News Excerpt:

Official data suggests that women constitute almost half of India’s health workers. Yet, only 18% of them reach the top of the pyramid, reaching leadership positions across health panels, committees, hospitals, colleges and ministries.

Key findings of the study:

• The cone of the pyramid has an “over-concentration” of not just men but of doctors, individuals from Delhi-NCR, and bureaucrats, according to a new analysis of India’s National Health Committees between 1943 and 2020. 
• The over-representation of privileged actors and lack of diversity indicates a “centralisation” of the health policy. 
  • This constitutes a very middle-class or an upper-middle-class elite set of policymakers, making decisions for 70% of people whose lives they don’t understand.
• Only 11% of women were present in 23 health committees, and no woman was present in 36% of the committees studied.
  • For instance, the Devi Shetty Committee was formed for the Prevention and Management of COVID-19 Third Wave in 2021. 
  • The committee was primarily led by male clinicians, lacking the diverse expertise needed to tackle a global health crisis. 
  • Initially comprising only men, the committee added two women after facing criticism. 
• As per the Lancet journal paper, only one woman has been out of the 16 All India Institute of Medical Sciences, New Delhi directors.
  • Only three women executive directors of the 18 new AIIMS proposed by the Ministry of Health and Family Welfare.
• The health system in India is designed in a way that women are concentrated at the frontline low-paid positions at the lower end of the hierarchy and find limited opportunities to climb the ladder. 
  • Women comprise 29% of doctors, 80% of the nursing staff, and nearly 100% of Accredited Social Health Activists (ASHAs) in the country. 
  • Moreover, their job is classified as ‘care work’, which is not technical enough, further devaluing their knowledge. 
  • Women across the workforce, on average, earn 34% less than men, according to another report by Dasra NGO.
• The National Sample Survey Office found that around 31% of women with medical education in 2018 were out of work because they were engaged with household tasks.
• The trend reflects globally: 70% of CEOs and board chairs across 201 global health organisations were men, and just 5% of leaders were women from low- and middle-income countries. 
• A report from Women in Global Health found women occupy only 25% of senior positions and 5% of leadership roles in the healthcare sector despite making up 70% of the overall global health workforce.
• The present study noted that post-2000, committees are getting more diverse, including women, NGOs and non-medical academia. 
  • At the same time, centralisation has increased, too, from 53% before 2000 to 83% in recent years.
• The research pointed out that doctors often reach executive leadership roles “based on seniority without ever receiving formal management training”.

Unique challenges in India’s health policy approaches:

• India is unique on two accounts: medical leadership is concentrated in Delhi-NCR (with almost half of the members present there), and there is a high degree of influence from doctors and government officials. 
• The hilly areas of the North-Eastern states have very low representation in the committees, while the metropolitan cities are disproportionately represented. 
• Different places arguably have different needs: a public health centre in Bastar or the northeast differs greatly from one in Delhi or Chennai. 
• From the Central Government, there is a “top-down” approach and an insistence on applying a “uniform pattern”. 
• For instance, the policy on ambulance services - in some parts of the country where ambulance buses don’t work, you might need a boat, or a person may need another mode of conveyance to connect them from the village to a road. 

Way forward:

• If power is concentrated in circles - with gender, geography and socio-economic markers at their compass - it risks creating skewed health systems ridden with inequality.
• With a more equitable representation from stakeholders, “the policy, program and implementation will all be different, and the outcomes will be much better. 
• The committees may have well-meaning people, but if these are all upper-caste, privileged men based in urban areas, it hinders the degree of detail, care, and attention needed for inclusive health policies.
• For instance, when officials started deliberating on rising anaemia and malnutrition levels among women, the public health messaging was to encourage women to eat better: green, leafy vegetables or eggs. 
• There was no recognition that women might be unable to afford it, and even if they do, there is an intra-household difference. 
• If a woman were on these committees from the start, ‘experts’ might have realized earlier that women’s food experience is gendered.
• The underrepresentation of women in medical leadership sets in motion a cycle: fewer women, fewer mentors, and fewer safe spaces for women to work and air their concerns.

Recommendations:

• The Women in Global Health report recommended a host of measures. 
• Hiring, promotion and rotating doctors decisions should be made considering identity-based challenges; efficient, anonymous systems to report misconduct; adapting systems to “encourage women doctors and medical leaders with dedicated resources and flexible working arrangements that promote work-life balance to shatter glass ceilings and glass fences”.
• In an Indian context, experts recommend reserving seats for women and people from marginalised social locations on health committees, similar to the women’s reservation in the legislature.
• The composition of India’s health committees reveals more than its gender or geographical make-up.
• There is a need to think about representing directly affected people. 
• For instance, while making policies on food fortification, the 80 crore people who will be handed rice through government schemes deserve representation. 
• Larger bodies of patient organisations, including the Consortium of Accredited Healthcare Organisations, advocate for hospitals to institute Patient Advisory Councils to promote patient involvement and safeguard their health rights.