Systemic structural gender discrimination and inequality in the health workforce: theoretical lenses for gender analysis, multi-country evidence and implications for implementation and HRH policy
Human Resources for Health volume 21, Article number: 37 (2023)
This commentary brings together theory, evidence and lessons from 15 years of gender and HRH analyses conducted in health systems in six WHO regions to address selected data-related aspects of WHO’s 2016 Global HRH Strategy and 2022 Working for Health Action Plan. It considers useful theoretical lenses, multi-country evidence and implications for implementation and HRH policy. Systemic, structural gender discrimination and inequality encompass widespread but often masked or invisible patterns of gendered practices, interactions, relations and the social, economic or cultural background conditions that are entrenched in the processes and structures of health systems (such as health education and employment institutions) that can create or perpetuate disadvantage for some members of a marginalized group relative to other groups in society or organizations. Context-specific sex- and age-disaggregated and gender-descriptive data on HRH systems’ dysfunctions are needed to enable HRH policy planners and managers to anticipate bottlenecks to health workforce entry, flows and exit or retention. Multi-method approaches using ethnographic techniques reveal rich contextual detail. Accountability requires that gender and HRH analyses measure SDGs 3, 4, 5 and 8 targets and indicators. To achieve gender equality in paid work, women also need to achieve equality in unpaid work, underscoring the importance of SDG target 5.4. HRH policies based on principles of substantive equality and nondiscrimination are effective in countering gender discrimination and inequality. HRH leaders and managers can make the use of gender and HRH evidence a priority in developing transformational policy that changes the actual conditions and terms of health workers’ lives and work for the better. Knowledge translation and intersectoral coalition-building are also critical to effectiveness and accountability. These will contribute to social progress, equity and the realization of human rights, and expand the health care workforce. Global HRH strategy objectives and UHC and SDG goals will more likely be realized.
This commentary contributes to understanding important gender-related aspects of the World Health Organization’s (WHO) 2016 Global Strategy on Human Resources for Health (HRH) and its implementation guidance, such as the 2022 Working for Health (W4H) Action Plan [1, 2]. It considers theoretical perspectives and evidence from 15 years of gender and HRH analyses conducted in countries in the six WHO’s regions  to strengthen data on human resources, align investment in human resources for health to address shortages with particular focus on the gender dynamics in health labor markets . Robust data and evidence on gender and HRH have been generally lacking . The 2022 Working for Health (W4H) Action Plan recognizes the potential of the health workforce to accelerate transformational social progress, equity and the realization of human rights. It highlights the need to generate data and use evidence to inform and drive decision-making . It also makes gender equality central to the Working for Health agenda [2, p. 13].
To achieve transformational social progress, equity and the realization of human rights, our understanding of gender equality and inequality in HRH should be informed by evidence, as must HRH policy. Both the theoretical/conceptual and evidence bases of gender and HRH should be strengthened to demonstrate the ways in which systemic structural gender discrimination and inequality (SSGDI) are dysfunctions that undermine gender equality, social progress and health/HRH systems’ objectives. In this commentary, we consider theoretical lenses for gender and HRH analysis, multi-country evidence of SSGDI and implications for implementation and policy. We address the following questions:
What are systemic structural gender discrimination and inequality (SSGDI) in the health workforce and why are they out of the awareness of most human resources (HR) planners, managers and service providers?
Why should it be a priority to collect data to make SSGDI visible in workforce systems?
What are the implications for implementation and HRH policy?
What are practical steps to make gender analysis results accessible to and actionable by HRH/M policy planners and managers?
What are systemic structural gender discrimination and inequality (SSGDI) in the health workforce?
Theoretical lenses for gender and HRH analysis
Theories and concepts from the sociology of gender, work and organizations describe some of the dynamics of gender discrimination and inequality in the health workforce. These can be applied as lenses through which to understand evidence generated by gender and HRH analyses, allowing policy planners and managers to connect the dots between gender dynamics and negative/dysfunctional HRH effects and consequences. Below, we highlight aspects of theory or concepts that contribute to understanding elements of systemic structural gender discrimination and inequality and provide illustrative examples in HRH systems. See Box 1 defining systemic structural gender discrimination and inequality in health education and employment systems.
