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Executive summary
Backgound
In this paper I discuss gender issues manifested within health occupations and across them. In particular, I examine gender dynamics in medicine, nursing, community health workers and home carers. I also explore from a gender perspective issues concerning delegation, migration and violence, which cut across these categories of health workers. These occupational categories and themes reflect priorities identified by the terms of reference for this review paper and also the themes that emerged from the accessed literature.
This paper is based on a desk review of literature accessed through the internet, search engines, correspondence with other experts and reviewing bibliographies of existing material. These efforts resulted in a list of 534 articles, chapters, books and reports. Although most of the literature reviewed was in English, some of it was also in Spanish and Portuguese. Material related to training and interpersonal patient-provider relations that highlights how occupational inequalities affect the availability and quality of health care is covered by other review papers commissioned by the Women and Gender Equity Knowledge Network.
Main Arguments
The World Health Report 2006 puts forward an inclusive definition of health workers, which is “consistent with the WHO definition of health systems as comprising all activities with the primary goal of improving health –inclusive of family caregivers, patient-provider partners, part-time workers (especially women), health volunteers and community workers” (WHO 2006: xvi). The plurality of health workers mentioned reflects the broad and diverse nature of health care tasks that exist, integrated by the division of medical labour specific to each country’s health system. The hierarchies that mark and coordinate such a diverse health work force are determined by technical needs, but also reflect power relations that structure health systems, often mirroring and sometimes even exacerbating inequalities in society.
Gender1, among other power relations, plays a critical role in determining the structural location of women and men in the health labour force and their subjective experience of that location. The resulting gender biases influence how work is recognised, valued and supported with differential consequences at the professional level (career trajectories, pay, training and other technical resources, professional networks) and at the personal level (personal safety, stress, autonomy, self-esteem, family and other social relationships). The resulting health system outcomes are inequitable, but also unproductive as they restrain the true capacity of individuals working in the health sector.
The first form of gender bias that must be addressed pertains to describing who does health work and how it is done. The omission of sex-disaggregated data and the biases involved in conceptualising and measuring health work either hide the presence of women entirely or misrepresent their work. Health work is often categorised by stylised oppositional categories, whether curative or caring, formal or informal, full or part-time, skilled or unskilled, paid or unpaid work. Not only are women over-represented in caring, informal, part-time, unskilled and unpaid work, elements of work that are routinely not measured, but women’s contributions also span a range of activities that blur some of these stylised distinctions. By failing to accurately describe the gendered nature of health work, women’s
contributions to health systems continue to be unsupported as they are under-valued or not recognised at all. Despite increased attention to human resources in health, the lack of research dedicated to documenting its gendered nature and in assessing interventions that redress gender inequalities must urgently be rectified.
As mentioned gender bias exists across as well as within health occupations. As a result, measures like substitution and delegation, which affect the professional ordering of health systems, cannot be seen as technical interventions alone. The gender dynamics of these measures need to be considered on a contextual basis, with an assessment of how gender hierarchies among health occupations are formally and informally sustained or subverted, in order to eliminate rather than exacerbate current inequalities across health occupations. It is essential that delegation be seen as part of long term planning and investment efforts that skillfully restructures health systems to do more in different ways, rather than as a means to stretch farther on a cheaper basis, often falling back on unsupported female labour.
Gender also influences the structural location of women and men within health occupations, resulting in significant gender differences in terms of employment security, promotion, remuneration, etc. It is important to not perceive these differences as either static or universal. They need to be analysed and monitored within changing national contexts, specific health system circumstances and by other social determinants. Nonetheless, research has shown that in several contexts even when organisational location, productivity and family leave are adjusted for, significant levels of gender difference remain, indicating unadulterated gender bias.
Gender also influences the structural location of women and men within health occupations, resulting in significant gender differences in terms of employment security, promotion, remuneration, etc. It is important to not perceive these differences as either static or universal. They need to be analysed and monitored within changing national contexts, specific health system circumstances and by other social determinants. Nonetheless, research has shown that in several contexts even when organisational location, productivity and family leave are adjusted for, significant levels of gender difference remain, indicating unadulterated gender bias.
Participatory gender training that focuses on values, is based on health workers’ own experiences and is also action oriented can succeed in raising individual health worker awareness of their own biases, empowering them to identify programmatic changes that can be made at their level of service delivery. Nonetheless gender training by itself cannot address the multiple forms of gender bias that exist simultaneously to constrain the capacity of women and men working in health systems. Such biases require holistic approaches that address the personal and professional struggles of health workers at both local level and higher levels of health systems management.
In order to succeed, affirmative action and training measures must be coupled with efforts that qualitatively transform how health work is conceived of and organised, so that the multiple forms of gender bias that act to obscure, devalue and constrain women’s contributions to health care are addressed. This means sustaining a range of efforts spanning concrete and diffuse actions, including improving access to family leave or child care provisions in a gender equitable manner; resolving gender differences in access to strategic resources like mentoring and supervision, administrative and infrastructural support, secure funding sources and employment contracts, formal and informal networking; addressing gendered vulnerabilities to sexual harassment and other forms of violence experienced by
health workers; addressing gender biases in measuring, rewarding and supporting work; and neutralising stereotypical work models.
