Participation of women in the health workforce in the fragile and conflict-affected countries: a scoping review

Human resources for health (HRH) are central to a quality healthcare system and essential for change and transformation of communities and societies [1‐3]. It is estimated that an additional 18 million health workers are required in low- and middle-income countries (LMIC) by 2030 in order to attain the United Nation’s sustainable development goals (SDGs) and the universal health coverage (UHC) [4]. The World Bank (WB) emphasizes gender equality at all levels to transform the distribution of opportunities, resources, and choices for men and women for sustainable development and women’s empowerment in all sectors [5].

The full participation of women as healthcare providers is recognized globally as critical to favorable outcomes at the individual, household and community, and healthcare system level [1, 6]. Simultaneously, the World Health Organization (WHO) acknowledges that systemic challenges, gender biases, and inequities exist for women in the health and social care workforce globally [2] and that fragile and conflict-affected states/countries (FCASs) have additional pressures that require more attention to overcome the existing gender disparities [2, 7, 8]. Moreover, the global strategy on HRH for 2030, adopted by the World Health Assembly, recommends that countries emerging from conflict adopt holistic approaches to improving health outcomes and broader socio-economic development [2].

The average life expectancy in FCASs is 62.2 years compared to 71.4 years globally; 42% of deaths are due to communicable diseases, maternal and perinatal causes, and malnutrition [9]. The maternal mortality rate (MMR) is varyingly high among FCASs. However, targeted interventions in FCASs [9‐11] have contributed to an overall reduction in MMR from 424 per 100,000 to 236 between 1990 and 2015 [9]. In addition to interventions targeting maternal and child health, it is vital to control modifiable risk factors for non-communicable diseases, like hypertension, notably twice the global average in FCASs [9]. In some FCASs, including Afghanistan, Iraq, Lebanon, and Mali, the dominance of strong patriarchal structures creates additional health challenges for women by prohibiting women to receive care from male providers [10, 12‐16]. In addition, females require permission from male family members to access education and employment in some contexts [7, 12, 15, 17], affecting women’s participation in the health workforce. Thus, women may face difficulty accessing care due to the non-availability of female healthcare providers [13, 14, 17].

Some studies concur on the critical need for a gender-balanced workforce and increased representation of women at all levels, including decision-making levels, in FCASs [1, 2, 7, 14]. In most contexts, women’s employment concentrated in low levels and lower-paid professions such as nursing and midwifery compared to men, who dominate the physician workforce [7]. That said, in some countries, nursing is too dominated by men [18, 19], as is evident in the sex-distributed data from the WHO’s global health observatory (GHO) in Fig. 1a, b [19]. This review seeks to explore the multiple issues affecting gender parity in health workforce participation by summarizing data from various sources from FCASs. It aims to further our understanding of how gender, a key social stratifier, impacts women's participation and career trajectory in the health workforce, particularly in FCASs.

WHO defines gender as “socially constructed roles, behaviors, activities, and attributes that a given society considers appropriate for men and women” [20]. This review focuses on women's participation in the health workforce in FCASs, and considering data presented by GHO, we use the term gender to reference the male and female binary. HRH is used interchangeably with the term health workforce. In order to ensure data consistency across nationally variable terminology and employment categories, we limited our discussion to physicians, nurses, and midwives. These three professions are identified by WHO as professionals based on criteria for education and training, regulation of the professions, and activities and job tasks which are drawn from the International Standard Classification of Occupations and other standards of classifications for social and economic statistics [21]. According to the WB’s harmonized lists for 2018 and 2019, 36 countries or territories [22] are categorized as FCASs based on their financial and security status, meeting the harmonized Country Policy and Institutional Assessment rating of 3.2 or less, and/or the presence of a UN and/or regional peace-keeping or political/peace-building mission during the last three years [9, 22]. Please see “Additional file 2” for the list of these FCASs.

