'Robust Dialogue' Needed About Equity of Women in Healthcare

Troy Brown, RN

October 18, 2017

"At least 75% of the health workforce are female, and looking around this room…there is no shortage of talented women in the pipeline. But the picture looks different at the top," Michele Barry, MD, director of the Stanford Center for Innovation in Global Health and senior associate dean for global health at Stanford University in California, told the audience at the inaugural Women Leaders in Global Health conference.

"With every step up the ladder, the proportion of women shrinks. The World Health Assembly is 68% men; 70% of health leaders are men; and, at least in US medical schools and public health schools and global health institutes, men predominantly hold the top positions, despite the fact that global health has become increasingly feminized. In Fortune 500 countries around the world, 26 out of 27 health center [chief executive officers] are men."

"How can we succeed when half of the talent sits on the bench, and how can we have a robust dialogue?" Dr Barry asked.

The fast-paced conference was held at Stanford University School of Medicine, on October 12. Aims of the meeting were to recognize women leaders in global health, help women develop leadership skills, and empower younger women to become leaders.

Why Gender Matters in Global Health

Gender matters in global health for many reasons. Women confront many major health issues, including childbirth, reproductive disorders, cervical cancer, violence, and poverty.

Every 2 minutes a woman dies — still — in childbirth, Afaf Meleis, PhD, DrPS(hon), dean of nursing emeritus, University of Pennsylvania, Philadelphia, said. These deaths are preventable 60% of the time.

"We are not immune in the United States; our maternal mortality rate is increasing by the day. Right now, it's 26.4 out of 100,000 births. In Finland, it is 3.8. We [have the worst maternal mortality rate] in the developed world," Dr Meleis said. Female genital mutilation is still common in some parts of the world, and many women die from abortions. Almost all abortion deaths are due to unsafe abortions, and not the procedure itself, she added.

"Disciplinary oppression" of female nurses, midwives, and other caregivers is also a problem, Dr Meleis said. These women healthcare providers do not have a voice; "they are not groomed for leadership, they don't sit on the policy tables, and they are forgotten."

Veronica Magar, DrPh, director for gender, equity, and human rights, World Health Organization (WHO), applauded WHO for having women in 64% of the most senior leadership roles.

Dr Magar said the top vision at WHO is to ensure universal health coverage, and others at the meeting said universal health coverage is important as well.

"Out-of-pocket payment, or health spending, drives more than 100 million people into poverty…universal health coverage has the potential to help women from multiple marginalized groups. We need to ask questions like, 'How far does this burden fall disproportionately on one sex?'" Dr Magar said.

"I think the thing we need to start thinking about in global health is the outrage that all of us should feel…that we're not addressing some of the hardest issues that are women-oriented issues [such as female genital mutilation].... Where are we going with that?" Steve Davis, JD, president and CEO of PATH, Seattle, Washington, said.

"What are we going to do to change the unconscious bias in research, where we're not just disaggregating by gender, but we're actually doing research oriented toward certain cohorts.… Why has there not been a global pledging conference on cervical cancer? It's outrageous that we're still letting women die of cervical cancer just because they're the last ones getting serviced in communities around the world," he added.

Removing Barriers for Women

In addition, women in global health face career obstacles and barriers to leadership, including salary inequity, unconscious gender bias, and sexism.

Glenda Gray, MBBCH, FCPaeds (SA), DSc (honoris causa), the first woman president of the South African Medical Research Council, spoke about what she has done to make the grant funding process more equitable. She said in the past, most funding went to white men in Ivy League universities, and established scientists were more likely to receive funding than early-stage scientists.

"We implemented a systematic review and process to change the way we fund people," Dr Gray said. They created an early-stage and a mid-career scientist program that allow scientists to compete with their peers. "We also looked at adjusting, so if you were an African female scientist, we would adjust some of the baseline points, as well as if you were from a historically disadvantaged institution," Dr Gray explained. "The majority of people that get funding now are black African scientists, and 50% women."

Dr Gray talked about how women often become scientists later in life because they are having babies when they are younger. For this reason, they have changed the cutoff age for women in the early-stage scientist program to allow them to become scientists later in life.

Return on Investment Not an Appropriate Metric

Nancy Snyderman, MD, consulting professor, Stanford Center for Innovation in Global Health, said that some in the private sector use return on investment (ROI) to explore the value of putting women in powerful positions.

"I've always had qualms about talking about the ROI on women. I have never seen anyone asking for ROI on men. I disagree with, and will never support, asking standards of women that for centuries have never been asked of men," Aparna Mehrotra, director, Division for Coordination of the UN system in UN Women, said. Gross domestic product would go up 26% worldwide if women were treated equally and included in an equal way in everything in work and life, she explained. Although it is true that women bring value, women should be valued for who they are as human beings, "not because we are some sort of instrument for some investment business. We're not a business model."

"I don't think that ROI is the way to go about doing this work at all. Rather than approaching from an ROI perspective," Davis said, we should question why this is a problem. "What can we start doing to actually think about changing this?" he said.

Men "Pay a Price" Too

"In a lot of ways, men are giving up a lot without having gender equality," said Gary Darmstadt, MD, associate dean for maternal and child health and professor of neonatal and developmental pediatrics in the Department of Pediatrics at the Stanford University School of Medicine. "We're giving up a lot in terms of opportunity, we're giving up a lot in terms of richness of relationships, we're giving up a lot in terms of the opportunity to bond with our children, to live a fuller life," he explained.

"Men are often boxed into certain stereotypical behaviors, and there's a sense of having to perform, and a sense of having to win, and to compete. I think we pay a price," Dr Darmstadt added.

Advice for Early- to Mid-Career Women

Two lightning round sessions at the day-long conference highlighted early- to mid-career women, who briefly described their work, and throughout the day speakers offered advice for women at the beginning of their careers.

When asked by an audience member how to develop a strategic plan for her career, Sania Nishtar, SI, FRCP, PhD, president, Heartfile, Islamabad, Pakistan, and short-listed nominee for director-general, WHO, said a cardinal rule of planning is to envision an outcome and work backward. "[L]ook at what processes, activities, outputs, and inputs you have to factor in to get there. One of the things I do very diligently is to manage my own strategic plans. Where do I want to be in 5 years' time, how does 1 year factor into that, what am I doing on a monthly basis? I'm very particular about the daily checklists. I do them almost thrice a day because when you're juggling so much, you constantly have to make sure [you don't let things slip through the cracks]," Dr Nishtar explained.

Donna Shalala, PhD, former US Secretary of Health and Human Services and former president of Miami University, Florida, moderated a panel discussion on how to become a change agent in global health.

Over and over, panel members described times when they "failed" at something and how important it is to keep trying. "Failure is incredibly important, and if it occurs earlier in life rather than later, you benefit more from it," Geeta Rao Gupta, PhD, MPhil, senior fellow, United Nations Foundation, said.

Call to Action

The meeting ended with a call to action, asking attendees to commit to working toward gender equity in global health. Tangible actions attendees can take include increasing visibility of women by ensuring gender balance when planning events. The Women Leaders in Global Health Initiative has an event organizer's checklist to help event planners.

Other measurable actions that can help include helping lift women up the ladder by including them in activities such as grant reviews, award nominations, and meetings; advocating for work-life balance; promoting career advancement by reporting on and increasing transparency of data on compensation and salaries; cultivating thought leadership by organizing events to discuss gender equal leadership; and including underrepresented voices, such as the LGBTQI community, people of color, and those with disabilities; and addressing the gender data gap.

Next year's conference will be held November 8 and 9, 2018, at the London School of Hygiene and Tropical Medicine, United Kingdom.

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