Stereotypical work models either assume women are the same as men and thus expect them to conform to male work models that ignore their specific needs or swing to the other extreme and naturalise women’s difference so they are seen as inherent to individual women rather than as differences structured by the social environment. For instance, women are more likely to be stereotyped as caring health personnel than men. This not only excludes, or even worse excuses men, but also presents a homogenised, static expectation of women’s capacities that absolves managerial responsibility from addressing their less autonomous and under-resourced roles in health systems. At the same time, the specific needs of women health workers are often not addressed, whether it is childcare or protection from violence. These problems are seen as caused by women, rather than by how health services are organised. By stereotyping women as being more caring in health work or conversely as
being problematic for health care organisations due to their sexuality and childcare needs, gendered ideologies obscure important structural elements of disadvantage and bias. Although the consequences of these biases are blunted by women’s individual private adjustments, they are not ‘women’s problems’ alone and require collective, public efforts to resolve.
With respect to female community health workers, they negotiate gender biases at various levels, starting from their own homes, the communities they work in and the health systems they belong to. Strategies that most successfully address the gender biases that question the legitimacy of female health workers deployed at community level address both elements of personal and professional prestige. Successful programmes provide them with avenues for growth by questioning and reinterpreting gender norms in a constructive manner; allowing them to assume broader roles than the original simple health care tasks they were encharged with; guide them with continuous training and supervision; back them up with functioning referral systems; and support them through positive relationships with peer groups, community members, other health professionals and managers. Although these system wide improvements will benefit all health workers at the community level, it is
notable how these systemic improvements are often undertaken in a gender blind manner, if at all. Too often community based health workers are expected to improve health outcomes, despite the lack of functioning health systems, reflecting false expectations that are themselves gendered.
Similar broad measures that strengthen the health systems that health workers are located in are required to address the gender dimensions of care work that is currently undertaken primarily by women in ways that are unsupported, poorly paid or unpaid at great cost to their own health and livelihoods. Significant effort must urgently address the biases in health services that work against recognising the value, difficulties and rewards of care work. Care work goes beyond assisting curative or palliative health care service provision to include basic services of a broad variety, it requires constant attendance since it cannot be regularly scheduled and entails substantial emotional involvement. In addressing these challenging realities, it is no longer acceptable for home-based care efforts to remain blind to who in the household shoulders the burden of home care in terms of gender and age. Support needs to integrate various kinds of social services beyond the formal health care sector to encompass social protection, employment, water, sanitation, agriculture, nutrition and housing, keeping in mind the perspectives of women as primary home carers, without stereotyping them as the only ones who can undertake care work.
The structural characteristics of increasingly globalised and under-resourced health systems also have gendered impacts through the migration of health workers. Not only are more female health workers migrating than before, but as skilled labour is drawn to more formal, better financed and functioning health systems, lower level health workers, who are more likely to be women, whether paid or not, are expected to shoulder the burden of sustaining crumbling health systems in source countries. Although pull factors play a critical role in sparking the current crisis of the global migration of health workers, this phenomena also draws its force from the significant numbers of unemployed or unproductive local health workers that form a pool of latent discontent within health systems. More must be done in
both source and recipient countries to retain local nursing staff, who in the absence of support either quit or migrate to better work environments.
While migration opens up new opportunities, it is also associated with new vulnerabilities and challenges that have gender dimensions. Female health workers are more likely that their male counterparts to face immigration or licensing systems that use gender blind criteria; have more difficulties reestablishing their careers in mid-life or even being recognised as a worker if termed as secondary migrants or dependent wives; unequally shoulder the responsibility of integrating their families into new communities, while maintaining family ties across farther distances; and are more likely to face sexual harassment and other forms of gender discrimination that may be heightened by the isolation and other insecurities specific to the migration process. Although some organisations and policies have responded to addressing these multiple forms of cumulative disadvantage faced by migrant female health workers, more research is needed to understand the gendered needs of migrant health workers and to assess the effectiveness of efforts to address their needs.
A gender analysis of the health labour force also reveals significant levels of violence experienced by health workers in the health sector. Women health workers are disproportionately victimised by such violence due to gendered ideologies that subjectively sanction such violence or due to their structurally disadvantaged position within the health labour force. As female health workers contravene conservative gender norms in their homes, in public spaces and through their health work, they risk attacks on their intimate selves, endangering their sexuality and personal safety, despite being educated and economically viable. Interventions must address both the normative values that naturalise and sanction such violence, as well as the structural biases that place female health workers at greater risk
through poor working conditions and gender blind management practices.
In conclusion, a gender analysis of human resources in health reveals that although health systems are themselves meant to provide a source of healing and a social safety net for society, it can replicate and exacerbate many of the social inequalities it is meant to address and itself be immune from. Health systems rely on a foundation of health workers that are often informal, poorly paid or not paid at all, poorly supported and disproportionately female. Even among formally recognised sections of the health labour force, significant forms of gender bias exists across and within health occupations. Despite the prevalence of such
structural and subjective biases, they are neither static nor universal, but actively contested, negotiated and adjusted to at the individual level. These individual efforts by women and men must be constructively and collectively amplified through policy and programme efforts at higher and broader levels in health systems. The results of such policy and programme efforts would result not only in more gender equality in the health labour force, but also improved health system functioning more broadly.
Footnote:
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Gender is understood here as the learned social characteristics that distinguishes males and females in society. By reflecting normative power relations it can sustain social inequalities between women and men. Other normative power relations that create social inequalities include those relating to social class, race, age, sexual orientation, etc.
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