A Gender-responsive Approach to Decent Work for the Health Workforce

There has been a lot of focus on affirming the pivotal role of health workers during the World Health Worker Week. Dr Tedros, the Director-General of the World Health Organization (WHO), aptly stated that “there is no health without health workers”. This important step - of recognizing them in and of themselves as individuals with fundamental rights than just a “delivery platform” for patient care – is legitimately the way forward to developing sustainable health systems. Safeguarding the dignity of health workers is crucial in bridging the gap in health worker shortfalls, meaningfully contributing to Sustainable Development Goals (SDG) or achieving Universal Health Coverage.

Health workers’ rights highlight the interdependence and confluence of rights in that the right to decent and safe working conditions along with freedom of assembly, freedom from discrimination and right to due process drives the attainment of the right to health. International human rights law, in particular Article 7 of the International Covenant on Economic, Social, Cultural Rights, calls for “just and favourable” work conditions including the “right to safe working conditions”. This is further explicated in the General Comment on Right to Work, which sets out respect for workers rights as well as individual’s fundamental rights, a living wage, and respect for workers’ physical and mental integrity, as the main components of decent work. The International Labour Organizations (ILO) Decent Work Agenda encapsulates these principles into four strategic objectives which include promoting productive employment, guaranteeing rights at work, extending social protection and promoting social dialogue.

With women forming over 70% of the health workforce, which in most countries is much higher than their share of employment in the economy as a whole, realizing decent and safe working conditions in health is also a step towards achieving gender equality and women empowerment, reflected specifically in SDG 5 and implied in several SDGs including 8.8, 10.3, and 16.b. The fact that women, in spite of the large number in lower health worker cadres, only make up 25% of senior roles makes this decisive. Further, interventions to increase access to health workers both in emergency situations and health care systems affected by brain drain involve role optimization to community health workers and volunteers, or alternatively counteracting the health worker shortfalls creates demands for unpaid or informal health care work. All these positions are disproportionately female, riddled with inconsistent standards, lack of adequate legislation and regulation, exposure to occupational hazards, little or no pay, and in many cases, there is unacknowledged and unaddressed personal repercussion including facing stigma in their own communities. In fact, intersecting inequalities of class and race result in low income, minority, and immigrant women mainly liable for unpaid and informal care work. The recent publication “Delivered by Women, Led by Men: A Gender and Equity Analysis of the Global Health Workforce” highlights and organizes these issues into four thematic areas – occupational segregation, decent work, leadership and gender pay gap.

Ensuring decent work should not stop at improving recruitment, training, motivation and retention of the health workforce but be cognizant of the inherent occupational risks of being a health worker. For starters, we need to acknowledge the discrimination, sometimes culminating into abuse and violence, health workers face during the course of their employment. The UNAIDS and WHO Agenda for Zero Discrimination in Health Care statement recognizes institutional discrimination perpetuated by co-workers and employers but stops short of specifically recognizing that abuse, violence or discrimination maybe perpetuated by patients or their families as well. Many a times discrimination is related to the health worker’s gender, race, national or ethnic origin, disabilities and even health status.

Likewise, unsafe working conditions - e.g. lack of water and sanitation, lack of retractable needles increasing the potential for needlestick and sharps injuries, lack of personal protective equipment - do not allow health workers to deliver care commensurate with their skills. Also, it has been shown that policies that improve basic infrastructure and services can also narrow gender inequalities by helping women better access labour market opportunities. Recently, attacks on health workers have escalated, further adding to already precarious work situations experienced in humanitarian settings. Alarmingly, in some incidences, health workers have been denied access to injured persons or are forced to be complicit in mistreatment and harm. These violate established principles of medical neutrality and contravene the Geneva Conventions.

Gender-responsive and equity-enhancing approaches to labour, wage and social protection policies can help narrow inequalities. Some examples include, substantive equality in hiring and promotions, family friendly policies, transitioning informal work to paid positions, organizational structures that do not sort jobs by gender, not attaching social benefits to earning and occupations, inclusive education systems and life long learning, eliminating gender based violence, zero-tolerance for sexual harassment, and adopting participatory and good governance practices. Therefore, gender mainstreaming, first proposed at the 1985 Third World Conference on Women in Nairobi, Kenya and later adopted by the Beijing Platform for Action, is necessary in any planned action, including legislation, policies or programmes, and in all areas and at all levels to secure equality de facto and not be limited to formal equality. Further, collection, reporting, analysis, interpretation and use of sex-disaggregated data along with disaggregation of all health worker cadres is important to understand the interconnected causes that create an unequal relation between the sexes.

Evidence shows that inadequate investment in health workforce leads to uncoordinated, piecemeal, and stopgap initiatives and solutions that may show transient positive results but does not improve patient quality of care or national health systems functioning on the long run. These structural failures become even more pronounced in resource strapped settings in low- and middle-income countries. Even, last minute influx of financial resources and logistical information cannot contain health emergencies without a robust healthcare workforce, as seen during the Ebola outbreak. Not to mention, that role optimization to community health workers and volunteers, though instrumental, cannot alone sustain population health needs. And, unpaid and informal care not only create medical poverty traps for women but masks health system inefficiencies.

In short, we cannot hope to increase access to health workers or make sustained progress on the right to health without ensuring a gender equal and basic minimum in safety and working conditions globally. Further, it makes a strong case for utilizing a rights-based approach to implementing the Global Strategy on Human Resources for Health: workforce 2030 and the subsequent joint WHO/ILO/OECD five-year action plan for health employment and inclusive economic growth (“Working for Health”). Besides, how can we hold health workers accountable for their responsibilities if we cannot ensure their rights.

Read the full WHO report here.

Soosmita Sinha is the founder of the Health Law Institute, which envisions that "All health workers will be supported and motivated to provide care commensurate with their skills, in safe environments, under decent working conditions, and empowered to be true stakeholders in the development of sustainable healthcare systems​. Follow the work @SinhaSoosmita & @HlthLawInst., #WomenDeliverHealth #GenderEquityHub

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