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1. News & Views
2. Strengthening systems...
3. Strengthening systems of accountability for women’s leadership in the health
sector

CCBY Open access

Analysis Gender Equality in the Health Workforce

STRENGTHENING SYSTEMS OF ACCOUNTABILITY FOR WOMEN’S LEADERSHIP IN THE HEALTH
SECTOR

BMJ 2024; 386 doi: https://doi.org/10.1136/bmj-2023-078960 (Published 17 July
2024) Cite this as: BMJ 2024;386:e078960

READ THE COLLECTION: GENDER EQUALITY IN THE HEALTH WORKFORCE

* Article
* Related content
* Metrics
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* Peer review
*

1. Kent Buse, co-chief executive1 2,
2. Harvy Joy Liwanag, postdoctoral research fellow3,
3. Aaron Koay, research officer14,
4. Sapna Kedia, assistant director, gender and social development5,
5. Sylvia Kiwuwa-Muyingo, research scientist6,
6. Soon-Young Yoon, representative to the UN7,
7. Sarah Hawkes, co-chief executive1 4

Author affiliations

1. 1Global Health 50/50, Cambridge, UK
2. 2Healthier Societies Program, George Institute for Global Health, Imperial
College London, London, UK
3. 3Institute of Social and Preventive Medicine, University of Bern, Bern,
Switzerland
4. 4Institute for Global Health, University College London, London, UK
5. 5International Center for Research on Alliance of Women, New Delhi, India
6. 6African Population and Health Research Center, Nairobi, Kenya
7. 7International Alliance of Women, New York, USA

1. Correspondence to: K Buse kent.buse@globalhealth5050.org

Accountability can improve equal opportunities for women’s career progression
and it must be strengthened in the health sector, argue Kent Buse and colleagues

People working in health sectors are generally familiar with the concept of
accountability for standards and quality in delivery of care.1 This means that
individuals and organisations are compelled to take responsibility for their
actions and inactions. Mechanisms for accountability can include clinical
audits, professional training requirements, and ultimately public scrutiny under
the auspices of public inquiries, courts, or parliamentary review.2 In this
analysis, we move beyond the question of accountability for healthcare delivery
and explore accountability for equality of opportunity in health sector careers,
with a focus on women’s leadership. We use a broad definition of the health
sector to include public and private health organisations beyond those directly
delivering care.

At the top of the sector’s leadership pyramids, large inequities exist in the
demographic profiles of leaders. Just 44 women were among 194 ministers of
health in 20203; a mere 10.4% of US Fortune 500 healthcare companies had a
female chief executive in 20234; and only 17 (<1%) of 2014 board members across
146 global organisations active in health are women from low income countries.5
These inequities persist despite multiple commitments and much advocacy for
health workforces to be more equitable.6 For example, target 5.5 in the UN
sustainable development goals (SDGs) commits 193 signatory countries to
“Ensuring women’s full and effective participation and equal opportunities for
leadership at all levels of decision-making.” The political declarations of the
high level meetings on universal health coverage7 and that of the 25th
anniversary of the fourth world conference on women,8 are among many other
commitments to increasing women’s leadership.

Our analysis, part of a BMJ collection on gender equality in the health
workforce,9101112 focuses on India and Kenya and uses a rights based framework
to assess accountability (box 1). We chose these countries because they are of
particular interest to the funder of our commissioned research, but the
performance of and insights from India and Kenya have lessons for other settings
wishing to improve accountability for women’s leadership. Our examples highlight
how accountability has been used to promote equal opportunities for women’s
careers and how it could be used to further their progress to formal leadership,
including in the health sector.

Box 1

PRINCIPLES OF ACCOUNTABILITY13

* An agency is responsible for reporting performance information in the public
domain (ie, transparency)

* Progress towards targets is independently reviewed

* Remedial actions enforced in cases of failure to meet obligations

RETURN TO TEXT

INTERNATIONAL AGREEMENTS AS PATHS TO STATE ACCOUNTABILITY

Several international mechanisms are available to drive accountability for
women’s leadership such as the International Labour Organisation (ILO)
tribunals, and the United Nations (UN) human rights special rapporteurs.
However, the principal international treaty mechanism concerning women’s rights
is the Convention on the Elimination of All Forms of Discrimination Against
Women (CEDAW).14 It was adopted by the UN General Assembly in 1979 and ratified
by 189 of the 193 member states.15 State parties to CEDAW have committed to
enshrine gender equality in their domestic laws and implement special measures
to accelerate substantive equality in the workplace including legislation
governing equal pay, workplace protections, pensions, flexible working and
work-life balance, among other domains.

