Ensuring fair compensation for female health workers ‘starts with political commitment’: Dr. Roopa Dhatt

One of the biggest paradoxes in global health is that women account for 70% of the global health and social care workforce yet hold only about 25% of the sector's senior leadership roles. Even worse, millions of female health workers work for very low pay – or no pay at all.

In 2015, Dr. Roopa Dhatt co-founded Women in Global Health to remedy that paradox and has since become one of the world’s most respected campaigners for gender equity in global health. Dr. Dhatt, who is also a practicing physician in Washington, D.C., says her mission is to “build a movement to transform women’s leadership opportunities in health” and address the intersectional issues of power and privilege that keep many women from these roles.

Today, Women in Global Health has 57 chapters in 51 countries and Dr. Dhatt has become a powerful figure in global health known for her strong advocacy for “bold” gender transformative policies, including creating all-female short-lists for open executive roles and promising certain positions to women.

In this first part of a two-part interview with Dr. Dhatt, Exemplars News asked her what steps global health institutions need to take to become gender transformative and how they can help make sure women health workers are properly compensated for their work.

Women in Global Health’s recent report ‘Subsidizing global health: Women’s unpaid work in health systems’ found that upwards of six million women around the world are subsidizing health systems with their unpaid or grossly underpaid labor. How can this injustice be remedied?

Dr. Dhatt: Ensuring fair compensation starts with a political commitment to recognize these women as workers. We know women have been subsidizing health and care from the start of time. It's become institutionalized over the past several decades, primarily because of the fact that women have been doing such a great job achieving health results, which has shaped how health systems and health policy makers and broader policy makers view this labor. These women are providing services. It's a job and they deserve fair pay.

Women in Global Health subscribes to the ILO's 5R Framework for Decent Care Work, which recognizes this work and reduces and redistributes unpaid care work. I'm particularly emphasizing the 'unpaid' because this pertains mostly to women. We need to reward care workers by generating more and better quality work, including pay. We need to shift from saying, 'Great job, volunteer. We're going to applaud you, we're going to recognize you. We may even hold a ceremony for you. We may give you a mobile phone or new shoes or some symbolic stipend.' Instead, we need to say, 'We're actually going to pay you. We're going to give you monetary funds so you have economic empowerment.' Then we need to promote the formal representation of unpaid workers and care recipients as workers.

This is not a new ask. In 1995, governments made commitments at the Fourth World Conference on Women in the Beijing Platform for Action to deliver safe and decent work and [not] unpaid work. Governments committed again in 2015 with Sustainable Development Goal number eight to 'promote sustained, inclusive and sustainable economic growth, full and productive employment and decent work for all.' In 2018, WHO issued guidance on community health workers. The global norm-setting bodies have said, 'This work must be recognized, and these women must be compensated, and we need to end this.' It's the follow-through that hasn't happened.

Some of the larger global health institutions have made progress. Several big organizations such as The Global Fund to Fight AIDS, Tuberculosis and Malaria, The U.S. President's Emergency Plan for AIDS Relief, and the U.S. President’s Malaria Initiative have all said they will address unpaid labor in their strategies. USAID's global health strategy work under Administrator Samantha Powers has recognized that women's unpaid work is subsidizing health. Some of these organizations have directly cited our ‘Subsidizing global health: Women’s unpaid work in health system’ report and said they were going to start evaluating how many of the programs they're funding have unpaid work, cost it out, and work to end that unpaid work.

What institutional policies would you like to see to support women in leadership positions?

Dr. Dhatt: The first thing I'd like to see are legal frameworks to ensure there isn't any discrimination in the workplace. This is something we may be taking for granted, but the data from ILO and UN Women has shown over and over again that legal frameworks are often not in place. UN Women last year released a report saying it will take close to 300 years to get to gender equality because of discriminatory policies.

We need better policies related to sexual harassment, bullying, and sexual assault. There are dozens of countries that still have not made sexual harassment illegal or even recognized it. That's one of the top reasons women are leaving the health sector. We also need to make sure women aren’t paying the motherhood penalty. That's definitely an issue for pay and promotion. But women also lose their jobs because they're pregnant. In our ‘Subsidizing global health: Women’s unpaid work in health systems’ report, we told the story of a Nigerian physician who went on maternity leave and no longer had a job when she returned, but was instead relocated to a very rural location, which, for all practical purposes, was a constructive dismissal. It's just one example of why we need legal frameworks to protect women in the workplace and the health sector.

We also need to look at policies that truly lead us to gender equality and address norms. We need to normalize paternity leave and other family-friendly policies. Organizations that are often rated highly in global health will say that men, women and all genders can take the same amount of parental leave. But when we look into it further, we find that men are not exercising paternity leave. So it's not just about having the policy, it's about normalizing it so people view both men and women as carers. That's how institutions can be a part of changing societal norms.

