Corinne Farrell recently sat down with Constance Newman, IntraHealth’s senior team leader for gender equality and health and a committed advocate for social justice, to discuss this year’s International Women’s Day theme of “connecting girls and inspiring futures.”

Asked how the International Women’s Day theme, Connecting girls, inspiring futures, relates to IntraHealth’s mission of empowering and supporting health workers, Constance Newman did not hesitate:  “It’s about connecting girls to school and protecting women’s ties to the paid health workforce.”

Fifty-seven countries are experiencing crisis-level shortages of health workers. In many of these countries, health workers are predominantly female, particularly nurses, midwives, and community health workers. Many health workforce leaders question whether gender issues, such as discrimination, are really among the most pressing issues contributing to health workforce shortages. Based on her 25 years of experience, observation, reading, and research in global health and the health workforce, Newman feels the urgency to document the evidence that will put these questions to rest and stimulate action. “If you don’t have women entering the paid health workforce, and if they aren’t safe, secure, and satisfied in their jobs, you are not going to have the workforce that you need—one that’s diverse and robust enough to meet the health challenges in these countries.”

Barriers for girls, experienced throughout their life cycle, from primary school through recruitment to and retention in the health sector, she says, are preventing countries from producing, hiring, and retaining enough health workers to meet their populations’ needs.

Newman’s office is packed with books and reports, and it only takes a few minutes to realize that she’s read and absorbed every one. Seeking out research and sharing her own come as naturally to her as breathing; integrating research into action is non-negotiable.

Connecting Girls to School

Newman showed me an enlarged photograph of a roadmap hanging on the wall, developed for a gender and health workforce sensitization workshop with staff in Tanzania that illustrates one of the biggest challenges affecting women’s participation in the health workforce: societal discrimination against girls. The roadmap symbolizes the path to employment in the health sector. The path starts in primary school, moves on to secondary and tertiary schools, and then into the paid workforce.

For boys, the path is mostly clear; for girls, however, it’s riddled with “pot holes,” the barriers that hold girls back at every stage and ultimately make it harder for women to become paid health workers. Newman said:

During primary school, girls are doing household chores—and boys are doing their homework. Girls are tasked with gathering firewood, taking care of children, and tending to sick people; they aren’t able to function as students once they get home, while boys are doing their homework and passing exams. Sexual harassment and abuse can also start early in schools, and families might object to girls attending. As girls venture along the ‘path’ there are other things, including pregnancy, perhaps unplanned, and marriage, that tend to pull women and girls out of school and off the path to paid work. If she is pregnant, a girl may be expelled from school. Once she has delivered, institutional policies or practice may make it hard for a girl to easily resume schooling. And these things at some point come to bear on the health worker pipeline. The boys are moving along the path, and the girls are falling off—facing the kinds of discriminatory expectations practices that seem to go along with being born female.

Ties to the Paid Health Workforce

If a girl is lucky enough to finish her education, there will be more “pot holes” on the path to a meaningful career in health. Newman and colleagues in Kenya, Uganda, Tanzania, and Zambia have begun to document evidence of women’s marginalization in the paid health workforce, especially at higher levels of management and decision-making. They are implementing a new gender discrimination and inequality analysis methodology and are documenting how gender issues, including pregnancy and caregiver discrimination, sexual harassment, and occupational segregation are affecting health students and workers.

“What I do is help decision-makers and leaders at all levels become aware of these challenges,” said Newman. “Knowing that gender issues affect the health workforce is one thing. Getting decision-makers on board to take action requires evidence and activism.”

Newman emphasizes the need to routinely collect gender data about the health workforce. Gender blindness in the governance of the health workforce, she says, is a huge problem. Being able to disaggregate data by gender is crucial. A recent analysis of health workforce data from Kenya—presented by Newman’s colleagues at the National Human Resources for Health Conference in Nairobi—showed strikingly disproportionate percentages of men in the jobs with the highest pay and a faster track to promotion for male nurses compared to females. In other, more disturbing findings published in World Health and Population, Newman and her co-authors revealed eye-opening gender inequalities in the health education system in Kenya, including “sex-engineered grades”—favorable exam grades given to female students only in exchange for sexual favors. Newman will be working with colleagues in Kenya to assist the Kenya Medical Training College to formulate a code of conduct that prohibits sexual harassment.  

Producing and presenting evidence, Newman said, “is not a walk in the park by any means because discrimination is normalized. Further, sexual harassment and affirmative action are issues of contention in some settings.” Documentation is only the first step. Newman recommends working with advocacy groups like national nursing associations to empower them with this kind of information. “Information is nothing unless there is some sort of activism attached to it,” she said. “When you think about how discrimination is normalized, and the fact that people aren’t bothered by it, it’s a big challenge.” 

The challenge is compounded by the fundamental changes Newman thinks are necessary to address these issues. She said:

Schools and workplaces are not structured to accommodate reproduction and family responsibilities. This is true for men as well as for women, but these responsibilities fall mainly to women. Men can function as what is called the ‘ideal worker,’ someone who is expected to be available for the job 100% of the time, can travel wherever the job sends him, and so forth. It’s very hard for women to do that, given their reproductive roles and family responsibilities. So if the health sector is to attract and retain a strong, committed  health workforce , then schools and workplaces need to be structured to support women and men as they respond to the demands of the human life cycle and participate in paid work.

Newman is a pioneer in the field of gender equality applied to the health workforce in developing countries, but she downplays her groundbreaking work. “It’s not like I’m creating anything new. There is a lot of information out there that has been documented, even 40 years ago, and it just needs to be applied. I look at these issues as social justice issues. It just happens to be applied to the health workforce.”

“My hope for the future,” Newman said, “is that this research will bring more interest in and funding for this kind of inquiry and activism in the health workforce. This work isn’t easy, and these are serious issues, but I am optimistic.”