On 8 March, International Women's Day, much multisectoral research is published to assess the situation of women around the world, in all areas. The COVID-19 pandemic has challenged health systems and monopolised resources, raising awareness of women's key role in the health sector. And there’s a good reason: they represent 70% of the workforce in the health and social care sector and provide the majority of health care services. Health security relies predominantly on women and we cannot achieve Universal Health Coverage without them. In response to these challenges, the World Health Organization (WHO) created the Gender Equity Hub in 2017, which it co-chairs with Women in Global Health, under the leadership of the Global Health Workforce Network. The Hub brings together key stakeholders and aims to strengthen guidance and capacity to support the implementation of transformative policies to achieve gender equality. The aim is to overcome sexist prejudices and gender inequalities among health and social workers around the world. The Hub's interventions contribute to the implementation of the Global Strategy on Human Resources for Health: Workforce 2030, and the Five-Year Action Plan (2017-2021). In 2018, the Gender Equity Hub identified and examined more than 170 studies as part of a literature review on gender and equity in the global health workforce. The analysis identified four key areas of concern, forming the basis of the Hub's priorities for action: occupational segregation; decent employment free from prejudice, discrimination or harassment, including sexual harassment; the gender pay gap; and gender parity in leadership roles. Occupational segregation: the horizontal and vertical segregation of men and women within professions is a global trend in the health sector, with some contextual variations influenced by culturally defined gender norms and stereotypes that determine jobs ‘for men’ and jobs ‘for women’. It manifests itself in discrimination against women, preventing them from accessing managerial/leadership positions, and also by the fact that gender stereotypes prevent men from choosing certain professions, for example nursing or midwifery (the rarity of the terms ‘man-midwife’ or ‘male midwife’ reflect the under-representation of men in these professions). Women working in the health sector are generally confined to junior and/or low-paid jobs. Female-dominated occupations have lower social value, status and pay. There is an over-representation of women in the lowest categories, and a scarcity of women in decision-making positions, and in professions that require a higher number of years of study. Global figures reflect this trend: 27% of the Ministers of Health globally are women, 26% of government representatives to the WHO World Health Assembly are women, and within WHO itself, only three in ten women hold leadership positions.

Figure 1: Proportion of Women vs Men in Health

  A study carried out in 20 middle and high-income countries in 2016 provides consolidated data. It shows the categories where women are obviously under-represented: with an average of 23% of women in 20 countries, Health Information Technician positions come first in the ranking of male-dominated professions. Doctors and Occupational Health professionals come second (32% female in both cases). In contrast, nurses and midwives, physiotherapists, allied health professional nurses and midwives, community health workers and social care workers, have the strongest female representation. Despite data not being available in all countries, the gender pay gap is already relatively high in middle and high-income countries, with a 27% difference between women and men in the same job category, despite the Equal Remuneration Convention. Decent employment free from prejudice, discrimination or harassment, including sexual harassment: a high percentage of women working in the health sector experience prejudice and discrimination or face sexual harassment, causing them harm, affecting their physical and mental health, and making them leave their job. The adoption of the International Labour Organization's (ILO) Convention 190 on Violence and Harassment, signed in 2019 and coming into effect on 25 June 2021, should provide victims with a legal instrument and commit signatory States (currently five signatories) to match their national legislation to the Convention's principles. Many countries do not have the legislation or social protection required to cement equality between men and women at work, and men working in the health sector are more often organised in trade unions than women. Women working in the health sector who find themselves on the front lines in conflict zones, emergency situations or remote areas face violence, suffer trauma and risk their lives. The gender pay gap: the health sector gender pay gap (26 %) is higher than the average gap in other sectors, partly explained by the high proportion of women in junior/low paid positions. Much of the work done by women in the health and social care sector is unpaid and is not captured in gender pay gap data. Many countries do not have equal pay legislation or collective bargaining systems. We also know that women carry part of the invisible and unpaid care work burden (caring for the elderly, the sick or the young at home or the community). The Equal Remuneration Convention dating from 1951 has been ratified by 173 countries but has not led to any consistent or accurate monitoring of these discrepancies, nor has it sparked the necessary political will to correct these inequalities. Leadership: women make up 70% of the global health workforce but only occupy 25% of leadership roles. The differences between men and women in leadership can be explained by stereotypes, discrimination, power imbalances and privilege. The prejudices suffered by women are compounded by other social identity factors such as race and class. The global health sector is weakened by the loss of female talent, ideas and knowledge. Staff retention policies are either non-existent or weak, and are generally not based on women's needs, despite women making up the majority of the health sector. The global context confirms this situation, with women largely underrepresented within the UN decision-making bodies and health bodies in particular, as shown in the figure below:

  The Place of Women in Health and Social Care Initiative

  Officially launched on 25 February 2021 by three partners (the French Government, WHO and Women for Global Health) this Initiative will be rolled out over the course of 2021 as part of the International Year of Health and Care Workers. It aims to advocate globally for the advancement of women and girls in the health and social care sectors. It is part of the United Nations' Generation Equality Campaign, supporting actions that promote gender equality and celebrating the 25^th anniversary of the Beijing Declaration and Platform for Action. This initiative aims to promote the implementation of concrete measures to:

1. Increase the number of leadership positions held by women in the health sector.
2. Promote the recognition of unpaid work and reduce the pay gap between men and women.
3. Protect women against sexual harassment and violence at work.
4. Guarantee safe and decent working conditions.

  What are global health stakeholders doing about gender equality? Key global health stakeholders are assessed on an annual basis by Global Health 50/50, which reviews the equality policies and practices of 201 global health and health policy organisations. According to the report released in March 2021, the Global Fund is ranked among the most inclusive organisations in terms of gender, alongside Gavi, Unitaid and the World Bank.

Source: Global Health 50/50 report 2020

The Global Fund seems proactive in the following areas: the promotion of women to management positions at Secretariat and Board level, staff recruitment, balancing family life with professional responsibilities and protecting pregnant women, as well as handling complaints of harassment or discrimination. What sets apart the most advanced organisations in terms of gender lies in their programme design, generating the tools needed for transformation and social change, moving from ‘gender sensitive’ to gender transformative'.  

Source: Global Health 50/50 report, 2020

This is where the concept of gender intersectionality comes in as an imperative for gender equality, not only among the global health workforce but also within funded programs, with a particular focus on Human Resources where huge inequalities remain. Regarding gender and the health system: there is a lack of research in this area, particularly with regard to Human Resources for Health, an area which would greatly benefit from innovation:

• The Global Fund could support the establishment of Gender Equality policies in Human Resource Management in Ministries of Health;
• It could also finance gender equality mainstreaming in Human Resources for Health tools (recruitment, promoting women to managerial positions, measures promoting work-life balance, equal pay, tools for identifying hidden volunteer work, mechanisms for reporting grievances and harassment), and women's representation in Ministry of Health management positions.
• It could encourage gender mainstreaming in key strategic documents (National Health Development Plans, National Strategic Plans by disease and by directorate, Community Health Strategies) to ensure the issue is addressed comprehensively within Ministries.
• Finally, it could promote inter-ministerial collaboration between Ministries of Women's Affairs, Ministries of Employment, Labour or Public Administration or Ministries of Higher Education, for example.