Delivered by women, led by men: A gender and equity analysis of

DELIVERED BY WOMEN,

LED BY MEN:

A GENDER AND EQUITY ANALYSIS

OF THE GLOBAL HEALTH AND

SOCIAL WORKFORCE

Human Resources for Health Observer Series No. 24

DELIVERED BY WOMEN,

LED BY MEN:

A GENDER AND EQUITY ANALYSIS

OF THE GLOBAL HEALTH AND

SOCIAL WORKFORCE

Human Resources for Health Observer Series No. 24

Delivered by women, led by men: A gender and equity analysis of the global health and social workforce.

(Human Resources for Health Observer Series No. 24)

ISBN 978-92-4-151546-7

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Contents

Foreword: Women in Global Health as co-chair of Gender

Equity Hub

............................................................... vi

Acknowledgements .................................................... vii

Abbreviations .......................................................... viii

Executive summary ..................................................... 1

Key findings from the four thematic areas of the review ........................... 1

Overarching findings and conclusions from the review ............................ 1

Key messages from this review .............................................. 3

Key recommendations ...................................................... 4

Section 1. Approach .................................................... 5

Chapter 1. Introduction ................................................. 5

1.1 Background ........................................................... 5

1.2 Gender Equity Hub (GEH) ................................................ 9

1.3 Rationale for gender analysis on the health workforce ........................ 9

Chapter 2. Objectives and methodology ........................... 11

2.1 Objectives .......................................................... 11

2.2 Methodology ......................................................... 11

2.3 Limitations ........................................................... 12

Section 2. Key ﬁndings ................................................ 13

Chapter 3. Occupational segregation ................................ 13

3.1 Key messages ........................................................ 13

3.2 Occupational segregation: literature review ................................ 13

3.3 Occupational segregation by gender in the global health workforce ............ 18

3.4 Factors that lead to occupational segregation .............................. 20

3.5 Why occupational segregation matters .................................... 20

iii

Chapter 4. Decent work without discrimination, bias and sexual

harassment

............................................................. 24

4.1 Key messages ........................................................ 24

4.2 Decent work: introduction .............................................. 24

4.3 Decent work in the global health workforce ................................ 25

4.4 Discrimination ........................................................ 25

4.5 Bias ................................................................ 26

4.6 Sexual harassment .................................................... 26

4.7 Why addressing decent work in the global health workforce matters ............ 28

Chapter 5. Gender pay gap ........................................... 29

5.1 Key messages ........................................................ 29

5.2 Gender pay gap: introduction and background ............................. 29

5.3 The gender pay gap in the global health workforce .......................... 31

5.4 Factors that contribute to gender pay gaps ................................ 32

5.5 Why is addressing the gender pay gap in the global health workforce important? .. 33

Chapter 6. Leadership ................................................. 36

6.1 Key messages ........................................................ 36

6.2 Leadership and gender: background ...................................... 36

6.3 Leadership and governance in the global health and workforce ................ 36

6.4 Why addressing gender gaps in leadership matters .......................... 39

6.5 Factors contributing to leadership gaps in the global health workforce ........... 39

Section 3. Conclusions ................................................ 42

Chapter 7. Conclusions: policy context, ﬁndings, and next steps . 42

7.1 Policy context ........................................................ 42

7.2 Findings of the GEH literature review ...................................... 43

7.3 Next steps ........................................................... 45

Glossary ................................................................. 46

References ............................................................ 49

Annex 1. Membership of the Gender Equity Hub in the Global

Health Workforce Network

........................................ 59

Annex 2. Literature matrix ............................................ 60

A literature review

Boxes

Box 1.1 Global Health Workforce Network Gender Equity Hub: priority areas ................................... 9

Box 1.2 Global Health Workforce Network Gender Equity Hub: ﬁve key activities

................................. 9

Box 3.1 Individual factors contributing to gender segregation

............................................. 21

Box 3.2 Organizational factors contributing to gender segregation

......................................... 21

Box 3.3 Societal factors contributing to gender segregation

.............................................. 22

Box 4.1 Origin of the #MeToo movement

........................................................... 28

Box 5.1 Factors contributing to gender pay gaps: key themes

............................................ 34

Box 6.1 Individual, household and community dimensions of gender stereotyping

.............................. 41

Box 7.1 Working for Health: ﬁve-year action plan for health employment and inclusive economic growth 2017–2021

(WHO, ILO, OECD)

........................................................................... 42

Figures

Figure ES.1 Key findings of GEH review of female health workforce, by thematic area ......................... 2

Figure ES.2 Overarching findings and conclusions of review

............................................ 2

Figure 1.1 Share of women employed in the health and social sectors compared to share of women employed in all

sectors by ILO region, 2013

.................................................................... 6

Figure 1.2 Sustainable Development Goals

......................................................... 7

Figure 1.3 Health workforce and gender: a theory of change

............................................ 8

Figure 1.4 Working for Health programme: a global movement for gender-transformative workforce development

..... 8

Figure 3.1 Women’s share of selected occupations (2012)

............................................ 14

Figure 3.2 Share of female doctors by OECD country (2015)

........................................... 15

Figure 3.3 Male and female employment (%) in health and education sectors (2015)

......................... 15

Figure 3.4 Average work day and unpaid work, men and women

........................................ 16

Figure 3.5 Paid and unpaid work (minutes per day) for men and women, by OECD country

.................... 16

Figure 3.6 Financial value of women’s contribution to the global health system, as part of global GDP

............ 17

Figure 3.7 The cycle of unpaid care work–paid work–paid care work

..................................... 18

Figure 3.8 United States share of nurses who are male (1970–2011)

.................................... 19

Figure 3.9 Percentage of economies that restrict women’s employment, by type of restriction

.................. 19

Figure 3.10 Do organizations have workplace gender policies?

......................................... 23

Figure 4.1 Percentage of United States medical academics reporting sexual harassment

...................... 26

Figure 4.2 Inadequacy of global sexual harassment laws

.............................................. 27

Figure 5.1 Equal pay versus the gender pay gap

.................................................... 29

Figure 5.2 Gender wage gap by country

.......................................................... 31

Figure 5.3 Female earnings as a percentage of men’s earnings among full-time, year-round nurses (2011)

........ 32

Figure 6.1 Who leads global health organizations?

.................................................. 37

Figure 6.2 Percentage of Member State ministries of health headed by women, by WHO region

................. 38

Figure 6.3 Women’s representation at World Health Assembly, 2005–2015

................................ 38

Figure 6.4 Global health leadership pyramid

....................................................... 39

Figure 7.1 Key finding in four focus areas of GEH literature review

...................................... 43

Figure 7.2 Key overarching findings of GEH literature review

........................................... 44

Foreword: Women in Global Health as

co-chair of Gender Equity Hub

On behalf of Women in Global Health I am delighted to receive this important report and acknowledge the many expert partners who gave their

time to generate the evidence that will underpin gender equality in health, and therefore better global health.

When I graduated as a medical doctor I knew I was standing on the shoulders of the pioneer women who had fought their way into medicine and

carved a path for me and other women. In some countries this is very recent history, since women did not qualify as doctors until the 1940s.

Today women account for 70% of the health and social care workforce and deliver care to around 5 billion people. But as this report shows,

despite progress, women remain largely segregated into lower-status and lower-paid jobs in health, are subject to discrimination, and, in some

contexts, are under the constant threat of violence. Global health is delivered by women and led by men, and that is neither fair nor smart.

Large numbers of women in health are working without the protection of legislation to guarantee them decent work and equal pay. Many are

underpaid or unpaid. The gender pay gap in the health sector is higher than other sectors despite it being a female-majority profession.

Disadvantage is multiplied by the intersection of gender with race, ethnicity, caste, or religion – depending where you are in the world.

We cannot wait for the global health system to correct its own course. Approximately 40 million new health and social care jobs will be needed

by 2030 to keep up with changing demographics and increased demand for health. Around 18 million health and social care jobs must be

ﬁlled in low-income countries to reach the Sustainable Development Goals (SDGs) and achieve the game-changing ambition of universal health

coverage. Gender-transformative change is needed to stop the leakage in the pipeline and loss of female ideas and talent. Similarly, we want to

increase male talent and perspectives in ﬁelds such as nursing where men are underrepresented.

Doing things differently by addressing gender inequities in global health and investing in the global health and social workforce will have a wider

multiplier effect, offering a “triple gender dividend” comprising the following.

• Health dividend. We can ﬁll the millions of new jobs that must be created to meet growing demand and reach universal health coverage and

the health-related SDGs by 2030.

• Gender equality dividend. Investment in women and the education of girls to enter formal, paid work will increase gender equality and

women’s empowerment as women gain income, education and autonomy. In turn, this is likely to improve family education, nutrition,

women’s and children’s health, and other aspects of development.

• Development dividend. New jobs will be created, fuelling economic growth.

This gender dividend, once realized, will improve the health and lives of people everywhere. The health and social care worker shortage is

global. This is everybody’s business.

As co-chair of the Gender Equity Hub with WHO, Women in Global Health are pleased to work in the vanguard with WHO and our partners to

catalyse gender-transformative policy change for better global health.

Dr Roopa Dhatt

Co-chair of the Gender Equity Hub

Executive Director and co-founder of Women in Global Health

A literature review

The lead authors and primary editors of this report are Mehr Manzoor, Research Director at Women in Global Health and a PhD candidate at

Tulane University, and Kelly Thompson, Programming and Gender Director at Women in Global Health and co-chair of the Gender Equity Hub.

Additional authors and editors are Ann Keeling, Senior Policy Adviser at Women in Global Health, and Roopa Dhatt, Executive Director at Women

in Global Health.

They worked under the close guidance of Tana Wuliji, Technical Ofﬁcer for Health Workforce at WHO and co-chair of the Gender Equity Hub, and

Paul Marsden, Technical Ofﬁcer for Health Workforce at WHO and acting co-chair of the Gender Equity Hub, as well as colleagues at Women

in Global Health who supported the project in many ways. We acknowledge the support and feedback provided by Temitayo Ifafore-Calfee,

Operations Director at Women in Global Health. They provided thought leadership, editorial advice and operational support for the development

of this report. We acknowledge editorial and graphic support by Christina Memmott, Graduate Student at Johns Hopkins University.

Extensive expert technical guidance was provided by Constance Newman, Senior Team Leader, Gender Equality and Health, Intrahealth

International. She provided extensive support and mentorship in the development of this paper and served as a constant source of expertise and

encouragement.

Over the course of the project several technical consultations were sought to seek relevant literature, input and feedback to strengthen the

report and its ﬁndings on the main theme of gender and equity within the global health workforce.

Gender Equity Hub members provided support and valuable feedback, including Lina Bader, Research and Evaluation Consultant at the

International Pharmaceutical Federation, who provided extensive support in evidence extraction and writing. Zahra Zeinali, Graduate Research

Assistant at Johns Hopkins University, provided key input on intersectionality. Extensive feedback was provided by Myra Betron, Director of

Gender at Jhpiego; Jennifer Breads, Technical Adviser in the Global Learning Ofﬁce at Jhpiego; Professor Ivy Bourgeault, Professor at University

of Ottawa; Samantha Law, Manager at Chemonics; Tracy McClair, Jhpiego; Rosemary Morgan, Assistant Scientist at Johns Hopkins University

and Research in Gender and Ethics; Rosie Steege, Research in Gender and Ethics; and Samantha Rick, Deputy Director of the Frontline Health

Workers Coalition and Advocacy and Policy Ofﬁcer at IntraHealth International.

External experts from international organizations and universities provided their generous support, guidance and feedback throughout the

development of this report. We would like to thank Ana Langer, Professor and Director of the Women and Health Initiative at Harvard University;

Jacquelyn Caglia, Assistant Director of the Women and Health Initiative at Harvard University; Ashveena Gajeele, Global Access in Action Fellow

at the Berkman Center for Internet and Society at Harvard University; Kate Hawkins, Research in Gender and Ethics; Rohina Joshi, Senior

Research Fellow at The George Institute for Global Health; Devaki Nambiar, Program Head–Health Systems and Equity at the George Institute

for Global Health; Ana Barata, USF Amora Saudável; Sara Causev, Women in Global Health Sweden Chapter; Kathleen Fenton, Paediatric and

Congenital Cardiac Surgeon at Cardiac Alliance; Isabelle Fox, Director of Surgical Missions at Mending Kids; Niyati Shah, Senior Gender Adviser

and Team Leader at USAID; and Geordan Shannon, Medical Doctor and Researcher at University College London.

Submissions of evidence and policy and practice experience were provided by Steven Buzuzi, ReBUILD Consortium; Mehr Manzoor, Women

in Global Health; Isabelle Carr, Australia Medical Students’ Association; Abigail Donner, Abt Associates; Vince Blaser, Frontline Health Workers

Coalition; Yvonne Commodore-Mensah, African Research Academies for Women; Neeru Gupta, University of New Brunswick; Mary Beth

Hastings, Iris Group; Carolina Haylock-Loor, Kirthi Jayakumar, Red Elephant Foundation; Estelle Kouokam, Countdown; Sandra Massiah, Public

Services International; Sarah McKee, Management Sciences for Health; Emma Nofal, Athena Swan NHS Fellow; Ema Paulino, International

Pharmaceutical Federation; Viktor Siebert, German Development Cooperation (GIZ); Marion Subah, Jhpiego; Sally Theobald, Liverpool School of

Tropical Medicine; Nupoor Tomar, Monash University; Sreytouch Vong, ReBUILD Consortium; and Sophie Witter, ReBUILD Consortium.

The report was commissioned by the World Health Organization.

Acknowledgements

vii

AFRO WHO Regional Ofﬁce for Africa

EMRO WHO Regional Ofﬁce for Eastern-Mediterranean

EURO WHO Regional Ofﬁce for Europe

G7 Group of Seven

GDP gross domestic product

GEH Gender Equity Hub

ILO International Labour Organization

OECD Organisation for Economic Co-operation and Development

PAHO Pan American Health Organization

SDG Sustainable Development Goal

SEARO WHO Regional Ofﬁce for South East Asia

WHO World Health Organization

WPRO WHO Regional Ofﬁce for the Western Paciﬁc

Abbreviations

A literature review

viii

Demographic changes and rising health care demands are projected

to drive the creation of 40 million new jobs by 2030 in the global

health and social sector. In parallel, there is an estimated shortfall

of 18 million health workers, primarily in low- and middle-income

countries, required to achieve the Sustainable Development Goals

(SDGs) and universal health coverage. The global mismatch between

health worker supply and demand is both a cause for concern and a

potential opportunity. Since women account for 70% of the health and

social care workforce, gaps in health worker supply will not be closed

without addressing the gender dynamics of the health and social

workforce. The female health and social care workers who deliver

the majority of care in all settings face barriers at work not faced by

their male colleagues. This not only undermines their own well-being

and livelihoods, it also constrains progress on gender equality and

negatively impacts health systems and the delivery of quality care.

In November 2017, the World Health Organization (WHO) established

the Gender Equity Hub (GEH), co-chaired by WHO and Women in

Global Health under the umbrella of the Global Health Workforce

Network. The GEH brings together key stakeholders to strengthen

gender-transformative policy guidance and implementation capacity

for overcoming gender biases and inequalities in the global health

and social workforce, in support of the implementation of the Global

Strategy on Human Resources for Health: Workforce 2030, and the

Working for Health ﬁve-year action plan (2017–2021) of WHO, the

International Labour Organization (ILO) and the Organisation for

Economic Co-operation and Development (OECD).

In 2018, the GEH identiﬁed and reviewed over 170 studies in a

literature review of gender and equity in the global health workforce,

with a focus on four themes: occupational segregation; decent work

free from bias, discrimination and harassment, including sexual

harassment; gender pay gap; and gender parity in leadership.

This report will inform the next phase of the work of the Global Health

Workforce Network GEH, which seeks to use these research ﬁndings

to advocate gender-transformative policy and action.

Executive summary

Key findings from the four thematic

areas of the review

The key ﬁndings in each of the four thematic areas covered by the

GEH review are summarized in Figure ES.1 and covered in detail in

Chapters 3–6 of this report.

Overarching findings and conclusions

from the review

In addition, the report identiﬁed eight overarching ﬁndings and

conclusions, summarized in Figure ES.2 and further elaborated in the

text below.

• Most of the 170 studies found and reviewed in this report come

from anglophone high-income country contexts and are unlikely to

be applicable to other contexts.

• There are gaps in data and research from all regions but the

most serious gaps are in low- and middle-income countries. This

is a major concern, since the most rapid progress in health is

needed in low- and middle-income countries to reach the SDGs,

attain universal health coverage and achieve the health for all

targets by 2030.

• Widespread gaps in the data and literature were found in countries

of all income levels on implementation research, application of

gender-transformative policy measures, and good practice on

addressing health system deﬁciencies caused by gender inequality.

• Major gaps and lack of comparable data were found in countries

from all regions. Examples include sexual harassment and gender

pay gap data.

• Studies were limited in methodological approaches. Few used an

intersectional approach to examine how gender disadvantage in

the health workforce can be compounded by other social identities

such as race and class.

Figure ES.1 Key findings of GEH review of female health workforce, by thematic area

Figure ES.2 Overarching findings and conclusions of review

Horizontal and vertical occupational segregation by gender is a

universal pattern in health, varies with context.

Driven by gender norms and stereotypes of jobs culturally labelled

‘men’s’ or ‘women’s’ work

Gender discrimination constrains women’s leadership/seniority

Gender stereotypes constrain men eg entering nursing

Women in health typically clustered into lower status/lower paid

jobs

Female majority professions given lower social value, status & pay

Women are 70% global health workforce but hold only 25% senior

roles

Gender leadership gaps driven by stereotypes, discrimination, power

imbalance, privilege

Women’s disadvantage intersects with/multiplied by other identities eg

race, class

Global health weakened by loss female talent, ideas, knowledge

Women leaders often expand health agenda, strengthening health for all

Gendered leadership gap in health is a barrier to reaching SDGs and UHC

Large % women in health workforce face bias and discrimination

Female health workers face burden sexual harassment causing

harm, ill health, attrition, loss morale, stress

Many countries lack laws and social protection that are the

foundation for gender equality at work

Male healthworkers more likely to be organised in trade unions

than female

Frontline female healthworkers in conﬂict/emergencies/remote

areas face violence, injury & death

GPG in health 26-26%, higher than average for other sectors

Most of GPG in health is unexplained by observable factors eg

education

Occupational segregation, women in lower status/paid roles, drives GPG.

