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Analysis: Women mostly deliver health services in Nigeria but men are leading

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The significance of the Africa Health Agenda International Conference (AHAIC) coinciding with the International Women’s Day (IWD) every March 8th could not have stood out more sharply this year. Over 2,000 virtual participants joined and speakers paid homage to women and their contributions to health, social and economic development.

But the upbeat mood of the event was interrupted by the urgency to bridge the gender imbalance in the leadership of health systems in Africa which experts say is undermining effective health outcomes.

The event underscored several factors stopping women from reaching top leadership positions in Africa’s health systems, including a patriarchal society structure.

In his opening remark at the event, WHO Director General, Tedros Adhanom Ghebreyesus echoed the need for robust investment in raising and nurturing motivated women leaders in global health.

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Globally, women represent 70% of the health workforce, and yet they make up just 25% of health leadership positions, the 2018 World Health Organization (WHO) Gender Equity Hub (GEH) report showed.

FOLIO POST in this report examines women’s poor representation in various decision making positions in the health system of Africa’s most populous nation, Nigeria.

Health ministers, commissioners spot

Adenike Grange was appointed as Nigeria’s first female minister of health on July 25, 2007. Just seven months in office, her appointment was terminated.

Halima Tayo Alao served as Nigeria’s first female minister of state for health. Appointed in August 2005, she also had a short spell as she was removed in less than a year.

Asides the two ex-officials, no other woman has occupied both positions considered the topmost portfolio in the health leadership cadre in the 60 years of Nigeria’s independence and development of the health sector, our check revealed.

Of Nigeria’s 36 states, only four women are currently occupying the position of health commissioners in four out of the six geo-political zones.

They are: Bettu Edu in Cross Rivers; Damaris Osunkwo, Imo state; Amina Mohammed, Kaduna state; and Tomi Coke, Ogun state.

There are no female health commissioners in the entire North East and North Central zones.

Heads of Health Agencies

There are eight federal parastatals and agencies under the health ministry.

Only one of them is currently headed by a woman.

Mojisola Christianah Adeyeye, a pharmacist and professor was appointed the Director-General of National Agency for Food and Drug Administration and Control (NAFDAC) on 3rd November 2017.

It is believed that it was the good precedence set by late Dora Nkem Akunyili, the first woman and longest serving head of the agency from 2001 to 2008 that spurred Mrs Adeyeye’s consideration by President Buhari Muhammadu Buhari.

Advocates for female inclusion believe that if there are more women who have previously held leadership positions, it will serve as a testament for their competence, thereby opening up more spots.

The National Health Insurance Scheme (NHIS), one of the most important health agencies have not had a female leader in its 15 years of existence.

The incumbent executive secretary of the NHIS, Mohammed Sambo was appointed in 2019.

Other agencies: The National Institute of Pharmaceutical Research and Development (NIPRD); National Agency for the Control of AIDS (NACA); National Primary Health Care Development Agency (NPHCDA); Nigerian Institute of Medical Research (NIMR); Pharmacists Council of Nigeria (PCN); and the Medical and Dental Council of Nigeria (MDCN) are all currently led by men.

Federal Teaching hospitals

Nigeria has 20 Federal Teaching Hospitals in Nigeria which falls under one of the three parastatals under the Federal Ministry of Health.

Teaching hospitals are the apex health institutions in the county.

Currently, the Chief Medical Directors (CMD) in all 20 teaching hospitals are men.

This is despite the fact that women comprise the majority of the health workforce at teaching hospitals.

COVID-19 Presidential Task Force

President Buhari had on March 9, 2020 constituted the Presidential Task Force (PTF) on COVID-19 with membership from various sectors beyond health.

Since then, the PTF has coordinated a multi-stakeholder response to the pandemic, while providing technical and material support to states to manage the outbreak.

The PTF also serves as an advisory body to the president on specific decisions such as imposing and lifting lockdowns and provides daily feedback to Nigerians on the work being done to contain the pandemic through daily media briefings with journalists.

While Boss Mustapha, the Secretary to the Government of the Federation (SGF) chaired the PTF, Sani Aliyu, former head of Nigeria’s AIDS agency (NACA) was appointed as the National Coordinator of the PTF.

Of the 12 officials appointed to pioneer the PTF, only one was a woman – Minister of Humanitarian Affairs, Disaster Management and Social Development, Sadiya Farouq.

