‘The XX Paradox’: Women dominate health work, but denied leadership roles

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MANILA, Philippines—Over the last five years, women in the health sector have remained underrepresented and denied leadership roles globally due to persisting cultural gender norms, discrimination, and ineffectual policies.

According to non-government organization (NGO) Women in Global Health (WGH), across the globe, women hold 70 percent of health worker jobs, including over 80 percent of nursing jobs and 90 percent of midwifery roles.

At least 5 billion people benefit from the health services and care provided by women in the health sector. Women are estimated to contribute $3 trillion annually to global health, “half in the form of unpaid work.”

Unfortunately, despite their massive contribution to the health sector, only a few women are able to secure senior leadership roles.

In a report titled “The State of Women and Leadership in Global Health,” WGH detailed the huge gender gaps in global health leadership and the possible ways to address the issue.

‘The XX Paradox’

While women represent more than half of the global health force, only 25 percent hold leadership roles. In contrast, men—who represent less than 30 percent of the health workforce—hold 75 percent of leadership roles.

“If leadership roles were allocated proportionally (assuming that women and men have equal merit) then, since women are 70% of health workers, 70% of health sector leaders would be women. This is the opposite of the current situation,” WGH explained.

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“The default health worker is a woman, and the default health leader should be too. This is the ‘XX Paradox’ that we seek to explain,” the organization added.

WGH saw that over the past five years, the proportion of Fortune 500 healthcare companies led by women rose from 5 percent to 12 percent. However, the number of female ministers of health dropped from 31 percent to 25 percent.

The analysis also showed that the proportion of World Health Assembly (WHA) delegations led by women has fallen from 27 percent to 23 percent between 2018 and 2022.

In the last seven decades, 83 percent of delegations to the WHA were mainly composed of men, and no WHA had more than 30 percent of women chief delegates.

“A patriarchal culture, which assigns leadership to men and domestic chores to women, restricts female workforce participation. Women also experience a ‘motherhood penalty’,” WGH stressed.

“This refers to the discrimination encountered by working mothers such as lower perceived commitment, higher professional expectations, and lower recommended salaries,” it continued.

Moreover, women leaders are still “labeled ‘too emotional’ for empathetic leadership styles, yet ‘bossy’ for exhibiting stereotypically male leadership traits (assertiveness, ambition, drive).”

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These stereotypes, WGH emphasized, greatly impact women’s potential leadership journeys.

Gender equity: Better health for all

Previous studies showed that women in politics prioritize social welfare policy, family policy, and gender equality issues.

WGH noted that increasing the number of women who hold leadership positions in global health could help further give greater priority to issues such as sexual and reproductive health that affect women and contribute to gender inequalities.

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“Gender equity in leadership will lead to better health for all. When women enter leadership, their professional expertise and perspectives strengthen health systems and health delivery,” the organization said.

“As more women enter leadership and formal jobs in the health sector, women health workers will gain income and autonomy, benefiting families,” it added.

Equal leadership for women in the health sector could also lead to a much wider “triple gender dividend”—which consists of health dividend, gender dividend, and economic and social dividend.

The triple gender dividend explains that enabling women to enter leadership in the health sector could result in an overall stronger foundation for health systems and support the achievement of global health goals such as universal health coverage.

Allowing more women to secure leadership roles in the health sector could also help more women in the sector gain income and autonomy, which will benefit families. Ultimately, “a gender-equal health workforce has positive impacts for everyone.”

Addressing women’s underrepresentation

Based on its analysis of the experiences and struggles for leadership of women in health sectors from India, Kenya, and Nigeria—including the global context—the WGH listed recommendations for addressing the “XX Paradox” of women’s underrepresentation in health leadership.

These were:

• Enable diverse women to lead.
• Fast track actions to redress gender inequality in global health leadership.
• Increase the visibility of women working in health.
• Mobilize men to lean out and step up as allies, and end ‘male bonus syndrome.’
• End the ‘default man’ bias; prioritize implementation of and accountability for policies that support women’s lives.
• Support women’s movements to accelerate collective action.
• Deepen understanding and the evidence base for policy with more research and data.

“The answer is not to ‘fix women’ to fit into workplace systems and cultures that favor men for leadership—male bonus syndrome—but to fix the systemic bias that creates barriers for women,” said WGH.

“Without urgent action, another generation of women in the health sector will be disadvantaged in their careers.”

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