Much of women’s work health/social care unpaid and excluded in GPG

data

Equal pay laws and collective bargaining absent in many countries

GPG leads to lifetime economic disadvantage for women

Closing GPG essential to reaching SDGs

OCCUPATIONAL

SEGREGATION LEADERSHIP

DECENT WORK:

DISCRIMINATION SEXUAL

HARASSMENT BIAS

GENDER PAY GAP (GPG)

OCCUPATIONAL

SEGREGATION LEADERSHIP

DECENT WORK:

DISCRIMINATION SEXUAL

HARASSMENT BIAS

GENDER PAY

GAP (GPG)

Overarching Findings from literature review:

• 170 studies in this review, most from global North

• Major gaps in data and research from low- and middle-income countries (LMICs) on

gender and equity dimensions health workforce

• Major gaps in implementation research on impact of policy change or gender

transformative approaches in different cultural settings

• Major gaps in data in all areas, particularly sexual harassment and data comparable

across countries on the gender pay gap

• Studies limited in methodological approaches. Very few adopt an intersectionality

lens or use mixed methods approaches

• Occupational segregation, vertical and horizontal, is major driver and consequence

of gender inequality

• Critical role of women in health (70% health workforce) is often overlooked, so

priority not given to addressing gender/equity in workforce

• Gender inequality in health and social care workforce will limit delivery of UHC &

health for all

A literature review

• Occupational segregation by gender in the health sector, driven

by gender inequality, is pronounced, and in turn is the foundation

for other gender inequalities identiﬁed in this report (such as the

gender pay gap). Although women hold around 70% of jobs in

the health workforce they remain largely segregated vertically,

with men holding the majority of higher-status roles. Female

health workers are clustered into lower-status and lower-paid

(often unpaid) roles and are further disadvantaged by horizontal

occupational segregation driven by gender stereotypes branding

some jobs suitable for women (nursing) or men (surgery). Women

are triply disadvantaged by social gender norms that attach

lower social value to majority female professions, which, in turn,

devalues the status and pay of those professions.

• Despite women being the majority of the global health and

social workforce, the role of women as drivers of health is often

unacknowledged. This contributes to a lack of priority given to

addressing gender inequality in the health and social workforce.

Gender-transformative policies and measures must be put in

place if global targets such as universal health coverage are to be

achieved. Also largely unacknowledged is the burden of unpaid

health and social care work typically done by women and girls.

Women’s unpaid work forms an insecure foundation for global

health.

• A key conclusion of this report is that gender inequality in the

health and social workforce weakens health systems and health

delivery. These gender inequities, however, can be ﬁxed, and an

alternative, positive future scenario is possible.

Adopting gender-transformative policies, addressing gender inequities

in global health, and investing in decent work for the female health

workforce offer a wider social and economic multiplier – a “triple

gender dividend” – comprising the following.

• Health dividend. The millions of new jobs in health and social

care needed to meet growing demand, respond to demographic

changes and deliver universal health coverage by 2030 will be

ﬁlled.

• Gender equality dividend. Investment in women and the education

of girls to enter formal, paid work will increase gender equality

and women’s empowerment as women gain income, education

and autonomy. In turn, this is likely to improve family education,

nutrition, women and children’s health, and other aspects of

development.

• Development dividend. New jobs will be created, fuelling

economic growth.

This triple gender dividend will improve the health and lives of people

everywhere. The health and social care worker shortage is global, and

addressing gender inequality in the health workforce is everybody’s

business.

Key messages from this review

The following key messages emerged from this review.

• In general, women deliver global health and men lead it.

Progress on gender parity in leadership varies by country and

sector, but generally men hold the majority of senior roles in health

from global to community level. Global health is predominantly led

by men: 69% of global health organizations are headed by men,

and 80% of board chairs are men. Only 20% of global health

organizations were found to have gender parity on their boards,

and 25% had gender parity at senior management level. Health

systems will be stronger when the women who deliver them have

an equal say in the design of national health plans, policies and

systems.

• Workplace gender biases, discrimination and inequities are

systemic, and gender disparities are widening. In 2018 it was

estimated that workplace gender equality was 202 years away –

longer than 2016 estimates. Many organizations expect female

health workers to ﬁt into systems designed for male life patterns

and gender roles (with, for example, no paid maternity leave), and

many countries still lack laws on matters that underpin gender

equality and dignity at work, such as sex discrimination, sexual

harassment, equal pay and social protection.

• Women in global health are underpaid and often unpaid. It is

estimated that women in health contribute 5% to global gross

domestic product (GDP) (US$ 3 trillion), out of which almost 50%

is unrecognized and unpaid. The World Economic Forum Global

gender gap report 2018 estimates the average gender pay gaps by

country at around 16%. The unadjusted gender pay gap appears

to be even higher in the health and social care sector, estimated at

26% in high-income countries and 29% in upper middle-income

countries. The gender pay gap in men’s favour is nearly universal

and largely unexplained. It has a lifelong economic impact for

women, contributing to poverty in old age. In sectors that are

female dominated, work is typically undervalued and lower paid.

• Workplace violence and sexual harassment in the health and

social sector are widespread and often hidden. Female health

workers face sexual harassment from male colleagues, male

patients and members of the community. It is often not recorded,

and women may not report it due to stigma and fear of retaliation.

Violence and harassment harms women, limits their ability to

do their job, and causes attrition, low morale and ill-health. In

Rwanda, female health workers experience much higher rates of

sexual harassment than male colleagues, and in Pakistan, lady

health workers have reported harassment from both management

and lower-level male staff.

• Occupational segregation by gender is deep and universal.

Women dominate nursing and men dominate surgery (horizontal

segregation). Men dominate senior, higher-status, higher-paid

roles (vertical segregation). Wider societal gender norms and

stereotypes reinforce this. Occupational segregation by gender

drives the gender pay gap and leads to loss of talent (for example,

with few men entering nursing).

Key recommendations

• It is time to change the narrative. Women, as the majority of the

global health and social care workforce, are the drivers of global

health. Research and policy dialogues on gender and global health

to date have neglected this reality and have focused on women’s

health and women’s access to health (both vitally important). It is

critical to record and recognize all the work women do in health

and social care – paid and unpaid – and bring unpaid health and

care work into the formal labour market. Women form the base of

the pyramid on which global health rests and should be valued as

change agents of health, not victims.

• Gender-transformative policies should be adopted that

challenge the underlying causes of gender inequities. Such

policies are essential to advancing gender equality in the health

and social workforce. Adding jobs to the health workforce under

current conditions will not solve the gender inequities that

exacerbate the health worker shortage, contributing to a mismatch

of supply and demand and wasted talent. Policies to date have

attempted to ﬁx women to ﬁt into inequitable systems; now we

need to ﬁx the system and work environment to create decent

work for women and close gender gaps in leadership and pay.

• The focus of research in the global health and social workforce

should be shifted. Research priorities must prioritize low- and

middle-income countries; apply a gender and intersectionality

lens; include sex- and gender-disaggregated data; and include

the entire health and social workforce, including the social care

workforce. Research must go beyond describing the gender

inequities to also evaluate the impact of gender-transformative

interventions. Such research will aid understanding of context-

speciﬁc factors, including sociocultural dimensions. Moreover,

research focused on implementation and translation into policy

is needed to assess the viability and effectiveness of policies and

inform gender-transformative policy action.

• A mid-plan review should be aligned with the independent

review of the Working for Health ﬁve-year action plan for health

employment and inclusive economic growth (2017–2021) and

the medium-term ﬁscal plan that is to be carried out in 2019

to mark the midpoint in the ﬁve-year action plan. This proposed

review would involve WHO, ILO and OECD, assess progress on

deliverables on gender equality, and recommend steps to ensure

delivery of action plan commitments by 2021.

A literature review

1.1 Background

At present, over 234 million workers staff the health and social care

sector globally (1). The health and social care sector is the fastest

growing employment sector for women, with women comprising seven

out of ten health and social care workers (1).

On average, the share of women working in the

health and social care sector is nearly twice

their share of the total workforce. Although

the proportion of women in the workforce has

steadily risen in the last quarter of a century,

industry segregation patterns persist. In 2013,

while the proportion of women in the workforce

worldwide was only 39.5%, the proportion of women employed by

the global health and social sectors amounted to 70.3%. Figure 1.1

provides a breakdown of female employment in the health and social

sectors compared to the workforce as a whole across global regions (1).

As the main providers of health, women deliver health care to around

5 billion people globally and contribute US$ 3 trillion annually to

global health (2). However, approximately half of this contribution is

in the form of unpaid care work (2). The reduction of mortality rates

across all age groups over the past half century is largely due to the

underrecognized contribution of women to health and social care

(3, 4). This report highlights a critical opportunity to address the gaps

in our understanding of the challenges posed by gender inequality

in the global health workforce. Gender analysis in global health has

primarily focused on the point of service delivery and quality of care.

This has largely ignored the fact that women are not only recipients of

health care but are the primary drivers of health globally. This report

aims to move forward the agenda of gender equality in the global

health workforce. We recognize, however, signiﬁcant gaps in research

and data, particularly from low- and middle-income countries, that

limit our evidence and conclusions.

It is essential to understand the gender-related trends and dynamics

in the health workforce if we are to build resilient health systems and

SECTION 1. APPROACH

Chapter 1. Introduction

achieve universal health coverage (2). Despite global momentum and

progress on gender equality, systemic challenges, gender biases, and

inequities persist in the global health workforce, predominantly to

the disadvantage of women. The women who run health systems do

not have an equal say with men in their design and delivery. These

signiﬁcant challenges have been linked to health system inefﬁciencies

that impact the health worker training and supply pipeline,

recruitment, deployment, retention, and attrition, and contribute to

health workforce distribution imbalances between the formal and

informal health workforce, as well as between the public and private

sectors (5). As a result of women in the health workforce being largely

clustered into lower-status and underpaid (or unpaid) jobs, health

systems lose female talent, perspectives and morale.

It is essential to understand the gender-related trends and

dynamics in the health workforce if we are to build resilient

health systems and achieve universal health coverage

The women who are employed in global health are working in very

diverse health systems, settings and socioeconomic contexts. In

general, the current inequality between men and women in the health

workforce globally reﬂects the following.

• Women’s employment rights in many countries are not protected

by legislation governing critical areas such as equal pay for equal

work, non-discrimination and collective bargaining.

WOMEN COMPRISE 7 OUT OF 10 SOCIAL

HEALTH CARE WORKERS

• Medicine was established as a male-only profession and it has

taken time for women to overcome discrimination against their

entry to the profession, senior posts and better-paid specialisms.

• Unequal access of girls to education in many low- and middle-

income countries, particularly to secondary schooling, has limited

their access to training for formal health sector jobs.

• Gender stereotypes and norms common to all societies have

driven occupational segregation, sorting men and women into

different kind of jobs. For example, nursing is predominantly a

women’s job with men accounting for only 10% of those entering

the profession, whereas men hold the majority of jobs in surgical

specialties.

• Health systems and work conditions have been established to suit

men’s life patterns and not women’s; for example, many health

workers have no paid parental leave entitlement.

• Female health workers face a burden of bias, discrimination,

sexual harassment and violence not faced by their male

counterparts, and often not recorded or addressed.

• There is a lack of data and research to highlight gender gaps in

critical areas and to drive accountability and policy change.

• Political will and incentives are lacking for politicians and decision-

makers in health systems to adopt the gender-transformative

leadership and measures necessary to drive equality among

people of different genders, and among other marginalized

identities based on race, caste, class, ethnicity or religion.

All these factors have been obstacles to gender equality in the health

workforce.

According to projections of the World Health Organization (WHO)

Global Strategy on Human Resources for Health (6) and the World

Bank, 40 million new jobs in health and social care will be created

globally by 2030 to meet rising demand driven by demographic

changes, while a shortfall of 18 million health workers will need to

be addressed, primarily in low- and lower middle-income countries,

by 2030 to enable countries to reach the Sustainable Development

Goals (SDGs) and achieve universal health coverage (7, 8). To

address this shortfall, major investments in the health workforce and

acknowledgement of women’s contributions as drivers of health care

are needed. The WHO SDG Health Price Tag study estimates that

investments of US$ 3.9 trillion are needed by 2030 to increase the

prospects of achieving the health-related SDGs (investing US$ 51 per

capita in upper middle-income countries, US$ 58 per capita in lower

middle-income countries and $76 per capita in low-income countries)

(9). About half of these investments are required in the form of

Figure 1.1 Share of women employed in the health and social sectors compared to share of women employed in

all sectors by ILO region, 2013

Source: International Labour Organization (1).

10.00%

20.00%

80.00%

0.00%

70.00%

90.00%

60.00%

40.00%

30.00%

50.00%

45.3%

Europe and

Central Asia

76.8%

43.1%

Americas

74.0%

42.2%

Africa

54.1%

39.5%

World

70.3%

37.4%

Asia and the

Pacific

63.5%

Arab States

15.6%

38.3%

Share of female employment in all sectors

Share of female employment in the health and soical sectors

A literature review

training, educating and employing health workers (9). Investing in the

health workforce maximizes women’s economic empowerment and

participation, extends universal health coverage, contributes to global

health security, and also has a powerful multiplier effect on economic

growth (10). Moreover, addressing gender biases and inequities in

the health workforce is essential not only for achieving SDG 5 (gender

equality) and SDG 3 (health and well-being), but also for achieving

other SDGs, such as SDG 4 (quality education) and SDG 8 (decent

work and inclusive economic growth) (Figure 1.2) (11).

As health systems around the world are facing a growing mismatch

between health worker supply and demand, the time is right for the

global health community to take collective action. Recent global health

and workforce strategies are recognizing the critical importance of

addressing the gender challenges of the health workforce as key

to achieving universal health coverage by 2030, and maximizing

women’s economic empowerment and participation. This evidence is

facilitating a new narrative on the health workforce, shifting the focus

from health as a cost and a drag on the economy to health as an

investment and multiplier for inclusive economic growth (3).

The three major global efforts seeking to address the health workforce

and gender are as follows.

• WHO Global Strategy on Human Resources for Health: Workforce

2030. The Global Strategy was developed to advance progress

towards attainment of the SDGs and universal health coverage by

ensuring equitable access to health workers. The Global Strategy

calls for the alignment of gender, employment, education and

health with national human resources development and health

system strengthening strategies (6). It argues that the projected

global deﬁcit of health workers, coupled with rising demand to

create approximately 40 million new health care jobs by 2030,

uniquely positions the health and social sector to offer substantial

and tangible opportunities for decent work, gender equity and

greater women’s labour participation.

• United Nations High-Level Commission on Health Employment

and Economic Growth. The High-Level Commission, established

by the United Nations Secretary-General in 2016, made the

following recommendation, reafﬁrmed by the 61st session of the

Commission on the Status of Women (2017) and the Milan Group

of Seven (G7) meeting (2017) (3):

Maximize women’s economic participation and foster their

empowerment through institutionalizing their leadership, addressing

gender biases and inequities in education and the health labour

market, and tackling gender concerns in health reform processes.

Figure 1.2 Sustainable Development Goals

• Working for Health ﬁve-year action plan (2017–2021).

Through the Working for Health ﬁve-year action plan, WHO, the

International Labour Organization (ILO) and the Organisation for

Economic Co-operation and Development (OECD) have agreed

to support the implementation of the High-Level Commission’s

10 recommendations. The recommendations and action plan

identiﬁed (a) the development of gender-transformative global

policy guidance and (b) support to build implementation capacity

to overcome gender biases and inequalities in the education

Figure 1.3 Health workforce and gender: a theory of change

Source: Based on WHO (12).

and health labour market as two key deliverables to maximize

women’s economic participation and empowerment (12). Gender-

transformative policy requires a series of actions to be embedded

at every stage of policy action (Figure 1.3 and Figure 1.4) (12).

With multiple stakeholders prioritizing gender equity, it is of utmost

importance that the approach to implementation is systematic,

coordinated and evidence based. To facilitate this process, the WHO

Global Health Workforce Network established the Gender Equity Hub

(GEH).

Figure 1.4 Working for Health programme: a global movement for gender-transformative workforce development

Source: Based on WHO (12).

Concerted, tri-partite

social dialogue

Improved health

labour market data,

analysis and evidence

Enhanced national

health workforce

strategies

Sustainable domestic

and international

investments

Transformation and

scale up of education,

skills and decent job

creation towards a

sustainable health

workforce

Accelerate progress towards universal health coverage and the SDGs by

ensuring equitable access to health workers within strenchened health systems

(1) Expansion;

(2) TRansformation of the health and soical workforce

(1) Advocacy, social dialogue and policy dialogue

(2) Data, evidence and accountability

(3) Education, skills and jobs

(4) Financing and investments

(5) International labour mobility

Vision

Work

streams

Goals

Orgs

SDGs

A literature review

1.2 Gender Equity Hub (GEH)

The development of evidence-based gender-transformative global

guidance and its implementation requires a collective and concerted

effort. The WHO established the GEH at the fourth Global Forum on

Human Resources for Health held in November 2017. The GEH brings

together key stakeholders to support the implementation of the WHO

Global Strategy on Human Resources for Health and to achieve the

deliverables of the Working for Health ﬁve-year action plan. The

purpose of the GEH is to accelerate large-scale gender-transformative

progress to address gender inequities and biases in the health and

social care workforce in order to achieve the SDGs. The GEH works in

tandem with the other thematic hubs of the Global Health Workforce

Network, focused on topics identiﬁed as crucial for progressing the

WHO Global Strategy and the Working for Health programme.

The GEH is co-chaired by WHO and Women in Global Health.

