Time to build back equal in global health leadership

By guest contributors Abhijit Dhillon*, Bhanupriya Rao*, Ruth Mbugua**, Lucy Wankuru**, Adepeju Adeniran***, and Oluwabukola Shaba*** (*Women in Global Health India; **Women in Global Health Kenya; ***Women in Global Health Nigeria)

This is part 1 of a two-part series written by a team of authors from Women in Global Health. You can find part 2 here.

Globally, women hold around 70% of health worker jobs, over 80% of nursing and over 90% of midwifery roles and deliver the majority of unpaid care and domestic work in families and communities. If leadership roles in health were allocated proportionally (assuming that women and men have equal merit) then 70% of health sector leaders would be women. Yet at the start of the COVID-19 pandemic in 2020 women held only 25% of leadership roles in global health.

This global situation is experienced as a day-to-day reality for women health workers around the world, from the USA to Europe, and in our own countries of India, Kenya and Nigeria. As part of the Women in Global Health (WGH) movement, in 2022, we worked collaboratively on research to explore the state of women’s leadership in health; using women’s testimony as data we sought to capture the experiences of and recommendations from women working in our health sectors.

Building on publications from the World Health Organization, our research sought to explain why if the default health worker is a woman, the default health leader is a man. Using an intersectional lens, we also explored why the primary target groups for most global health organizations and programs – women from the Global South – are least represented in global health leadership.

Our research sought to explain why if the default health worker is a woman, the default health leader is a man.

In the first part of this blog, we describe the findings of our research, which have recently been published in a new policy report: The State of Women and Leadership in Global Health; the full country case studies will be published later in 2023. At the global level, new analysis confirms that over the last five years women’s status in global health leadership has remained unchanged. Women still hold only 25% of senior leadership roles.

Although progress has been made in places the ‘glass ceiling’ largely remains intact. For example, the 13 major global organizations committed to The Global Action Plan (GAP) for Healthy Lives and Well-being for All have made gains towards gender parity in leadership; as of February 2023, women hold 61% of senior roles in GAP agencies. However, only 5 out of 13 agencies are headed by women. The glass ceiling effect is especially evident among women from the countries most targeted by global health organizations:  only 1 of the 13 agencies is headed by a woman from a low-income country.

At national level, in Kenya, women hold 42% of mid-level and 40% of top-level leadership positions in the health sector. However, in Nigeria women face a ‘glass ceiling’ in reaching the most senior roles, for example only 1 out of 28 Directors of Federal Medical Centers are women. In India, women average around 28% in leadership roles across national health organizations, however, averages can be misleading, and some organizations have almost no women in leadership positions.

Women’s progress in health leadership has been threatened by the COVID-19 pandemic which reinforced the stereotypes of men as ‘natural leaders’. At WHO’s Executive Board meeting in January 2022 only 6% of member state representatives were women, down from a high of 32% in 2020. A WGH study in 2020 found 85% of 115 national COVID-19 task forces had majority male membership, showing how women have been excluded from decision-making during the pandemic, despite being the majority of workers in the sector. On the frontlines of the response, women health workers typically managed a double burden of high patient numbers, long hours, high stress and risk at work, plus additional unpaid care work at home and in the community. After three years, women health workers 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 of 10 million and reduce women’s representation in leadership.

Despite the contextual differences, our most substantial finding was the similarity in qualitative data describing the challenges experienced by women in India, Kenya and Nigeria. For example, the commonalities in how gender norms and roles limit women’s participation at work and in leadership:

“Since childhood, I have only heard this as gospel truth: ‘Women’s primary job is to take care of the household.’ It is difficult to keep challenging this notion, even internally, when everyone around you keeps saying this. When I got married, my mother-in-law very explicitly told me that my job is to do ‘Seva’ (serve) for my husband and my future son.”- Doctor, India

“There are cultures which believe very strongly that women should not have leadership roles. And sometimes when you are in a leadership role, and your spouse is not in a leadership role, it already brings some conflict…women may shy away from taking up those roles.”- Doctor, Kenya

Interviews with women leaders across the three countries in our research demonstrate that perceptions of competent leadership are based on traits such as assertiveness and stubbornness, seen as stereotypically male behaviors. Women face a ‘double bind’: they are either penalized for being too ‘masculine’, for example, a senior doctor in India was overlooked for promotion because she was considered to have an “abrasive and overbearing style” and was required to provide a written undertaking to the administration that she would “be more amiable and tone herself down”; while women leaders who adopt a more empathetic style of leadership can face a backlash for being “too emotional”.  Because leadership is perceived in the light of gendered stereotypes, women and men leaders can be judged by different standards:

“When you’re working with men, when you go to offices as leaders seeking for services, sometimes they look at you a certain way, like you don’t belong. They look at you like you are a weak species.” – Clinical Officer, Kenya

“Right from day one, you are literally expected to do better than your brother, to do better than everybody else, but at the same time, you’re told you’re not good enough.” – Doctor, Nigeria

In addition to the discrimination from gendered stereotypes, women face practical challenges working in a sector designed to fit the ‘default man’. Workplace policies may treat menstruation, pregnancy, miscarriage, breastfeeding and menopause as ‘the exception’ despite women being the majority in the health workforce. In Nigeria, respondents said that they had to forgo promotions as institutions do not make special arrangements for pregnant women and even actively find ways to penalize them.  Women reported “being punished for falling pregnant” by being posted to remote locations after they returned from their maternity leave. Even women without children can be disadvantaged in career progression by the assumption that they will have children in the future and are therefore ‘less suitable’ for promotion than their male peers.

As long as societal gender barriers are not addressed and systemic bias against women continues, men, who are the vast majority of health leaders at national level, will continue to dominate global health decision-making. More diverse women recognized and supported in leadership at national level will positively disrupt this global pro-men’s leadership bias and status quo. There is no shortage of women in the health leadership pipeline; in most countries women are the majority of junior doctors, nurses, pharmacists and dentists. There are leaks in the pipeline that mean leadership is not inevitable for women in health.

Source: Women in Global Health (2020), shared with permission.

In the second part of this blog, our colleagues from WGH’s global team outline the actions needed to end what we call the ‘male bonus syndrome’, where the career of male health workers benefit from women being handicapped by rules and policies because they were designed for men. 

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Disclaimer: Views expressed by contributors are solely those of individual contributors, and not necessarily those of PLOS.