How gender equity strengthens health system resilience

January 6, 2023 by Elizabeth Rowley and Mesele Damte Argaw

PATH experts explain why gender equity is a critical prerequisite for resilient health systems and universal health coverage.

Nakalema Annet Doreen, a midwife, sits for a portrait at the maternity clinic in Mpigi Health Centre IV in Mpigi Town, Uganda. Photo: PATH/Will Boase.

Nakalema Annet Doreen, a midwife, sits for a portrait at the maternity clinic in Mpigi Health Centre IV in Mpigi Town, Uganda. Photo: PATH/Will Boase.

A resilient health system requires a resilient health workforce, which can’t be realized without gender equity. A resilient workforce has the skills and resources to provide lifesaving health services during a crisis. But, just as importantly, it also has the policies and practices in place to ensure that health workers are valued, safe, and fairly treated regardless of their gender identity.

According to a 2019 World Health Organization (WHO) report, women comprised 70 percent of workers in the health and social sectors in 104 countries. Women are the main health service providers for about 5 billion people worldwide. This work is valued at an estimated $3 trillion annually and often involves unpaid health care.

In many settings, gender norms in and out of the workplace have long eroded gender equity in the health workforce in ways that undermine health system resilience. In many countries where PATH works, women health workers deliver the bulk of health services, but they receive limited investments in their professional advancement, economic security, or social support.

“Health system resilience greatly depends on a government’s ability to support the health workforce in providing quality and accessible health care for all,” says Nanthalile Mugala, MD, PATH’s Africa Region Chief. “This means supporting women health workers, who are often the first point of care for their communities yet face disproportionate challenges.”

“Health system resilience [requires] supporting women health workers, who are often the first point of care for their communities.”
— Dr. Nanthalile Mugala, Chief of the Africa Region, PATH

Barriers for women health workers

Gender norms prevent many women health care workers from accessing job training, wage equity, leadership opportunities, and a safe workplace.

Close family and peer support. In many countries, women hold the largest responsibility for household work and childcare. Some women health workers face open disapproval for working outside the home, while others may be encouraged to work but left to juggle domestic work with little support. This makes it more difficult for women to enter the health workforce, and it hinders their ability to advance later in their careers.

Women in health leadership positions in Ethiopia point out that some women in the health workforce may avoid competing for senior leadership posts due to lack of close family and peer support. This includes not only husbands but also other women in their lives, like mothers, mothers-in-law, and women friends.

Job training. Career advancement in the health sector requires advanced training. In many places where PATH works, girls have unequal access to secondary school. This means relatively fewer women than men have the initial training needed to pursue higher-level, better-paid health care positions that require advanced formal education.

For women in the health care sector who must balance housework and caregiving with their jobs, it is difficult to pursue the higher-level training needed to advance their skills and career opportunities. Evidence from crisis-affected countries indicates women health workers are especially impacted by loss of educational opportunities that could lead to better-paying positions when training centers and universities are closed.

Leadership opportunities. Career progression from entry-level positions to leadership roles is influenced not only by skills, experience, and qualifications but by gender norms and expectations regarding women’s leadership qualities.

While women comprise 70 percent of the global health workforce, the same 2019 WHO study found that women in these countries hold only 25 percent of leadership roles, in part due to entrenched power structures within health systems, gender stereotyping, and discrimination that favors men over women. These factors typically echo overarching gender norms that perceive leadership qualities as traditionally male characteristics related to power, strength, and control.

Health systems often lack a clear succession plan, and there are limited opportunities for coaching, mentoring, shadowing, and networking to elevate women as health leaders.

Wage equity. A recent WHO report on the gender pay gap in the health sector shows that the gender wage gap (the difference in average earnings between women and men) in the health and care sector ranges from about 15 percent (in the case of median hourly wages) to about 24 percent (in the case of mean monthly earnings). Closing this gap is fundamental to ensuring health systems are resilient in the face of pandemics and other challenges.

Researchers found that only a small part of the wage gaps is explained by differences between women and men in their labor market characteristics (e.g., age, education, and whether they work full-time or part-time). Instead, they point to the motherhood gap—the pay gap between mothers and non-mothers—and the fact that women are over-represented in lower-level health care jobs, performing undervalued work. These two factors contribute to pay discrimination against women and necessitate change in gender norms and stereotypes.

