The Alliance Lift is a series that spotlights the journeys of Alliance alumni shaping health systems around the globe. In this Q&A, Ms Idil Shekh Mohamed, host of the Alliance Lift, speaks with Professor Asha George, the South African Research Chair in Health Systems, Complexity and Social Change at the University of the Western Cape. A globally recognized qualitative researcher, Professor George examines the interface between communities, health workers and health systems through lenses of governance, gender and human rights. She also serves as the Alliance’s 2025 Thinker in Residence, supporting reflection on how the field of health policy and systems research can engage more intentionally with gender equality.
Idil spoke with Asha about how early work shaped by global commitments on women’s rights influenced her approach to health systems, what she learned from working within her own health system in India and why she believes health workers’ lived realities must be more central to health systems research and practice today.
In this interview, also available as a video and podcast, Professor George reflects on the importance of listening to voices that are often marginalized, addressing silences that have become normalized within health systems and building alliances that connect evidence to action.
Learning from the past
Q: You began your career working in Mexico with government ministries and UN partners to advance the Cairo and Beijing agendas? What did you take away from being part of that movements and how did it influence your work today?
The Cairo agenda was an international conference that pivoted the frame with which we saw family planning. It really looked at women’s empowerment and gender equality as being key to family planning and contraception. It was one of those moments where the paradigm shifted and women’s experiences, women’s voices and gender equality were put as a fundamental foundation for talking about sexual and reproductive health. There were sections also addressing the role of men in advancing gender equality. And the Beijing agenda was a culmination of different meetings that happened over time – the women’s movement working to affirm women’s rights as human rights and advancing key tenets about gender equality being a global commitment.
I think it was a very unique time, in which there was so much mobilization by civil society. There was an opening – a demand that government open itself up. There were both government negotiations, but also civil society platforms. It was incredible to hear directly from the women’s movement what were the issues that were concerning them and how do we get it onto government agendas.
There were many consultations – listening to women’s voices from the ground, but also understanding how do we broker a more inclusive way of shaping policy. And I think that’s critical today as well, as inequality is so much more than it was even then.
Q: You returned to India to do your PhD, looking at health systems on maternal health from a gender equality and rights perspective. What drew you back to India at that point in your career?
I’m an Indian citizen that grew up in Mexico, and I felt if I was going to work in public health, I felt very strongly I had to work in my own health system as well. I’ve never been someone who has learned from books alone. It couldn’t be theoretical. I had to be based in my own health system and that’s why I went back.
I chose a programme that would allow me to work with key mentors. They were researchers, but activists also. They did research because they were concerned about changing health systems to make them more just. They are the ones who taught me public health, and that privilege to be able to work with them across many different initiatives – many of which were not funded – really marked my time in India. We collaborated because it was the right thing to do, and funding came as we worked on these issues. When you are passionate about certain topics, you connect with people and you create an agenda for change together. Those ten years have created a foundation I always go back to, and I have a huge debt to all those people.
Q: You served as editor for the Alliance’s 2017 Health policy and systems research reader on human resources for health. When you think back to that reader, what would you say was most significant about it?
We really pushed the boundaries in terms of looking at health workers as human beings themselves and not just as robots or inputs into a bigger log frame that leads to better health outcomes. They are critical actors in a social system – they’re social beings themselves. The reader helped to reframe how we look at human resources for health. Even the term “human resources for health” is very instrumentalist.
It was also an incredible opportunity to develop the reader in a very consultative way. We shaped the outline consultatively, and we had various webinars where we invited input. We invited people to send their favourite articles – it was a process of public engagement itself. In the end, it’s not just the reader, it’s the process of engagement as well in bringing so many people together to input in developing a knowledge output like that.
Living in the present
Q: Human resources for health is one of those building blocks that seems like a perennial challenge, but it’s not discussed much these days. Why do you think that is?
It is one of the profound paradoxes of our time that the key actor that underpins our health systems is often overlooked, underpaid, under-supported. And it is predominantly female at the lower levels of the health system, where you have the most interface with patients, users and communities. A lot of their work is not just delivering vaccines, giving out tests and giving out tablets. It is also about human connection with community members.
How do we put a human face on those health workers? How do we affirm their humanity and empower them as forces for change? There are many frameworks that look at why the health workforce isn’t more productive, or that focus on quality and standards. But fundamentally, at its core, is how do we affirm the dignity of health workers themselves?
