Pathways to leadership: what accounts for women's (in)equitable career paths in the health sectors in India and Kenya? A scoping review.

OBJECTIVES: We aimed to capture evidence on enablers and barriers to improving equal opportunity and effective organisational interventions that can advance women's leadership in India and Kenya's health sectors. METHODS: We systematically searched JSTOR, PubMed, SCOPUS and Web of Science databases, reference lists of selected articles and Google Scholar using string searches. We included studies that were published in English from 2000 to 2022 in peer-reviewed journals or grey literature, focused on paid, formal health professionals in India or Kenya, described factors relating to women's representation/leadership. RESULTS: We identified 26 studies, 15 from India and 11 from Kenya. From each country, seven studies focused on nursing. Participants included women and men health sector workers. Seven studies used mixed methods, 11 were qualitative, 5 were quantitative and 3 were commentaries. Factors influencing women's career progression at individual/interpersonal levels included family support, personal attributes (knowledge/skills) and material resources. Factors at the organisational level included capacity strengthening, networking, organisational policies, gender quotas, work culture and relationships, flexibility, and work burden. Nursing studies identified verbal/sexual harassment and professional hierarchies as barriers to career progression. Structural barriers included a lack of infrastructure (training institutes and acceptable working environments). Normative themes included occupational segregation by gender (particularly in nursing), unpaid care work burden for women and gender norms. Studies of interventions to improve women's career progression and sex-disaggregated workforce data in India or Kenya were limited, especially on leadership within career pathways. The evidence focuses on enablers and barriers at work, rather than on organisations/systems to support women's leadership or address gender norms. CONCLUSIONS: Women in India and Kenya's health sectors face multiple impediments in their careers, which impact their advancement to leadership. This calls for gender-transformative interventions to tackle discrimination/harassment, provide targeted training/mentorship, better parental leave/benefits, flexible/remote working, family/coworker support and equal-opportunity policies/legislation.

Legislation for advancing women's leadership in the health sector in India and Kenya: a 'law cube' approach to identify ways to strengthen legal environments for gender equality.

OBJECTIVES: This paper examines the availability of legal provisions, or the lack thereof, that support women to progress equitably into leadership positions within the health workforce in India and Kenya. METHODS: We adapted the World Bank's Women, Business and Law framework of legal domains relevant to gender equality in the workplace and applied a 'law cube' to analyse the comprehensiveness, accountability and equity and human rights considerations of 27 relevant statutes in India and 11 in Kenya that apply to people in formal employment within the health sector. We assessed those laws against 30 research-validated good practice measures across five legal domains: (1) pay; (2) workplace protections; (3) pensions; (4) care, family life and work-life balance; and (5) reproductive rights. In India, the pension domain and related measures were not assessed because the pension laws do not apply to the public and private sector equally. RESULTS: Several legal domains are addressed inadequately or not at all, including pay in India, reproductive rights in Kenya and the care, family life and the work-life balance domain in both countries. Additionally, we found that among the Kenyan laws reviewed, few specify accountability mechanisms, and equity and human rights measures are mainly absent from the laws assessed in both countries. Our findings highlight inadequacies in the legal environments in India and Kenya may contribute to women's under-representation in leadership in the health sector. The absence of specified accountability mechanisms may impact the effective implementation of legislation, undermining their potential to promote equal opportunities. CONCLUSIONS: Government action is needed in both countries to ensure that legislation addresses best practice provisions, equity and human rights considerations, and provides for independent review mechanisms to ensure accountability for implementation of existing and future laws. This would contribute to ensuring that legal environments uphold the equality of opportunity necessary for realising gender justice in the workplace for the health workforce. PRIMARY SOURCE OF FUNDING: Bill & Melinda Gates Foundation (INV-031372).

Understanding the factors affecting global political priority for controlling sexually transmitted infections: a qualitative policy analysis.