State parties are required to report every four years to the independent CEDAW
committee of experts, which evaluates countries’ progress in upholding their
treaty obligations.16 The latest available reports from India (2012-13) and
Kenya (2016) show that both have assigned responsibility to an agency (National
Commission for Women in India, Gender and Equalities Commission in Kenya) to
report information and go through a process of independent review. The countries
therefore meet two of the three principles of accountability (box 1).

CEDAW’s final recommendations in response to state reports include concerns
raised in shadow reports submitted by civil society organisations (CSOs). Such
submissions could therefore help heighten awareness of women’s leadership.
Shadow reports have previously been used to highlight women’s concerns in
tobacco control,17 and CSO advocacy campaigns have supported the adoption of
CEDAW principles in the development of local government ordinances and
policies.18 At least 12 Kenyan CSOs submitted shadow reports in 2016, which
could help bolster the accountability of the government. No shadow reports were
submitted during India’s last review in 2012-13.

Both countries address CEDAW obligations through a range of domestic
legislation, including enshrinement of gender equality in their constitutions
and the adoption of legal efforts that set a one third quota for women’s
representation in political leadership and government service. Challenges,
however, remain. The CEDAW committee has highlighted problems such as the
absence of a comprehensive national law in India that localises its
international obligations, and the discretion of Kenya’s parliament not to
implement CEDAW provisions that contradict local customs and beliefs.19 In both
countries the absence of remedial action exposes the limits of the CEDAW
process, which is vague on the extent it is able to compel governments to act.20
For example, India has failed to respond to issues raised by the CEDAW committee
in its last report despite two reminder letters from the CEDAW rapporteur.21

ACCOUNTABILITY THROUGH SUSTAINABLE DEVELOPMENT GOAL REVIEWS

Another mechanism for increasing women’s leadership is the high level political
forum (HLPF) on sustainable development, which reviews progress towards the
SDGs.22 Integrated into the HLPF are voluntary national reviews, which are meant
to be country led, transparent, participatory, people centred, and with a focus
on people left furthest behind.23 Unlike CEDAW, participation in the HLPF is
voluntary, and responsibility for reporting does not necessarily lie with an
authority that holds a specific mandate for gender equality.

The voluntary national reviews synthesis report for 202224 reviewed progress
towards SDG target 5.5 (women’s full and effective participation and equal
opportunities for leadership) in 44 countries but did not include India and
Kenya, which each reported in both 2017 and 2020. While progress was reported in
some areas (eg, in political leadership in 10 countries), the synthesis report
did not explicitly describe progress on the proportion of women in managerial
positions (indicator 5.5.2). Only 86 countries have reported on this indicator
since 2015, and neither India nor Kenya have reported.25 As with CEDAW, the HLPF
system is transparent but not independent. Furthermore, the HLPF process is
vague about the consequences of states not submitting reports, and there do not
seem to be any penalties for states not reporting or failing to make progress on
these targets.

ORGANISATIONAL ACCOUNTABILITY FOR WOMEN’S CAREER PROGRESSION

State led measures to respect, protect, and fulfil rights to gender equality,
including in the workplace, are fundamental to human rights, including that of
non-discrimination. In addition, employers can have critical roles in creating
conditions for career equality and supporting women’s leadership, particularly
when employer actions specifically acknowledge and address their underlying
“inequality regimes.”26 Other articles in this BMJ collection identify the
multiple levels across societies that drive workplace inequalities,1112 and the
importance of more targeted policy interventions at the level of organisations
and employers to promote career equality.9 Our research in India and Kenya finds
that employment inequalities are reinforced through entrenched patriarchal norms
that persist in many health workplaces and which perpetuate gendered
occupational segregation, devalue professions that predominantly comprise women
(eg, nursing), and embed biases and discrimination that perceive men (not women)
as leaders.12

More globally, a systematic review of interventions to advance women in
healthcare leadership described five categories of effective actions that
organisations can take to promote equality: organisational processes (eg,
supporting flexible working); awareness and engagement (eg, increasing male
allyship); mentoring and networking (eg, peer support for women); leadership
development (eg, encouraging women to apply for leadership roles); and tools
aiming to reduce inequalities in recruitment, retention, and promotion and for
measurement and evaluation (eg, evaluation of organisational culture).27 The
authors of the systematic review note that “leadership commitment and
accountability were critical in championing these policies and practices,”
although the exact mechanisms of accountability were not detailed.27 Various
approaches can be taken to monitor organisational progress and ensure remedial
action when required (box 1).