Sity Mohamed, a health care worker, sits outside her health post in Yalo, Ethiopia, with a box of syringes and two cold boxes. Photo: PATH/Therese Bjorn Mason.

Sity Mohamed, a health care worker, sits outside her health post in Yalo, Ethiopia, with a box of syringes and two cold boxes. Photo: PATH/Therese Bjorn Mason.

Safe workplaces. Research indicates that up to 62 percent of all health workers in many locations have reported experiencing workplace violence by patients and visitors, including 24 percent who experienced physical violence in the previous year. Women health workers are seriously impacted by workplace violence, which can include psychological and sexual harassment by male colleagues, physical threats from patients, and physical and sexual assault during home visits.

It is widely recognized that gender inequality is a root cause of violence against women. The consequences for women health workers can be profound. A systematic review focused on sexual harassment against female nurses found evidence that of those who experienced workplace violence, 43 percent experienced a range of psychological harms and 30 percent reported physical health problems.

This is how gender inequity weakens health systems. During crises, these challenges are often exacerbated, further weakening health systems when they are needed most. These challenges are not new. Rather, they have been long ignored.

“As we work towards universal health coverage, we must recognize women’s vital role in the global health workforce by prioritizing their safety and well-being, reducing gender-based pay gaps, and creating opportunities for women to advance,” says Rachel Ndirangu, Advocacy Partnership Co-lead at PATH.

“We must recognize women’s vital role in the global health workforce by prioritizing their safety and well-being, reducing gender-based pay gaps, and creating opportunities for women to advance.”
— Rachel Ndirangu, Advocacy Partnership Co-lead, PATH

Building a gender-equitable workforce

At PATH, gender equity is integral to our mission to advance health equity. In our work, we identify gender-related barriers to health, implement gender-equitable solutions, and monitor and evaluate progress toward gender equality.

As we work toward gender equity and health system resilience, in collaboration with our government and community partners, six principles guide us:

Equitable training opportunities. An equitable, resilient health system is one in which health workers, regardless of their gender identity or other characteristics, have equitable access to training opportunities.

Public health leaders and decision-makers must identify and promote trainings that can help women address health service demands and advance their careers. They can also partner with women and community leaders to structure training logistics in ways that are responsive to women’s needs, from timing and location to financial subsidies for childcare or other family needs when training opportunities require extended time commitments and/or travel away from home.

Shifting workplace gender norms. Inequitable gender norms negatively affect women health workers’ well-being and the overall quality of health services. Managers must develop and enact policies and strategies to ensure that the dignity and rights of health workers, especially women health workers, are respected every day.

Clear career paths. The world needs 18 million more health workers to face projected needs in 2030. This gap poses dire challenges to health system resilience worldwide.

To retain and expand the largely female workforce, health managers must review existing career paths, identify opportunities that may be inherently biased against women, and design approaches to ensure clear and attainable growth pathways—for their individual benefit and for the viability of resilient health systems as a whole.

Leadership equity. Women and individuals of all gender identities have perspectives and viewpoints that are critical before, during, and after a crisis hits. Health managers must examine the gender balance of existing leadership, make adjustments toward parity, and identify measures to promote leadership opportunities that deliberately consider gender equity.

Financial equity. Pay gaps between women and men health workers in the same job rank must be systematically identified and remedied. This may involve reviewing salary structures and promotion schedules to identify inherent biases, advocating with budget holders, and implementing specific gender pay gap measures. It also means examining and addressing payment practices for community health workers, who are often women.

Harm prevention. Leadership, women health workers, and other stakeholders should work together to identify and address key threats to safety and well-being during both normal and crisis periods. This may include facilitated critical analysis of entrenched gender norms that underlie violence, improving workplace violence and harassment monitoring and reporting mechanisms, and the provision of legal aid and other forms of support to the survivors of workplace violence and harassment.

Stakeholders committed to health system resilience must do things differently now. The urgent shortage of health care workers critically undermines the global community’s efforts to achieve health system resilience. Many of the next generation of health workers will be women, but it’s not just about filling a need with numbers.

Advancing toward universal health coverage will require gender norms to change in the workplace and at a societal level. The viability and ultimate success of health system resilience depends on it.