Gender has been defined differently over disciplines and contexts, with some seemingly irreducible differences and some common elements [5, 6]. One commonality is that gender is a socially constructed phenomenon . For this paper, definitional elements should explain the gendered processes and mechanisms operating in the health workforce, for example, its highly gendered composition and occupational structures . The WHO 2022 Health Labour Market Analysis Guidebook refers to gender as “Socially constructed identities, attributes and roles for women and men and society’s social and cultural meaning resulting in hierarchical relationships between women and men and in the distribution of power and rights. This social positioning of women and men is affected by political, economic, cultural, social, religious, ideological and environmental factors and can be changed by culture, society and community [8, p. 167]. This definition is compatible with the sociological analysis of sociocultural, historical, structural and relational drivers in systemic, structural gender discrimination and inequality (SSGDI) in health systems. See Box 1.
Sociological-relational theories give a central place to the small-scale behaviors and social interactions and large-scale patterned relations between women and men (and among women and among men) that constitute gender as a social structure, and which are shaped by, address, and modify this social structure . Gender relational theory encompasses economic, power, affective and symbolic relations, operating simultaneously at intrapersonal, interpersonal, institutional and society-wide levels . Social structures exist in the larger societal gender order (e.g., families) and in organizational gender regimes (e.g., hospitals). Gender is brought into social relations through interactions  that are infused by systems of beliefs and ideology. For example, patterned relations between men and women in the health sector generally reflect the ideology of domesticity [11, 12], where nurses do “emotional work” with clients and or are expected to serve physicians .
It has been observed that «gender is one of the three or four identities (including class, race, religion) that are central to the process by which people render themselves comprehensible to themselves and others in terms that are socially valid within their society…As a result, both men and women have deep cognitive interests in maintaining a clear and reasonably stable framework of gender beliefs that define “who” men and women “are” by differentiating them» [14, 15]. An HRH example of deep cognitive interests in maintaining the gender status quo was demonstrated in a special gender analysis of occupational segregation conducted in HIV/AIDS care and support in Lesotho, where men were publicly ridiculed for engaging in the female-identified tasks involved in childrearing . Even though «gender» may change  over time, the strength of societal/institutional interests in preserving frameworks of gender belief and social identity should not be underestimated.
Gender systems not only constitute people as significantly different in essence, but also as of greater or lesser value. Social relations of inequality are then organized in hierarchies on the basis of greater or lesser value [14, 16]. The apparent human tendency to differentiate by supposed essential traits and to stratify by superior–inferior positioning in structural inequality is exemplified by the gender segregation of occupations, one of the most profound, widespread and enduring dimensions of labor market inequality, compared with segregation by race or class . An example of a large-scale pattern of hierarchical gender inequality is evident in a sector where care is delivered by women but led by men . The deference expected from nurses, midwives and other paramedical cadres in relation to physicians is transmitted through beliefs about differential value and power during the socialization of students in the gender regimes of health education institutions . Violence, coercion and harassment also underpin vertical segregation and gender status maintenance in the gender regimes of health education and employment institutions. For example, a gender and HRH analysis of sex-based harassment in Uganda found that intimidation, demands for sex, coercion and gender subordination were common management/supervisory behaviors in staff recruitment, promotion and performance evaluations .
Other structural inequalities include the glass ceiling and the glass escalator, aspects of occupational segregation in the health sector. Glass ceiling practices consist of invisible barriers to reaching top leadership and management positions, that include, for example, the initial placement of (usually) women in relatively low-level, dead-end jobs; not offering job assignments that lead to advancement; not promoting women or greater scrutiny on women’s performance relative to men’s before being promoted; or a lack of access to informal networks and opportunities for mentoring . A gender and HRH analysis in the public health sector of Uganda demonstrated how a glass ceiling was generated (perhaps unintentionally but exclusionary in effect) during recruitment by a criterion for a leadership and management position required the job candidate to have a medical degree to be selected—a condition to which the majority-female nurse workforce in Uganda was unable to comply . The glass escalator refers to a workforce effect whereby men bring their privileged status from the wider society/culture to their entry into predominantly female occupations. Male nurses are often accepted and well-integrated in a female-dominated profession such as nursing and given fair if not preferential treatment in hiring and promotion decisions, despite their being in a minority .
