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.