Women in Global Health is a not-for-proﬁt organization built on a

global movement that brings together all genders and backgrounds

to achieve gender equality in global health leadership. The GEH

includes members from a range of global health stakeholders,

including intergovernmental and multilateral agencies, civil society

organizations, academic and research institutions, think tanks,

foundations, the private sector, and individual experts. Its main

objectives are to advance knowledge, data and research on gender

and the health workforce; develop tools to promote gender-

transformative approaches; and accelerate progress on addressing

gender inequities and bias. The four key GEH priority areas were

identiﬁed through a consultative workshop held at the fourth

Global Forum on Human Resources for Health (Box 1.1). The major

activities of the GEH were deﬁned by examining areas of comparative

advantage, identifying gaps in existing work, and addressing high-

priority needs. Additionally, key activities needed to drive evidence-

guided policy change were identiﬁed (Box 1.2).

Box 1.1 Global Health Workforce Network

Gender Equity Hub: priority areas

• Occupational segregation

• Decent work: workplace free from bias, discrimination and

all forms of harassment, including sexual harassment

• Gender pay gap

• Leadership and governance

Box 1.2 Global Health Workforce Network

Gender Equity Hub: five key activities

• Mapping: global evidence on good practice

• Data, evidence and accountability: evaluating current data

and evidence, and identifying gaps for future research and

development

• Policy tools: developing policy briefs and tools

• Dissemination: advocacy, social dialogue and policy

dialogue to disseminate evidence, policy tools, advocacy

kits, accountability scorecards and guidance to other

Global Health Workforce Network hubs

• Implementation: facilitating implementation of policy

through policy workshops, business solutions and private

sector engagement

1.3 Rationale for gender analysis on the

health workforce

Most of the evidence and research on gender in health has focused

on the demand dimension of health care, such as barriers to service

access experienced by women and the impact of health expenditure

discrimination on women (13). The evidence base is relatively thin

on the gender dimensions of the health care delivery side and the

workforce. In particular, evidence from low- and middle-income

countries is limited. There is also little evidence available on the

social workforce. Where available, research in this area rarely extends

beyond simple sex disaggregation into the more critical aspects of

gender power relations in health systems and their implications for

working practices, career patterns and occupational choices (13, 14).

A gender-based analysis of the health workforce is important for

health systems research. For research to instigate social and policy

change for better health, it should aim “to transform institutions,

structures, systems, and norms that are discriminatory” (15). In recent

years different forms and frameworks for researching gender relations

have emerged, including calls for adopting an intersectionality lens

that considers, in addition to gender, other identity factors that

contribute to discrimination. Other approaches, such as substantive

equality, emphasize the importance of considering the effects of past

discrimination, recognizing that rights, entitlements, opportunities and

access are not equally distributed throughout society, and there is

sometimes a need to treat people differently to achieve equal results.

For research to instigate social and policy change for better

health, it ought to aim “to transform institutions, structures,

systems, and norms that are discriminatory”.

A gender-based analysis of the health workforce is also urgently

needed to ensure that the expansion of health systems in the SDG era

capitalizes on the opportunity to transition to gender-transformative

health systems. Since this scale-up will focus on addressing the

projected global shortage of health and social care workers by

2030, and women are the majority of workers in these sectors,

gender analysis is critical to creating new jobs that will attract and

retain women workers. Investing in evidence on gender aspects of

human resources for health can inform global health policy-makers

and institutions and encourage them to apply a gender lens to the

health workforce. Effective gender-transformative health workforce

policies will address discrimination and rights abuses (such as sexual

harassment) that contravene good employment practice and law,

eliminate the gender pay gap, address occupational segregation and

increase gender-equal leadership. Gender analysis of the female

health and social care workforce will enable realization of a wider

gender dividend by bringing more women into paid, formal labour

market jobs with a positive multiplier for the health, education,

nutrition, income and empowerment of those women, their families

and communities.

With global health policy responsiveness to gender lagging behind,

more evidence on the gender dimensions of the health workforce

is needed to support the development of evidence-based, gender-

transformative health policies and actions across global health

systems and institutions.

A literature review

2.1 Objectives

The main objectives of this literature review are:

• to identify the available data and evidence from the literature

(published and grey) on addressing gender inequities in the health

workforce;

• to examine case studies, policies, tools, and strategies and their

impact on addressing health workforce gender inequities and

occupational segregation issues;

• to map programmes, initiatives, stakeholders, campaigns and

intersectoral opportunities across the public and private sectors of

relevance to addressing gender inequities and biases in the health

workforce;

• to synthesize lessons learned from the evidence, programmes,

initiatives and campaigns.

2.2 Methodology

Coupled with a global call for case studies, the GEH undertook a

comprehensive review of peer-reviewed articles, policy briefs and

programme interventions to evaluate gender and equity research within

the health workforce globally. Although the GEH prioritizes gender and

equity within the global health and social care workforce, the literature

on the social care workforce was not explored in this report, given the

limited material available. The process was as follows.

1. The GEH conducted a global call for best practices from December

2017 to January 2018. All articles, policy briefs, programmes and

other interventions received were analysed. The GEH received a

total of 25 submissions through this call, which included peer-

reviewed publications, programme interventions, and policy briefs.

All these submissions were included in the review.

Chapter 2. Objectives and methodology

2. Following the completion of the call for submissions, the GEH

members provided further publications and articles to guide the

literature review during February 2018 and March 2018. A total of

98 articles were received after removing duplicates.

3. A comprehensive and robust literature review was conducted

from December 2017 to July 2018 utilizing a keyword search of

the PubMed and Google Scholar electronic databases. Keywords

used to perform the search included the following: gender,

intersectionality, bias, discrimination, inequalities, harassment,

sexual harassment, violence, stereotyping, gender wage/pay gaps,

occupational segregation, gender parity, women’s leadership in

global health, health workforce, technology, corporate and ﬁnance.

AND/OR Boolean operators were used to search the databases.

A total of 100 additional articles were found after removing

duplicates from step 1 and step 2.

4. For the articles retrieved in steps 2 and 3, paper titles and

abstracts were examined using the following inclusion criteria:

» studies published in peer-reviewed journals

» published in the year 2000 and beyond

» English language publications

» articles for which the full text was available or accessible to us

» articles that provided evidence from three other sectors:

technology, corporate and ﬁnance.

Studies evaluating gender and equity dimensions in the workforce,

and articles pertaining to the health workforce, were prioritized.

The search ended upon saturation of the ﬁndings.

5. A total of 170 articles were included in the review after

performing steps 1 to 4.

6. We applied a structured evidence matrix and extraction tool

to extract ﬁndings from the 170 articles in eight months from

December 2017 to July 2018.

7. A draft report was made available for consultation from May 2018

to July 2018.

2.3 Limitations

There is a vast amount of literature, policies and programmes on

gender in the workforce. However, when the scope of the search

is narrowed to English language literature on gender in the health

workforce, the amount of material is much more limited. The members

of the Global Health Workforce Network GEH (see Annex 1) provided

extensive research articles and materials to ensure the review was

comprehensive. We received and reviewed very few programmes

and even fewer policies during this review, with the shortage being

particularly apparent for low- and middle-income countries. Literature

from the social care sector was not included in this review but will be

considered in subsequent reviews. Overall, there were some common

trends in the limitations of the overall body of literature on gender and

the health workforce, as described in the following paragraphs.

Intersectionality

The review was unable to apply a truly intersectional lens to gender

in the health workforce as the evidence predominantly focused on

gender, but did not provide further intersectional review, or provide

additional understanding of the impact of factors such as class, race,

ethnicity or religion on the health workforce.

Geographical focus

More reviews of the health workforce, particularly women in medicine,

have been undertaken in the United States of America, and to some

extent in Europe. However, there is limited evidence for gender in

the health workforce across other regions. Additionally, there is

no comprehensive global review of gender in the health workforce

available. It is important to note here that the review only took

into consideration evidence in English, which also imposed some

limitations on the geographical scope of the evidence.

Occupational focus

The literature demonstrated a focus on women in medicine,

particularly in the leadership and governance thematic area. There

was limited literature on the social workforce. Within medicine, there

was also a focus on speciﬁc specialties, in particular surgery. In recent

years, there has been more evidence emerging on nurses, midwives

and community health workers, though there is still limited information

about the experiences of women in other occupations throughout the

health workforce.

Sex- and gender-disaggregated data

Studies that evaluate discrimination as an aspect of gender are very

challenging. In many research studies, discrimination remains implicit.

The lack of data disaggregated by sex and gender within global health

further elevates the problem. This has resulted in limited attention to

gender discrimination within the health workforce.

Focus on women

The overwhelming majority of studies available look at gender and the

health workforce focusing on women. The experiences of men and

non-binary people were not found in any of the materials reviewed.

There is a need to shift the narrative and research focus away from

traditional or mainstream approaches that examine the deﬁcits

in female characteristics or the perceived positive attributes of

male leadership, behaviour and job preferences towards a more

transformative approach that investigates the root cause of gender

inequalities embedded in systems of discrimination, bias, norms,

institutional systems and pay policies.

While the review was focused on the health sector to ensure that it

was manageable and useful, additional evidence was drawn from

other sectors included in the review methodology (such as technology,

ﬁnance and corporate).

Finally, while the evidence focused on barriers that affect women

in the health workforce, there is very limited information and few

case studies on the application of evidence-based recommendations

and policy actions to address these barriers. Many of the

recommendations or solutions put forward in the evidence were based

on barriers or drawn from the literature reviewed but were not tested.

Further implementation research is required to assess their viability

and effectiveness.

A literature review

3.1 Key messages

• Occupational segregation impacts service delivery and the health

system by limiting full participation of all genders in all aspects of

the health workforce, fostering greater gender inequities.

• Both horizontal and vertical occupational segregation by gender

are found globally in the health sector but vary depending on the

context and history of the country. Occupational segregation has

its roots in two cultural ideologies: gender essentialism and male

primacy.

• Occupational segregation by gender is driven by long-standing

gender norms that deﬁne caring as female work and portray men

as more suited to technical specialisms in medicine.

• Gender discrimination is a primary reason for women not entering

higher-earning medical specialties or taking leadership roles,

while gender stereotypes deter men from joining female-majority

professions such as nursing.

• The horizontal and vertical dimensions of occupational segregation

combine to cluster women into lower-paid and lower-status work,

with a lifelong impact on their earnings and economic security in

old age.

• Female-dominated professions, including caregiving and nursing,

tend to be given lower social value by gendered social norms, and

are therefore associated with lower pay and prestige.

3.2 Occupational segregation:

literature review

Occupational segregation is the ﬁrst of the four workforce themes

prioritized by the GEH. The concept of “sex segregation” was ﬁrst

introduced by Gross (1968) to elaborate the differences in the kinds

SECTION 2. KEY FINDINGS

Chapter 3. Occupational segregation

of jobs men and women undertake, on the basis of both supply-

side factors such as personal choice and demand-side factors

such as discrimination in the workplace (16). Prior to this the word

“segregation” was used primarily in reference to separation of races.

Segregation is a fundamental pathway to social inequalities that

not only separates different groups based on their demographic

characteristics such as gender, race or class, but also forms a basis

for discrimination and bias (17).

Occupational segregation impacts all genders and their experiences in

labour markets. Gender segregation manifests itself in various forms,

ranging from a narrower set of choices and job opportunities for speciﬁc

genders to stereotypes that result in gender pay gaps and reinforce

unequal power structures within a society (18). It is one of the most

enduring aspects of labour markets across the world and exists in

diverse political, economic, cultural and religious settings (17).

Women account for 70% of the health workforce, but they are

mostly concentrated in nursing and midwifery professions,

while far fewer are physicians

There are two types of occupational segregation: horizontal

segregation and vertical segregation (19). The levels of segregation

are determined by size of occupation, gender composition of the

workforce and distinctions in occupational settings (16). It is important

to assess segregation by examining both within occupational

categories and across categories. For example, women account for

70% of the health workforce but they are mostly concentrated in

nursing and midwifery professions, while far fewer are physicians (20).

According to UN Women, globally women are concentrated in service

jobs (61.5%) as compared to agriculture (25%) or industry (13.5%),

and women occupy fewer leadership roles as parliamentarians (23%)

or as chief executive ofﬁcers (4%) compared to men (21). Figure 3.1

depicts women’s share of selected occupations in the United States in

2012 (22). While women are highly represented as dental assistants,

nurses, and even pharmacists, they make up less than half of the

physicians and surgeons in the United States (22).

Patterns of occupational segregation, especially women’s participation

in the formal labour market, vary signiﬁcantly by region and country,

and are inﬂuenced by culture, income levels, local law and other

factors such as education or qualiﬁcations. Figure 3.2 highlights

how occupational segregation can vary signiﬁcantly by country, as

evidenced by the share of female doctors in each OECD country (23).

The gender stereotype that assigns men the role of breadwinner while

women are prescribed the role of homemaker and child care is still

dominant and pervasive in many cultures. This stereotype remains

the leading cause of occupational segregation, as it either devalues

women’s contributions in the labour force or limits their participation

in the workforce. Moreover, a range of inequities emerge as a result

of gender segregation; for example, female-dominated jobs are

associated with lower salaries, fewer on-job trainings and limited

opportunities to exercise authority (16). The concept of occupational

segregation is applicable to all people, regardless of whether they

live in high-income countries or low-income countries (17). However,

the patterns of segregation may differ. For example, in high-income

countries women are concentrated in health, education, wholesale

and retail, while in low-income or lower middle-income countries

they are concentrated in the agriculture sector (21). Occupational

Figure 3.1 Women’s share of selected occupations (2012)

Source: Based on data from Hegewisch and Hartmann (22).

segregation in the health and education sectors is signiﬁcantly more

disproportionate in high-income countries compared to upper middle-

income, lower middle-income, and low-income countries, as seen in

Figure 3.3 (24).

Occupational segregation has historically been attributed to factors

such as investments in human capital, social norms and stereotypes,

comparative advantages men have over women due to their physical

and biological characteristics, and the differences in income levels

between men and women (25). Women have had to struggle to

gain their basic rights to education and economic opportunities

(26). Women were also banned from entering different professions,

including medicine. For example, in the United Kingdom, women were

not allowed to enrol in medical schools until the late 19th century.

Realizing that the only pathway for women in the United Kingdom to

enter the medical profession was through nursing education, Elizabeth

Garrett gained her nursing qualiﬁcation in 1865 and later became the

ﬁrst woman to qualify as a doctor (27). The ﬁrst woman to register as

a medical doctor in the United States was Dr Elizabeth Blackwell in

1858, and even then, she obtained a foreign degree to do so. In some

countries it took until the 1940s before a woman was able to qualify

as a doctor. Restrictions on women’s entry to speciﬁc professions and

types of work continue today but vary signiﬁcantly across regions.

Men and women also spend very different amounts of time on unpaid

care work, with women spending between 2 and 10 times more time

20%

30%

90%

80%

100%

70%

50%

40%

60%

Computer

Programmers

Bus

Drivers

Libraians

Registered

Nurses

Pre-

Kindergarten

Teachers

10%

Dental

Assistants

Cashiers LawyersPharmacists Photographers Mail

Carriers,

Post Office

CarpentersPhysicians

and

Surgeons

Civil

Engineers

A literature review

Figure 3.2 Share of female doctors by OECD country (2015)

Source: Based on data from ILO (24).

Source: based on data from OECD Health Statistics 2018.

Switzerland

Chile

Korea

Italy

Luxemburg

Japan

United States

Australia

Belgium

Iceland

50.0%30.0%20.0%0.0%

Turkey

10.0% 40.0% 60.0% 70.0% 80.0%

Hunary

Greece

Canada

Isreal

Ireland

New Zealand

France

German

United Kingdom

Norway

OECD34

Austria

Sweden

Denmark

Spain

Netherlands

Portugal

Czech Republic

Poland

Slovak Republic

Finland

Slovenia

Estonia

Latvia

Figure 3.3 Male and female employment (%) in health and education sectors (2015)

Male Employment

Female Employment

35%

30%

25%

15%

10%

20%

High IncomeUpper-Middle

Income

Lower-Middle

Income

Low Income

on unpaid care compared to men, depending on the country. This

unequal division of unpaid care work is associated with gendered

social norms of femininity and motherhood (28). Time use surveys

or data reveal that women spend more time on unpaid care and

household work compared to men (29). In general, women carry out

almost three more hours of unpaid work per day than men (29, 30)

(Figure 3.4). For example, women are expected to take care of

their families, home, children, or elderly relatives. In lower-income

countries, women are more likely to spend time on chores such as

collecting ﬁrewood and water; travel related to household activities;

or grocery shopping (29). Unpaid care work is directly correlated with

occupational downgrading, whereby women remain segregated into

part-time or vulnerable working conditions (31). Figure 3.5 displays

a breakdown of minutes per day spent on paid and unpaid work

between men and women in selected OECD countries (32).

Unpaid and informal work makes up nearly half of women’s

contributions to the global health sector. In 2015, the Commission on

Women and Health analysed data accounting for more than half of

the world’s population and found that women’s ﬁnancial contribution

to the global health system amounted to nearly 5% of global GDP.

Of this contribution, nearly half was for unpaid work, as shown in

Figure 3.6. Dr Felicia Knaul, Director of the Harvard Global Equity

Initiative, announced that the “ﬁndings on women’s paid and unpaid

ﬁnancial contributions to health worldwide only begin to explore and

quantify the work of women as health professionals in the paid health

care labour force, and their unpaid work to support health and prevent

illness undertaken in their own homes, in the homes of others, and

through volunteering in the health sector” (2).

While women’s contributions to the global health care sector makes

a substantial difference to countries’ economies, as well as individual

and societal well-being, the ratio of paid to unpaid work means that

Figure 3.4 Average work day and unpaid work, men

and women

Source: Based on data from World Economic Forum (30).

Unpaid work

7 HRS, 47 MIN

8 HRS, 39 MIN

1 Hour

30 Min

4 Hour

47 Min

Figure 3.5 Paid and unpaid work (minutes per day)

for men and women, by OECD country

Source: World Economic Forum 2017, based on data from OECD social

protection and well-being database.

Poland

Portugal

Austria

Italy

India

Japan

Ireland

Australia

Work (minutes per day)

Slovenia

China

Germany

Hungary

New Zealand

Spain

United Kingdom

Netherlands

Canada

South Africa

Estonia

Belgium

Denmark

United States

France

Finland

Korea, Rep.

