Gender & Health System Leadership: Increasing Women’s Representation at the Top

By , , and on September 30, 2016

Radhika Arora is an EV 2012 & ITM MPH alumnus.  

Esther Nakkazi is a freelance science and technology reporter, a blogger at Uganda ScieGirl and a media trainer. She has mentored African science journalists in the World Federation of Science Journalists project.  Follow her on twitter @Nakkazi. She is the 2016 Journalist in Residence Fellow at the Institute of Tropical Medicine in Antwerp, Belgium. 

Rosemary Morgan is a Research Fellow at the Johns Hopkins Bloomberg School of Public Health

Women make up the bulk of the healthcare workforce but so few are in the top leadership roles. The role of women in leadership, or rather the lack of women in leadership positions and its impact on health policies, is indeed one which we must continue to question. What are the implications of having so few women at the top? How do we encourage the representation of women at the top? And, if more women were in healthcare leadership positions would we have better policies, remuneration and better long-term improvements in the sector?

The majority of health workers in lower tiered positions, such as within primary health care provision, are women. Despite women making up a significant proportion of health care workers, they are grossly underrepresented in leadership positions across the world. This is not unique to the health sector. In the corporate world, for example, the report on The State of Women in Healthcare: 2015 indicates that only 4% of CEOs are women.

Greater participation of women at the leadership level has been shown to result in policies which enhance the position and rights of women. For instance, Rwanda which has the highest level of women parliamentarians of any country, has also over the years invested in policies on ending violence and discrimination, investing more in health services, and investing more in improving women’s participation in the workforce. In the case of Rwanda, the participation of women at the political level went way beyond the 30% quota instilled in 2003. Contrast this to the Kurdistan Region of Iraq, where despite a similar quota women constitute only 3% of leadership positions. This raises the question of the need for, and role of, quotas for women at the leadership level.

Encouraging women’s representation through quotas?

Deliberate efforts like putting quotas, reservations, and affirmative action to ensure participation of people from marginalized, vulnerable or less vocal sections of the populations could encourage more women’s participation at multiple levels of policymaking and the workforce. But do they really work? Are quotas a legitimate way to reach equilibrium and ensure at best some form of equal representation at the top? While quotas might ensure that more women have a seat, do they actually increase women’s meaningful and effective participation? If not, what is needed alongside quotas to ensure women’s meaningful and effective participation?

While a quota system may provide a way to encourage women’s representation at the leadership level, it is only a short-term solution. If women’s participation at the top is going to be meaningful and effective, longer-term strategies are needed to transform the unequal gender norms, roles, relations which perpetuate and reinforce gender inequities within the health system and inhibit women’s participation at the leadership level.

Increasing women’s value within the health system

Community health workers –the cornerstone of early primary health service programs, and for many people their only contact with the health system – are largely women. Women who take on this position often do so for little or no pay. Even as one acknowledges the role of the female community worker, we wonder if they would be better paid and organized if the majority of the workforce were men. Studies have found, however, that even within the same occupation (including those that are female dominated) not only are women promoted less frequently than men, but they also earn less. Gender inequities within the health system are a reflection of gender inequity within society. Gender pay inequity can therefore been seen as a reflection of the value placed on women’s work and their overall status within society. Women’s work is often seen as less important or worthwhile, and their role has health workers is no exception. As we usher in the Sustainable Development Goals, we should strive to progressively change the value placed on women’s work and role within the health system, and offer equal opportunities and compensation to reflect this.

Minimizing gender bias within the health system

The issue of women’s role within the health system is becoming increasingly important, especially as we start to see a feminization of the medical workforce. In many countries, for example, the number of medical graduates are increasingly female. It will be interesting to see if the feminization of the health workforce translates to the top – as more women enter the health workforce will this be reflected at the leadership level? This is unlikely if we do not first minimize gender bias within the health system (and society more generally), which devalues women’s work, leads to lower compensation, and means that less women are given the opportunity to advance within their career.

Minimizing gender bias within the health system “requires systematic approaches to building awareness and transforming values among service providers,” along with developing policies and strategies to remove barriers to women’s career advancement and ability to engage in leadership roles. Women make up a large majority of the health care profession – it is time that they are recognized for their contribution and adequately represented at the top.


