Beyond Numbers: Addressing Gendered Workplace Violence to Advance Universal Health Coverage

The latest UHC Global Monitoring Report finds that, as of 2023, 4.6 billion people still lacked access to essential health services, and, in 2022, 2.1 billion face financial hardship paying for care and health costs. The lack of access to a health worker is among the main barriers preventing people from benefiting from health and care services. Human resources for health (HRH) constitute the backbone of any functional health system and whether health-care services are effective, accessible, and of high quality is ultimately dependent on the workforce providing them, thereby making HRH a fundamental component of achieving Universal Health Coverage.

Unfortunately, the situation isn’t expected to improve as, by 2030, the global shortfall of health workers is projected to reach 11 million, with nursing accounting for more than half. As Dr. James Kengia explained, on the supply-side, most efforts to achieve UHC target its visible symptoms, focusing on quantitative metrics, such as increasing the number of healthcare workers, rearranging workforce distribution, or expanding health insurance coverage. Although these measures may be necessary they, however, leave unaddressed the essential drivers of workforce shortage, turnover, and migration: that is the safety, motivation, mental health, and general well-being of the primary healthcare (PHC) workforce, particularly of women who constitute a substantial share of frontline health workers.

Women’s safety and working conditions matter directly for UHC in that they are directly linked to patient outcomes and overall healthcare service quality. Indeed, empathetic, compassionate, high-quality, equitable healthcare services appear unachievable if health workers’ personal safety, well-being, and psychological integrity are found to be compromised. As mentioned, focusing on headcount alone, without attention to the conditions under which workers actually operate, thus risks overlooking crucially determinant barriers.

Workplace violence is key in these discussions. Evidence indicates that more than 60% of health workers have experienced some form of workplace violence (WPV). Yet, as Kedibone Mdolo notes, approximately, 70% of workplace violence incidents in the health sector goes unreported due to fear of reprisal, a lack of clear, safe, and confidential reporting channels, organisational stigma, and institutional inaction. From burnout and moral distress, to ‘compassion fatigue’, to absenteeism and attrition, to the degradation of quality of care, the dire effects of WPV extend from individuals to entire systems. Indeed, not only does WPV undermine the safety, well-being, and agency of healthcare workers, especially at primary health care (PHC) level, but, in doing so, also weakens the resilience and responsiveness of PHC systems as a whole. Importantly however, as Dr. Sally Mtenga notes, the well-being and safety of healthcare workers are not only a question of system performance but a fundamental human rights issue.

Structural gender norms significantly shape workers’ exposure and experience of workplace violence, notably in that they directly influence occupational segregation, power imbalances, resource distribution, job insecurity, and work arrangements. Dr. Mariam Seynou explained how, in Burkina Faso, societal expectations dictating that a ‘good woman’ should be compliant, tolerant, and respectful participate in making female healthcare workers that assert authority, enforce facility rules, or even defend themselves against abusive patients, colleagues, or supervisors, prone to being labeled as insubordinate or accused of behaving disrespectfully. In addition, gender norms surrounding ‘masculinity’ also shape men’s response to WPV, with expectations of strength, courage, and self-reliance driving even lower reporting rates amongst male staff subjected to abuses.

As such, tackling gendered workplace violence isn’t just an occupational safety intervention but both a health-system investment and a human rights imperative. Protecting frontline health workers, particularly women, and creating safer, more equitable and supportive workplaces is crucial to help retain a skilled workforce and improve the quality and continuity of care. These, in turn, offer a direct path toward UHC.

The IMARISHA project provides an important platform for examining gendered workplace violence within primary health-care settings and generating evidence to inform gender-responsive approaches to strengthening the health workforce and advancing UHC.

Among the opportunities for action discussed during the webinar, speakers emphasised two first overarching strategies:

• Building on existing frameworks and taking advantage of policies and legislations - when existent - as premises for action to address workplace violence and its gender dimensions.
• Generating robust evidence to inform the design of trusted, safe, and confidential reporting mechanisms, through which health workers can raise concerns and needs without fear of intimidation or penalisation.

However, practical actions and concrete examples of what works on the ground are often missing from these discussions. Kedibone Mdolo helped fill this gap by highlighting strategies developed in her own context in South Africa, one of which was clinic committees in which community representatives take part in multi-stakeholder forums and act as a bridge between health workers and communities, capable of explaining challenges within primary health care in the communities’ own language. Other measures include suggestion boxes and environmental design, such as improved lighting, to make facilities safer.

The webinar concluded by emphasising the need for national health systems, governmental actors, community stakeholders, and facility managers to collaborate and support each other in implementing structured, gender-responsive measures across their respective levels of intervention, in order to mitigate workplace violence and consequently effectively support UHC targets.