Norway

Sweden

400200400800 600 200 600 800

Mexico

Turkey

Unpaid work, men

Paid work, men

Unpaid work, women

Paid work, women

A literature review

Figure 3.6 Financial value of women’s contribution to the global health system, as part of global GDP

Source: Langer et al. (2).

nearly half of this work remains unrecognized and unaccounted for in

decision-making. Unpaid or informal health care work, often critical

to a society’s health care system and well-being, routinely goes

unvalued. For instance, in Spain, 88% of all health work is unpaid

(33). The burden of unpaid work in health and social care, which falls

mainly upon women and girls, limits their access to both education

and paid work in and beyond the care sector, forming a “unpaid care

work-paid work- paid care work” circle as shown in Figure 3.7. (34)

Since women and girls from socially disadvantaged groups carry a

disproportionately large burden of unpaid care work; it affects both

the type and quality of jobs that are available to them and reinforces

their disadvantage. (34) These unfavourable conditions impact gender

equality both within the labour market as well as in unpaid care

contributions; resulting in gender segregation of jobs.

The segregation of people into occupations based on gender is

reinforced by two culturally determined narratives (35).

• Gender essentialism: the belief that men and women are different

and have different working styles and skills. This assumes, for

example, that women have a natural tendency for caring, nurturing

jobs while men are more inclined to be managerial or mechanical.

2.47%

2.35%

Global GDP

Unpaid

Paid

• Male primacy: the belief that men and boys are naturally more

dominant and more status worthy compared to women and

girls. Gendered barriers restrict women and girls from entering

male-dominated occupations such as surgical care, while there

are barriers that restrict men from entering female-dominated

occupations such as education or social care (35).

Despite making progress towards gender equality, equal engagement

of all genders in certain occupations and levels of decision-making

is limited. In their book Occupational ghettos, Charles and Grusky

argue that while egalitarian forces have reduced vertical segregation

in “non-manual” jobs (managerial, sales or service jobs), horizontal

segregation persists due to gender essentialism as women remain

concentrated in non-manual jobs in the post-industrial era while men

dominate the skilled trades (36). Women are entering male-dominated

jobs at a faster rate than men are entering female-dominated

occupations. Less than 10% of all registered nurses in the United

States are male, though that proportion has been steadily increasing

over the past 50 years, as seen in Figure 3.8 (37). While women face

gender-based discrimination and the “glass ceiling” limiting their

advancement in male-majority jobs, men who enter female-majority

professions have advantages that may speed their promotion, referred

to as the “glass escalator” (38).

The ILO 2018 report on world employment highlights that women

in low- and middle-income countries are in more vulnerable forms

of employment compared to men, and there are fewer employment

opportunities for young people (below the age of 25 years) (39). In

Arab States and northern Africa, women are twice as likely to be

unemployed as men (39). One reason for this is labour laws that

restrict women from entering certain ﬁelds. Women face more

institutionalized restrictions in the workplace in some regions

compared to others, such as South Asia, Middle East and North

Africa, as seen in Figure 3.9 (40). These differences hinder progress

on gender equality. A report commissioned by the European Union

determined that an acceptable level of gender gap for “gender-

neutral” occupations would be a mix of men and women between

40% and 60% (41). The United Nations has put this benchmark

between 45% and 55% (42).

Trends in the labour market have changed signiﬁcantly, with most

countries projecting growth in women’s participation in the labour

force. But it is a concern that globally, women’s labour force

participation has declined on average by 2% between 1990 and 2017

(43). Only high-income countries have shown an upward trend during

this period, while low-income countries have ﬂuctuated between

downward and upward trajectories. While there are many variations

Figure 3.7 The cycle of unpaid care work–paid work–paid care work

Source: ILO (34).

between countries, the trend for the middle-income, low- and middle-

income, and lower middle-income categories of countries is for a

decline in women’s formal labour market participation (43). There

are many possible explanations, one being that as families increase

their income there is pressure for women to revert to the traditional

stereotype of a homemaker, or that in economic recessions women

are often the ﬁrst group pushed out of the formal labour market into

the informal sector.

Globally, women’s labour force participation has declined on

average by 2% between 1990 and 2017.

3.3 Occupational segregation by

gender in the global health workforce

Women in the global health workforce have an inverted career

pyramid (44). Gender differences in participation in the global health

workforce are driven by men’s greater access to education, training

and the formal labour market; historical discrimination against

women’s access to higher-status and higher-paid specialties, which

manifests in a lack of female role models, gender stereotyping and,

PAID CARE

WORK

PAID WORK

Levels and distribution of unpaid

care work impact the conditions

in which unpaid carers enter and

remain in paid work, and influence

working conditions of care

workers.

Gender equality in the labour market,

including in women’s participation,

employment and working conditions

also imply positive outcomes for care

recipients.

Care workers in adequate numbers and

working conditions contribute directly to

gender equality in the world of work and the

redistribute unpaid care work.

UNPAID CARE

WORK

A literature review

Figure 3.8 United States share of nurses who are male (1970–2011)

Source: United States Census Bureau (37).

Figure 3.9 Percentage of economies that restrict women’s employment, by type of restriction

Share of registered nurses who are male

Share of licensed practical and vocational nurses who are male

2.0%

12.0%

0.0%

10.0%

6.0%

4.0%

8.0%

2011

1990

1980

1970

20062000

Source: World Bank (40).

50%30%20%0% 10% 40% 60% 70%

East Asia & Pacific

Latin America & Caribbean

Europe & Central Asia

Sub-Saharan Africa

South Asia

Middle East & North Africa

OECD High-income

Jobs deemed hazardous, arduous or morally inappropriate

Industry-specific restrictions (eg. in mining or construction)

Restrictions on working during night hours

in some countries, formal restrictions on women’s work during night

hours; women’s greater burden of unpaid reproductive work, which

may deter them from entering some specialties; cultural stereotypes

that deter men from aspiring to join majority female professions such

as nursing; and gender discrimination against women in entry to

higher-status specialties and leadership roles.

Globally, women are highly concentrated in primary care, nursing

and midwifery, with signiﬁcant variation between countries. This is

an example of horizontal segregation, such as Denmark, women

make up 90% of the nursing and midwifery professionals (20). In

addition, women account for one third of all physicians within the

United States, while in Scandinavian countries women make up

45–56% of doctors, and in the Russian Federation 70% of physicians

are women (45). Despite a large proportion of female physicians in

Russia, studies noted that far few were found to be in prestigious

specialties, tertiary care and academic medicine. (45) The percentage

of women in dentistry globally is projected to increase to 28% by

2030 (46). Horizontal segregation leads to the feminization of certain

medical specialties (47); women are more likely to choose the ﬁelds of

paediatrics, paediatric surgery, obstetrics, gynaecology, oncology and

dermatology (48–52).

Globally, women are highly concentrated in primary care,

nursing and midwifery, with significant variation between

countries

Moreover, gender inequality within the medical workforce remains

highly contested, particularly for surgical specialties, as only one

third of women doctors select surgery compared to men (53). One

reason for this is the perception that surgical specialisms are a male

domain where toxic masculinity is common, creating a hostile work

environment for women. The #MeToo movement in the United States

has encouraged women in medicine to come forward and share their

experiences of harassment in hospitals and operating rooms (54).

The higher numbers of men pursuing internal medicine and hospital

specialisms, plus the higher numbers of women pursuing family

practice, obstetrics and gynaecology, has resulted in the gender-

based segregation of men and women in medicine in the United

States (55). Women are increasingly entering obstetrics, while their

numbers in breast surgery and urology remain low.

While there is plethora of literature investigating why men and women

studying medicine pursue different specialties, most of these studies

have been conducted in the United States or the United Kingdom.

This limits our understanding of the factors explaining why more and

more women are being excluded from different health care specialties

(53, 56). With large gender gaps in wages and leadership positions in

health care, it is critical to understand the drivers of these patterns of

occupational segregation (57–59).

Horizontal segregation also impacts women in health across all

occupations. In the United States, women in nursing and medicine

work the same number of hours as men but earn 78% of their male

counterpart’s earnings (60). Women health workers tend to work

fewer hours than men in countries where data are available, except

in the Russian Federation, where they were found to work longer

hours (60). In Canada, when primary care providers were compared

by gender, women self-reported fewer hours of work than men, saw

less patients and delivered fewer services. However, using hours as an

indication of work impact did not reﬂect the realities that women were

more likely to spend longer with their patients, and to address more

problems during each visit (61).

In the United States, women in nursing and medicine work

the same number of hours as men but earn 78% of their male

counterpart’s earnings.

3.4 Factors that lead to occupational

segregation

There is no single factor that can unilaterally explain gender

segregation in education and the labour market (62). Boxes 3.1, 3.2

and 3.3 highlight some of the individual, organizational and societal

factors contributing to gender segregation.

3.5 Why occupational segregation

matters

Global health policy-makers and decision-makers need to understand

the factors that lead to the clustering of men and women in certain

jobs. Studies have shown that organizations that adopt policies to

attract, develop, compensate and retain the best talent will be the

ultimate winners (81). However, an analysis of the gender-related

A literature review

Box 3.1 Individual factors contributing to gender

segregation

EARLY DEVELOPMENT AND FAMILY RELATIONS

Early development impacts the career choices people make.

Examples

• Gender-biased toys given to children inﬂuence their

interests and career choices (63).

• Demographics and personal values are associated with

gender differences in specialty choice (55, 64).

WORK–LIFE BALANCE

Control of lifestyle and work–life balance inﬂuence specialty

preference for women (49, 65, 66) and men (67).

Women’s greater burden in terms of household work,

responsibility for family, child care and protected time for

breastfeeding is considered one of the drivers for occupational

segregation (55, 68).

Examples

• Often workplaces do not have private space for feeding

mothers (69).

• In comparison, due to decreased societal expectations

of child care, men with children see less impact on their

careers compared to women. Women on the other hand

often have to struggle to balance expectations (70).

CHOICE AND INTERESTS

Gender norms also inﬂuence occupation choice and interest

as students – women are encouraged to pursue a career

choice based on idealism, where men are more likely to be

inﬂuenced by the prospect of a good income or prestige (48).

Example

• The #MeToo movement has enabled many American

women in medicine to come forward and admit that

they chose a female-dominated specialty over a male-

dominated specialty just to avoid exposure to toxic working

environments.

Box 3.2 Organizational factors contributing to

gender segregation

WORKING HOURS

Work scheduling challenges – such as long training hours

and inﬂexible rotation schedules – conﬂict with the societal

expectation that women are the primary caregivers in their

families.

Examples

• It has been shown that the more inﬂexible or time

consuming a specialty is, the more likely it is to be male

dominated, as in the case of surgery (2, 71, 72).

WORKING CONDITIONS (AUTONOMY, WAGES, JOB

SECURITY, HEALTH AND SAFETY)

Working conditions can lead to gender segregation.

Examples

• Women in male-dominated sectors tend to experience

gender discrimination, differences in task allocation, fewer

opportunities for promotion and lower salaries at higher

frequencies (73).

• Fear of workplace discrimination or selection bias leads

women to take lower-paying jobs.

ROLE MODELS

The paucity of female role models and lack of successful

women in surgical specialty is the most often cited reason for

reduced interest in surgery among female medical students.

Example

• One study found that only 35% of female medical students

could identify a mentor during surgical clerkship; while in

another study found that among female surgical students

who had mentors, 90% had a male mentor as compared

to female mentor. (74, 75).

INSTITUTIONAL POLICIES

Social policies such as parental leave, maternity leave, and

subsidized child care also inﬂuence the career choices of men

and women (76) and ways in which they organize personal

lives (68).

Box 3.3 Societal factors contributing to gender

segregation

GENDER STEREOTYPES

There are gender stereotypes that deﬁne characteristics of

female-dominated jobs.

Examples

• There are expectations that women may be willing to take

on more tasks, are less inclined to complain, and are more

patient with monotonous work. Women’s lower participation

in labour unions keeps women in low-paying, ﬂexible roles

and in jobs that involve less decision-making (77).

• Overall, gender stereotypes drive institutional policies, for

example with regard to parental leave, care leave, and

availability of child care facilities. The lack of gender-

responsive policies, combined with societal expectations,

means lower retention and recruitment of women (41).

• The fact that certain medical specialties conform with

traits seen as traditionally masculine also deters women

from joining, for example the existence of the so-called

“male surgeons’ club” (78).

• When men enter occupations that are traditionally more

feminine they can experience setbacks in prestige and

pay. Men with children are more likely to avoid these

occupations (79).

DISCRIMINATION

Sex and gender are important considerations for hiring and

promotion (77).

Examples

• Women may be discouraged from taking surgery as a

specialty due to discriminatory attitudes during training

rotations in general surgery (52, 78).

• Women discriminating against women may perpetuate the

cycle of gender disparity, especially within surgical care (80).

Occupational segregation is an important workforce priority because

it can lead to loss of talent and diverse voices from the workforce.

Gender segregation is one of the major reasons behind shortages

and surpluses of workers across occupations, as women tend to

be concentrated in roles seen as caring and nurturing, while men

are in technical or managerial jobs. Gender segregation is also an

established source of gender inequality, as it reinforces some of

the gender stereotypes associated with men’s and women’s gender

roles, working styles and competencies. It is also linked to economic

empowerment and poverty. Women often have less coverage for social

protection, such as pensions, due to their absence from the labour

force. They are also prone to higher levels of employment in unpaid or

part-time jobs and have less access to quality employment (39). Men

are more concentrated into higher-paying jobs in the private sector

and in sectors that are less willing to provide protected leave for care

needs, such as child care or elder care. Social stigma is attached to

men entering more female-dominated jobs. These stereotypes limit

women’s participation in labour markets and, on the other hand, put

signiﬁcant pressure on men to not take leave, such as parental leave,

when it is available to them (18). Gender segregation also results in

lower salaries and worse working conditions in occupations dominated

by women (17).

Gender segregation also affects the educational choices of men

and women and the type of specialties they choose during medical

training. Gender segregation in the health workforce has implications

for the development of strong and resilient health systems that are

capable of tackling health needs worldwide (83). The number of

women enrolled in medical schools has increased over the years.

Recent data from the Association of American Medical Colleges in

the United States show that in 2017 women outnumbered men in

medical colleges for the ﬁrst time in history (84). Since 2015, female

enrolment has increased by 4% while male enrolment has decreased

by 6.7%, which indicates that the future of medicine and global health

is female (84). However, an increase in enrolment at medical schools

does not necessarily ensure a supply of health care professionals

to meet population needs. For example, women continue to be

underrepresented in the ﬁelds of surgery and surgical subspecialties,

a trend that is found not only in the United States, but also in Canada,

the Netherlands and the United Kingdom (53, 80).

Gender segregation in the health workforce has implications for

the development of strong and resilient health systems that are

capable of tackling health needs worldwide.

policies of 140 global health organizations found that only 43%

had speciﬁc policies in place to promote gender equality in their

workplaces, including strategies to support women’s career paths.

In fact, 30% of these organizations did not even mention workplace

gender equality in their policies (Figure 3.10) (82). The time is right for

global health systems and organizations to reﬂect on their strategies

and design systems and structures that create conducive working

environments where all members of the workforce can thrive and

achieve their full potential.

A literature review

Organizational structures or systems need to create enabling

environments for all genders. As more women are getting trained

and educated, we need to create job opportunities where all workers

regardless of their gender can thrive. Similarly, we need to change

mindsets around men entering female-majority jobs such as nursing.

There is a need to remove labels such as “male dominated” and

“female dominated” from the health and social care workforce

vocabulary if we are to adopt gender-transformative approaches

within the health and social care sector and achieve gender equality in

this sector. Failure to address the shortage of health workers will have

a crippling effect on poverty alleviation, development, and economic

growth, as well as stalling progress on the SDGs and universal health

coverage.

Figure 3.10 Do organizations have workplace gender

policies?

Source: Global Health 50/50 (82).

have specific

measures in

place

commit to gender

equality but lack

specific measures

simply comply

with laws

15%

make no

reference

to any

measures or

commitments

30%

12%

43%

4.1 Key messages

• A large percentage of women in the global health workforce face

discrimination, bias and sexual harassment.

• Women are more likely to face sexual harassment in the workplace

than men. For example, in the United States 30% of female

medical academics reported accounts of sexual harassment

compared to 4% of men.

• Many countries, particularly low- and middle-income countries,

do not have a legislative framework to support gender equality at

work, including laws to prohibit sexual discrimination and sexual

harassment at work.

• While the #MeToo movement has encouraged more open

discussion of sexual harassment in some countries, it remains a

serious and widespread abuse causing attrition, loss of morale,

stress and ill-health for survivors.

• Female health workers in conflicts or emergencies or working

in remote areas can face violence in the course of their work,

with a number of female health workers severely injured or killed

every year.

“To reduce the gender gap and add up to US$ 6 trillion to the

global economy by 2025, nations must eliminate gender biases

and inequities for women at work, including in the health

labour market.” James Campbell, Director, WHO Health Workforce

Department, December 2017

4.2 Decent work: introduction

Decent work is the second of the four workforce themes prioritized

by the GEH. SDG 8 – Decent work and economic growth – sets the

agenda for full and productive employment and decent work, and for

Chapter 4. Decent work without

discrimination, bias and sexual harassment

promotion of sustained, inclusive and sustainable economic growth

for all as key to alleviating poverty, protecting the environment, and

ensuring people’s well-being (11). Decent work involves creating

conducive work environments built on the principle of equal

opportunities for all, free of discrimination, bias or harassment,

including sexual harassment. This is an important goal that is a

cross-cutting theme across other forms of inequalities, including

occupational segregation and the gender pay gap. In the context

of this paper, decent work includes work free from discrimination,

bias and sexual harassment, and with equal pay within the health

care workforce. The gender pay gap is discussed in Chapter 5.

Addressing discrimination and bias within the global health workforce

is an important step towards achieving gender equality and building

stronger and resilient health systems that uphold the basic principles

of human rights (5).