Both the glass escalator and glass ceiling are linked to notions of the greater status worthiness of men (i.e., male primacy) , for example, the presumption of greater male competence in leadership. These dynamics were made clearly visible in a 2019 global gender and HRH analysis of occupational segregation in nurse leadership . This analysis also found that pregnancy and family responsibilities, in the absence of childcare, was a key contributor to women’s time poverty, a material barrier to seeking more education and credentials which are part of career progression. Pervasive, intense gender-relational stereotyping and “prove it again” dynamics  for women underpinned a glass escalator in recruitment and promotion of male nurses, which served to exclude female nurses from senior leadership roles in service delivery, research, and health policy.
The foregoing examples demonstrate the processes of gender differentiation, stratification, coercion/violence and exclusion that are aspects of systemic structural gender discrimination and inequality in HRH systems.
Why are systemic structural gender discrimination and inequality (SSGDI) out of the awareness of most human resources (HR) planners, managers and service providers?
The dynamics of SSGDI are usually masked or invisible unless concerted efforts are made to make them visible. They are masked because they are expressions of everyday behaviors and norms which are central to the smooth operation of small-scale interpersonal interactions or large-scale institutional patterns in gender systems. Often, masculine-typed behaviors are taken as the norm—either as universal or normalized. For example, an analysis of sexual harassment in Uganda’s public health sector  showed that unwanted sexual attention towards female health workers and body-shaming were parts of day-to-day staff interactions in workplaces with no policy to regulate such behaviors. Gender-blind institutional policies also ignore and mask sexually harassing behaviourial norms and may contribute to maintaining class and, possibly, race and ethnic, stratification, which may also be masked in organizations .
The term «gender blindness» («Gender neutrality» in human rights and sociological literature) describes why/how SSDGI operate out of the awareness of most HR planners, managers and service providers. It refers to «behaviors or policies that ignore gender norms, roles and relations and very often reinforce gender-based discrimination. By ignoring differences in opportunities and resource allocation for women and men, such policies are often assumed to be “fair” as they claim to treat everyone the same.» . For example, a wage policy can try to be fair by being “blind” with respect to gender and yet implicitly reward a assumed gendered “breadwinner” in the household.
Health organizations are gendered and jobs embodied
It is not unusual to be blind to the gendered nature of organizations and jobs. Common understandings of the «job» are often based on an implicit assumption that there is an abstract, disembodied universal worker who can dedicate 100% time to the job unencumbered by child-bearing/rearing, a worker (usually a man) who can depend on someone else to play the gendered role of a «wife» who takes care of domestic needs, children and other family responsibilities. The conception of an abstract, disembodied universal worker in a disembodied job nevertheless operates through a gender-based division of labor and the separation between the public and the private spheres which are evident in the masked but widespread phenomenon of occupational segregation . Implicit in the abstract universal worker are actual preferences for men’s expectations of paid work in the public sphere and looser relationships to procreation and labor in the private sphere (not to mention so-called masculine leadership traits and higher representations of men in senior leadership) . Implicit assumptions of an abstract job underpin workplace norms of full-time labor market availability to which men can more easily comply, which ultimately marginalize women in the gendered organization .
Gender-blind language such as «health workers» also masks the reality of a gendered relationship to public and private spheres. For example, a time-use survey comparing the public- and private-sphere workloads of female and male full-time health workers in Mali found that female health workers had more domestic responsibilities than male health workers and that these took more time (e.g., cooking, washing dishes feeding and caring for children and spouses and family, breastfeeding, supervision of children's homework, housekeeping, etc. [45, 46]), essentially another full-time job.
It should be noted that health jobs are occupied by embodied workers with the potential to procreate, among other things. At a minimum:
«…All serious gender theory concerns bodies. Gender is a structure of a specific kind, built from the relationships that concern the reproductive distinctions between human bodies. Gender practice is a reflexive process of social embodiment…how a society handles sexuality, reproduction, child growth, motherhood, fatherhood, and all that is socially connected with these processes.» [9, p. 1677]
That health labor market jobs involve social embodiment is typically ignored in gender-blind HR policies and practice. For example, a gender and HRH analysis in Senegal’s public health sector (which requires continuous operation) found that night duty was delegated to nurses and midwives the majority of whom were married women of reproductive age with children, separated by deployment policy from spouses in rural areas with no institutional or familial childcare support. To manage the conflicts created by tending to private-sphere responsibilities at night, these health workers were often obliged to bring their infants along with them into the public sphere where night guard duty took place. Failure to factor embodiment and public and private sphere workloads into HRH policies, job design, schedules and workloads is at the heart of the widespread problem of «work–life conflict» and attrition.