Note:  This blog is based on an online discussion with 14 members of the new cohort of the Emerging Voices. Over the past few weeks we engaged in a discussion on gender in health systems (one of three parallel discussions) with these 14 EVs. One of the most visible themes to have emerged from the discussions, and also perhaps an instinctive reaction of health system practitioners was that of gender (here mostly in the context of women) within the context of human resources for health and human resources in general.  The blog presents reflections on the issue of leadership and HRH from our discussions.

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4 Responses to “Gender & Health System Leadership: Increasing Women’s Representation at the Top”

  1. Meena

    Gender bias to be minimized,but “HOW” is the million dollar question.Are there any successful strategies to alter the power equations within the health system other than quota system?

  2. Rosemary

    Hi Meena – that is a good question and one in which we’ve been grappling with in my project “Research in Gender and Ethics (RinGs): Building Stronger Health Systems”. Firstly, I think it begins with awareness, making people aware of the issues and that this bias exists and is holding women back. Research which explores these issues is important – what are the barriers to women’s advancement and how might we address these? Training is also important – training those within the health system (at all levels) to be aware of gender bias and act upon it.

    Gender mainstreaming and integration is another strategy – ensuring that all policies and procedures take into account gender. Policies and procedures are needed which address the barriers to women’s advancement (such as maternity and paternity leave, flexible hours, etc.). At the larger level we need to change gender norms and relations – this is a long term strategy. Participatory approaches are needed which challenge norms and beliefs that value male leaders over female leaders, that place women as carers within the home and men as providers, etc.

    Such approaches and strategies are also needed at the educational level – training of medical students and other health personnel to recognize gender bias and address it. Gender mainstreaming tools are available on the internet. One I like is “Gender mainstreaming for health managers: a practical approach”

    To learn more about how gender analysis can be integrated into research the RinGs website has a lot of great resources:

  3. Manoj Kumar Pati

    Hi Rosemary- First of all I would like to congratulate you people for this wonderful blog and your reflections on two of the burning issues of our time those are grappling our health system from long past. One is on gender, and the other is on human resources for health. These issues, to my understanding, never exist in silos; rather they cross-cut multiple concepts such as: equity, ethics, fairness, justice, quality of service delivery to even policy making and decision making.

    Now, I will bring you to your own words! Gender inequities within the health system are a reflection of gender inequity within society. I also agree, what bias we are seeing in recruitment to top level positions embedded in health system is a true reflection of the value placed on women’s work and their overall status within society. Women’s work is often seen as less important, and in health system we obviously get no exception.

    My question, rather reflection here is, if such is the case and environment we live in, is it wise to expect placing women in healthcare leadership positions would would automatically result in better policies, remuneration and better long-term improvements in the sector. Unfortunately, I do not think so! To my understanding, by this although we will be able to solve part of the problem, there is in all possibilities, we may miss to address the root of the problem and the whole problem per se.

    Though you have provided good examples of health systems of how increasing women participation in leadership role result in better policies, I would not assert that a global phenomenon. See for a example of a country that I come from, India, largely struggling with reported violence against women now and then, outside and at home, men-led decisions etc etc, all this even after we tell we have an excellent quota system not just to recruit women but recruit them in leadership positions across different sectors not just health. Our former president was a women, our current foreign affairs minister is a women, 25% of parliamentary cabinet consist of women, many states ruled by women chief ministers, yet policy and decisions are not different from yester years, not definitely women supportive.

    The thing is whether we want it to be an ideal 100% women friendly, again yes in current societal context and no in true sense of gender fairness. Both men, women and people from all other gender should given priority on equal basis not only for acquiring top level positions but to render them with equal respect and trust. I completely agree with your point on requirement of long term strategies to balance unequal gender norms. However, the apathy is how long a strategy can be expected to result in visible outcomes, we are not sure.

    I also see lots of similarity of gender debate with it’s parallel social stratifiers like caste, class, age, race, ethnicity and so on. From long globally, like in my country, we are trying to uplift the so called vulnerable backward class/caste: scheduled caste and scheduled tribe just by quota system, recruiting them into jobs with extra weight- age which includes recruitment into managerial and leadership positions as well. What we have achieved so far, may be nothing great in terms of tangible outcomes. People still differentiate based on class and value less the work done by them.