“By 2030, achieve full and productive employment and decent

work for all women and men, including for young people and

persons with disabilities, and equal pay for work of equal

value.” SDG 8, Decent work and economic growth, Target 8.5

With 40 million new health jobs to be created by 2030, the

overarching objective is now to create jobs differently, according to the

principles of decent work, and to meet the targets in SDG 8, especially

Target 8.5. Currently, the majority of women in the global health

workforce work under conditions that do not meet the standards

for decent work, not least because of the near universal gender pay

gap. So, the objective must also be to ensure that both new jobs and

existing jobs in the global health workforce are upgraded to meet

decent work standards, not only because it is the right thing to do but

also to create a stronger foundation for better health for all.

While modern workplaces are far less dangerous and demanding than

they were historically, they are manifesting discrimination and bias in

subtle ways (85). There is a large body of research that shows women

face discrimination in almost every ﬁeld of science and engineering

(86). The discrimination also varies based on career stage and ﬁeld

A literature review

(86). As a result, men and women have different work experiences

even if they work in the same organization. For example, the

expectation to work long hours, to be constantly available, to adapt

to rigid career tracks and to have inﬂexible work schedules creates

stress, reduces morale, and conﬂicts with the work–life balance

of employees. Women are more likely to face these challenges to

work–life balance than men. The difﬁculty of keeping up with these

growing expectations pushes women to take up part-time jobs, or

remain segregated into female-majority jobs, or take leave from work

(85) to fulﬁl their caring roles at homes. Women have been observed

to move towards professions that offer greater ﬂexibility. They often

have to trade off ﬂexibility and earnings (87). Men and women may

start off with the same salaries or lower gender pay gaps, but the gap

increases over the course of their career due to career interruptions

and differences in job experience or number of hours worked (87).

The penalty for taking leave or time out is huge and accounts for

about 67% of the total penalty from career interruptions (87). Highly

trained women pay a higher price for returning to work after leave

(88, 89), and working mothers are perceived to be less committed

to work due to their family obligations and hence considered less

desirable for hiring or promotion (90). When it comes to hiring or

promotion decisions, gender bias against female candidates favours

male candidates (91).

Some women at the workplace face an additional dilemma of “double

jeopardy” – a double burden of discrimination, not only on account of

their gender, but also because of their race or caste (92). Most of the

expectations at work result from the gender norms and stereotypes

to which men and women are assigned. As a result, men gain

opportunities while women more often lose both in career progression

and earnings.

4.3 Decent work in the global health

workforce

The gender and power relationships that exist within and outside

the health system create differences in exposure and vulnerabilities

among men and women that lead to reproduction of inequalities

within the health system (84). Power relations, based on hierarchical

health systems that “rank” the value of each profession and each

person, create a workplace environment that fosters a lack of decent

work conditions.

Workplace violence and discrimination is also linked to the social norms

that create gender hierarchies and imbalances, starting from home and

progressing to society at large. Women face a disproportionate burden

of violence and discrimination across all sectors (80, 93).

4.4 Discrimination

There are many forms of gender discrimination, including direct

discrimination (for example, excluding women from decision-making

and training opportunities); indirect discrimination (for example,

exclusion of informal or home-based health workers from protective

labour laws); sexual harassment; gender stereotyping that limits

women to inferior roles and informal care roles (as in the case of

community health workers); vertical and horizontal occupational

segregation; wage discrimination; and beneﬁts and working conditions

discrimination (5, 94). Gender discrimination and inequality are key

barriers to entry, re entry and retention of female health workers (5).

Caregiver discrimination is prevalent in many forms, for example, by

fee demotion for pregnant students, who are often left behind in their

curriculum or practicum; or by prohibiting pregnant students from

continuing education (95).

Literature suggests that gender discrimination and gender inequality

within organizations are linked to low morale, low self-esteem, and

lower productivity for the workers, and affects mental and physical

health (5, 96–98). This gives rise to health system inefﬁciencies

that obstruct the pipeline of qualiﬁed and skilled health workers,

create recruitment challenges, and lead to absenteeism, attrition and

maldistribution of the health workforce (5).

Gender discrimination and gender inequality within

organizations are linked to low morale, low self-esteem, and

lower productivity for the workers, and affects mental and

physical health.

Female-majority jobs often face a greater burden of discrimination.

For example, the WHO report on midwives’ voices (99) highlights how

power structures and gender dynamics should be restructured to

address the needs of midwives. Midwives provide high-quality care

to women, newborns and their families, but many are frustrated with

their lack of voice and power to bring change. Of the nurses in the

study, 36% reported not being respected by their seniors, 32% said

they would like to be heard or listened to, and about 37% of midwives

faced harassment at work (99).

Women’s childbearing and family obligations also prevent them from

undertaking health trainings or scholarships or enrolling in schools

(95), often because training is not set up to accommodate the needs

of workers with care responsibilities.

4.5 Bias

Women are more likely to face bias at work. It is important to note

that gender is only one intersection, and that many women experience

additional bias due to their race, ethnicity, culture, regional, caste

or class. These types of bias lead to a double burden or “double

jeopardy” faced by women with additional marginalized identities (92).

Men can also face bias in female-majority jobs, which may result in

lower status.

Gender bias in global health academia is well established. One

study found that both men and women have a subtle bias towards

women when it comes to hiring and promotion. Another study

found that letters of recommendations are written differently for

men (“his research”) and women (“her teaching”) (100). These

biases exacerbate gender gaps in academic medicine. For example,

women represent only 20% of deans in the top 25 global schools of

medicine and 36% in the top 25 global schools of public health (101).

Academic publishing is also a gendered system, with fewer women

represented on editorial boards and as peer reviewers (102). Women

are likely to publish less during the ﬁrst decade of their scientiﬁc

careers compared to men (103). This is evident from data revealing

that men authored about 70% of the total publications on Web of

Science between 2008 and 2012 (104).

4.6 Sexual harassment

Sexual harassment refers to unwelcome sexual advances or requests

for sexual favours, whether verbal, physical or visual. There are

many forms of sexual harassment: it may include hiring, ﬁring and

promotion decisions subject to provision of sexual favours, unwanted

sexual advances, touching, sexual violence, and inappropriate

comments or obscene remarks, which generally create a work

environment for women that is hostile, intimidating and demeaning.

Men also face sexual harassment at work but women suffer the

majority by far. For example, in the United States, 30% of female

medical academics reported sexual harassment compared to 4%

of men (Figure 4.1) (105). Of those who reported harassment, 47%

stated that these experiences negatively impacted their career

development (105). Female health and social care workers face

harassment and violence from three sources – male colleagues, male

patients and the wider community, including visitors to facilities or

men in the community if they are outreach workers. The stigma in

reporting cases in the health professions has created a misperception

that sexual harassment cases are rare. But health systems are no

exception. Nurses and community health workers have commonly

been subject to sexual harassment despite the work environment

being predominantly women (106).

Sexual harassment against female health workers appears to be

a universal phenomenon. Migrant female health workers can be

particularly vulnerable to violence and harassment, as can female

health and social care workers in domestic settings. A review in

Rwanda found that approximately 39% of health workers had faced at

least one form of workplace violence, such as verbal abuse, bullying

and sexual harassment, in the 12-month period prior to the study,

with women disproportionately affected (83). In Nepal, 42% of health

workers reported experiencing sexual harassment in the form of

verbal and physical abuse, and almost two thirds of the health workers

reported being harassed by their senior male colleagues (96). Lady

health workers in Pakistan reported experiencing sexual harassment

from both senior and junior staff, including management (107, 108).

In the Republic of Korea, 19.7% of women in nursing reported

experiencing sexual harassment, noting that the operating theatre was

the most frequent place for this to occur (109). Women are likely to

experience sexual harassment, even if they are higher in the traditional

medical hierarchy. In a survey of physicians in the United States, 30%

of those surveyed reported having faced a personal incident of sexual

violence in the workplace (106). Threats of violence or harassment do

not only come from sources internal to the health system; for example,

Figure 4.1 Percentage of United States medical

academics reporting sexual harassment

Source: Based on Jagsi et al. (105).

1,066 recipients of NIH academic

career development awards

30%

A literature review

community health workers in Kenya experienced threats of violence

by husbands when providing HIV testing to wives. Cases of rape were

also reported, leading to calls for security services to accompany

community health workers (108).

Women are likely to experience sexual harassment, even if they

are higher in the traditional medical hierarchy.

Sexual harassment in the workplace is difﬁcult to combat on a global

scale, given the vast differences in laws and policies addressing or

penalizing sexual assault around the world. Figure 4.2 depicts the

number of countries that have no laws, civil remedies, or criminal

penalties for workplace sexual harassment (110).

Harassment is prevalent in academic medicine as well. A meta-analysis

of studies on harassment and discrimination in medical training showed

that around 60% of students and trainees experienced discrimination

and sexual harassment during their training period (111, 112). A recent

report from the National Academies of Sciences, Engineering, and

Medicine raised concerns about the prevalence of sexual harassment

in academic sciences, engineering and medicine, which threatens the

integrity of education and research in these ﬁelds (113). The survey

ﬁndings from this survey found as high as 50% of female medical

students experiencing sexual harassment from faculty or staff at one of

the universities in United States .

Conﬂict-affected countries or remote settings present unique risks to

women in health care, where they are highly vulnerable to violence

(114). In Cambodia, women in conﬂict-affected areas face reported

risks to their personal safety, and loss of family contact (115). In

Pakistan, female polio outreach workers have been murdered and

attacked, not only causing tragic loss of life (116) but also stalling

elimination of polio from the country. A young midwife in Nigeria was

abducted and killed in October 2018 (117). Failure to protect front line

female health workers in conﬂicts and emergencies inevitably restricts

services to highly vulnerable women desperately in need of all health

services but particularly during pregnancy and childbirth.

In Pakistan, female polio outreach workers have been murdered

and attacked, causing not only tragic loss of life but also

stalling elimination of polio from the country.

Sexual harassment is so prevalent it cannot be treated as an

individual occurrence or aberration and needs organizational

strategies, based on law, to address culture, prevention, accountability

and support to survivors. Very few organizations keep systematic data

on cases and outcomes, making it difﬁcult to analyse the extent of

sexual harassment and its impact on female health workers, and to

build policy measures to eliminate it. While the #MeToo movement has

built momentum towards raising the proﬁle of sexual harassment and

assault, it remains a source of stigma and taboo. The onus of proving

guilt too often falls on the shoulders of the survivor. Since power

remains the underlying motive behind acts of sexual harassment and

violence at work (118), survivors are often silenced or risk facing

retaliation. Where there are no proper guidelines or policies to address

incidents of sexual harassment, cases may be dealt with on an ad

hoc basis, often favouring the perpetrator, who is likely to be more

powerful in the system (119).

Due to imbalances of power, fear of not being believed, and the

prospect of retaliation, survivors of harassment have often remained

silent. But with the #MeToo movement, the focus has rightly shifted to

addressing all forms of harassment in the workplace, including sexual

harassment (120). Issues that were once considered taboo can now

be more openly discussed in workplaces in some countries (121).

While this gives a unique opportunity to global health policy-makers

to agree and commit to institutionalizing policies and culture change

to eradicate all forms of harassment and discrimination, there are still

many contexts where discussions of sexual harassment are culturally

inappropriate, and where women are either silenced or face the threat

of losing their jobs if they report harassment (Box 4.1).

Figure 4.2 Inadequacy of global sexual harassment laws

Source: Council on Foreign Relations (110).

59 countries do not have laws

prohibiting sexual harassment in

the workplace

100 countries do not have civil

remedies for sexual harassment in

the workplace

110 countries do not have

criminal penalties for sexual

harassment in the workplace

4.7 Why addressing decent work in the

global health workforce matters

Bias and discrimination rob women of opportunities but also rob health

systems of female talent. This becomes everybody’s problem because

it impacts the quality of health systems used by all genders. Creating

safe and enabling work environments where all genders can work to

their full potential has huge implications for the economic productivity

Box 4.1 Origin of the #MeToo movement

The #MeToo movement ﬁrst originated in 2007, when Tarana

Burke, an African American woman, launched a campaign

to reach out to sexual assault survivors in underprivileged

communities (122).

This campaign turned viral when actress Alyssa Milano

converted it into a hashtag and called on followers to share

their stories of sexual harassment and assault on Twitter using

the phrase “Me Too” (122).

and well-being of populations. It would improve health workforce

recruitment and productivity, as well as retention. It would also have

positive effects on quality of care, which would improve patient

outcomes and health system efﬁciencies. It is the fundamental right of

health workers to have freedom to express their opinions and be able

to participate and engage in improving the conditions of the health

workforce. Ensuring workplaces where all female health workers are

assured of safety, dignity and respect is essential to addressing global

health worker shortages, meeting health care demands, and unlocking

wider social and economic potential.

Creating safe and enabling work environments where all

genders can work to their full potential has huge implications

for the economic productivity and well-being of populations.

Sexual harassment in the workplace has a variety of negative impacts

on female health workers, including on their physical and mental

health. Studies have shown sexual harassment experienced during

medical training can inﬂuence decisions on specialty and residency

programme selection (95). Furthermore, this effect extends beyond

the individual experiencing harassment to the health system as a

whole. Examples of systemic consequences include impediment of

health workers’ advancement, increased stress and decreased morale

and productivity, and a limited pool of health workers to deal with

today’s health challenges (5, 123). In a world needing to create an

additional 40 million health and social care sector jobs there is an

immediate need to record, prevent and address the causes of sexual

harassment, not only because it is a human rights violation but also

because it results in attrition, loss of female talent, and reduced

morale and productivity. The perception that certain types of work or

sectors are likely to make women vulnerable to the risk of violence

and sexual harassment will affect recruitment and health worker

supply. Current levels of sexual harassment are diminishing patient

outcomes and creating major inefﬁciencies in health systems.

A literature review

5.1 Key messages

• Most of the gender pay gap remains unexplained by factors

such as age, experience, education, number of hours worked, or

specialty choice. This suggests discrimination and bias against

women and in favour of men.

• The unadjusted pay gaps in health and social care, estimated at

26% in high-income countries and 29% in upper middle-income

countries, are higher than other economic sectors.

• Occupational segregation by gender, with women tending to be

clustered into lower-status and low-paid sectors and specialisms

in health, is associated with a gender pay gap in favour of men.

• Equal pay for equal work legislation and strong collective

bargaining, absent in many countries, are essential for addressing

the gender pay gap in the health sector.

• The gender pay gap results in lower lifetime income for women,

reduced access to pay-related social and health beneﬁts (where

they exist), and increased poverty for women in older age.

Chapter 5. Gender pay gap

• Women’s economic inclusion, and therefore closing the gender

pay gap, is critical to achieving the SDG overarching objective of

leaving no one behind.

5.2 Gender pay gap: introduction and

background

The gender pay gap – the third theme prioritized by the GEH – refers

to the difference in average earnings between men and women. Equal

pay refers to men and women performing the same role receiving the

same pay – that is, equal pay for work of equal value (Figure 5.1).

Gender pay equity was ﬁrst deﬁned by the ILO Equal Remuneration

Convention, 1951 (No. 100), which aimed to ensure that the work

done by men and women was compensated equally (124–126).

The Convention was the ﬁrst of its kind, recognizing that women

were on the front line of production during the Second World War in

many countries and that there was a need to address gender pay

discrimination if equality was to be achieved (125). Almost 70 years

later the Convention is still relevant, as differences in pay remain the

most prevalent form of discrimination against women.

Figure 5.1 Equal pay versus the gender pay gap

EQUAL PAY

Means that mean and women

performing the same role must

receive the same pay

*for representation purposes only

THE GENDER PAY GAP

VS.

Indicates the difference in

average earnings between

men and women

$ $

Currently, awareness of the gender pay gap and the implications for

women of unequal pay are of higher proﬁle politically than ever before,

and a global framework for action has been set within the SDGs.

SDG Target 8.5 aims to achieve “equal pay for work of equal value”

by 2030. Also, 2017 saw the launch of the Equal Pay International

Coalition, a multistakeholder partnership including ILO, UN Women

and OECD, established to drive concerted action to close the gender

pay gap. WHO is currently working with the ILO to analyse labour force

survey data for around 104 countries to generate more insights.

At the meeting of the G7 held in Canada 2018, commitments

were made to prioritize action on the gender pay gap as a way to

achieve economic equality. Measures such as prohibiting employers

from asking about previous salaries and ensuring some form of

transparency on pay determinations were prioritized. Following this,

gender equality and women’s empowerment, including reducing

the gender pay gap, have been put onto the agenda for the 2019

G7 meeting in France (127). Similarly, recognizing that no Group of

Twenty (G20) country has yet closed the gaps in women’s economic

participation, a political commitment was made by the G20 to reduce

these gaps by 25% by 2025 (128).

The SDG uses average hourly earnings for men and women as its

measure (Indicator 8.5.1). Differences in the methodology used lead

to different estimates of the gender pay gap. A 2018 ILO report on

the gender pay gap comparing average (mean) hourly wages for

men and women from 73 countries found a global gender pay gap

of 16% (129). Using a measure comparing median earnings of men

and women, however, increased the gap to 22%. A complementary

measure, the weighted gender pay gap, allows for the clustering

of men and women into different occupations, analyses gaps in

occupational subgroups and then weights them reﬂecting the size

of each subgroup in the total workforce. Using this methodology, the

mean hourly gender pay gap identiﬁed by the 2018 ILO data was

positive in all but two countries, and the mean hourly global gender

pay gap increased from about 16% to 19% (129). Clearly, adopting

the same measure would facilitate cross-country comparisons.

It is important to control for the difference in hours worked by men

and women and divide total compensation by hours worked to assess

the gender pay gap, since men may work more hours than women.

Women are more likely to work part time than men where the option

is available. Hourly wages, however, do not include bonuses, stock

options, and other forms of compensation that may be included in

annual salaries, particularly for higher-level positions. Since men are

more likely to hold positions of leadership where such beneﬁts are

available, total compensation is a better measure than hourly wages

(130, 131).

It is also important to note that the gender pay gap, by deﬁnition,

measures paid work and so omits the substantial amount of unpaid

health and social care work done by women. In Lesotho, in response

to the increase in HIV/AIDS, women were expected to take up most of

the informal and predominantly unpaid care. There was no expectation

that men would work for free (108). Including unpaid work would

substantially increase the gender pay gap between men and women.

