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OPINION: Women should not be propping up healthcare systems without proper pay

by Ann Keeling | Women in Global Health
Friday, 22 July 2022 16:00 GMT

Neonatal Nurse Kirsty Hartley checks on premature baby Theo Anderson whilst he's in the arms of his mother Kirsty Anderson in the Neonatal Intensive Care Unit at the Lancashire Women and Newborn Centre at Burnley General Hospital in East Lancashire, following the outbreak of the coronavirus disease (COVID-19), in Burnley, Britain May 15, 2020. Picture taken May 15, 2020. REUTERS/Hannah McKay/Pool

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* Any views expressed in this opinion piece are those of the author and not of Thomson Reuters Foundation.

Woman health workers are the backbone of medical care across much of the world, so why are they treated so poorly?

Ann Keeling is Senior Fellow at Women in Global Health.

When I first arrived to work in Pakistan in 1989, I would regularly visit villages where mothers had died in childbirth, often with their newborns. The health system just didn’t reach that far.

I had arrived in Pakistan with my own young baby and we were both healthy. Because the health system reached us.

The previous year a young female Prime Minister, Benazir Bhutto, had replaced a military dictator. She asked how health services could reach women in remote, conservative communities. 

So, in 1994 the Lady Health Workers Programme was launched. For the first time in Pakistan, the health system reached women just about everywhere.

For 20 years, on and off, I watched those women become the backbone of the health system, battling low pay, dealing with harassment, and travelling long distances on foot. Sometimes they weren’t paid at all.

Women working unpaid and underpaid in health systems is not new. The Lancet Commission on Women and Health in 2015 estimated that women contribute $3 trillion to global health annually, half in the form of unpaid work.

During the pandemic, stories surfaced of women community health workers forming the critical frontline of global health security, going door-to-door tracing contacts, informing communities, often without adequate personal protective equipment and often unpaid. It was the right time to ask who these women were, how many there were and why women from low-income families with already heavy work burdens, added unpaid health work to their busy days?


In a report just published by Women in Global Health, “Subsidizing Global Health”, we calculated that upwards of six million women are working unpaid and grossly underpaid - often as ”volunteers” - to prop up health systems worldwide.

This is the first time a figure like this has been calculated, and we were conservative in our estimate. Not all countries include frontline community health workers in their formal workforce or labor market statistics, even though they are delivering core health services.

In interviews, we found that women worked for low pay for a mixture of reasons. Though they were proud to carry out voluntary work, and were positive about the benefits to the community, it came at a personal cost.

For women from low-income families and with low levels of education, unpaid work was an opportunity that might lead to some paid work or an asset like a mobile phone or bicycle. Unpaid work in health can also bring women social recognition and in many contexts, it is seen as “honorable work” that families will approve of for a woman.

Our research showed that for others, it offered passage out of the home to freely move about for a positive purpose, an opportunity to learn, and also to achieve personal and professional rewards. 

The bottom line, however, is that women do this work because they are backed into a gendered corner, with their choices constrained simply by being women. Men have greater mobility and more options. And, although many women benefit in ways and would choose to continue doing this work, they want to be fairly paid and recognised.


“Subsidizing health systems” sets out recommendations to governments and policymakers to help address the problems faced by more than six million women.

First, we ask that the numbers of unpaid and underpaid workers are counted, both male and female. Once official numbers are known to health ministries, then the process of moving them from the informal into the formal health workforce can begin. 

Next, we ask that proper working conditions with adequate pay are provided. This includes proper renumeration, adequate worker protection and the introduction of standards on a par with those working in the formal sector, such as paid holidays, maternity leave and workplaces free from sexual abuse and harassment.

Introducing basic policy measures to address inequities in the workforce would mean that women, their families, and whole communities would benefit from the shared economic dividends that would trickle down to lift whole communities out of poverty.

Formalising the informal workforce is not just economically sound, it is our moral duty. Taking advantage of women’s poverty, their lack of opportunity in male-dominated societies, particularly in low-income countries, is not sound policy for the sustainability of resilient health systems.

Morale is at an all-time low in the health sector, as proven by the so-called “great resignation” of health workers in high-income countries. The projected shortfall in the health workforce of 18 million should be enough to cause alarm.

Women working without pay are creating social and economic value that is uncounted, unrecorded, and unrewarded. When we start to address this problem, we can address the inadequacies of global health systems, we can address the problems facing a burnt out, demoralised health workforce that lacks not just the viability to face future country-wide health crises, but also global pandemics.