    So in summary, why not build capacities of both women and men equally from their basic education, given society will start value them equally in all fields of knowledge, and at the end decide owner of positions based on one’s skills and caliber instead of tilting to either men or women favoritism.

    Given health system researchers context also, I think we should give away the thought that gender means just issues with women and things to deal with maternal and sexual health. We have other two dimensions of universal health coverage to deal with-service delivery and financial security not just covering all population. We are talking of resilient and responsive health systems. In all this, we need equitable representation of both men and women in leadership positions based on their skills and calibre, their upbringing- weightage based on their access to quality education, wealth and such things and not just because women being a oppressed class.


  4. Rosemary

    Hi Manoj,

    Thank-you for your thoughtful reflections on the above post. You’ve touched on many important issues which I think are worth consideration. Firstly, I would agree with you that gender does not just mean women and maternal/ sexual health and we are trying to move away from the position that gender = women. My project RinGs has recently published a brief that reflects on the challenges of encouraging the incorporation of gender analysis into health systems research, one of which is the notion that gender equals women only ( Gender roles, norms, and relations affects men’s health also, in addition we need to think of the role men play in women’s health. I have written a blog reflecting on this topic which you may find interesting: Dominant constructs of masculinity and gender inequality: what are they and what can be done to challenge them? (

    I like how you have reflected on how social stratifiers interact to create different experiences of marginalization and discrimination – gender analysis should incorporate an intersectional lens. It is important that men aren’t all treated the same and women aren’t all treated the same. As you rightly state men and women from different castes will have different experiences of power and privilege. The blog above touches upon this, as does a paper we recently published on intersectionality (

    Now to your main point – the need for equitable representation of both men and women in leadership positions based on their skills and education. I certainly do not disagree with this point, however, I think that it is important to keep in mind that even when men, women, people from different castes and ethnicities, etc. have similar skills they are not always given the same opportunities for advancement. In addition, not everyone is given the same educational opportunities – in situations where there has been historical structural and institutional discrimination (whether it be sexism, racism, a combination of the two, etc.) it can take a long time to reach a point, if we can ever really get there, where all groups are on an equal playing field. Yes we need to build the capacities of both men and women equally, but even when those capacities are in place there is no guarantee that each will have the same opportunities.

    You mention that men and women should be given position based on their “skills, caliber, and upbringing -weightage based on their access to quality education, wealth and such things and not just because women being an oppressed class”. What happens when a person’s upbringing is a result of privilege and associated power that their class, gender, caste affords them? Such privilege allows certain groups to access quality education which in turn allows people access to top level positions. Historically this is why there has been a lack of diversity at the top level – for years white men (or men in general) held these positions which is still the case in many areas and professions. If those in groups which have been historically discriminated against and oppressed do not have access to quality education how are they going to be able to compete to hold these positions? And even when they are able to access this education, this historical discrimination and oppression often still prevents career advancement.

    In my opinion it is important to have a two pronged approach – one which is more short term like a quota system, and one which is longer term – for example providing educational opportunities and transforming unequal gender norms. I see such quotas as a type of affirmative action – a policy or action which allows people from discriminated groups a place at the table, who in otherwise would not be given a place due to historical discrimination and oppression. In a way, it is trying to level the playing field recognizing that not all individuals benefit from the same level of power and privilege within society.

    There are many studies that show that women and other marginalized groups are discriminated against in hiring committees and career opportunities even when they have the same level of education. And in contexts which there is extreme gender inequity, even when women are given a place at the table they are going to struggle to facilitate change unless they have the backing of other important players and/or there is a shift in societal norms. Having women in these positions is a step in the right direction as I think that it starts to create dialogue and change perceptions about women’s value and ability to hold these positions.

    Parallel this to Universal Health Coverage, the aim of which is to provide equal access to health care. We have seen that in countries which are on the path to UHC those who are most vulnerable and marginalized are least likely to benefit unless policies and strategies are put in place to target these groups. It is the middle and upper classes who are most likely to benefit. If we are going to improve the lives and health of the most vulnerable, or ensure that there is equal representation of men and women in leadership positions, we need targeted approaches. Otherwise these systems will continue to perpetuate inequity.


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