UN Women concluded that globally women earn 77 cents for every

dollar earned by men – a gap that will take an estimated 70 years to

close (132). In high-income countries women earn 75% of the pay

of their male counterparts, and in low-income countries, 83% (133).

ILO’s 2018 report found signiﬁcant differences between countries,

with the mean hourly gender pay gap ranging from 34% in Pakistan to

–10.3% in the Philippines, meaning that women in the formal labour

market in the Philippines earn 10% more on average than men (129).

Globally women earn 77 cents for every dollar earned by men –

a gap that it is estimated will take 70 years to close.

Most of the studies evaluating the gender pay gap and the factors

contributing to wage differentials between men and women have

been based on data from high-income countries, especially the United

States. Due to limited data from low-income countries, there are

very few cross-country or regional comparisons. Currently the few

comparative studies that exist have compared high-income countries,

such as European countries (134).

As shown in Figure 5.2, the OECD collects data on the gender wage

(pay) gap for selected countries, with the highest gender wage (pay)

gaps found in Republic of Korea 34.6 %, Estonia 28.3%, and Japan

24.5 %, and the lowest found in Romania 1.5 %, Costa Rica 3.0

% and Luxembourg 3.4 % (135). Despite limitations, the current

evidence provides lessons to draw from and highlights the need

for more research to understand the factors driving variations in

the gender pay gap across and within countries and occupations,

particularly in low-income countries.

A literature review

5.3 The gender pay gap in the global

health workforce

In global health there is limited evidence on the gender pay gap

and an urgent need to understand it better. Evidence from low- and

middle-income countries is particularly limited. The 2017 Global

gender gap report estimated the average gender pay gap by country

at between 16% and 21% (30, 127). Figures from the ILO, however,

on the unadjusted gender pay gap in the health and social care

sectors, estimate it at higher than other sectors, at 26% in high-

income countries and 29% in upper-middle countries (1). Employment

sectors with a majority of female employees, such as health and

social care, are typically given lower social value and paid less. More

evidence with better methodologies is needed, particularly from low-

income countries, to identify gender pay gaps in the health and social

sectors, assess the causes and translate evidence into effective policy

measures.

The gender pay gap varies across different occupations within health

care. In the United States, the health care industry has one of the

largest gender pay gaps for any sector, and there are also large

differences in wages between professions in health (134). In the

United States, the number of women pharmacists has increased but

the gender pay gap persists (136). The gender pay gap still existed

amongst academic pharmacists, even after allowing for qualiﬁcations

and years of service. Similarly, the number of women taking up

anaesthesiology in the United States is increasing but female

anaesthesiologists still earn 25% less than their male counterparts

compared with a 17% gap for all physicians (137–139). One study

conducted in medical faculties in the United States concluded that

women were less likely to become full professors compared to men

and earned lower wages even after controlling for observable factors

(140). A recent survey of 65 000 physicians in the United States

revealed that women doctors earned an average of 27.7% less than

their male counterparts in 2017, a total average of US$ 105 000 less

in a year (141). One study from Australia found the average gender

pay gap to be 16.7% (142). Even in health sectors where women play

a large role, such as dentistry, they continue to earn less than their

male colleagues (45, 143).

A study from Australia showed that gender pay gaps tend to be

wider in high-paying jobs, and that men receive higher returns

to schooling compared to women (142). Association between the

gender pay gap and “family gap” is also signiﬁcant (144). While pay

for fathers increases with the number of children, every additional

child a woman has is associated with a drop in pay (144). The most

likely explanation for this is that men with children are considered to

be more committed to their work, and thus deserving of and more

Figure 5.2 Gender wage gap by country

Note: 2017 or latest available data; based on data from OECD 2017

(https://data.oecd.org/earnwage/).

30200 10 40

Romania

Norway

Colombia

Hungary

France

Ireland

Spain

Cyprus

Netherlands

Portugal

Slovak Republic

Czech Republic

Finland

United States

EU (28 countries)

Latvia

Japan

Korea

Slovenia

Denmark

Luxembourg

Bulgaria

likely to be offered higher wages, whereas women with children are

considered less committed. Gaps vary, based on income levels, with

wider gaps amongst low-income women. Thus, the women who can

least afford it are not seen as deserving by employers and perceived

to lack commitment (142, 144).

Research also highlights that the gender pay gap between men and

women in medicine is connected with gender differences in specialty

choice and hours worked. However, recent studies suggest the gender

gaps in physician salaries persist even after controlling for specialty,

practice type, and hours worked (138). Women physicians also faced

trade-offs between career and family: one study found that women

physicians earned 11% less if they were married; 14% less if they

had one child; and 22% less if they had more than one child (145).

On one hand, there are studies that show the gap in wages converges

after controlling for observable factors such as specialty and numbers

of hours worked; while other studies show a disparity in physicians’

starting salaries. Limitations in these studies, due to methodological

differences or lack of comparable data, make it difﬁcult to draw

conclusions, except that more and better research is needed to

identify gender pay gaps by men and women in comparable jobs,

medical sectors and levels, and the drivers of those gaps.

Figure 5.3 (37) shows the average female nurse earnings as a

percentage of men’s earnings, indicating that on average across all

nurse occupations women earned only 91% of what men earned.

5.4 Factors that contribute to gender

pay gaps

Research shows that both microeconomic and macroeconomic

factors affect the gender pay gap, and that there is a pay difference

between men and women regardless of the industry or profession

studied. Additionally, non-employment-related factors, such as

gender, race and ethnicity, create advantages for certain people, while

disadvantaging others (146). Disability is likely to be another important

factor. It is critical, depending on the context, that the gender pay gap

is analysed with an intersectional lens.

Initially, human capital factors associated with greater work

productivity, such as years of education, training, skill sets, number

of hours worked and years of work experience, were thought to be

major drivers of gender pay gaps. However, recent studies show that

even after controlling for such observable factors the gender pay gap

remains, and a large portion of the gap remains unexplained (142,

147–150). The 2018 ILO Global wage report (129) decomposed the

gender pay gap by human capital attributes, characteristics deﬁning

job in a sector, and the type of workplace, and found considerable

variation between countries; however, on average, education and other

labour market factors explained relatively little of the gender pay gap

(129). The ILO concluded: “The unexplained part of the gender pay gap

generally dominates almost all countries, irrespective of income group.

In high-income countries, education contributes on average less than

1 percentage point of the gender pay gap, through it contributes much

more in some individual countries.”

“The unexplained part of the gender pay gap generally

dominates almost all countries, irrespective of income group.

In high-income countries, education contributes on average

less than 1 percentage point of the gender pay gap, through it

contributes much more in some individual countries.” 2018 ILO

Global wage report

The ILO concluded that this ﬁnding on education should not be

surprising, since in many countries women have higher educational

levels than men in the same occupational sectors but earn less.

Although lower-income countries and middle-income countries may

have a large percentage of women with low levels of education,

those women tend to be clustered in the informal rather than the

formal labour market, and so do not impact gender pay gap ﬁgures.

The report puts forward several drivers of the gender pay gap: the

fact that women are not paid equally for work of equal value; the

Figure 5.3 Female earnings as a percentage of men’s

earnings among full-time, year-round nurses (2011)

Source: United States Census Bureau (37).

878684 85 89

LPN/LVN

Average

(all nurses)

Nurse

anesthetists

Nurse

practicioners

Registered

nurses

88 90 91 92 93 94

A literature review

clustering of women into female-majority jobs and sectors giving less

value and lower rewards; and the “motherhood gap”, which varies

widely between countries and may be related to a number of factors

that affect working mothers, including constrained choices of more

“family-friendly” jobs, reduced hours, career interruptions, or gender-

biased hiring and promotion. Data from the report estimate that the

motherhood pay gap ranges from 1% or less in Canada, Mongolia

and South Africa to as much as 30% in Turkey (129). The drivers for

these signiﬁcant differences need to understood and built into policy

measures.

Feminist economists have argued that use of gender as a dummy

variable in labour market analysis and wage regressions fails to

account for processes in which gender intersects with other social

stratiﬁers and how it shapes individual experiences of men and

women within the workforce as well as society at large. These

theorists argue that deeper understanding of discrimination is

required in labour market analysis, using feminist thinking (151, 152).

An important issue is the gendered social value given to professions

and jobs, which attaches greater value and rewards to work typically

done by men than to work typically done by women. This is highly

relevant for “caring professions”, such as nursing, which are female-

majority occupations.

Gender pay gaps are pervasive among all sectors, but they are greater

in private organizations compared to public sector and non-proﬁt

sectors (153). It has been argued that this is because the public

sector is expected to act as a model employer that is more equitable

and value based (154).

Occupational segregation and job sorting by sex remain the leading

factor linked to the gender pay gaps, particularly in the health and

social care sector. Findings on occupational segregation in the

health sector are outlined in Chapter 3 of this review. Occupational

segregation is a dominant phenomenon within labour markets, with

women more likely to enter teaching and nursing jobs while men

enter more technical and mechanical professions. However, evidence

on trends in occupational segregation are not always available to

policy-makers, meaning they cannot make a connection between

low-paying jobs, in which women are often employed, and gender pay

gaps (94, 134, 155). Moreover, as stated above, a large part of the

gender pay gap remains unexplained. This means that studies have

found gender pay gaps in labour market analysis even after controlling

for observable factors such as specialty choice, work hours, or other

characteristics, and a large part remains due to “unexplained factors”

in the regression model (142, 147–149). Discrimination as well as

subtle and unconscious bias are often difﬁcult to control for, and are

likely to be major drivers of gender pay gaps. However, putting these

complex terms in an “unexplained” error term is problematic, as it

gives no explanation on which to base policy (151). These gender

biases have implications for women’s careers, hiring rates, salaries

and promotions; hence, these unseen and unfair barriers women face

in the health care labour market will need to be addressed if we are

to reduce gender pay gaps (86, 134). Better research and context-

speciﬁc data are needed to deepen our understanding of gender pay

gaps within the health and social sector.

Gender biases have implications for women’s careers, hiring

rates, salaries and promotions; hence, these unseen and unfair

barriers women face in the health care labour market will need

to be addressed if we are to reduce gender pay gaps.

The fact that there are gender pay gaps in health care is a major

cause for concern at many levels as it implies that women, despite

being the majority of the global health workforce, are still unable to

gain respect and job status equal to their male counterparts. It is

estimated that almost US$ 160 trillion is lost globally due to gender

differences in earnings between men and women (162). Thus, the

gender pay gap remains a huge global health concern, since building

stronger and more resilient health systems would require that those

health systems enable women to participate in the workforce to their

full potential.

5.5 Why is addressing the gender pay

gap in the global health workforce

important?

Addressing the gender pay gap is critical to achieving fair and

resilient health systems. Gender differences in income have long-term

economic implications and lead to a gender wealth gap and poverty

for many women in old age (163). Wealth inequalities are gaining

interest among scholars as wealth accumulation increases ﬁnancial

stability, opportunities, and purchasing power (164). Financial stability

and empowerment are also important factors in seeking health care

and continuing treatment, especially for women (165). The gender

pay gap therefore has implications for women’s own health outcomes.

Addressing gender equality and the elimination of discriminatory

practices in the workforce are closely linked.

Box 5.1 Factors contributing to gender pay gaps: key themes

INDIVIDUAL FACTORS

Differences in education, training, skills

Gender pay gaps exist even after controlling for differences in education, skill set, and training. The gaps widen with higher levels of

education for women, while men receive higher returns on schooling. Factors such as age, experience, specialty choice, and practice

settings also do not explain the gap (142, 156–158).

Differences in work experience

The gender pay gap widens with seniority (159). This phenomenon was found to be true for both physician and non-physician groups

of women (140). Large deﬁcits in rank for senior faculty women were conﬁrmed in logistic models that accounted for a wide range

of other professional characteristics and achievements, including total career publications, years of seniority, hours worked per week,

department type, minority status, medical versus non-medical ﬁnal degree, and school (140). Gender gaps are also wider for higher-

salaried jobs (66).

Differences in numbers of hours worked, or part-time versus full-time work

Gender pay gaps are prevalent across almost all occupations but differ signiﬁcantly in size. One factor that is associated with this

difference is whether an occupation is male dominated or female dominated, with male-dominated jobs being higher paid. Among

the many reasons for this is the difference in total number of hours worked, with women working fewer hours than men. Women face

constraints in balancing paid work with family responsibilities; hence they either opt out of the workforce or take up part-time work.

Women with children pay what is known as a “motherhood penalty”, whether as a single or married parent, as they are likely to work

less hours than men. The penalty is higher for women with low-paying jobs. Married men and those with dependent children, on the

other hand, gain a “fatherhood bonus” and have been found to earn higher wages than single men (142, 158, 160).

INSTITUTIONAL FACTORS

Occupational segregation

Industrial and job sorting of men and women into speciﬁc types of jobs substantially contributes to men’s higher compensation,

especially in the United States and Europe. Women are concentrated in primary health care, low-grade and low-paying jobs, the public

sector, and part-time employment (94, 134, 155). Low awareness of occupational segregation and the gender pay gap contributes to

maintaining the status quo (161).

Workplace authority

The pay gap widens at executive levels and with higher levels of education.

Hiring and promotion

Subtle unconscious biases in hiring and promotion processes have implications for women’s careers and advancements that impact

their earning potential.

Collective bargaining and unions

Men tend to be more likely to be part of networks and unions. Collective bargaining has been shown to be effective in negotiating

comparable salaries. When men participate in unions and women are not union members, then even the same hourly wages may lead

to pay differentials. Female-dominated jobs and sectors are still largely non-unionized, which has also led to gender pay gaps (134).

A literature review

Within the health workforce, it is important to address the gender pay

gap for multiple reasons, including the following.

• The gender pay gap is directly linked to poverty, as it has

implications for lifelong ﬁnancial stability. Poverty affects women

at disproportionately higher rates compared to men (166), and

eliminating the gender pay gap could halve poverty levels for

women (167).

• Earning lower pay means lower pensions and less income from

social security for retired women compared to retired men (168).

Similarly, it means women qualify for lower disability and life

insurance beneﬁts.

• Wage differences lead to lower morale and motivation to work

longer hours, or may cause women to quit the health workforce

altogether. With the majority of the health care workforce being

women, this has serious implications, as women may be more

likely to opt for working shorter hours and part-time jobs. With a

major and growing global shortage of health workers, addressing

the gender pay gap will improve the health workforce labour

supply, support achievement of universal health coverage, drive

economic growth, and help meet the health care needs of the

global population.

• Societal expectations of gender roles may lead women to either

delay marriage and childbearing until their thirties or to forgo it

completely. This phenomenon has long-term implications for the

health and well-being of societies (169, 170).

• Understanding patterns of the gender pay gap in a particular

context will drive solutions and more inclusive labour markets for

women. For example, if the widest gender pay gap is amongst

low-paid women workers, then minimum wage legislation, social

protection for women on the boundaries of the informal and formal

labour markets, and support for collective bargaining will be

critical. If the widest gap is amongst women in higher-status jobs

or mothers or fathers, then other policy solutions will be needed.

Despite advances in policies and reductions in the gender pay gap

over the years, a signiﬁcant difference persists, calling for global

action to address the problem. In a recent survey on equal pay

conducted in the United States, it was found that almost one third of

Americans were not aware that the gap existed and men were twice

as likely to think it did not exist compared to women (156). In another

study, 80% of men thought their salaries were comparable to those

of women, compared to 41% of women who felt their incomes were

comparable to those of men (171). Thus, there is a need to increase

awareness of the problem in order to address it.

A major conclusion on the gender pay gap from this review is

that existing data and evidence are too scarce and not sufﬁciently

comparable to use as the foundation for policy measures in most

countries. Too much remains “unexplained”, and we need to move

beyond simple measures of the gender pay gap to more complex

methods that adjust for occupational segregation of men and women

(both horizontal and vertical), take an intersectional approach relevant

to the social context, and include the large numbers of women

working outside the formal, paid labour market. In the health sector,

addressing occupational segregation (Chapter 3) and the gendered

leadership gaps (Chapter 6) will both be critical to reducing gender

pay gaps.

6.1 Key messages

• Women make up 70% of the global health workforce but occupy

only 25% of leadership roles. Men hold the majority of leadership

roles in health at all levels, from global to community.

• The current gender gaps in leadership are predominantly a result

of power imbalances, gender stereotyping, discrimination and

structures that create pathways for one gender to excel while

others remain segregated in subordinated roles.

• Lack of gender balance in health leadership means global health

loses female talent, perspectives and knowledge. The women who

deliver global health do not have an equal say in its design and

delivery.

• Women’s limited opportunity to enter leadership roles is

compounded by the intersection with other factors such as race,

religion, caste, class and ethnicity, which can further disadvantage

women with more than one marginalized identity (for example, a

low-caste woman).

• There is evidence that women in leadership positions in health

expand the agenda, giving greater priority to rights – such as

sexual and reproductive health and rights – that apply to all

genders but, where absent, can have the most negative impacts on

women’s health.

• The persistent absence of female talent from leadership positions

is likely to prove a signiﬁcant barrier to the rapid scaling up of the

global health and social care workforce needed to achieve the

SDGs, including universal health coverage.

6.2 Leadership and gender: background

Leadership is the fourth theme prioritized by the GEH. The current

gender gaps in leadership are predominantly a result of power

imbalances, gender stereotyping, discrimination and structures that

Chapter 6. Leadership

create pathways for one gender to excel while others remain segregated

in subordinated roles. Gender gaps in leadership are pervasive in all

sectors, including health. Women make up only 5% of the Fortune 500

CEOs (172); 24% of parliamentary seats (173); and 39% of the total

labour force (43). With the SDGs restating gender equality as a global

priority, addressing gender gaps in leadership is key.

6.3 Leadership and governance in the

global health and workforce

Leadership comes in many forms and it matters at all levels of global

health. Women are leaders in their communities providing health at

the front line, they are the ﬁrst responders in outbreaks and disasters,

and they are predominantly the caregivers in their homes and family.

However, due to power structures within workplaces, women remain

underrepresented in top positions.