INTRODUCTION: Sexually transmitted infections (STIs) are a significant public health challenge, but there is a perceived lack of political priority in addressing STIs as a global health issue. Our study aimed to understand the determinants of global political priority for STIs since the 1980s and to discern implications for future prioritisation. METHODS: Through semistructured interviews from July 2021 to February 2022, we engaged 20 key stakeholders (8 women, 12 men) from academia, United Nations agencies, international non-governmental organisations, philanthropic organisations and national public health agencies. A published policy framework was employed for thematic analysis, and findings triangulated with relevant literature and policy documents. We examined issue characteristics, prevailing ideas, actor power dynamics and political contexts. RESULTS: A contrast in perspectives before and after the year 2000 emerged. STI control was high on the global health agenda during the late 1980s and 1990s, as a means to control HIV. A strong policy community agreed on evidence about the high burden of STIs and that STI management could reduce the incidence of HIV. The level of importance decreased when further research evidence did not find an impact of STI control interventions on HIV incidence. Since 2000, cohesion in the STI community has decreased. New framing for broad STI control has not emerged. Interventions that have been funded, such as human papillomavirus vaccination and congenital syphilis elimination have been framed as cancer control or improving newborn survival, rather than as STI control. CONCLUSION: Globally, the perceived decline in STI control priority might stem from discrepancies between investment choices and experts' views on STI priorities. Addressing STIs requires understanding the intertwined nature of politics and empirical evidence in resource allocation. The ascent of universal health coverage presents an opportunity for integrated STI strategies but high-quality care, sustainable funding and strategic coordination are essential.

Protecting and promoting the rights of the 'reserve army of labour': a policy analysis of structural determinants of migrant worker health in Pakistan and Qatar.

Labour migrants who travel overseas for employment can face deep health inequities driven in large part by upstream social and structural determinants of health. We sought to study the 'labour migrant health ecosystem' between one sending country (Pakistan) and one host country (Qatar), with a focus on how the ecosystem realizes the rights of labour migrants when addressing the social and structural determinants (e.g. housing, employment law, etc.) of health. Study objectives were to (1) undertake an in-depth review of policies addressing the structural and social determinants of the health of labour migrants in both Pakistan and Qatar, analysing the extent to which these policies align with global guidance, are equity-focused and have clear accountability mechanisms in place, and (2) explore national stakeholder perspectives on priority setting for labour migrant health. We used a mixed methods approach, combining policy content analysis and interviews with stakeholders in both countries. We found a wide range of guidance from the multilateral system on addressing structural determinants of the health of labour migrants. However, policy responses in Pakistan and Qatar contained a limited number of these recommended interventions and had low implementation potential and minimal reference to gender, equity and rights. Key national stakeholders had few political incentives to act and lacked inter-country coordination mechanisms required for an effective and cohesive response to labour migrant health issues. Effectively addressing such determinants to achieve health equity for labour migrants will depend on a shift in governments' attitudes towards migrants-from a reserve army of transient, replaceable economic resources to rights-holding members of society deserving of equality, dignity and respect.

A Rapid Ethnographic Assessment of Cultural and Social Perceptions and Practices About COVID-19 in Bangladesh: What the Policy Makers and Program Planners Should Know.

Anthropological literature on health beliefs and practices related to COVID-19 is scarce, particularly in low and middle-income countries. We conducted a qualitative research on perceptions of COVID-19 among slum residents of Dhaka, Bangladesh from November 2020 through January, 2021. Methods included in-depth interviews and photo elicitation with community residents. Interviews were transcribed and analyzed thematically. Results show scientific explanations of COVID-19 conflicted with interviewees' cultural and spiritual beliefs such as: coronavirus is a disease of rich, sinful people; the virus is a curse from Allah to punish sinners. Interviewees rejected going to hospitals in favor of home remedies, and eschewed measures such as mask-wearing or social distancing instead preferring to follow local beliefs. We have highlighted a gap between community beliefs about the pandemic and science-led interventions proposed by health professionals. For public health policy to be more effective it requires a deeper understanding of and response to community perceptions.

Sex-disaggregated data matters: tracking the impact of COVID-19 on the health of women and men.

Sex and gender matter to health outcomes, but despite repeated commitments to sex-disaggregate data in health policies and programmes, a persistent and substantial absence of such data remains especially in lower-income countries. This represents a missed opportunity for monitoring and identifying gender-responsive, evidence-informed solutions to address a key driver of the pandemic. In this paper we review the availability of national sex-disaggregated surveillance data on COVID-19 and examine trends on the testing-to-outcome pathway. We further analyse the availability of data according to the economic status of the country and investigate the determinants of sex differences, including the national gender inequality status (according to a global index) in each country. Results are drawn from 18 months of global data collection from over 200 countries. We find differences in COVID-19 prevention behaviours and illness outcomes by sex, with lower uptake of vaccination and testing plus an elevated risk of severe disease and death among men. Supporting and maintaining the collection, collation, interpretation and presentation of sex-disaggregated data requires commitment and resources at subnational, national and global levels, but provides an opportunity for identifying and taking gender-responsive action on health inequities. As a first step the global health community should recognise, value and support the importance of sex-disaggregated data for identifying and tackling an inequitable pandemic.

Promoting labour migrant health equity through action on the structural determinants: A systematic review.

