The World Health Organization is a specialized agency of the United Nations with primary responsibility for international health matters and public health. Through this organization, which was created in 1948, the health professions of some 165 countries exchange their knowledge and experience with the aim of making possible the attainment by all citizens of the world by the year 2000 of a level of health that will permit them to lead a socially and econ­ omically productive life. By means of direct technical cooperation with its Member States, and by stimulating such cooperation among them, WHO promotes the development of comprehensive health services, the prevention and control of diseases, the improvement of environmental conditions, the development of health manpower, the coordination and development of biomedical and health services research, and the planning and implementation of health programmes. These broad fields of endeavour encompass a wide variety of activities, such as developing systems of primary health care that reach the whole population of Member countries; promoting the health of mothers and children; combating malnutrition; controlling malaria and other communicable diseases, including tuberculosis and leprosy; having achieved the eradi­ cation of smallpox, promoting mass immunization against a number of other preventable diseases; improving mental health; providing safe water supplies; and training health personnel of all categories. Progress towards better health throughout the world also demands international cooperation in such matters as establ'1shing international standards for biological substances, pestic'ldes, and pharmaceuticals; formulating environmental health criteria; recommending international nonproprietary names for drugs; administering the International Health Regulations; revising the International Classification of Diseases, Injuries, and Causes of Death; and collecting and disseminating health statistical information. Further information on many aspects of WHO's work is presented in the Organization's publications. WOMEN AS PROVIDERS OF HEALTH CARE HELENA PIZURKI Consultant Health Manpower Systems World Health Organization Geneva, Switzerland ALFONSO MEJIA Chief Medical Officer Health Manpower Systems World Health Organization Geneva, Switzerland IRENE BUTTER Professor of Health Planning Department of Health Planning and Administration School of Public Health University of Michigan, Ann Arbor, Ml, USA LESLIE EWART Technical Officer Health Manpower Systems World Health Organization Geneva, Switzerland WORLD HEALTH ORGANIZATION GENEVA 1987 ISBN 92 4 156104 1 © World Health Organization 1987 Publications of the World Health Organization enjoy copyright protection in accordance with the provisions of Protocol 2 of of the Universal Copyright Convention. For rights of reproduction or translation of WHO publications, in part or in toto, application should be made to the Office of Publications, World Health Organization, Geneva, Switzerland. The World Health Organization welcomes such applications. The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of the Secretariat of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. The mention of specific companies or of certain manufacturers' products does not imply that they are endorsed or recommended by the World Health Organization in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. The authors alone are responsible for the views expressed in this publication. PRINTED IN SWITZERLAND 86/6990---Populaires---8000 CONTENTS Acknowledgements 4 Introduction 5 Chapter 1 The contribution of women to national health development 9 Chapter 2 The situation of women working in the formal health care system 25 Chapter 3 Nursing and the condition of women 58 Chapter 4 Strengthening the role of women in the provision of health care 76 Chapter 5 The challenge to individual countries 95 References 134 Annex 1 Preparation and presentation of proposals to funding agencies 138 Annex 2 Papers from countries participating in the WHO Multinational Study on Women as Providers of Health Care: summaries and action taken 150 Annex 3 WHO Consultations on Women as Providers of Health Care 160 ACKNOWLEDGEMENTS This book is the result of an international cooperative effort in which a large number of countries, agencies, and individuals have been involved. The authors express their sincere thanks to all those- too numerous to mention- who have contributed to its preparation. The text relies heavily on ideas and opinions put forward in the working papers, discussions, and reports of two multinational consultations on Women as Providers of Health Care, which took place in December 1980 and August 1982. The names of the participants in these two consultations are listed on pages 160-163. We are particularly indebted to Dr B. Grab and Dr Bui Dang Ha Doan who provided statistical input to Chapter 2, to Mrs He1ga Morrow and Miss Ellen Cahill for their contributions to Chapter 3, and to Dr Beverley DuGas who revised Chapter 5. Mrs Helena Pizurki devoted much effort and interest to this publication but sadly she passed away before the work was completed. Her intellec­ tual input was considerable and her devotion encouraged the authors to maintain the momentum needed to complete the work. 4 INTRODUCTION In conformity with the objectives of the United Nations Decade for Women (1975-85), which stressed the equitable participation of women in national development, WHO, with financial support from the United Nations Fund for Population Activities (UNFPA), has initiated a number of projects, including the Multinational Study on Women as Providers of Health Care. 1 Although its title might give the impression that the project is limited to research, this is only one of its components. Essentially a country-based effort with an active, problem-solving approach, it began early in 1980. It was envisaged at the outset that national efforts would be promoted and supported by certain inter­ national activities, including consultations and workshops at which countries and agencies would be represented, and the production and dissemination of material designed to stimulate awareness and encourage appropriate action. The present publication is the first on the situation of women as providers of health care to be prepared by WHO, and the first in the world to provide a general survey and analysis of this situation and guidance for those entrusted with the development of programmes to deal with it. It represents both a result and an expansion of the earlier stages of the study. The project that has led to the publication of this book consists of a set of interrelated activities organized and managed by WHO. These have included: (a) the first WHO Consultation on Women as Providers of Health Care, at which priority issues were identified; (b) the second WHO Consultation on Women as Providers of Health Care, at which participants identified and discussed the main constituents of a national strategy for achieving the long-term aims of the project, as specified below; (c) the preparation of an annotated bibliography on women as health care providers in both formal and non-formal health systems; and (d) the preparation of papers by participants from 17 different coun­ tries, each dealing analytically with a specific issue and containing broad proposals for action (see Annex 2). 1 Consultants to the project: Dr Irene Butter, Professor of Health Planning, School of Public Health, University of Michigan, Ann Arbor, Ml, USA; and Dr Bui Dang Ha Doan, Director, Centre of Medical Sociology and Demography, Paris, France. 5 Women as providers of health care Long-term aims The general long-term aims of the WHO project are: (a) to enhance the political, economic, and social status of women as health care providers in both formal and non-formal health systems; (b) to ensure that all women receive education, training, and/or orien­ tation that will enable them to provide health care for themselves, their families, and other members of the community; (c) to ensure that, within the formal health care system, there is no discrimination against women employees as regards position, pay, responsibility, and authority; and (d) to facilitate in other respects the participation of women in both national and international efforts to achieve "Health for all by the year 2000". Within this framework, the present publication aims more directly at: (a) creating a broader awareness among people in general, and decision-makers in particular, of the extent of women's contribution to national health development and the obstacles they face both inside and outside the formal health system; (b) creating a broader awareness of the sources of the imbalance between men and women in the extent and nature of their partici­ pation in health care; (c) providing information, particularly to women themselves and to decision-makers, concerning the basic factors to be considered in the development of a long-term strategy to improve the socioeco­ nomic status of women health care providers; and (d) guiding both women and men on the planning of relevant action and on the preparation of proposals for funding