Women’s representation in top policy-making positions remains

low in global health agencies, with women holding around 25% of

the most inﬂuential leadership and governance roles. As shown in

Figure 6.1, an evaluation of 140 global health organizations found

that decision-making power remains largely in the hands of men,

with 69% of organizations and 80% of organization boards led by

men (82). Moreover, beyond gender parity, women have less visibility,

less recognition and less inﬂuence than men. This shapes the health

agenda and resources at all levels – even at the community level.

Anecdotal examples of the contribution made by community health

workers is important in capturing the impact women are having on

the health of their communities, but most have little or no opportunity

for promotion to more inﬂuential leadership roles. This applies across

health professions. Most recently, nurses and midwives, in response

to leadership disempowerment, have launched the Nursing Now 2020

campaign, with one key goal being to have nurses or midwives in

leadership roles and on governing boards at all levels in health (174).

The gender gap in health leadership goes beyond the numbers.

Deep-rooted power structures, including patriarchal and gender bias,

creates a preferential opportunity for men to be leaders in the mostly

A literature review

powerful, inﬂuential roles in society. In the health sector, especially

given the historical structure of hospitals and health systems based on

hierarchy and patriarchy, the power relations create an environment

that enables men and disempowers women, limiting their ability

to reach their maximum potential as leaders. A contextual analysis

of women in the health workforce shows there are unique barriers

women face based on gender. They are less invested in and supported

in their roles, as they operate in environments that are not enabling

for all genders (2).

In the health sector, especially given the historical structure of

hospitals and health systems based on hierarchy and patriarchy,

the power relations create an environment that enables men

and disempowers women, limiting their ability to reach their

maximum potential as leaders.

One study identiﬁed those positions that embody power, inﬂuence

and leadership as the “ﬁnal male bastions” and noted that women

are less likely to be in positions of power and authority, have the

opportunity to advance, be rewarded for the work they do, and ﬁnd

themselves in strong support networks (175). These positions of

power and leadership roles in global health can take on many forms,

from the executive team of a United Nations agency to the head of

a community nongovernmental organization or to the head of a local

health clinic. While leadership is often linked to the most senior and

well paid positions, one can be a leader at all levels, including in

underpaid or underrecognized roles in health.

Across the health workforce, women are underrepresented in the

upper levels of management, leadership and governance. Only 31%

of ministries of health are led by women (176, 177). At the high end is

the Africa Region with 38%, with South-East Asia at the low end with

18% of ministries of health led by women (177) (Figure 6.2).

In examining health leadership, Women in Global Health found on

average 25% of Member State chief delegates, to the World Health

Assembly, were women, increasing over time, since 2005, as seen

in Figure 6.3. (101). Percentages of women 2016-2016 were

26%, 31% and 29% respectively. In many cases this mirrors the

underrepresentation of women in the senior levels of ministries of

health. For example, women held only 20% of senior roles in the

Ministry of Health in Cambodia (178). However, there is an opportunity

to transform the health leadership to be more representative of the

largely women-led health workforce (Figure 6.4).

The majority of the reviews of leadership in the health workforce have

previously focused on women’s leadership in medicine. Emerging

literature has started exploring trends in other sectors, for example,

the work undertaken by the Nursing Now campaign. Similarly,

another study in 2006 found that despite increasing numbers of

women in pharmacy, they are still underrepresented in leadership

roles (136). Research is expanding beyond the United States; for

example, one study found that women are underrepresented in

prestigious specialisms and leadership roles regardless of the rate at

which women are entering the health sector in a country (45). Within

anaesthesiology women’s leadership is lower than in other medical

professions in the United States (179). Looking at the leadership in

the World Federation of Societies of Anaesthesiologists, a striking

Figure 6.1 Who leads global health organizations?

Executive Directors

20% 80%31% 69%

Board Chairs

Source: Global Health 5050: https://globalhealth5050.org/gh5050-summary-ﬁndings-on-leadership-and-parity/.

Figure 6.2 Percentage of Member State ministries of health headed by women, by WHO

Source: Women in Global Health, 2018

36%

64%

31%

69%

39%

61%

19%

81%

18%

82%

24%

76%

Figure 6.3 Women’s representation as chief delegates at World Health Assembly, 2005–2015

Source: Women in Global Health, 2018

Gender representation at the World Health Assembly 2005- 2017

HOW CAN WE ACHIEVE GENDER PARITY IN GLOBAL HEALTH?

@WomeninGH

WomeninGH

www.womeningh.org

2005

16%

WOMEN

2015

22%

WOMEN

2017

31%

WOMEN

A literature review

lack of representation can be observed across boards (5:1, men:

women), councils (15:5) and committee chairs (9:1) (180). There

are gender gaps in academic medicine as well, for example, in the

top 50 American medical schools only 24% of the directors were

women (181). A gender analysis of Kenya’s health training institutions

found that women made up 76% of the nursing profession, but men

held 62% of the faculty positions (182). One study found that men

with 15 to 19 years of experience were 17% more likely to hold full

professorships when compared to women with the same years of

experience, even after adjusting for other factors such as number of

publications and degrees (160).

6.4 Why addressing gender gaps in

leadership matters

Addressing gender gaps in leadership sets the agenda for equal

representation of genders at all levels of the organization as well

as across different sectors of health. It leads to a more empowered

workforce, improved motivation, reduced attrition, improved quality of

care, and better understanding of health systems, which feeds into

designing more suitable solutions (183).

Addressing gender gaps in leadership leads to a more

empowered workforce, improved motivation, reduced attrition,

improved quality of care, and better understanding of health

systems, which feeds into designing more suitable solutions.

There is a need for the diversiﬁcation of leadership in the health

workforce. Across sectors women are seen to exhibit transformational

leadership qualities, including those that focus on motivating others,

supporting the advance of the whole team while attending to individual

needs, and creating excitement about the future, more frequently than

men. With these foundational qualities, studies have conﬁrmed that

overall women were seen as more effective leaders (184). Within the

health sector, there is some evidence to indicate the same. Several

studies in India indicated that women leaders in health have resulted in

positive beneﬁts such as the reduction of neonatal mortality, increased

expenditure on health facilities, antenatal care and immunizations, and

prioritization of issues traditionally related to women (181). Evidence

also shows that providing nurses with the opportunity to lead and shape

health services leads to improvements in health outcomes and supports

innovation, recruitment and retention (185).

6.5 Factors contributing to leadership

gaps in the global health workforce

The lack of women in leadership is often said to result from a “glass

ceiling”, but recent literature aptly identiﬁes that the lack of women

in leadership is more the result of a labyrinth, a twisting and turning

series of barriers that are both visible and invisible, rather than a

sudden and clear limit that prevents women from reaching the ﬁnal

upper level of leadership (186). There are a multitude of barriers faced

by women in advancing in leadership. These barriers exist at the

individual, interpersonal, institutional, and community levels, and up

Figure 6.4 Global health leadership pyramid

Source: Women in Global Health, 2018

1. Fortune 500 list for healthcare sector, Fortune, 2018

2. Global Health 50/50 Report, Global Health 50/50, 2018

3. World Health Organization Member States, Womean in

Global Health (data) unpublished), 2018

4. Work Health Organization’s World Health Assembly List of Delegates and Other

Participants, Women in Global Health (data unpublished), 2018

5. QS World Ranking 2018: Top 25 Global Universities for Public Health and Medicine, 2018

6. Improving employment and Working conditions in health services, international Labour

Organization, 2017

7. Improving employment and Working conditions in health services, international Labour

Organization, 2017

Women’s representation in global health leadership, based on influence

Fortune 500

Healthcare CEOs

(1)

Heads of

global health

organizations

& boards of

global health

organizations

(2)

Ministers of

Health (3)

World Health

Assembly heads

of Delegations

(4)

Deans of top

Public Health &

Medical Schools

(5)

Health

and Social

Workforce (6)

Long-Term Care

Workforce (7)

3.7%

25%

31%

27%

28%

70%

90%

= 10%

to the public policy level. The global health and social workforce has

a problem which is not limited to a “glass ceiling effect”. Rather, the

whole pipeline is leaking women all the way up to the top. (187).

The lack of women in leadership is more the result of a

labyrinth, a twisting and turning series of barriers that are

both visible and invisible, rather than a sudden and clear limit

that prevents women from reaching the final upper level of

leadership.

It is important to note that gender is only one dimension of the

labyrinth that women in the health workforce must negotiate on

their way to leadership. There are multiple ways to understand

marginalization within health systems leadership. For example, a

unitary approach focuses on one primary marker of difference as

sufﬁcient for explaining a social problem, in isolation from other

markers (for example, gender as separate from race) (188); a

multiple approach considers more than one explanatory factor but

does so in an additive manner (for example, gender plus race equals

greater disadvantage) (188); and an intersectionality approach

explicitly focuses on the relationships between factors and mutually

constructed processes that lead to social differences. Inequities are

never the result of single, distinct factors; rather, they are the outcome

of intersections of different social locations, power relations and

experiences (189). Gender as one aspect of an individual’s identity

plays a major role in a person’s experience of the world, including

professional development and career advancement. However, not

acknowledging the dynamic interconnectedness of gender with other

social identities, especially when considering women who do not fulﬁl

the “white woman from the West” benchmark, is a pitfall that hinders

adoption of solutions that beneﬁt all women. And this benchmark is

the typical image used to portray most women in leadership positions.

The majority of the reviews and studies found similar barriers to

women advancing within their professions and reaching leadership

positions across geographies and occupations. They include the

following.

• Overall gender norms and expectations of men and women

negatively impact women’s advancement to leadership (115, 190).

Traditional gender norms do not portray women as leaders, and

leadership qualities are associated traditionally with masculine

traits. Women are perceived as having more communal traits,

leading to a double bind if they exhibit leadership traits perceived

as traditionally masculine (184). In Uganda and Zambia,

gender norms and the understanding of key leadership traits

negatively impacted the advancement of women and skewed

the organizational processes leading to leadership – such as

hiring and promotion – as leadership itself was gendered (190).

Leadership stereotyping is only one way in which gender norms

impact women’s advancement in the health workforce. One study

noted that gender norms inﬂuenced women’s progression to

leadership at three intersecting levels – individual, household and

community – as shown in Box 6.1 (178).

• Bullying and sexual harassment have negatively impacted women’s

advancement to leadership positions (191, 194). Adverse systemic

consequences include “impediment of health workers’ advancement,

increased stress and decreased morale and productivity”, and

a “limited pool of health workers to deal with today’s health

challenges” (5). The story of Dr Caroline Tan, an Australian

neurosurgeon, personiﬁes the impacts of sexual harassment and

assault on women’s career advancement in health care. Dr Tan, who

won a tribunal case against a fellow surgeon, faced targeted attacks

by the perpetrator to undermine her credibility, a delay in the award

of her fellowship by the Royal Australian College of Surgeons, and

difﬁculty in securing a position, despite high examination scores and

excellent references (195).

• The interrelationship between horizontal occupational segregation

and the occupational leadership hierarchy within the health

workforce has inﬂuenced women’s career advancement and the

way women leaders are represented. In Jordan, a study found

that two thirds of men in the health workforce were doctors,

whereas almost 80% of nurses were women, while men held

90% of managerial positions (196). It was noted that in South and

Central Asia, nursing was seen as a low-status profession and

nurses were directly managed by doctors who served in the main

decision-making roles (186). Nurses were seen as “extra hands”

for doctors, and were presented with few or no opportunities for

career advancement and leadership (186). The Review Board of

the All-Party Parliamentary Group on Global Health in the United

Kingdom found “overwhelming evidence” that nurses in leadership

were not being engaged adequately in policy-making or decision-

making at all levels, from local to global (186).

• Women often report that lack of recognition and respect is a

detriment to their career advancement and entry into leadership

roles. One study found that women received only 1 in 10 awards in

health and medicine (197), while another study found that female

A literature review

Box 6.1 Individual, household and community

dimensions of gender stereotyping

INDIVIDUAL

In Cambodia, it was shown that gender norms affected how

men and women engaged in the health sector, and in turn

their progression to leadership (115).

HOUSEHOLD

Regardless of organizational policies, women were held back

by gendered time use. In Cambodia, women’s advancement

was impacted by family responsibilities (115). In Japan, women

in medicine saw a “motherhood penalty” with reduced hours

worked, and several years of unemployment during early

child-rearing, with consequences for their access to leadership

(45). Even in Scandinavia, where policies and cultural attitudes

promote work–life integration, women were more likely to

switch from specialties and leadership tracks after childbirth

to positions that provided more ﬂexibility with childrearing (45).

A study of women doctors in the United Kingdom attributed

the lack of women’s leadership roles to the rigidity of career

paths leading to leadership within medicine, and reliance on

a hierarchical system that disregards the modern needs of

people to balance career expectations with other responsibilities

outside work (191).

COMMUNITY

In a review of the post-conﬂict health system in Cambodia,

women had reduced clinical time due to community

expectations of gender roles. For example, women reported

being unable to work night shifts due to disapproval from the

community (115). In Zimbabwe, men were more likely to be

selected for very remote and rural areas, where they were

able to gain invaluable career experiences. These experiences

supported men’s career advancement over women through

increased promotions, and participation in international

trainings and workshops (192). In Afghanistan, women were

able to gain increased access to resources at the community

level as community health workers, due to gendered social

norms, but men were more likely to hold leadership positions

and in turn control resource allocation (193).

managers felt that their voices were not as respected as those

of their male colleagues, and also faced additional discrimination

due to younger age or perceived lower technical skills (198).

In Pakistan, where the requirement for lady health workers to

travel to people’s houses and to work with men clashed with

cultural norms, lady health workers reported lack of respect and

devaluation of their work (199).

• These studies also highlight the need for a deeper analysis of

the detrimental impact that gender inequality in health workforce

leadership is likely to have on health outcomes.

Removing gender gaps in leadership roles makes good business sense.

It leads to the creation of a workforce pipeline that supplies educated,

trained and skilled health workers using 100% of the talent pool.

This chapter brings together the ﬁndings of the GEH literature review,

draws conclusions, and outlines next steps. All these will inﬂuence

gender equity in the health workforce. Since countries have different

starting points in terms of health systems, resource levels, health

worker supply, gender equality and socioeconomic context, there

can be no universal blueprint for addressing gender equality in the

health workforce. All policy measures will need to be contextualized to

suit the local situation, with all genders in the local health workforce

having a voice in the decision-making process.

The ﬁndings of this report and the Gender at Work framework (200)

will form the foundation for the next phase of gender policy work by

the GEH, with the aim of supporting country-level implementation and

measurement of context- and evidence-based policy solutions.

7.1 Policy context

The Sustainable Development Goals (SDGs), the overarching

goal to reach universal health coverage, the Global Strategy on

Human Resources for Health, and the joint WHO, ILO and OECD

Working for Health ﬁve-year action plan (Box 7.1) together create

a strong platform for addressing the gender inequality that causes

inefﬁciencies in the health workforce. They also set a timetable, since

the commitments of the ﬁve-year action plan are to be delivered by

2021, and the SDGs, universal health coverage and Global Strategy

on Human Resources for Health have a timeline of 2030.

There is no health without the people who deliver health care.

With growing global demand for health care and a projected health

worker shortage, there is an urgent need to scale up the numbers of

new health worker jobs in high-, middle- and low-income countries.

Since women form the majority of health and social care workers,

the Working for Health five-year action plan 2017–2021 recognizes

the importance and urgency of addressing gender inequity in the

health workforce. The deliverables of the plan include gender-

SECTION 3. CONCLUSIONS

Chapter 7. Conclusions: policy context,

ﬁndings, and next steps

transformative policy development and implementation capacity to

overcome gender inequities and form the foundation for the work of

the GEH, including this report.

Box 7.1 Working for Health: five-year action

plan for health employment and inclusive

economic growth 2017–2021 (WHO, ILO, OECD)

RECOMMENDATION 2

Maximize women’s economic participation and foster their

empowerment through institutionalizing their leadership,

addressing gender biases and inequities in education and the

health labour market, and tackling gender concerns in health

reform processes.

DELIVERABLES

2.1 Gender-transformative global policy guidance developed

and regional and national initiatives accelerated to analyse

and overcome gender biases and inequalities in education

and the health labour market across the health and social

workforce (for example, increasing opportunities for formal

education, transforming unpaid care and informal work into

decent jobs, equal pay for work of equal value, decent working

conditions and occupational safety and health, promoting

employment free from harassment, discrimination and

violence, equal representation in management and leadership

positions, social protection/child care, and elderly care).

2.2 Gender-transformative policy development and

implementation capacity to overcome gender biases and

inequalities in education and the health labour market

supported.

A literature review

Horizontal and vertical occupational segregation by gender is a

universal pattern in health, varies with context.

Driven by gender norms and stereotypes of jobs culturally labelled

‘men’s’ or ‘women’s’ work

Gender discrimination constrains women’s leadership/seniority

Gender stereotypes constrain men eg entering nursing

Women in health typically clustered into lower status/lower paid

jobs

Female majority professions given lower social value, status & pay

Women 70% global health workforce but hold only 25% senior roles

Gender leadership gaps driven by stereotypes, discrimination, power

imbalance, privilege

Women’s disadvantage intersects with/multiplied by other identities eg

race, class

Global health weakened by loss female talent, ideas, knowledge

Women leaders often expand health agenda, strengthening health for all

Gendered leadership gap in health is a barrier to reaching SDGs and UHC

Large % women in health workforce face bias and discrimination

Female health workers face burden sexual harassment causing

harm, ill health, attrition, loss morale, stress

Many countries lack laws and social protection that are the

foundation for gender equality at work

Male healthworkers more likely to be organised in trade unions

than female

Frontline female healthworkers in conﬂict/emergencies/remote

areas face violence, injury & death

GPG in health 26-26%, higher than average for other sectors

Most of GPG in health is unexplained by observable factors eg

education

Occupational segregation, women in lower status/paid roles, drives GPG.

Much of women’s work health/social care unpaid and excluded in GPG

data

Equal pay laws and collective bargaining absent in many countries

GPG leads to lifetime economic disadvantage for women

Closing GPG essential to reaching SDGs

OCCUPATIONAL

SEGREGATION LEADERSHIP

DECENT WORK:

DISCRIMINATION SEXUAL

HARASSMENT BIAS

GENDER PAY GAP (GPG)

7.2 Findings of the GEH literature

review

The ﬁndings of the GEH literature review are divided into two parts:

1. ﬁndings from each of the four focus areas covered by the report;

2. overarching ﬁndings and conclusions generated from the exercise.