BACKGROUND: Labour migrants, who represent over sixty per cent of international migrants globally, frequently have poorer health status than the population of host countries. These health inequities are determined in a large part by structural drivers including political, commercial, economic, normative and social factors, including living and working conditions. Achieving health equity for migrant workers requires structural-level interventions to address these determinants. METHODS: We undertook a systematic review of peer-reviewed literature designed to answer the question "what is the evidence for the effectiveness of interventions to address the structural determinants of health for labour migrants?" using the Ovid Medline electronic database. FINDINGS: We found only two papers that evaluated structural interventions to improve the health of labour migrants. Both papers evaluated the impact of insurance - health or social. In contrast, we found 19 evaluations of more proximal, small-scale interventions focused on changing the knowledge, attitudes and behaviours of labour migrants. INTERPRETATION: Despite the rise in international migration, including for work, and evidence that labour migrants have some higher health risks, there is a paucity of research addressing the structural determinants of health inequities in labour migrants. The research community (including funders and academic institutions) needs to pay greater attention to the structural determinants of health - which generally requires working across disciplines and sectors and thinking more politically about health and health inequities. FUNDING: Wellcome Trust (208712/Z/17/Z).

Barriers and opportunities to restricting marketing of unhealthy foods and beverages to children in Nepal: a policy analysis.

BACKGROUND: Marketing of foods and non-alcoholic beverages high in saturated fats, trans-fatty acids, free sugars, or salt ("unhealthy foods") to children is contributing to increasing child obesity. However, many countries have not implemented WHO recommendations to restrict marketing of unhealthy foods to children. We sought to understand the absence of marketing restrictions and identify potential strategic actions to develop and implement such restrictions in Nepal. METHODS: Eighteen semi-structured interviews were conducted. Thematic analysis was based on Baker et al.'s 18 factor-framework for understanding what drives political commitment to nutrition, organised by five categories: Actors; Institutions; Political and societal contexts; Knowledge, evidence and framing; Capacities and resources. RESULTS: All factors in Baker et al.'s framework were reported to be acting largely as barriers to Nepal developing and implementing marketing restrictions. Six factors were identified by the highest number of respondents: the threat of private sector interference in policy-making; lack of international actor support; absence of well-designed and enacted policies and legislation; lack of political commitment to regulate; insufficient mobilisation of existing evidence to spur action and lack of national evidence to guide regulatory design; and weak implementation capacity. Opportunities for progress were identified as Nepal's ability to combat private sector interference - as previously demonstrated in tobacco control. CONCLUSIONS: This is the first study conducted in Nepal examining the lack of restrictions on marketing unhealthy foods to children. Our findings reflect the manifestation of power in the policy process. The absence of civil society and a multi-stakeholder coalition demanding change on marketing of unhealthy food to children, the threat of private sector interference in introducing marketing restrictions, the promotion of norms and narratives around modernity, consumption and the primary role of the individual in regulating diet - all have helped create a policy vacuum on marketing restrictions. We propose that stakeholders focus on five strategic actions, including: developing a multi-stakeholder coalition to put and keep marketing restrictions on the health agenda; framing the need for marketing restrictions as critical to protect child rights and government regulation as the solution; and increasing support, particularly through developing more robust global policy guidance.

The gender and geography of publishing: a review of sex/gender reporting and author representation in leading general medical and global health journals.

INTRODUCTION: Diverse gender and geographical representation matters in research. We aimed to review medical and global health journals' sex/gender reporting, and the gender and geography of authorship. METHODS: 542 research and non-research articles from 14 selected journals were reviewed using a retrospective survey design. Paper screening and systematic data extraction was conducted with descriptive statistics and regression analyses calculated from the coded data. Outcome measures were journal characteristics, the extent to which published articles met sex/gender reporting guidelines, plus author gender and location of their affiliated institution. RESULTS: Five of the fourteen journals explicitly encourage sex/gender analysis in their author instructions, but this did not lead to increased sex/gender reporting beyond the gender of study participants (OR=3.69; p=0.000 (CI 1.79 to 7.60)). Just over half of research articles presented some level of sex/gender analysis, while 40% mentioned sex/gender in their discussion. Articles with women first and last authors were 2.4 times more likely to discuss sex/gender than articles with men in those positions (p=0.035 (CI 1.062 to 5.348)). First and last authors from high-income countries (HICs) were 19 times as prevalent as authors from low-income countries; and women from low-income and middle-income countries were at a disadvantage in terms of the impact factor of the journals they published in. CONCLUSION: Global health and medical research fails to consistently apply a sex/gender lens and remains largely the preserve of authors in HIC. Collaborative partnerships and funding support are needed to promote gender-sensitive research and dismantle historical power dynamics in authorship.