MONITORING

Five broad monitoring approaches could be expanded to encompass performance on
efforts leading to gender equality in the workplace. The first concerns scrutiny
of organisational performance. For example, in fulfilling its diversity,
equality, inclusion, and belonging policy, Population Services International
routinely assesses the gender diversity of its leadership and shares the data
with its employees and board.28 Second, annual reporting of environment,
sustainability, and governance (ESG) by many private sector companies includes a
focus on gender diversity, inclusion, and pay equity among executive officers
and corporate boards. Data from 2023 found that 99% of US companies in the
Standard and Poor 500 index (including healthcare sector companies) report ESG,
and 40% report on diversity and inclusion.29 Efforts are underway to make such
reporting mandatory in several jurisdictions.30

Third, external accreditation for progress towards gender equality occurs
through charter mark type initiatives that cover issues related to workplace
culture and practice. For example, the Athena Swan Charter promotes gender
equality in higher education and research careers in the UK.31 Such charter
marks serve to monitor progress towards specific equality goals and also apply a
level of conditionality in resource access; expanding this approach to the
health sector could be considered. Fourth, independent monitoring related to
gender equality within organisations is provided by organisations such as ours,
Global Health 50/50. Although lacking the power to enforce remedial action, we
aim with this independent mechanism to encourage organisational change towards
fairer working practices, which we have documented in numerous organisations.32
Fifth, in many workplaces, monitoring and advocacy by labour unions or staff
associations could serve to enhance accountability for equality in leadership.
For example, the UNAIDS Staff Association has a working group that seeks to hold
the organisation accountable for implementing its gender action plan.33

REMEDIAL ACTION

Several mechanisms oriented towards remedial action have been used successfully
to encourage accountability, including litigation and collective action. For
instance, in 2005, around 1500 women workers in the UK’s National Health Service
won an employment tribunal on the grounds of pay discrimination.34 Broader
collective action can also drive corporate action on gender equality in the
workplace. In 2023, the Africa Women Journalism Project launched a campaign
challenging Kenyan companies to publish their gender pay gaps to accelerate
progress on the country’s equal pay law.35

TOWARDS STRONGER SYSTEMS OF GLOBAL AND ORGANISATIONAL ACCOUNTABILITY

The health sector, characterised by a female dominant workforce but with men
dominating leadership, has not delivered on either legally mandated or voluntary
commitments to equality of career opportunity including in leadership. Change is
occurring,36 but slowly. Establishing and strengthening accountability
mechanisms offers an additional route towards hastening change.

Monitoring in international and organisational systems of accountability is
currently piecemeal, resulting in incomplete pictures of whether and what
progress is being made. This could be improved, for example, by mandating states
to report national progress (or lack thereof) in global accountability
mechanisms. There is also a deficit of clear avenues for remedial action.
Understanding what works to strengthen systems of accountability at global and
organisational levels is currently limited by a relative absence of evidence and
more systematic evaluation is needed.

The potential of using CEDAW or HLPF mechanisms to hold employers, including
those in the health sector, to account for their commitments to equality in
women’s leadership is not being realised. This may be the result of lack of
awareness among health sector stakeholders of these mechanisms, a deficit of
gender disaggregated workforce, and leadership data, and the absence of
authoritative remedial actions. For CEDAW, stakeholders in the health sector
could use three routes to enhance equitable leadership: advocating that state
reporting to CEDAW includes provisions that explicitly support women’s equal
leadership, including disaggregated by sector; encouraging CSOs to ensure
women’s leadership is included in shadow reports; and making use of the optional
protocol,37 which provides a mechanism for the CEDAW committee to hear
individual complaints about violations of the treaty. The optional protocol has
so far been used to investigate 11 cases against countries on domestic violence,
parental leave, and forced sterilisation.38 The protocol could also serve to
sanction countries where there is systematic discrimination against women in
assuming leadership roles.