Some managers view human reproduction as an intrusion into the workplace and respond not by proactive planning but by excluding (not hiring or promoting) women of reproductive age from good jobs in the labor market. Research demonstrates that family caregiving excludes women from health education and training [26, 45, 46, 48] and that pregnancy has been used to legitimize firing or demotion in the name of organizational efficiency [27; Also, Additional file 1].
Combined effects and consequences: Social closure
Finally, the concepts of social closure and social closure discrimination  are useful to understand the combined effects and consequences of the processes in small- and large-scale, yet masked interactions and patterns that affect health labor market participation, and which include relational stereotyping, sexual harassment, pregnancy and reproductive role discrimination (sometimes referred to as the «maternal wall» ), the glass ceiling and escalator and the gender segregation of occupations . Social closure involves the drawing of boundaries between groups in “a process of subordination in which one group secures its advantages by closing off the opportunities of another group that it defines as inferior and ineligible”, and by maximizing rewards by restricting access to resources and opportunities to a limited circle of eligibles» [28, 29] in masked or invisible inequality generating processes [30, 31]. They are involved in closing off occupational and professional opportunities in which female health workers are relegated to “occupational ghettoes” in low-status, lower-paying jobs, with fewer prospects for career advancement in labor markets .
Evidence of systemic gender structural discrimination and inequality
Inequality generating processes of gender differentiation, stratification, coercion/violence, exclusion and social closure are at work in systemic structural gender discrimination and inequality (SSGDI) in the health workforce. Evidence in Table 1 shows how widespread patterns of gendered interactions/relations act as HRH dysfunctions with negative effects on health workers’ career and economic prospects, as well as on the achievement of health systems’ objectives.
Sources of data
The evidence of SSGDI in Table 1 comes from a program of multi-country gender and HRH policy research undertaken by IntraHealth International in nine (9) USAID-funded country projects in sub-Saharan Africa between 2009 and 2021, as well as from a 2019 Johnson and Johnson foundation-funded gender analysis of occupational segregation conducted in collaboration with the global Nursing Now campaign. The global nursing survey provided responses from nurses practicing in 117 countries  that are included in WHO’s regional groupings : African Region (AFR); Region of the Americas (AMR); South-East Asian Region (SEAR); European Region (EUR); Eastern Mediterranean Region (EMR); and Western Pacific Region (WPR). Five of the countries in Table 1 appear on the WHO Health Workforce Support and Safeguards List, countries which face the most pressing health workforce challenges related to Universal Health Coverage .
The methodological approach taken in the multi-method analyses summarized in Table 1 (termed Gender Discrimination and Inequality Analysis or GDIA) anticipated and addressed the need for evidence especially from low- and middle-income countries (LMICs) on the gender dimensions of the health workforce . The GDIAs employed focus groups, key informant interviews, (on- or offline) surveys, analysis of personnel data and document reviews, yielding sex- and age-disaggregated and gender-descriptive data. Some GDIAs (Mali and Senegal) featured time-use surveys to compare the time spent by male and female health workers in paid health, unpaid care and domestic labor.
Qualitative techniques from ethnography (e.g., detailed narratives in «thick description»  were tested and documented to evoke health workers’ beliefs and perceptions and to generate enough context-specific evidence to inform relevant HRH policy development  and implementation, and to assess the cross-cultural portability of some aspect of gender-related theory developed in the United States, the United Kingdom and parts of Europe where gender and workforce studies found early traction. Additional file 1, Systemic structural discrimination and inequality in Senegal’s public health sector, discusses the meaning of GDIA data in terms of sociological-gender concepts and substantiates their cross-cultural portability.
