Enabling Women To Lead In The Health Sector: It’s Time To Fix Inequality, Not Women – Health Policy Watch

Afghan women health workers.

The COVID-19 pandemic was a stress test for the health sector, which is one of the fastest growing economic sectors in the world, and also one of the largest employers of women. Women are 70% of the health and social care workforce and 90% of nurses but they are clustered into jobs that are lower paid, often unpaid, and given lower social status.                   

In a recent report by Women in Global Health, Subsidizing Global Health, we calculated that six million workers worldwide are in fact propping up health systems with their unpaid and grossly underpaid labor. This is cause for concern in the context of the WHO’s recent estimation that there is a projected shortfall of 10 million health workers by 2030.

Cause for further concern is the fact that though the default health worker may be female, women hold only 25% of senior decision-making roles in health and that pattern has continued in the pandemic.

In a previous survey by Women in Global Health, it was calculated that 85% of national COVID-19 task forces had majority male membership. Despite their exceptional contribution in responding to COVID-19, women do not have an equal place in decision-making in health systems and there is evidence that they have lost ground in health leadership and governance since the start of the pandemic. 

This is a loss to women, but also to health systems that lose out on the professional knowledge, talent and perspectives of the women who are experts in the health systems they largely deliver.

Women excluded throughout history 

While women have had roles in healing and birth, they were often excluded in the health sector.

If leadership jobs were awarded on merit, we would see more women leaders in the sector. Why then are women the minority of health leaders? History matters. For millennia women were traditional healers, makers of herbal remedies and birth attendants. 

Despite this, when medicine was formalized as a profession in Europe and North America, it was established by men as a profession for men, and women were formally excluded from training and practice.  

That practice spread throughout the world as modern medicine and medical schools were established, again excluding women. Women fought their way into medicine but in some countries, it took until the 1940s before the first woman was able to graduate and practice as a doctor. 

The barriers were very different for women in different countries, with women from minority races, ethnicities, castes and other disadvantaged social groups still fighting to overcome the gendered obstacles to entering medicine and higher status occupations such as surgery.  

Legacy of exclusion remains 

The legacy of the formal exclusion of women is reflected today in women’s place in the sector.  Even in countries where women first broke into medicine, the legacy remains. 

In the US, only 18% of hospital CEOs are women and only 17% are full Professors of Medicine. In Canada, 63%  of medical students are women, 41%of doctors but only 12% of Deans of Medicine. 

Women still face ‘glass ceilings’ in their career progression while the small minority of men in nursing are said to have ‘glass escalators’ that take them to the top quickly, leaving their women counterparts on the ground floor.

COVID-19 exposes gender inequity 

Women continue to work on the frontlines of the pandemic unprotected by vaccines.

COVID-19 has been a major shock to health systems, economies and societies. It has exposed the deep inequalities within and between countries. 

Although many people in high-income countries speak as though the pandemic is over, the Africa Centres for Disease Control reported in May 2022 that only 17%  of people in Africa were fully vaccinated. Significant numbers of health workers in Africa, mostly women, are still working on the pandemic frontlines unprotected by vaccines. 

A recent Women in Global Health report also noted that over six million women health workers are working unpaid or grossly underpaid.  A systemic shock as big as COVID-19 must prompt us all to consider the value of health and the value of the women who largely deliver health services.

We know how to close the gaps

In the health sector, a majority of health workers are women.

The gender gaps in leadership, pay and career progression in the health sector are wide, but we know how to close them. In some science, technology, engineering and mathematics (STEM) sectors the issue is to attract women into the sector. 

This is not the case in health since women are already the majority of health workers, especially in younger age groups. A study by the World Health Organization found that in 104 countries, the majority of doctors, nurses, midwives, pharmacists and dentists under 40 years of age were women. 

These trends show that women are keen to enter the health sector and their numbers are increasing everywhere. The gender imbalance in leadership clearly, however, will not just come into balance over time. 