HLPF reporting could be enhanced by ensuring countries meet their obligations to
collect and report data on the proportion of women in managerial positions,
including disaggregated by sector (eg, health, education, finance, law, etc).
These data should be included in the synthesis reports of voluntary national
reviews, together with relevant findings from CEDAW reports. Health sector
organisations should also engage with CSOs that produce independent reports on
SDG progress to include issues related to workplace equality in their reports.

Collective action, including through litigation at the organisational level, is
a powerful lever, but it is an expensive and time consuming route for many
employees. Holding health sector employers to account through a performance
related charter mark system may be a more feasible and affordable alternative
for system-wide change, and a charter mark should be developed for health sector
workforces globally.

Commitments for a more equitable workplaces are little more than empty
rhetorical statements without systems of accountability. The struggle to
facilitate women’s leadership needs disruption. More systematically
strengthening systems of accountability can provide that disruption. But we
should not overlook the argument that equality in career opportunities
(including leadership) is a starting point.10 What we also need are the types of
leaders who will deliver system-wide transformational change—in other words,
efforts to promote a model of feminist leadership that eliminates systemic and
overlapping inequalities among all people working in health sectors and promotes
social justice.

KEY MESSAGES

* Most governments and many organisations working in the health sector have
committed to gender equality through numerous international agreements and
calls to action

* Nevertheless progress falls short of substantive equality in leadership
opportunities for women

* Laws and organisational policies represent potentially critical levers for
change but are ineffective without accountability mechanisms to ensure their
implementation

* Monitoring of progress is largely voluntary and lacks independence while
mechanisms to ensure remedial action are lacking

* Mandatory reporting on women’s representation and a global charter mark
system are among several actions we identify which could help hold countries
and health sector organisations to account for gender equality

FOOTNOTES

* Contributors and sources: This article builds on two decades of research and
practice in global governance for health, including on soft law and
accountability by KB and on research and practice by SH and KB on gender and
health, including over the past seven years as co-founders and co-chief
executives of Global Health 50/50, a research-cum-advocacy, not-for-profit
organisation that seeks to enhance accountability for gender equality in
health. KB is a former staff member of UNAIDS, and member of its staff
association. HJL, AK, and SYS contributed insights to article development,
drawing on their expertise and experience in health systems research in low
and middle income countries in Asia (HJL), gender and health research (AK)
and advocacy and engagement for women’s rights in the United Nations system
(SYS). KB and SH led the framing of the analysis and drafting of the article
with HJL and AK co-writing different sections. SK, SKM, and SYS advised and
reviewed the draft and revisions. All authors approve the final submission.
KB is the guarantor.

* Competing interests: We have read and understood BMJ policy on declaration of
interests and have the following interests to declare: KB and SH are co-chief
executives of Global Health 50/50. AK works for Global Health 50/50.

* Provenance and peer review: Commissioned; externally peer reviewed.

* This article is part of the BMJ collection on gender equality in the health
workforce, developed in partnership with Global Health 50/50, Africa
Population and Health Research Centre, and International Center for Research
on Women, and funded by the Bill & Melinda Gates Foundation (INV-031372). The
BMJ commissioned, peer reviewed, edited, and made the decision to publish
these articles. The lead editors were Seye Abimbola, Jocalyn Clark, and Emma
Veitch for BMJ Global Health and The BMJ.

http://creativecommons.org/licenses/by/4.0/

This is an Open Access article distributed in accordance with the terms of the
Creative Commons Attribution (CC BY 4.0) license, which permits others to
distribute, remix, adapt and build upon this work, for commercial use, provided
the original work is properly cited. See:
http://creativecommons.org/licenses/by/4.0/.

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Kent Buse co-chief executive, Harvy Joy Liwanag postdoctoral research fellow,
Aaron Koay research officer, Sapna Kedia assistant director, gender and
social development, Sylvia Kiwuwa-Muyingo research scientist, Soon-Young Yoon
representative to the UN et al
Buse K, Liwanag H J, Koay A, Kedia S, Kiwuwa-Muyingo S, Yoon S et al.
Strengthening systems of accountability for women’s leadership in the health
sector BMJ 2024; 386 :e078960 doi:10.1136/bmj-2023-078960

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Form analysis
5 forms found in the DOM