Q: What does the gender lens of the Imarisha consortium bring to the field and how can it help us expand what we think of as central to health systems research?
Imarisha means strengthen in Kiswahili. We can’t talk about strengthening primary health care unless we look at health workers, and a gender lens to that means understanding them in their full totality – so it’s not just looking by gender, but by age, by health worker profession, by how they’re in the labour economy. We have to unpack the many different dimensions of who makes up our health workforce to support them more.
One role of Imarisha is to put a flashlight on who these health workers are and what their daily lived experiences are. One daily lived experience is facing violence. It’s striking to me that there’s such a gap in our scholarship. It’s tacitly understood. Every health worker I’ve spoken to in South Africa, or policy-maker, can recall vividly an experience of violence, and yet we don’t acknowledge this experience as being fundamentally traumatic.
And yet there’s a normalization of it, and there’s a complete silence. A gender lens, a feminist lens, is about giving voice to people, but also tackling those silences – looking at what are the topics that are not spoken about and trying to understand why, and how do we work with health workers and managers to address them.
Q: You mentioned there is a gap in the research when it comes to the lived realities of people working within health systems. When it comes to influencing research, as well as agendas and policies, what would you say is most key in being able to do this work?
A lot of the interventions to date come from psychology and are about what kind of counselling and training opportunities we can have to help health workers cope better. But the role of health policy and systems research is to change the frame. There needs to be a paradigm shift because it can’t be just helping victims cope with the violence they face. We need to build alliances to prevent violence, address it, stop it – and look at what the system has to do to support individuals and not leave them to handle this on their own.
We need the numbers, but we also need the stories and the voices of people. When something has been normalized and accepted, we need more than numbers. It’s also the alliances that bring people together in brokering knowledge to impact change. Different groups are working in their own silos, so health policy and systems research has a role in creating connections to have policy impact.
Levelling up for the future
Q: We’re in a moment where gender equality, sexual and reproductive health and rights-based approaches are facing renewed and coordinated pushbacks in many parts of the world. What does health policy and systems research as a field need to prioritize in this climate?
The pushback has broader structural determinants. Health policy and systems research can help us understand what’s behind this campaign, including its political origins.
If we are about defending universal health coverage and universal access to services, it means we need to stand up for gender equality. Gender inequality shapes whose rights and needs are being recognized, including adolescent health. In certain countries, policies for adolescent health have not been passed because of this pushback, and yet in many contexts a very large share of the population is young. How can you have a health system that doesn’t represent their interests? Where are their voices?
Health systems now more than ever need to remain open, not be undermined by this pushback and stand up for sexual and reproductive health services for adolescents, gender-affirming care and services such as HIV and mental health that LGTBQI+ people need, especially when they have been discriminated against. The health system, much broader than health services, is a key way of addressing the social determinants of health and making sure people don’t fall between the fault lines of inequality that has widened so much today. Given the attacks against these marginalized groups, health system researchers and actors now more than ever need to be allies to those defending gender equality, as well as sexual and reproductive health and rights, as central to universal health coverage and primary health care. These are not separate agendas, but ones that are deeply intertwined.
Q: Thinking about the next generation of researchers entering health policy and systems research, especially those passionate about these topics, what kind of institutional, structural support would help them to thrive?
For me, research is a force for action, for change. So who are you doing that research with? It’s a twinning process of bringing academic rigour and being embedded in larger processes. Who are the activists? Who are the movements looking to affect change – and making sure you are in conversation.
It’s not just a paper you’re producing. If your work is to matter, to make sure health systems are a force for change, it means being connected to those who are at the coal face of affecting change in health systems.
And what’s really important is spending time developing relationships in the health systems where you’re located. Having networks and relationships helps build trust, resilience and flexibility to respond to emergent innovations and unanticipated collaborations you can support. But you can’t do that if you’re just in a place for six months then moving to another place. You really need to build relationships and understand context.
Q: Before we close, is there any final thought or message that you would like to share with listeners?
If I look back on my career, some of the things that were incredibly meaningful were ideas and connections with people that didn’t happen with funding. It happened because we identified a gap, brought people into the conversation and created a collaboration, which then later got funding.
Not everyone has the privilege to do that, but you have to seize the opportunities as they come and the connections you can forge, and shape the funding opportunities that come, rather than waiting for a funding window to open. It’s about making connections, collaborating, being creative to make that change.
