A nurse walks into a hospital ward in Janakpur in Dhanusha District in southern Nepal. Credit: UNICEF/Rupadhayay

By Roopa Dhatt and Susannah Schaefer
WASHINGTON DC / NEW YORK, Apr 7 2023 (IPS)

As World Health Worker Week draws to a close on April 7, health organizations from around the world have been celebrating women’s vital role in the health workforce and sharing stories about the enormous value they bring to all areas of health and care.

But platitudes are not enough. It’s time for global health leaders to step up and turn these words into action.

Globally, women make up almost 70% of the global health workforce and 90% of the frontline health workforce, contributing over $3 trillion to global health each year. The health systems in which they work play a significant role in remote and marginalized groups’ access to health, especially in times of crisis. Despite this, the challenges faced by community health workers (CHWs) are frequently overlooked.

CHWs play a critical role in providing care to vulnerable populations, but they are undervalued and accorded lower status in the “informal” workforce. Upwards of six million women are estimated to be either unpaid or grossly underpaid despite working in core health systems roles and just 14% of CHWs in Africa are salaried.

It is unjust that global health systems rely on the labor of unpaid women who are creating social and economic value that is uncounted and unrewarded. Unpaid work reduces women’s economic security and increases their lifetime poverty.

It also weakens health systems. The pandemic has demonstrated the need for strong and resilient health systems, but there can be no global health security while health systems are subsidized by some of the world’s poorest women.

Women health workers continue to make huge sacrifices to work on the frontlines. They went door-to-door educating households on the COVID-19 virus, tracing contacts, and delivering vaccines.

At last year’s World Health Assembly, India’s one million women community health workers known as accredited social health activists (ASHAs) were honored for successfully protecting the health of millions of people during the pandemic.

At the start of the pandemic, however, reports were coming out of India about the unacceptable risk faced by ASHA workers who were being sent into communities without lack of infection controls and facing stigma and abuse as perceived vectors of the virus.

In 2020, they launched widespread street protests and strikes to demand better pay, protection, and working conditions. ASHA workers may have been acknowledged as global health leaders, but they continue to be underpaid with small performance-based honorariums. They are still fighting for a fair and regular salary and the benefits that come with formal sector roles.

Pre-pandemic the World Health Organization (WHO) projected a global shortage of 10 million health workers by 2030, which COVID-19 now has deepened. Health workers lost their lives to the virus and significant numbers are unable to work, affected by ‘long-COVID’. There have been increased reports of violence towards women health workers during the pandemic–from colleagues as well as patients and their families.

In a 2018 report on health policy and system support to optimize CHW programs, one of the primary WHO recommendations included fair remuneration for CHWs, but this is still far from the norm. When CHWs are compensated, it often fails to align with WHO recommendations, which call for financial packages that are commensurate with the demands of the job, the level of complexity, the training required, and the hours worked.

This World Health Workers Week, we come together with our partners to call on global health leaders, governments and policy makers to disrupt the status quo. We believe that every person, regardless of gender, should have access to quality health and care and opportunities to thrive.

We know a fairly-compensated health workforce–alongside training, supervision, and safe working environments–leads to improved productivity, wider access to healthcare, and better patient outcomes.

The gender pay gap in health of 24% is one of the largest of any sector. We are calling on leaders to take measures to close that gap. We stand with our partners in calling for and focusing on transformative change, including gender-equal leadership in global health and a new social contract for women health workers centered on the need for fair and equal pay and safe and decent work.

There is increasing urgency in both high-income and low- and-middle income countries to prioritize changes in guidelines, funding, and policies. After three years of COVID-19, women health workers, who have been the majority in patient-facing roles, are burned out and traumatized.

Understandably, women are leaving the health sector at all levels in a ‘Great Resignation,’ which threatens to deepen the global health worker shortage crisis.

Addressing these injustices is a moral obligation and an economic necessity. Investing in health workers is a win-win proposition and will send a message that we recognize and value them as professionals.

Not only can we restore justice to neglected global health systems, but we can improve the working conditions and pay of health workers, unleashing broader economic benefits.

We would like to send a clear message that as heads of global health organizations we are committed to building stronger health systems and a more equitable world. Achieving true health equity includes quality care for all–including health workers.

Dr Roopa Dhatt is Executive Director and Co-Founder Women in Global Health, a fast- growing women-led movement with 47 chapters worldwide.

Susannah (“Susie”) Schaefer is Executive Vice Chair, President, and Chief Executive Officer (CEO) of Smile Train, the world’s largest cleft-focused organization with a sustainable and local model of supporting surgery and other forms of comprehensive cleft care.