Highlights of Table 1
Systemic, structural gender discrimination and inequality in or between educational and health employment systems appear across national/sociocultural and political contexts. The GDIAs demonstrate organizational processes of gender differentiation, stratification/subordination coercion/violence, exclusion that close off career paths and relegate female health workers to lower-level sex-typed jobs. Occupational and/or task segregation existed in a constellation of other forms of gender discrimination and inequality. Table 1 suggests the near-ubiquity of reproductive status and role discrimination, gender stereotyping and work–life conflict, where female health workers juggled the unequally shared demands of unpaid family care and domestic work and full-time health job responsibilities. Work–life conflict destabilized marital, familial and professional relations. Occupational and career barriers closed off career advancement (i.e., social closure). Among other factors, undesirable or unsafe tasks often performed during unpaid night work together suggested a category bias against nurses and midwives  in Senegal’s public health sector. The dynamics of male primacy in the glass ceiling and glass escalator, the devaluation or denigration of women and their competence, and the contesting of women’s authority or presence in workplaces, were underpinned by beliefs about female incompetence (Rwanda) or an ideology of domesticity (Lesotho, Senegal), made visible by the GDIAs.
Sex-based harassment (including gender harassment, sexual coercion, quid pro quo and exploitation) or fear of sexual violence and retaliation occurred in all nine  country health systems studied. For example, the consequences of “sex for grades” in preservice education systems were lack of safety, student drop-out and reduced health worker pipelines (Mali, Kenya). Quid pro quo and sexual coercion (Uganda) operated as “sex for employment rewards” which created hostile work climates and conflicts between supervisor and staff or between colleagues, barriers to career advancement and turnover and sometimes resulted in workforce exit and discontinuity of health services. Sexually harassing behaviors were typically normalized, silenced by victim-blaming and stigma, not reported and thus obscured in daily work interactions, though also considered an “open secret” (Uganda, Kenya, Senegal).
The negative HRH effects and consequences summarized in Table 1 occurred in employment and education systems where gender-blind HRM policy environments allowed gender bias, discrimination and inequality and social closure to operate freely. All these factors were obstacles to health workforce development, retention and expansion—and to the economic security of female health workers.
Why should it be a priority to collect data to make SSGDI visible in workforce systems?
As seen in Table 1, evidence from gender and HRH analyses can demonstrate how SSGDI work and their undesirable HRH effects and consequences. Once these are understood, the HRH/M policy planner or manager can anticipate certain bottlenecks to workforce entry, internal flows, and exit. Better evidence can make HRH/M policy action more proactive and effective. For example, if jobs are understood to be occupied by embodied workers, then lifecycle events would more likely be planned for and staff shortages (temporary or permanent) mitigated through, for example, a pregnancy cover policy. Health service discontinuities would likely be mitigated. If enabling conditions, such as access to childcare, were routinely offered as HRM infrastructure, perhaps female health workers would less easily become targets of marginalization. Parental leave might be an incentive to sharing the burden of unpaid care and domestic work, which would promote equity and social progress, since to achieve gender equality in paid work, women need to achieve equality in unpaid work . Any of these evidence-informed policies would likely alleviate the tension, conflicts, burnout and the ad hoc crisis management that often attends family-related absences from work. Policies to prevent sex-based harassment of employees and clients would make professional environments less hostile and exclusionary, improve teamwork, reduce health worker turnover or resignations, improve the poor reputation of health facility and likely increase the utilization of health services .
What are the implications for implementation and HRH policy?
To draw strong linkages between SDG5 targets and non-health Sustainable Development Goals (SDGs): gender and HRH analyses must be conceptually stronger, produce better data, and enable policy planners to connect the dots between evidence of an HRH problem and corrective policy action. All SDG 5 targets (Box 2) are relevant to HRH. Stronger data related to SDG 5.4 are needed to supplement data related to SDG 5.1 and 5.2, which together will strengthen our understanding of the interplay of discrimination and inequalities and how to counter systemic, structural gender discrimination and inequality.
Gender and health workforce analyses provide opportunities to strengthen intersectoral linkages and impact non-health SDGs, for example, SDG 4 (Education), SDG 8 (Employment and Decent Work) and especially SDG 5 (Gender equality and empowerment of women and girls .