Of the 36 FCASs, we found literature for only 11 countries. More than 80% of identified articles were published after 2014, and in these studies, more than 50% of participants (nurses, physicians and midwives) were female compared to earlier studies, which was less than 50%. The increased representation of females in these studies is indicative of feminization of the health workforce in FCASs and that women are gaining more attention to meet the targets of global goals for UHC and SDGs by 2030 [2, 37, 50]. However, women’s employment remains concentrated in lower-paid occupations such as nursing and midwifery [7, 44, 45, 49, 51, 53, 56] as compared to men who dominate in medicine in most FCASs. Women are less likely to hold a specialty, although they are well represented in pediatrics, general practice, and gynecology. More research is called for to track the impact of the feminization of medicine [50, 55]. Furthermore, decision-making and leadership positions are overwhelmingly occupied by men [1, 7, 16, 47, 51, 55]. These findings are consistent with the gender and equity analysis of the health and social workforce by WHO’s gender equity hub which found widespread adherence to traditional gender norms in HRH [58]. In addition, studies found the lack of women in decision-making positions limited women's voice at policy levels with resultant gender-blind HRH policies [1, 11, 43]. These findings emphasize the need for HRH policies and strategies that take into account gendered socio-cultural norms and gender equity [8, 12, 43].

While nursing remains dominated by women, an interesting pattern of increased representation of men in nursing was observed in several FCASs [16, 19, 48]. While there may be benefits to the professional status of nursing from increased male participation [16, 53], there are concerns that in highly patriarchal societies, male nurses will gain preferential access to senior and leadership positions which in turn could lead to increased migration of female nurses to other countries [56] and professions [16] in FCASs. Therefore, further investigations are suggested to explore the career motivations of male nurses in these FCASs and to determine the maintenance/reproduction of patriarchy in these contexts.

Cultural norms affected the recruitment and mobility of women in the health workforce [7, 17]. Women bear the burden of inequitable gendered expectations and stereotypes from their supervisors (most cases men), such as the beliefs that women are suited to caring behavior while men are equipped to live and travel alone in challenging environments [1, 7]. Studies found that women were required to resign from their jobs and accompany their husband upon relocation [7], while women were discouraged from being accompanied by their family when they assumed a new position [44, 46] creating strained family relations [12, 52]. Similarly, women in the health workforce were penalized for their reproductive role, as male managers perceived that maternal responsibilities negatively affect women's productivity [1, 55]. Contrary to the views of managers, women were found to perceive education and career as a priority; believe they could simultaneously manage family and education [55] and were willing to take on challenges and leadership positions [1]. These findings recommend the creation of gender equitable opportunities for career development in the health workforce [58].

Some sources highlighted that the post-conflict period serves as a window of opportunity to break down gender biases and stereotypes due to renewed political will and to leverage support from international aid and development agencies [7, 11, 36]. Other research highlighted influences by non-state actors, such as NGOs and private sectors attracting and retaining the workers, including females, that negatively affect staffing in governmental institutions [8, 17] and create sustainability issues. Percival et al. [11] highlighted insufficient consultation of national stakeholders by consultants and donors for policy reforms. Despite the availability of resources, donors and consultants were found to narrowly focused on programs and interventions related solely to women's reproductive and sexual health, rather than taking a comprehensive approach to gender mainstreaming in the health system's restructuring, including HRH. These findings suggest consulting relevant national stakeholders, including women, during HRH planning within the FCASs to result in a gender-sensitive health system.

The growing literature in the FCASs revealed that women are over-represented in the HRH in the lower valued professions, mostly in nursing and midwifery. In some instances women have overcome the obstacles to become and remained in the health workforce, in general women struggle to function to their full capacity due to constraints related to professional hierarchies, gendered socio-cultural norms in the family and healthcare system, and security conditions in FCASs. Despite the post-conflict period providing a window of opportunity to break down gender biases and stereotypes in the context of resource availability, most FCASs fail to address gender equity in HRH planning because of the lack of intersectoral collaboration, insufficient consultation with national stakeholders by consultants and donors, and influences by non-state actors. FCASs need a comprehensive approach to gender mainstreaming in restructuring the healthcare system, particularly HRH, rather than a narrow focus on women's reproductive health. Without this, equal participation of women in the health workforce and progress towards achieving the SDG on gender equality by 2030 remains a parable.