The following subsections highlight what the literature review found –

or did not ﬁnd – in the sources that were reviewed.

7.2.1 Key findings of the GEH literature review on the

four focus themes

Key ﬁndings from the four focus areas of the GEH literature review

are summarized in Figure 7.1. Each theme is explored in depth in a

separate chapter of this report.

Figure 7.1 Key finding in four focus areas of GEH literature review

7.2.2 Overarching findings from the GEH literature

review

Of the eight overarching ﬁndings (summarized in Figure 7.2), ﬁve

highlight serious deﬁciencies in data and research, which limit

compilation of a comprehensive global picture upon which to base

policy.

First, the majority of the 170 studies identiﬁed and reviewed in this

report come from the global North and report ﬁndings from the

global North, many of which are not transferable to settings with

different cultures and resource levels. There are major gaps in data

and research from all regions, but the most serious gaps on gender

and equity in the health workforce are in low- and middle-income

countries. This is of particular concern since the most rapid and

radical progress is needed in low- and middle-income countries to

reach the SDGs, attain universal health coverage and achieve the

health for all targets by 2030.

In addition, widespread gaps in the data and literature were found from

countries of all income levels on implementation, application of gender-

transformative policy measures and what works to change the health

system weaknesses and deﬁciencies caused by gender inequality. This

will be an important focus for the work of the GEH going forward.

Major gaps and lack of comparable data were also found in countries

from all regions. Examples include sexual harassment and gender

pay gap data. Despite the prominence the #MeToo movement has

given to the issue of sexual harassment in the last year, a disturbing

59 countries still lack legislation prohibiting sexual harassment in

the workplace. The #MeToo movement has prompted women in

health in some countries to speak about their experience of sexual

harassment and abuse at work. Although, from conﬁdential reports,

sexual harassment of female health workers by co-workers, patients

and members of the community appear to be widespread, with

consequent harm both for women affected and for health systems,

systematic collection of data and research studies are not common. A

supportive legal framework and data collection are the starting points

for identifying patterns of and trends in sexual harassment, abuse

and violence suffered by female health workers and putting in place

preventive measures and support for survivors.

Similarly, with the gender pay gap, data collection is uneven and not

always comparable across countries, while several studies conclude

that much of the gender pay gap is “unexplained” by observable

factors. Clearly, research is needed to explain the “unexplained” and

identify solutions to inequities in pay, which have serious lifelong

impacts for women’s income, autonomy and well-being.

Figure 7.2 Key overarching findings of GEH literature review

Finally, in the list of deﬁciencies in the data and literature, studies

identiﬁed for the review were limited in methodological approaches.

Although in many countries female health workers are clustered into

different sectors of health and social care by social identities such

as race, ethnicity, class, and migrant status, very few studies take

an intersectional approach to highlight how gender disadvantage in

employment can be compounded by other social identities. Some

countries are now investigating pay gaps based on disability and race,

in addition to gender. It is critical to take an intersectional approach to

understand how multiple identities interact with gender in the health

workforce to compound inequity.

Three further overarching conclusions from this review also need

emphasis. The ﬁrst is the near universal and pronounced occupational

segregation of women and men within the health workforce. This

report emphasizes that the fast-growing health and social care sectors

are important employers of women and critical drivers of economic

growth. But although women hold around 70% of jobs in the health

workforce, they remain largely segregated within it, both vertically

and horizontally. Vertical segregation, with men holding the majority of

higher-status, higher-paid roles, is a pattern found in most countries.

It is particularly acute in the health and social care sector, resulting in

an estimated gender pay gap higher than the average for other sectors

of the economy. It is a paradox that even in female-majority health

professions, such as nursing, the small minority of male employees

often have a “glass escalator” to the top, reaching leadership positions

faster than their female colleagues. Women in the health workforce

are disadvantaged by being clustered into lower-status and lower-

paid (often unpaid) roles, and are further disadvantaged by horizontal

OCCUPATIONAL

SEGREGATION LEADERSHIP

DECENT WORK:

DISCRIMINATION SEXUAL

HARASSMENT BIAS

GENDER PAY

GAP (GPG)

Overarching Findings from literature review:

• 170 studies in this review, most from global North

• Major gaps in data and research from low- and middle-income countries (LMICs) on

gender and equity dimensions health workforce

• Major gaps in implementation research on impact of policy change or gender

transformative approaches in different cultural settings

• Major gaps in data in all areas, particularly sexual harassment and data comparable

across countries on the gender pay gap

• Studies limited in methodological approaches. Very few adopt an intersectionality

lens or use mixed methods approaches

• Occupational segregation, vertical and horizontal, is major driver and consequence

of gender inequality

• Critical role of women in health (70% health workforce) is often overlooked, so

priority not given to addressing gender/equity in workforce

• Gender inequality in health and social care workforce will limit delivery of UHC &

health for all

A literature review

occupational segregation resulting from gender norms and stereotypes

that brand some jobs in health more suitable for women (nursing) or

men (surgery). Women are then triply disadvantaged by social gender

norms that attach lower social value to majority female professions and

thereby devalue the status and pay of those professions.

Occupational segregation in the health sector is driven by gender

inequality and, in turn, is the foundation for other gender inequalities

identiﬁed in this report. Occupational segregation in the health

workforce drives the gender pay gap and also makes lower-status

female health workers, often on insecure contracts and less unionized

than men, more vulnerable to sexual harassment, abuse and violence.

There is nothing inevitable about occupational segregation by gender

in the health workforce. Education and employment patterns in many

countries have changed rapidly over the last 25 years with far more

women entering medicine and, in some countries, now forming the

majority of medical students. Countries vary, for example, in the

percentage of men in nursing. Occupational segregation in health is not

ﬁxed over time or across countries and policy measures can be taken to

change it. In its next phase of work, the GEH will identify good practice

examples to see what lessons can be learned and transferred.

A second and related point is that, despite women being the majority

of the global health workforce, their role as drivers of health is often

unacknowledged. Trends in applications for medical training show that

health as a profession continues to attract women and is likely to remain

a major employer of women. The lack of acknowledgement of women’s

role, however, contributes to a lack of priority given to addressing

gender inequality in the health workforce. This has to change fast, with

gender-transformative policies and measures put in place if global

targets such as universal health coverage are to be achieved.

Critical and also largely unacknowledged is the burden of unpaid

health and social care work typically done by women and girls caring

for sick and disabled family and community members. Women also

perform (unpaid) voluntary roles in health promotion and service

delivery. This review has focused on ﬁndings from the formal labour

market and a priority going forward will be to gather evidence on the

unpaid health and social care work that forms an insecure foundation

for the global health pyramid. Women’s unpaid work must be recorded

and valued, with measures put in place to enable women and girls

engaged in unpaid work to access education, training and the formal

labour market, where their work would be counted and paid.

Finally, a key conclusion of this report is that gender inequality in

the health and social workforce weakens health systems and health

delivery. However, an alternative, far more positive future scenario is

possible. Addressing gender inequalities in global health and investing

in decent work for the female health and social workforce will have

a wider social and economic multiplier – a “triple gender dividend” –

comprising the following.

• Health dividend. The millions of new jobs in health and social care

needed to meet growing demand, respond to demographic changes

and deliver universal health coverage by 2030 will be ﬁlled.

• Gender equality dividend. Investment in women and the education

of girls to enter formal, paid work will increase gender equality and

women’s empowerment as women gain income, education and

autonomy. In turn, this is likely to improve family education, nutrition,

women and children’s health, and other aspects of development.

• Development dividend. New jobs will be created, fuelling economic

growth.

This triple gender dividend will improve the health and lives of people

everywhere. The health and social care worker shortage is global, and

addressing gender inequality in the health workforce is everybody’s

business.

7.3 Next steps

This literature review is the foundation for the next phase of the work

of the Global Health Workforce Network GEH, which will use these

ﬁndings, together with an analysis of best practices from within and

beyond the health and social sector, to inform gender-transformative

policy and action.

To advance this work, the GEH will develop advocacy and policy

toolkits to target key stakeholders, including WHO Member States, to

integrate gender-transformative health and social workforce policies

into their national health workforce plans.

The GEH will also bring together various actors at the national level

to design and evaluate gender-transformative health workforce

policy interventions, with the aim of supporting implementation and

measurement of context- and evidence-based policy options. This

will provide a platform for policy-makers to collaborate with key

governmental partners and external experts.

Finally, the GEH will convene a review in 2019, midway through the

Working for Health ﬁve-year action plan 2017–2021, supporting WHO,

ILO and OECD to assess progress on the two action plan deliverables

on gender equality and, on the basis of that review, recommend steps

to ensure the achievement of these deliverables by 2021.

Bias is an inclination or prejudice for or against one person or group, especially in a way considered to be unfair, that often results in

discrimination (5).

Decent work is deﬁned by the ILO as “the aspirations of people in their working lives. It involves opportunities for work that is productive

and delivers a fair income, security in the workplace and social protection for families, better prospects for personal development and social

integration, freedom for people to express their concerns, organize and participate in the decisions that affect their lives and equality of

opportunity and treatment for all women and men” (201).

Discrimination in employment and occupation includes practices that place individuals in a subordinate or disadvantaged position in the

workplace or labour market because of characteristics (race, religion, sex, political opinion, national extraction, social origin, or other attribute)

that bear no relation to the persons’ competencies or the inherent requirements of the job (5).

Feminization is the movement of women into traditionally male-dominated occupations (202).

Gender is a social construction reﬂecting the distribution of power between women and men, girls and boys and gender-diverse persons. This

distribution of power is inﬂuenced by history, laws, policies and politics, and by economic, cultural, community and family norms that shape the

behaviours, expectations, identities and attributes considered appropriate for all people – women and men, girls and boys, and gender-diverse

people. How an individual expresses their gender identity varies across context, time, and place, and throughout their life-course. Gender

interacts with, but is distinct from, the binary categories (male, female) of biological sex. When a person’s gender identity does not correspond

with their assigned sex, they may identify as transgender (2). Gender also intersects with, and is shaped by, other axes of inequality – age,

education, economic position and power, race, and ethnicity.

Gender blind refers to the failure to recognize that the roles and responsibilities of men and boys, and women and girls, are assigned to them

in speciﬁc social, cultural, economic, and political contexts and backgrounds. Projects, programmes, policies and attitudes that are gender blind

do not take into account these different roles and diverse needs. They maintain the status quo and will not help transform the unequal structure

of gender relations (203).

Gender discrimination describes any distinction, exclusion, or restriction made on the basis of socially constructed gender roles and norms that

prevents a person from enjoying full human rights. It can be direct or indirect, or overt or covert, and is associated with negative consequences

for the person who experiences it (5).

Gender equality in the health workforce describes a condition whereby men and women can enter the health occupation of their choice,

develop the requisite skills and knowledge, be fairly paid, enjoy fair and safe working environments, and advance in a career without reference

to gender. It implies that workplaces are structured to integrate family and work and to reﬂect the value of caregiving for men and women (204).

Gender equity is the process of being fair to all genders. To ensure fairness, measures must often be put in place to compensate for the

historical and social disadvantages that prevent women and men from operating on a level playing ﬁeld. Equity is the process by which equality

can be achieved as an outcome (205).

Glossary

A literature review

Gender pay gap encompasses differences in men’s and women’s average earnings, which refer to (a) remuneration in cash or in kind paid to

an employee for the work done, together with remuneration for time not worked; (b) net earnings from self-employment; or (c) total earnings

from both employment and self-employment (125).

Gender-transformative policies and programming include policies and programmes that seek to transform gender relations to promote

equality and achieve programme objectives. This approach attempts to promote gender equality by (a) fostering critical examination of

inequalities and gender roles, norms, and dynamics; (b) recognizing and strengthening positive norms that support equality and an enabling

environment; (c) promoting the relative position of women, girls, and marginalized groups; and (d) transforming the underlying social structures,

policies, and broadly held social norms that perpetuate gender inequalities (206).

Health workforce is deﬁned by WHO as “all people engaged in actions whose primary intent is to enhance health”, including those engaged

in direct care roles (such as physicians, nurses, midwives, pharmacists, and dentists), leaders, policy-makers, researchers, management and

support staff (such as ambulance drivers and accountants). This review focuses on direct care providers (207).

Horizontal segregation refers to differences in types of occupations and sectors in which men and women are concentrated. Greater numbers

of women, for example, are concentrated in low-paying, part-time and unpaid care or domestic work as compared to men (19).

Intersectionality is a feminist theory and analytical tool for understanding and responding to the ways in which gender intersects with other

identities to create new oppressions. The experiences of marginalization and privilege are deﬁned not only by gender but also by other identity

factors such as race, class, age, religion and sexual orientation, all of which are determined, shaped by, and embedded in social systems of

power. Intersectional paradigms view such characteristics as race and class as mutually constructed systems of power that require special

measures to reach women who face multiple forms of discrimination (191).

Non-binary, also referred to as genderqueer, is a category for gender identities that do not conform to the gender binary of masculine or

feminine. Non-binary people may express a combination of masculinity and femininity, or neither, in their gender expression. Those who

incorporate aspects of both male and female may identify as “androgynous”, “mixed gender” or “pangender”, while those who move between

genders in a ﬂuid way may identify as “bigender”, “gender ﬂuid” or “pangender”. Some people who move between two or more than two

genders identify as “trigender” or “pangender”. Some people identify with an additional gender, known as “third gender”, “other gender”

or sometimes “pangender”. Note that “pangender” is a ﬂexible term. People with no gender identify as “agender”, “gender neutral”, “non-

gendered”, “genderless”, “neuter”, or “neutrois” (208).

Occupational downgrading is a phenomenon “where women choose employment below their skills level and accept poorer working

conditions” (29).

Occupational segregation is the distribution of workers across and within occupations (24).

Occupational gender segregation is the difference in the types of jobs men and women enter (19).

Sexual harassment refers to unwelcome sexual advances or requests for sexual favours, whether verbal, physical, or visual. These behaviours

are illegal if the submission to such behaviours is made a condition for employment or a decision affecting the individual, or has the purpose of

interfering with an individual’s performance (209).

Substantive equality is a principle that considers the effects of past discrimination, recognizes that rights, entitlements, opportunities and

access are not equally distributed throughout society, and accepts the need to sometimes treat people differently to achieve equal results.

It allows for differential treatment to level the playing ﬁeld for women, particularly where structures of dominance and subordination are

embedded in the baseline of opportunity (191).

Tokenism refers to a phenomenon whereby an organization includes a representative from a minority or disadvantaged social group in an

activity or position only in order to give an appearance of fairness and inclusion. It may be said to occur in the workplace when one group

represents less than 15% of an organization. The members of that group may be subject to predictable forms of discrimination (210).

Toxic masculinity refers to stereotypical masculine behaviours associated with the male gender. It includes the social expectation for men to

act in a dominant or “alpha male” manner. These expectations restrict men and boys from expressing their emotions or being affectionate, and

limit their emotional range to such negative expressions as anger (211). Toxic masculinity also leads men and boys to engage in higher-risk

behaviours such as use of alcohol or tobacco, violence, and aggressive driving (212). This is also related to the concept (introduced by R.W.

Connell) of “hegemonic masculinity” – an attitude that legitimizes men’s dominance over women and other gender identities that are perceived

to be feminine in a given society (213).

Unpaid care work refers to all unpaid services provided within a household for its members, including care of persons, housework and

voluntary community work (29). These activities are considered work because theoretically one could pay a third person to perform them.

“Unpaid” indicates that the individual performing the activity is not remunerated. “Care” refers to the activity that provides what is necessary for

the health, well-being, maintenance, and protection of someone or something. “Work” refers to an activity that involves mental or physical effort

and is costly in terms of time resources (29). This includes services provided by community health workers that are unpaid or on a voluntary

basis.

Vertical segregation refers to the concentration of men and women in different positions of power, leadership and decision-making, for

example, men dominating leadership positions and political life compared to women (19).

Women’s rights. The Beijing Platform for Action, in paragraph 2 of its mission statement, states: “The Platform for Action reafﬁrms the

fundamental principle … that the human rights of women and of the girl child are an inalienable, integral and indivisible part of universal human

rights. As an agenda for action, the Platform seeks to promote and protect the full enjoyment of all human rights and the fundamental freedoms

of all women throughout their life cycle” (214).

Workplace violence includes physical assault, verbal abuse, sexual or racial harassment, bullying or mobbing (5).

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A literature review

Co-Chairs:

Women in Global Health

World Health Organization

Organizational members:

Canadian Institute for Health Information

Canadian Health Human Resources Network

Chemonics/HRH2030

DAI Global, LLC

The George Institute for Global Health

Global Association of Student and Novice Nurses (GASNN)

Frontline Health Workers’ Coalition (FHWC)

International Pharmaceutical Federation (FIP)

International Federation of Medical Students’ Associations (IFMSA)

IntraHealth International

Jhpiego

The Net Community

Public Services International (PSI)

Research in Gender Ethics (RinGs)

Save the Children

Wemos

Women Deliver

Annex 1. Membership of the Gender Equity Hub in

the Global Health Workforce Network

SR# Submission

Lessons Learned

Policy/Implications (how will the study/initiative

findings or outcomes be used in the

Limitations

Strengths

Key Results/Findings

Methods of Analysis

Input Variable(s)

Output Variable

Research Design

A) Qualitative

B) Quantitative

C) Mixed Methods

Interventions

Study Participants

A) Students in education and training

B) Graduations and early

Context

Reasearch/Program Objectives

Research Area

A) Leadership

B) Gender

C) Decent work/harassment/violence

Study Title

Year Published

2. Co-authors

1. Lead author

Type of submission

Insert your name as a reviwer

Annex 2. Literature matrix

GENDER EQULTY EVIDENCE MAPPING EXTRACTION TOOL

A literature review

Health Workforce Department

World Health Organization

20 Avenue Appia

CH1211 Geneva 27 Switzerland

www.who.int/hrh

ISBN 978-92-4-151546-7