‘Action, not evolution’ 

Women make up 75% of the global health workforce, but hold only 25% of senior positions.

It will take intentional action, not evolution, to ensure women have an equal place in health leadership.  We can enable women to succeed in leadership by focusing on four areas:

First, by building the legal and policy foundations for equality: Governments must create the legal foundation to enable women to engage equally with men at work. 

This will include laws to support women’s rights to equal pay and decent work, protection of women from violence and harassment at work and the removal of all barriers to women’s participation in work. Minimum wage legislation and support for collective bargaining will enable over six million women working unpaid and grossly underpaid in health systems, to enter formal labor market jobs where they can progress in their careers.  

Governments must enable girls to finish second education and more.

In many low-income countries, governments must enable girls to finish secondary education at the same rate as boys so they can enter tertiary education and professional training. Poverty and low levels of education limit women’s access to formal sector jobs in health. 

The pandemic has blighted the education of a generation of girls in some countries. We must create routes back into education for girls whose schooling has been interrupted.

Second, we must address the social norms and stereotypes that drive gendered segregation in the health workforce and place lower value on professions that are majority female. Gendered stereotypes of occupations and of leadership as a “man’s role” take hold long before people join the workforce. 

These stereotypes encourage men and women to enter different occupations in the health sector, with women typically entering nursing and more men entering surgery; and they also disadvantage women in leadership. 

A 2020 United Nations Development Program survey in 75 countries found around 50% of men and women believed men make better political leaders than women, while more than 40% felt that men made better business executives.  The same study found that bias against gender equality is rising, especially amongst younger men, with a backlash recorded in Sweden, India, South Africa and Romania. 

We must pay attention to the education of our young men and women if we are to build equal and strong societies as we emerge from the pandemic.

Women do not need to be fixed, they need to be supported and given opportunities to enter leadership roles.

Third, we must address workplace systems and organizational culture. Interventions in the past have focused on ‘fixing women’ by training them in self-esteem or self-presentation, on the assumption that women needed to change to compete with men. It is the workplace cultures and policies that exclude women that need to be fixed, not women. 

Women face systemic inequality, bias and the exercise of power that favors men for leadership roles. Quotas and targets for women in senior roles have proved highly effective at increasing women in leadership roles, even as an interim measure until parity is achieved. 

In addition, visible and accountable support by senior leaders of all genders and adopting an equal and family-friendly policy framework are essential to enabling women’s progression into leadership.

Fourth, we must enable women to achieve. Women do not need to be ‘fixed’ but they can be supported with measures including peer support and mentoring for women, developing formal and informal networks for women’s leadership and increasing the visibility of women’s leadership. 

Global networks, such as Women in Global Health, along with partnerships like Every Woman Every Child and the Partnership for Maternal, Newborn and Child Health, enable women to work together to share experiences and campaign together for change on a local and global scale.

New social contract for women in health 

The pandemic has exposed the weaknesses, inequalities and gender gaps in our health, social and economic systems.  A systemic shock as big as COVID-19 must prompt us all to consider the value of health and the value of the women who deliver health and care services. 

We cannot expect women to continue to support a system of gender inequality as we emerge from this pandemic. We are asking for a new social contract for women in health that closes the gender gaps, recognises their contribution and enables them to lead on an equal basis. 

This is not a marginal women’s issue, it is central to strong health systems and global health security, and it is everybody’s business.

Magda Robalo is the Global Managing Director of Women in Global Health and H.E. Kersti Kaljulaid is  Former President of Estonia and the UN Secretary-General’s Global Advocate for Every Woman Every Child

Image Credits: WHO, WHO Eastern Mediterranean Regional Office , PAHO/Sebastian Oliel, WHO Africa Region, Mass Communication Specialist 3rd Class Everett Allen/Flickr, Paul Hudson/Flickr, UN Women, World Health Summit , Kersti Kaljulaid/Twitter .

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