Flexible working options are another area I’d like to see more investment in. We do recognize that women health workers have care responsibilities, and many societies don't have the social protections to support them, whether they’re doing care work at home or childcare or elderly care. But we need to be flexible and enable women to return [to work] after having a child and not say, ‘Well, you got to return to the same conditions as before you became a mother or carer.’

We also need to acknowledge that menstruation and menopause can have a significant impact on health and well-being and that women's health needs should be recognized and funded. Institutions need to recognize menopause and menstruation and provide support and services, and normalize being able to talk about these issues. Many organizations tend to focus on fixing women and getting women to fit the institution. We need to create gender transformative environments and gender transformative leaders, including men, women, and all genders, who create enabling environments.

Are there any positive outliers in terms of women's global health leadership in governance structures that stand out in your mind? Or countries or subnational geographies in terms of women's paid labor in health systems?

Dr. Dhatt: In terms of global institutions, besides the organizations I mentioned earlier, the WHO's work on becoming a gender transformative leader is great because the commitment comes from the highest level. The director general, Dr. Tedros Adhanom Ghebreyesus, made a commitment to Women in Global Health during his election period that the [WHO's] senior cabinet would have at least 50/50 representation and followed through. In the first cabinet, he had 67% women from diverse backgrounds. He's maintained a similar percentage since then. But beyond representation, the WHO has adopted different strategies in their global program work to be more gender transformative and responsive and is trying to gender mainstream the entire organization.

I'd also give the WHO a shout-out for what they've done with one of the most heartbreaking discoveries – the massive sexual exploitation that took place in responding to Ebola in the DRC. There were dozens of cases and supposedly many more we don't know about, so you can assume hundreds of cases of sexual exploitation by the aid sector with WHO being named as one of the perpetrators. The organization took a very bold approach by saying, 'We're not going to do what the UN always does. We're going to approach this differently. We'll do the formal UN investigative processes, but we're going to appoint an independent commission led by two women from the Global South to investigate and let them come to their own conclusions and recommendations.'

We told WHO we wouldn't applaud them until we saw the results, so it's been a few years of them crossing milestones, but they've recognized sexual exploitation as an issue that needs an organization-wide approach. They reformed their policies. We had a team member passing through a [WHO] country office in Africa, and there were posters very clearly saying, 'Zero tolerance. This is what inappropriate behavior looks like.' That was new.

For government shout-outs, many of them are trying to figure it out right now. About 20 governments have joined our Gender Equal Health and Care Workforce Initiative that we co-host with France. They all recognize that they must find solutions to the issues women health workers face from a gender equity perspective. One of the countries that has done some commendable things has been Ethiopia, which for the first time conducted a gender-based violence audit. They recognized that female health workers face higher levels of violence so they're doing an audit of all health workers to collect data and design solutions. Ethiopia has already been recognized for being one of the first countries to formalize its cadre of community health workers and community health extension workers and compensate them.

The Liberian government under former President Ellen Johnson Sirleaf did something similar. They first tried [to allocate formal health worker roles] in a gender-blind way. But when those jobs became formalized, men started taking them. They realized they instead had to approach the program in a gender transformative way, so have been working for the last few years to create policies that ensure women community health workers are also getting those formal job opportunities. I could go on, but what we are seeing is a willingness and recognition that women are the majority of the health workforce and solutions must come from acknowledging the needs of women – and not merely in a gender-blind way because that's actually gender harmful.

How can health institutions better enable women from diverse backgrounds to lead, especially those who may have missed out on formal education and traditional qualifications?

Dr. Dhatt: I'm delighted to see this question because we often say, 'We've just got to get gender equality.' We need to recognize that a majority of global health programs are targeting women from the Global South, particularly from low to middle-income countries. Yet, when you take a look at the representation in decision making at the highest levels, less than 5% of global health institutions have women from the Global South leading them.

This means we're not really able to put the best solutions forward because we don't have diversity in leadership. Research shows when you have diversity across geographies and professions, so not just physicians, but also nurses and community health workers, you get better results. Women in Global Health published a paper in The BMJ where we talk about the dividend of having diverse teams and diverse leadership. In global health we should agree that diversity is not only the right thing to do, it's the smart thing to do. It leads to more sustainable solutions and more ethical decision making.

So how do you get women from diverse backgrounds into leadership roles? We need to recognize it's an issue, change the narrative, and view them as leaders. The six million women community health workers subsidizing health care are often going to be disqualified from being viewed as leaders because they don't have what's considered the educational requirements to be a formal health worker or have the formal credentialing. We're saying we should view them as leaders and create opportunities for them to input on decision making because of their expertise and proven track records. For some women community health workers, this has been their entire life's work and they can find solutions better than anyone else in their community.

Supporting women leaders from diverse backgrounds also means creating more targeted training that addresses the barriers they face to being recognized [as formal workers]. It's not about fixing them, it's about making sure the training they receive gives them the credentialing or recognition to be able to say, 'Yes, I have met the competencies, or I am professionalized.'

This interview has been edited for length and clarity. Read part two here.