While COVID-19 has exposed a global failure to invest in pandemic preparedness, it also painted a clearer picture of a fundamental gender imbalance in the leadership of global health systems.

A recent report by Devex revealed that in the U.K., the pandemic security response team is entirely men; in its first phase, the U.S. team was the same.

Why are women underrepresented in health leadership in Nigeria?

Even though women, for the most part deliver health services in Nigeria constituting over 60% of the health workforce, they have a less equitable representation in the sought-after and consequential professional and leadership positions.

Experts traced this imbalance to a protracted patriarchy system which cuts across cut across the political, economic and developmental structure of the country.

In Nigeria, marginalization of women in juicy top spots go beyond the health system.

“The same issue that limits women from attaining political leadership positions is the same issue that limits them from attaining leadership positions in the health sector – Patriarchy in the system.”, Abiodun Essiet, a gender activist and community development worker said.

Mrs Essiet, a nurse said there are more women in the nursing profession than any other medical profession. “But doctors are regarded as the head of the medical profession and they are mostly men which limits another sector like nursing to attain the leadership position where you have most men.”

Austin Aigbe, a gender advocate agreed with Mrs Essiet’s position.

“The leadership of health workforce is streamline to only medical doctors, as you know there has been a challenge, on who should lead in the sector. As of this day, Medical doctors still seem to be leading”, he said.

“Doctors are appointed even in the health facilities to lead others. They are the ones appointed as ministers and commissioner of health, Chief Medical Directors (CMD), etc.

“It is true that women account for about 70% of health care workers, but they are largely found in Nursing and Midwifery, and other low lever cadre of the medical professional”, Mr Aigbe, a programme director at the Centre for Democracy and Development (CDD) said.

A 2018 report published by the Nigerian Bureau of Statistics (NBS) revealed that only about 30 to 35 per cent of doctors in Nigeria are women. The data also showed that Nigeria had 29.5 per cent of female dentists in 2015.

“From this statistics, it is obvious that the medical doctor profession is dominated by men. And if medical doctors are the ones leading the sectors, you are going to always have low representation of women in the leadership position”, Mr Aigbe explained.

The years women invest in child birth and reproduction is also attributed to factors impeding their progression to leadership positions.

There is also the ever-present conflict between work and family life, for which because of the gendered role of home building, the woman is more affected than the men.

Why does it matter?

The CDD official said it is the same consequences with the poor representation of women in political leadership that play out in the health sector. “It means that more than half the population of the workforce aren’t duly represented. It means that matters that affect and impact on women are not prioritized. It means that the less (minority) will always decide for the more (majority).”

In health care, experts believe the gender misrepresentation is partly responsible for the adverse health outcomes and indices in Nigeria.

For instance, maternal mortality influences an increase in child mortality and contributes heavily to poor health indices of children in Africa.

Nigeria accounts for 20% of global maternal deaths, according to the WHO.

Children in households where a maternal death has occurred are about four times more likely to die than other children, a report by the Nigerian Health Watch revealed.

“One of the major roles of women is the role of caregiver. Based on the role of women as caregivers and as the major gender that accesses health services, women understand the challenges within the health system better, and if the health system is not in good shape women suffer, and the health indicators worsen”, Mrs Essiet said.

“Not having women in leadership positions in health sectors, limit women from making a critical decision in health that can improve the health system.”

Way forward

To improve female involvement in health leadership in Nigeria, Yemisi Oyegbile, a gender advocate said, “we must change cultural orientation that promote male domination in our society by creating awareness at home, school and church. Stereotypic beliefs that women are supposed to be seen and not heard no longer have a place in our lives.”

“Remove barriers that restrict women to providing only domestic roles

Promote women leadership and recognize those occupying leadership positions”, she noted.

For Mrs Essiet, “we must ensure an affirmative action principle that will lead to more women in the medical doctor’s cadre.”

Mr Aigbe said there is a need for structural adjustment in the health system to accommodate more women in leadership positions. “We need to sensitize women to aspire for leadership positions at the union and association level.”

“This means, we must begin from the entry point, at the colleges and medical schools. Intake must pay attention to enlistment of young women. There should be incentive for women to consider the cadre. And just before medical school, we must initiate programs that supports women in science. Promote actions that engages young girls to pursue science and then follow them up to be enlisted into the profession, not just nursing and Midwifery”, he noted.

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