IPS UN Bureau

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Women in the health and care sector face a larger gender pay gap than in other economic sectors, earning on average of 24 per cent less than peers who are men, according to a joint report by the International Labour Organization (ILO) and the World Health Organization (WHO). Credit: ILOGENEVA (ILO News)

By Roopa Dhatt and Ebere Okereke
WASHINGTON DC / LONDON, Mar 16 2023 (IPS)

Women health workers are more than two thirds of the health workforce and represent 90% of the world’s frontline health workers, yet hold less than a quarter of senior leadership roles – a situation which is unfair and a significant risk for global health security.

Despite five years of ad hoc commitments, our new report The State of Women and Leadership in Global Health shows few and isolated gains, while overall progress on women’s representation in global health governance has remained largely unchanged.

The report, launched on March 16, assessed global data together with deep dives into country case studies from India, Nigeria and Kenya. It found that women lost significant ground in health leadership during the COVID-19 pandemic.

A Women in Global Health study calculated that 85% of 115 national COVID-19 task forces had majority male membership. At global level, during the World Health Organisation’s Executive Board meeting in January 2022 just 6% of government delegations were led by women (down from a high point of 32% in 2020).

It appears that during emergencies like the pandemic, outdated gender stereotypes resurface with men seen as ‘natural leaders’.

A key and disturbing finding in the report was that women belonging to a socially marginalized race, class, caste, age, ability, ethnicity, sexual orientation, gender identity or with migrant status, face far greater barriers to accessing and retaining formal leadership positions in health.

Without women from diverse backgrounds in decision-making positions, health programs lack insight and professional experience from the women health workers who largely deliver the health systems in their countries.

Expanding the representation of diverse leaders in health is not just a matter of fairness, it also contributes to better decision-making by bringing in a wider range of knowledge, talent and perspectives.

Further, the report shows there is a ‘broken pipeline’ between women working in national health systems and those working in global health. As long as men are the majority of health leaders at national level and systemic bias against women continues, the global health leadership pipeline will continue to funnel more men into positions with global decision-making power.

The issues women face in national health systems are then reproduced at the global level where women are excluded from political processes and marginalized from the most senior appointments.

A deep dive of case studies in India, Nigeria and Kenya confirms that women are held back from health leadership by cultural gender norms, discrimination and ineffectual policies which don’t redress historic inequalities.

The similarities in the barriers faced by women health workers from very different socio-economic and cultural contexts are marked, indicating widespread systemic bias right across the global health workforce.

The consequences of locking women out of leadership represents a moral and justice issue, and also a strategic loss to the health sector. Through the pandemic, we saw how safe maternity and sexual and reproductive health services were deprioritized and removed from essential services in some countries, with catastrophic consequences for women and girls.

We saw women health workers unpaid or underpaid, and we saw dangerous conditions escalate as community health workers were sent to enforce lockdown, do contact tracing or provide services in unsafe conditions with no forethought given to providing security.

The findings of our report show that systemic change goes beyond numbers in gender parity leadership. What is needed is a transformative framework for action involving all genders from institutional, to national and global level.

Recommendations to drive transformative approaches include:

● Men must ‘lean out’ and become visible role models in challenging stereotypes to make way for qualified women
● Normalization of paternity leave to shift gender norms and reduce the burden of care of women
● Governments taking targeted actions to fast track the number of diverse women in health leadership roles through quotas and all-women shortlists, particularly for senior global health leadership roles that have never been held by a woman
● Institutions must be intentional about creating and maintaining a pipeline for women to move into leadership
● Measurable actions such as mentorship, shadowing / pairing and deputizing opportunities should be created and monitored to ensure women are visible for promotion opportunities
● A zero tolerance of discrimination towards pregnancy
● Supported flexible working options for all parents and carers

Investing in women is not only the right thing to do, but it also makes good business sense. When we get it right, we can unlock a “triple gender dividend in health” that includes more resilient health systems, improved economic welfare for families and communities, and progress towards gender equality.

The lessons of the pandemic have taught us much about the value of the health workforce and even more about the value of health workers. They are mostly women. It’s time for them to take their rightful roles in leadership.

Dr Roopa Dhatt is Executive Director and Co-Founder Women in Global Health, Washington, DC and Dr Ebere Okereke is Snr Health Adviser Tony Blair Institute London & incoming CEO Africa Public Health Foundation, Nairobi

IPS UN Bureau

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