Gender and HRH analyses can improve policies by making the dynamics, effects and consequences of SSGDI visible as health systems dysfunctions to be addressed by proactive or corrective HRH policy. Revealing masked occupational or professional (social) closures for women in health sector is particularly important for understanding workforce flows into, in and around and out of health systems. Relevant contextual gender and HRH evidence should be available for the development of any HRH policy to demonstrate why gender-blind HRH policies would likely be ineffective in countering discrimination and correcting an uneven playing field of gender-segregated labor. Once the operation and consequences of SSGDI are visible, HRH/M policy planners would have the rationale to counter discrimination and inequality though anti-discrimination and substantive equality policies and measures to bring about changes in the real conditions of health workers’ lives and work—for the better. Gender transformative policy will then be workforce transformative. The reader is referred to readings that describe gender-transformative substantive equality and nondiscrimination principles and special measures [22,23,24, 41].
What are practical steps to make gender analysis results accessible to and actionable by HRH/M policy planners and managers?
Conducting a gender and HRH analysis is not sufficient to develop and implement effective gender- and workforce-transformative policies. New understandings of gender discrimination, inequality, equal opportunity, nondiscrimination and substantive gender equality will be necessary. To do this, systematic knowledge translation  and intersectoral coalition-building are critical. Knowledge translation should feature locally led, iterative, awareness-raising, education, uptake and capacity-building activities in intersectoral coalitions that together can plan evidence-based, gender-transformative strategies and policy. In this way, knowledge translation activities will counter resistance and foster accountability. Such activities require investments of time and money. The findings in Table 1 certainly suggest that investments targeting gender equality and women’s economic empowerment should pay attention to the health workforce, especially since health jobs are potentially important sources of female employment and economic security, economic growth and social development.
Making the dynamics of SSGDI visible will allow HRH policy planners and managers to craft effective policy and anticipate bottlenecks to workforce entry and flows and transform the actual conditions of health workers’ work and lives for the better. There must be new understandings about systemic structural gender discrimination and inequality in HRH, investment in collecting and using context-specific, sex- and age-disaggregated, gender-descriptive data and translating knowledge into intersectoral policy action to counter their systemic, structural effects and negative consequences for the health workforce. Gender transformative policy based on nondiscrimination and substantive equality principles will be workforce transformative. Global HRH strategy and W4H Action Plan objectives and UHC and SDG goals will more likely be realized.
Availability of data and materials
Datasets and transcripts from the Sénégal study were destroyed. Data necessary to interpret, replicate and build upon the findings are in unpublished text files and a technical report available from the corresponding author on reasonable request.
Gender Discrimination and Inequality Analysis
Human Resources for Health
Human Resources Management
Low- and Middle-Income Countries
Sustainable Development Goals
Systemic, structural gender discrimination and inequality
Universal Health Coverage
World Health Organization
Working for Health
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We thank the Senegalese Ministry of Health and Social Action Division of Planning, Research and Statistics and Research and the Gender Cell for supporting the gender analysis and this publication; and IntraHealth International Senior Program Manager Mélanie Joiner for moral and instrumental support in the planning and implementation of the Senegal gender and HRH analysis. Our deep thanks to the key informants and health workers in all the countries in which Gender Discrimination and Inequality Analyses were conducted, who shared their views with the study teams in the hopes of gender equality, safe and decent work in the health sector. Finally, we extend thanks to our peer and editorial reviewers whose insights and recommendations greatly improved the final draft of the manuscript.
The US Agency for International Development in Senegal funded the GDIA and implementation through Cooperative Agreement # AID-685-A-16-00004 (NEEMA).
Ethics approval and consent to participate
The Senegal Neema project submitted a research protocol and data collection tools to the National Ethics Committee for Health Research (CNERS) after an internal ethics review. The protocol was approved by CNERS under No. 0020/MSAS/CNERS/SEC on 11 February 2021.
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There are no financial or non-financial competing interests.
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Newman, C., Nayebare, A., Gacko, N.M.N.N. et al. Systemic structural gender discrimination and inequality in the health workforce: theoretical lenses for gender analysis, multi-country evidence and implications for implementation and HRH policy. Hum Resour Health 21, 37 (2023). https://doi.org/10.1186/s12960-023-00813-9