Photo: Community Health Workers in Kenya. Credit: Brian-Otieno - Photo: 2022

Advocating for Gender Equality in Universal Health Coverage

By Roopa Dhatt & Samiratou Ouedraogo

Roopa Dhatt is Executive Director and Co-Founder of Women in Global Health. Samiratou Ouedraogo is the Coordinator and Co-Founder of Women in Global Health, Francophone West Africa, Ouagadougou, Burkina Faso.

WASHINGTON DC (IDN) — If there was a Harvey Weinstein in health, we probably wouldn’t know about it. Not because sexual harassment in the health workforce isn’t widespread—we know that it is and not because women don’t want to report their experiences of sexual exploitation, abuse and harassment (SEAH) at work—we know that they do; but because across much of the world’s health systems, there are simply no feasible reporting or legal mechanisms in place that women health workers can use with confidence.

To this day, there are huge gaps in the data about SEAH of women health workers and cases are largely unrecorded and therefore officially invisible. Where studies do exist, they are generally isolated in specific countries with inconsistent and incomplete data, and in many instances not disaggregated by sex. This absence in the evidence and knowledge base on SEAH means that policy action can’t be informed to prevent it.

It is important to ask why data is not collected routinely on an abuse that causes physical and mental harm to health workers delivering essential services?

As a global movement advocating for gender equity in health with women-led chapters in over 45 countries worldwide, we hear directly from women health workers about the lived experience of the daily abuses they face.  Our work has shown that SEAH against women is widespread in global health, even in countries with appropriate laws and policies in place.

In response, Women in Global Health harnessed the power of women’s stories as part of a #HealthToo research project and online platform and have used women’s testimony as data. Our latest policy report, Her Story: Ending Sexual Violence and Harassment of Women Health Workers analyzed stories submitted by women in 40 countries in 10 languages. The stories are harrowing and the findings are compelling.

Women in all parts of the world in the health sector experience work-related SEAH that includes sexualized verbal abuse, sexual assault and rape. SEAH in the health workforce is first and foremost a human rights violation.

It is unwanted and unprovoked by women who are highly trained professionals and just want to be left alone to focus on their work. Women’s stories revealed that their responses varied depending on the type of SEAH and their personal circumstances. There is no ‘right response,’ the report acknowledged, only recognition that the victim is not responsible.

Power imbalance

A major driver of the abuse, the report found, is the power imbalance favouring men in the hierarchical health profession. Men currently occupy 75 per cent of all leadership roles in health, with women clustered into roles accorded lower status and lower pay. Women have less power to speak and more to lose, and this power dynamic creates an enabling environment for SEAH.

Many stories in the report describe sexist behaviour that belittles and demeans women. They reveal that this behaviour is motivated by power differentials and stereotypes of women’s subordinate position, more than it is by sexual desire.

Certain groups of women health workers are at higher rise—trainees, interns, migrant women, women of marginalized races, castes and ethnicities, reinforcing the issue of unequal power dynamics.

Another related theme of the report findings is the problem of unsanctioned serial abusers.  A pattern emerged from the stories of men in higher status positions abusing power to coerce and force female employees into unwanted sexual contact in a cycle of ‘grooming’, threats and retaliation.

This behaviour, states the report, is effectively enabled by ‘silent bystanders’ supporting a patriarchal culture that legitimizes, downplays and perpetuates SEAH against women health workers.

Lack of reporting mechanisms

Most women reporting to #HealthToo did not make an official complaint or report. Without survivor-cantered reporting mechanisms, SEAH is unrecorded and has a cost primarily for the victim, while the perpetrator is enabled to continue the pattern of behaviour. In some places, reporting mechanisms exist but on paper only.

Women do not use them for fear of retaliation, stigma and not being believed.  In many countries, particularly those in the global south, there is no effective employment law and policy to protect women from SEAH.

In a significant number of countries, sexual harassment at work is still not a legal offence. In practice, women don’t have the protection of law and have no form of redress.

From global, to institutional to personal level, the report calls for establishing the legal foundations for gender equality in the workforce and for a culture change so that perpetrators of abuse are reported and sanctioned.

Mental health

The associated trauma and mental health fallout as a result of the SEAH experienced by women health workers was a key aspect of the report findings. Despite the severity of the problem, trauma was found to be downplayed in the health sector and even ‘normalized’.

The stories collected record the very serious trauma of women victims, including post-traumatic stress disorder (PTSD) and suicidal thoughts. Not only does this affect women’s ability to carry out their work, with wider consequences for the provision of quality care, it is also an issue of accountability and responsibility by employers who are failing in their most basic duty of care.

Employers are failing to calculate the costs, human and economic, of protecting a minority who choose to abuse, over protection of the majority of health workers who simply want to exercise their professional duties. The report’s recommendations include instituting a survivor-cantered approach to ensure the rights of women health workers are clear; that they are protected from retaliation and have access to mental and legal support.

Women’s underrepresentation in leadership

The default male bias in health leadership means that women have been locked out of decision-making in helping to address SEAH in the health workforce. #HealthToo received just one report of a woman employee sexually harassed by a senior woman. Put simply, women don’t rape and they rarely sexually abuse and harass other women.

Increasing women’s representation in leadership would allow them to bring their lived experience as women and also their experience working in health systems to the table. Their inclusion would also serve to change the health agenda and reduce cases of SEAH.

Internationally, many countries still lack laws to prohibit work-related sexual harassment. ILO Convention No. 190 (C190) is the first international treaty to recognize the right of everyone to a world of work free from violence and harassment, including gender-based violence and harassment.

It was drawn up by the International Labour Organization (ILO) in wide consultation with workers, employers and women’s organizations, and came into force on June 25, 2021. Countries now have a real opportunity to end SEAH in the health sector and beyond by addressing weaknesses in legal and policy frameworks and definitions.

To date only 23 countries have ratified C190. Prioritizing its ratification would enable all countries to bring their domestic law into line with the convention.

Committing SEAH in the health sector is a choice made by some employees, patients and community members—almost exclusively men. It is a choice they make because they calculate they have impunity, they will get away with it and the costs will fall on their victims.

Decisive action by leaders to end SEAH in health will send a clear signal to these men that the odds have changed. They will be caught and they will be sanctioned. And it will send a clear signal to women, the majority of health workers, that their work is valued and that they will be protected. [IDN-InDepthNews — 21 December 2022]

Photo: Community Health Workers in Kenya. Credit: Brian-Otieno

IDN is the flagship agency of the Non-profit International Press Syndicate.

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