Bridging the Gap: Addressing Gender Disparities in Leadership Roles Among Nurses and Midwives

In today’s interconnected world, health systems face unprecedented challenges. The recent global Covid-19 pandemic made it clear that the impacts of fragile health systems are not contained by borders, underscoring the critical importance of supporting the development of robust health systems and Universal Health Coverage for all – a fundamental principle of the Sustainable Development Goals.

At the centre of every health system is the health workforce. Investing in the health workforce is imperative to achieving efficient, resilient and sustainable health systems capable of rising to the health challenges of the future. Within the health workforce, nurses and midwives play a critical role in delivering essential primary healthcare, advocating for the needs of their communities and for maternal health, and shaping policies and practices on a health systems level – improving health outcomes across the world.

Globally, 67% of the health and social workforce are women, where nursing and midwifery occupations represent a significant share of the female workforce. The role of nurses and midwives in maternal and neonatal healthcare is vital. Appropriate care from skilled health professionals during and after childbirth is the difference between life and death for women and children. With 253,000 women already dying every year during pregnancy and childbirth, this has alarming implications for women’s health. Worse still, 95% of these maternal deaths occur in Low- and Middle-Income Country (LMIC) health systems, with 70% occurring in Sub-Saharan Africa alone, where maternal and neonatal care is already under strain. Investing in the health workforce, and specifically, the female health workforce, has never been more important.

Moreover, despite making up the majority of the health workforce, women are grossly underrepresented in leadership positions – being consistently undervalued and underpaid. WHO’s policy report ‘Gender, Equity and Leadership in the Global Health and Social Workforce’ highlights exactly why this is so important: “Gender inequity in health and social care work remains a challenge. Women may hold 67% of jobs in the health and social care workforce but they hold only 25% of leadership roles. Global health is delivered by women and led by men”. With the implications of an under resourced and undervalued female health workforce on both women’s status in the workplace and on women’s health more widely, we are further reminded of the importance of leadership development interventions in providing a platform for women to enter into healthcare leadership roles. The report goes on to explain: “Addressing gender gaps in leadership leads to a more empowered workforce, improved motivation, reduced attrition, improved quality of care, and better understanding of health systems, which feeds into designing more suitable solutions”. Having more women in leadership roles in the health workforce will raise their profile and status and enable them to advocate for the importance of the nursing and midwifery cadres in women’s health, as well as for women’s health rights and policies.

That’s why the Global Health Workforce Programme (GHWP), funded by the Department of Health and Social Care (DHSC) and managed by the Tropical Health and Education Trust (THET), is working to strengthen the health workforce. Through investing in Human Resources for Health, the GHWP aims to ensure the effective utilisation of the current health workforce and secure the health workforce of the future. By funding existing and brokering new strategic alliances between health institutions, the GHWP is supporting health partnerships interventions to tackle the challenges of health worker shortages and strengthen health systems in Ghana, Kenya and Nigeria. Investing in the performance, well-being, and retention of nursing and midwifery cadres will strengthen healthcare delivery, promote gender equity and equality and help to build robust and resilient health systems.

The strategic health partnership between the UK’s Florence Nightingale Foundation (FNF) and the Nursing Council of Kenya (NCK) has made significant strides towards this objective since the project’s inception in February 2024. In early May 2024 this health partnership held their first intensive leadership development intervention in Machakos county in Kenya, which brought together 50 mid-level nursing and midwifery managers from all 47 counties in Kenya, along with stakeholders from Kenya’s National Union of Nurses, Ministry of Health, the Council of Governors and the President of the Kenya National union of Nurses. 
 

The gender disaggregation of participants was 66% female, 34% male, supporting the GHWP objective of addressing gender inequity and developing leadership skills among the female health workforce.

Throughout the week of training, these nursing and midwifery managers participated in a number of leadership development workshops, including sessions on introduction to self as a leader; styles of leadership; and exploring the leadership of change management and quality improvement.  As part of the training, each participant developed a ‘change’ project addressing performance, retention, or workplace issues, to be pursued over the next 8 months, the remaining programme timeframe. Participants developed their change project proposals with guidance from the facilitation team and have had a subsequent online training workshop in July 2024 led by FNF expert facilitator Becky Thomas, to refine their plans and learn more about key principles of change management. Examples of the issues and challenges that the participants are addressing through their change management projects include: reducing out of stock occurrence of medical and non-medical supplies; reducing the number of missed appointments among pregnant women with HIV in one sub-county; and utilisation of partograph and ultrasound for women in labour in a district hospital delivering Primary Healthcare.
Moreover, the engagement and participation of policy makers with this HP is part of the GHWP priority to embed and align interventions with national priorities and policies, enhancing ownership, sustainability, recognition and support of nurse/midwife leadership roles.  

Alongside these efforts to embed interventions in policy and practice, the trained nurses and midwives will cascade the knowledge, skills and competencies acquired through the leadership development intervention down to facility co-workers, with ongoing mentorship support provided by the Kenyan diaspora nursing community in the UK: the Kenya Nurses and Midwives Association UK (KENMA UK) and Royal Berkshire NHS Foundation Trust. These efforts are made to enhance sustainability of the projects and impact beyond the lifetime of the programme.  

The participating nurses and midwives reported high levels of appreciation for the opportunity to strengthen their leadership skills and competencies, noting that they rarely get to participate in these types of interventions as these  are usually only made available to senior level managers. One participant reflected on the training: “In my community and in my workplace, there are a lot of issues that I believe, both globally and locally in Kenya, if I am open to the world and I research about them, I will get solutions to. So that is one thing that I’m looking to do – find the space to work through several projects[ so] that I bring a change to the community and leave a legacy.”

Through health partnerships like the one between the Florence Nightingale Foundation and the Nursing Council of Kenya, the GHWP is equipping nursing and midwifery managers with leaderships skills and competencies to improve their performance and well-being, empowering and enabling them to advocate for health workforce improvements. Having more women in leadership roles will help bring attention to underrepresented groups and the health areas – especially within women’s health – that are often overlooked. Investing in the performance, well-being, and retention of nursing and midwifery cadres will strengthen healthcare delivery, promote gender equity and equality and help to build robust and resilient health systems. 

Acknowledgements: This piece was put together with the help and support of the Florence Nightingale Foundation, the Nursing Council of Kenya, the Grant Manager for the GHWP in Kenya, Grace Rukwaro, and THET’s Health Systems Strengthening team Margaret Caffrey and Jess Fraser.