out of academic circles and to get it in front of funders, policymakers and policy implementers. We established an impressive advisory council of well-connected gender champions, such as Jan Beagle, the Secretary-General’s choice for managing UN reform, Bience Gawanas, the Secretary General’s special advisor for Africa, as well as a number of young gender activists who also wanted to see more accountability for gender equality in global health. Supported by a team of volunteers, we produced the first-ever report on the gender-related policies and practices of 140 global health organisations. Writing in the Foreword to the GH5050 inaugural report, UN Deputy Secretary-General Amina Mohammed argued that similar analysis on gender equality should be conducted across every development sector.

8. You launched your first report last month, were there any findings in that report that you found particularly surprising?

We were struck by how few global health organisations make an explicit commitment to gender equality and that among those that do, so few define what they mean. Too many organisations continue to conflate gender with women. Having said that, it is shocking that in 2018, only 20% of board chairs and CEOs of global health organisations are women. The report makes for disturbing reading. It has a great interactive data base and features 19 recommendations. We are very encouraged that a number of these organisations have contacted us to discuss ways of improving their practice.

9. What is the main message that you would like people to take away from work of Global Health 50/50?

We were very pleased with the response to our first report. Richard Horton, the Editor-in-Chief of The Lancet, described it as a landmark report in the history of global health. Helen Clark, who a for long time topped the leaderboard of UN Social 500, described GH5050 as an accountability tool that was sorely lacking in global health. I think that there are the two takeaway messages: first, gender equality needs to become the new normal; second, the evidence shows that gender equality can become the new normal (as the leading organisations attest), but it is likely only to materialise with bolder leadership and stronger mechanisms for accountability.

10. You’ve been high in the UN Social 500 leaderboard since you joined back in 2017. Do you have any top tips for getting the most out of social media?

The UN Charter famously starts with the words ‘We the people…’ More than websites and press releases, social media is an essential tool for the UN to communicate with millions of people about what it does and what it tries to achieve. With the increased transparency that the UN Social 500 demands, I hope that more people will have a real-time understanding of what the UN does. Hopefully, greater understanding will lead to enhanced trust in the UN system and renewed public support for multilateralism. 

Communicating my work outside of the bureaucracy is one of my motives to dedicating time (too much according to my family) to Twitter. Beyond transparency, social media is of direct and practical benefit to my work in at least three ways, by enhancing my exposure to 1) people; 2) products; and 3) protest.

On the first issue, many people complain that social media has become an echo chamber. While I fear they are too often correct, I have ‘met’ and developed productive relationships with many like-minded people via Twitter. Social media has greatly expanded the network of people with whom I collaborate and strategize in real-time. More and more of these include people whom I have never met face to face, but with whom I now collaborate on pushing agendas, pursuing research and publishing papers.

As for new products and ideas, my Twitter feed brings a torrent of new papers, reports, vlogs, and new perspectives on issues on a rolling basis. Filtering can pose a challenge, but I continuously find useful new content. I also love having access to live tweeting from events and like to make a contribution by doing the same, whether it is reporting live from the UNAIDS board (the official feed is typically 6 hours late) or on the speech by the UN Secretary-General.

For protests, my Twitter feed takes an excellent pulse on how communities are responding to global and local events. It complements the mainstream media in a qualitatively different way. While there are those that deride clicktivism, it does provide an outlet for protest (and spun more positively, advocacy).

At this point in history, it’s true that for many people, if ‘it’ doesn’t exist on social media, ‘it’ doesn’t exist at all. Hyperbole and post-modernism aside, I am surprised that more of my colleagues have yet to appreciate the need to invest more in a social media presence – they are only slowing down our efforts to make the UN a system fit for the 21st century.

11. Why did you decide to join the UNSocial500? Do you find it has benefited your work?

Kudos to Toby Beresford for setting up UN Social 500 back in 2015 to promote the visibility of the UN. I am a relative latecomer to Twitter, but I can see the benefits of the platform in at least three ways. First, as mentioned earlier, any incentive to get UN staff to communicate with the public in a way that the public engages ought to be supported. Second, the Social 500 leaderboard gives a sense of the extent to which people are interacting with my postings (or not) – and as such it provides some measure of interest and possibly impact in terms of shaping perspectives. Third, a little friendly competition is a great motivator for some people, because you can never have enough people commenting or retweeting the tweet of the day – especially if it’s your own ?.