A pandemic of inequality: gender disparities in global health

Author:

Ekelru Jessica and Christian Djoko

Article Type:

Article Number: 7

This article highlights the continued pay disparities and the absence of women in higher level leadership positions within global health organizations. These create a damaging power imbalance, affecting decisions and policies that do not fully reflect women's needs. By bridging these gaps, we strengthen global health by enabling women to occupy key positions where their skills can contribute to significant advances.

The burden on women’s shoulders

 

Three years ago, we wrote an article entitled “Health services provided by women in a sector dominated by men”. The aim of this article was to take stock of the issue of female health human resources, their significant numbers, their access to positions of responsibility, but above all to denounce the persistent inequalities between men and women in the health sector. Three years on, despite the intentions expressed at the height of the COVID-19 crisis, nothing has fundamentally changed. The global healthcare landscape remains riddled with inequality, which at its heart is a matter of gender imbalance. Women, the backbone of healthcare delivery, face more disproportionate challenges than ever and are under-represented in decision-making bodies, creating a system that does not fully meet their needs and those of the communities they serve.

 

According to the International Council of Nurses, worldwide[1], women make up 70% of the health and social care workforce, often working as nurses, midwives and community health workers. However, this dedication is rarely accompanied by fair recognition or compensation. They are often undervalued, underpaid and lack access to adequate training and resources, leading to burnout and a decline in the quality of care. According to a joint report in 2022 by the International Labour Organization and the World Health Organization, women working in the health and care sector face a wider pay gap than in other areas of the economy, earning on average 24% less than their male counterparts. This comprehensive analysis of the gender pay gap in healthcare also reveals a gross gap of around 20 percentage points, which increases to 24 percentage points when factors such as age, education and working hours are taken into account.

 

More broadly, across the globe, women invariably take on three-quarters of unpaid care work, accounting for precisely 76.2% of the time dedicated to these tasks. In no country is the responsibility for unpaid care work equally shared between men and women; on average, women spend 3.2 times more time on it than men, 4 hours and 25 minutes a day versus 1 hour and 23 minutes for men. Over the course of a year, this equates to 201 8-hour days for women and 63 for men. In all regions of the world, women spend more time than men on unpaid care work, with variations ranging from 1.7 times more in the Americas to 4.7 times more in the Arab States. Unpaid care work (Figure 1) is particularly demanding for women and girls living in middle-income countries, who are married and of adult age, have lower levels of education, live in rural areas and have pre-school children. This unpaid work not only limits their economic opportunities, but also has an impact on their physical and mental health.

 

 

Multi-faceted invisibilization

 

Although they make up the majority of the workforce and contribute significantly to the healthcare ecosystem, women remain largely under-represented in management positions. In Cameroon, for example, no major hospital is currently headed by a woman. A closer look at the organization charts reveals that the presence of women gradually diminishes as one explores the hierarchical levels. The majority of positions of responsibility are held by men.

 

This invisibilization extends beyond national borders. A report published in 2023 by Women in Global Health revealed that only 25% of senior positions in the world’s leading healthcare organizations are held by women (Figure 2). The glass ceiling effect is particularly evident among women from the countries most targeted by these organizations: only one of the 13 agencies is headed by a woman from a low-income country.

 

 

A report published in 2023 by Global Health 50/50 concurs. It shows that power inequalities persist in the global healthcare system (Figure 3), particularly when it comes to gender equality and diversity in leadership positions. Although the number of women in CEO and board chair positions has risen slightly since 2020, gender parity in global healthcare will not be achieved by the 2030 deadline set by the Sustainable Development Goals.

 

 

This under-representation and exclusionary cycle marginalizing women’s voices and perspectives in decision-making processes, persists despite evidence that diversity in leadership contributes to better health outcomes.

 

Indeed, a wealth of research conducted by Women in Global Health has shown that organizations with more women in leadership positions are more likely to prioritize gender equality and invest in programs that address women’s specific health needs. In addition, diverse leadership teams foster more inclusive workplaces and decision-making processes, ensuring that a wider range of viewpoints are taken into account.

 

Let’s take another example to reinforce our point. Among people living with HIV, 76% of women have a suppressed viral load, compared with 67% of men. From 2010 to 2022, new HIV infections fell by 50% among teenage girls and young women, and by 44% among teenage boys and young men. Improved treatment uptake among women has also led to an almost 60% reduction in new paediatric infections over the same period. The rate of treatment uptake in this population exceeds that of men, demonstrating their resilience. Yet, despite their significant contribution to the fight against HIV, women and girls, who face a disproportionate risk and heavier burden of HIV, have been consistently neglected and insufficiently taken into account in HIV research and programs. Structural and regulatory barriers have often excluded women from clinical trials, particularly pregnant and breast-feeding women, who regularly experience delayed access to new drugs. In addition, women face difficulties in accessing pre-exposure prophylaxis (PrEP), which was originally developed for men in same-sex relationships, highlighting a persistent inequality in PrEP deployment.

 

Breaking the glass ceiling

 

Breaking through the glass ceiling requires immediate, simultaneous and uncompromising commitment in several key areas as outlined in the joint ILO/WHO report 2022 and the Women in Global Health Policy Report, 2023.

 

Priority Areas

 

1. Pay equity: It is imperative to ensure that women’s pay fairly reflects the value of their work and skills. Pay equity is not simply a question of justice, but also helps to promote a diverse workforce, thus fostering innovation and excellence in healthcare delivery. As per the joint ILO/WHO Report, 2022, “the introduction of pay transparency and legal instruments to counter pay discrimination, combined with initiatives to change gender-related cultural norms and combat stereotypes, are proving to be effective ways of reducing the unexplained gender pay gap.

 

2. The gender approach: promoting gender-sensitive budgeting within health systems (care, research, governance, etc.) can ensure that resources are allocated equitably and meet the specific needs of women and girls. More broadly, the gender approach advocated here suggests paying particular attention to the gender factor in public health policies, but especially in statistics. In concrete terms, we could adopt a “gender test” to analyze legal texts and public policies from a gender perspective. This must become an inescapable prerequisite and a transversal filter.

 

3. Women’s leadership: It is essential to promote women’s leadership in global health organizations. Initiatives such as Women in Global Health and Global Health 50/50 strive to achieve equal representation in leadership positions, advocating policies that remove systemic barriers and support women’s career development.

 

An example of progress: The Global Fund was EQUAL-SALARY certified in 2019 after successfully passing a statistical analysis of its salary practices. These demonstrated effective implementation of equal pay for men and women. In addition, the 13-member Board of Directors of the Global Fund includes 8 women and 4 men. As an organization, the Global Fund is viewed as a star performer (Figure 4). However, there is still a long way to go to include, at this level of governance, more members from the countries of the global south, where the burden of disease is heaviest.

 

 

Conclusion

 

Let’s stress that achieving gender equality in global health is not just a moral imperative. It is also a public health issue. By eliminating discriminatory factors such as wage gaps and under-representation, we will be able to significantly optimize the efficiency of our healthcare systems.

 

 

[1] For the ICN, “the labor shortage represents the greatest threat to global health”, The International Council of Nurses (ICN),12 May 2022.