The first and longest serving health minister (from 1947 to 57), Rajkumari Amrit Kaur grants India unique bragging rights for the distinction of having the first female health minister worldwide. As members of the Women in Global Health (WGH) India chapter striving for greater representation and influence of women in health leadership, we take inspiration from this promising beginning. Although there have been occasional spikes in women's leadership, that has not been the case specifically for nurses and midwives in health policymaking, despite being celebrated as key primary health care providers of India. This has also not occurred frequently enough to be normalised or transform into nurses and midwives-led; and women-led development to have a significant impact, as has been vouched under the G20 tagline. The men-only-panels at the recent 76th World Health Assembly, the medical-men only panels at numerous platforms and the midwife-excluded Indian panels about midwifery at the 33rd International Confederation of Midwives' triennial congress, are glaring examples of this reality.
The upcoming G20 meeting in India presents a unique opportunity for the country to further cement its global health leadership record and pave the way internationally to advance the gender equality agenda. This could serve as a timely break in history, given the urgent need to address the inequalities that COVID-19 pandemic has exacerbated globally and inequitably across the intersections of sex, gender, race, and socioeconomic status, to name a few. The consequences have been far reaching, particularly the impact of wage loss and the growing instances of unpaid domestic and care work which falls disproportionately on women serving as midwives and nurses.
In India, the gendered impact of the pandemic is starkly evident across the various stages of women's lives, including the toll it has taken on their health and rights (sexual, reproductive, and maternal). The COVID-19 pandemic resulted in increase in domestic violence by 2.5 times, 17% lower rate of vaccination for COVID-19 for women, as compared to men and resulted in an estimated 2.4 million unintended pregnancies.1,2 Across global health, WGH data reveals that 75% of the global health and care workforce are women, mostly midwives and nurses, delivering the bulk of health programs on the ground, and yet they hold just one-quarter of the decision-making roles.3 A UNWOMEN article also suggested that only 13% of the COVID-19 related taskforces consisted of women even though 80% of the health workforce in India is of nurses and midwives.1 The state of West Bengal, for instance, presents a commendable governance structure for nursing, although it does not have a director of nursing to lead the profession. The midwifery systems and structures are experiencing regression due to the lack of attention and focus to midwifery and midwives in the draft National Nursing and Midwifery Bill 2020.4 This is a crucial regulatory policy document for both midwifery and nursing was passed in August 2023 at the parliament.
In the area of health policymaking and governance, men, both medical and non-medical, dominate leadership positions,5 while women remain clustered into cadres accorded lower status and lower pay, such as Accredited Social Health Activists (ASHA), Auxiliary Nurse Midwives (ANMs), nurses-midwives, midwives, and nurses.6 This is the reality for the majority of female workforce in India, despite recent accolades at the 75th World Health Assembly (WHA) awarded to ASHA workers, who were recognised as global health leaders for their role in the pandemic response.7 The ongoing marginalisation of women's leadership even after they have proven their expertise underscores the importance of organizations like WGH and ANSWERS who work to advocate for gender equity and accountability, and demand action from global health leaders.
In recent years, we have worked hard to encourage nurses' and midwives’ participation and leadership in health systems delivery, governance, and policymaking. We have done this through our participation in WHO Assembly sessions and global health conferences, our recognition of outstanding women during the annual Heroines of Health awards, and our recognition of nursing and midwifery leaders in the year of the nurse and the midwife (YONM) 2020. All our work is focused on challenging power and privilege in global health and bringing pressure to bear on holding leaders accountable to their gender equity commitments.
Championing the vision of its global counterparts, WGH India and Academy for Nursing Studies and Women's Empowerment Research Studies (ANSWERS) have been working to advance the gender transformative agenda through a range of advocacy efforts with grassroots and community leaders from various cadres. This includes working with ASHAs, ANMs, nurses, midwives, self-help group leaders, elected women representatives, and other allied health and care professionals. The WGH India chapter has engaged stakeholders at various levels, from grassroots to policy. This has included initiatives such as organising the Frontline Workers (FLW) Dialogue Series and Community Health Worker Evidence Webinar Series to create platforms for discussion in collaboration with ANSWERS in 2021. WGH India has also released a demand charter for FLWs ahead of Union Budget announcements and have written advocacy briefs demanding new social contracts for FLWs.
Drawing on this extensive groundwork, we identified three priority areas that require commitment, action, and investments at the G20 summit to advance the gender equality and equity agenda.
Priority 1: health care workforce-safety, dignity & fair pay
Protect and empower women health and care workers, as essential actors in health systems and global health security. This can be achieved by (a) increasing the proportion of women in leadership roles in health at all levels; (b) protecting women health workers from harassment and violence in the workplace through the ratification of ILO190; and (c) ensuring safe and decent working conditions for all health workers, everywhere, through investments in gender-responsive policies that take into account the specific needs of different groups of health workers. This is a crucial step to create compassionate work and team cultures.
Priority 2: women's participation in their sexual, reproductive, and maternal health and rights-based decision making supported by midwives and nurses
Women should be the key stakeholders as care seekers, in the decisions for their health and rights, and midwives and nurses are best positioned and qualified to care, support and advocate for them. This has been denied to women consequently leading to measures such as meagre incentives for over-medicalised care experiences in under-resourced health care delivery systems to increasing evidence on obstetric violence (a form of gender-based violence in obstetric settings). In general, women's participation in their social, economic, and health-based decision-making is the most crucial aspect of ‘nothing about us, without us’ narrative in all sectors. Midwives educated to international standards can meet up to 90% of the care needs.8 Midwifery implementation needs to be prioritised as an important strategy to substantially reduce maternal (67%), neonatal deaths (64%) and stillbirths (65%) and save 4.3 million lives annually by 2035.9
Priority 3: midwifery and nursing leadership in health governance and policy making to aid universal health coverage and improve healthcare service delivery
Ensure women's and women health care worker's leadership, such as midwives and nurses and other community health leaders such as ANMs and ASHAs, in health workforce governance and health service delivery and policy making spaces. Actions for gender transformative leadership should start at the pre-service education for medical, midwifery, nursing, to create an enabling environment by sowing the seeds of equity among health professionals early on. They must be engaged in the conceptualisation and implementation of policies on education, regulation, and workforce governance for their own professions, to ensure better and compassionate health care delivery in partnership.
In conclusion, while it is fitting that a leading nursing institute in Delhi was named after Rajkumari Amrit Kaur, the RAK college of Nursing established in 1946, it is appalling that nurses and midwives continue to be side-lined from global health policy making. We strongly encourage G20 summit in India to focus on our recommended priority areas, which would advance the gender equity agenda for nurses, midwives, and women as key leaders in global health.
Contributors
KM and DS: conceptualisation, literature search, writing–original draft and revision. SN: writing–revision.
Declaration of interests
None.
References
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