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Although women comprise 70 per cent of the overall health workforce and 90 per cent of frontline staff, men occupy three-quarters of the leadership positions in health. Ironically, women are already leading health service delivery - and are doing it well as they have demonstrated throughout the pandemic. But they are clustered in roles accorded lower status and lower pay, and it is this power imbalance that exposes them to sexual exploitation, abuse and harassment (SEAH), according to a recent policy report from our organisation, ‘Women in Global Health'. 

This lack of representation means that women have no power where it counts to hold perpetrators to account, and challenge and transform harmful gender norms 

Testimonies from women in 40 countries, submitted in ten languages, were collected on our #HealthToo platform in an effort to better understand the underlying causes of the widespread problem of SEAH in health.

A major pattern that emerged from the stories was that of men in higher-status positions abusing power to coerce and force female employees into unwanted sexual contact in a cycle of ‘grooming’, threats and retaliation. This behaviour, the report states, is enabled by those who witness but do not act in defence of colleagues, effectively supporting a patriarchal culture that legitimises, downplays and perpetuates abuse. In order to address the power dynamic that has played into the hands of perpetrators of sexual abuse and exposed women to repeated abuse, there is an urgent need for “upstanders” to take action.

Another major root cause of SEAH in health is the lack of sanctions on men. Men are abusing women because they know they can do it with impunity. If they knew they would be sanctioned, lose their jobs and be called out publicly, they would be unlikely to initiate or prolong the abuse. It is therefore critical to address the underrepresentation of women in leadership, with women health workers locked out of the control room. This lack of representation means that women have no power where it counts to hold perpetrators to account, and challenge and transform harmful gender norms that perpetuate inequality and marginalise women’s voices.  

Another problem is that, in much of the world, there are virtually no mechanisms in place for women to report abuse with confidence. Most women reporting to the online #HealthToo platform did not make an official complaint. In some places, reporting mechanisms exist but on paper only and women do not use them for fear of retaliation, stigma and fear around standards of proof.  And in a significant number of countries, sexual harassment at work is not even yet considered a criminal offence, leaving women without legal protection and without any means of seeking justice. 

Without data collection and analysis, the issue remains hidden, exacerbating the difficulty for women to report such incidents.

Furthermore, international data on sexual harassment in the health sector is scarce, and where it does exist, it is not disaggregated by sex and is inconsistent and incomplete. Without data collection and analysis, the issue remains hidden, exacerbating the difficulty for women to report such incidents.

The associated trauma and mental health fallout experienced by women health workers was another key aspect of our findings. Despite the severity of the problem, trauma was found to be downplayed in the health sector and even ‘normalised’. The stories collected record the very serious trauma of women victims, including post-traumatic stress disorder (PTSD) and suicidal thoughts.

Our report thus makes several recommendations to address sexual exploitation, abuse and harassment in health. These include instituting a survivor-centred approach to ensure the rights of women health workers are clear; that they are protected from retaliation and have access to mental and legal support. Without clear targets, mandates and accountability measures set by decision-makers, there is a lack of information to inform policy decisions. In this absence of guidance, employers are neglecting to calculate the cost, both human and economic, of prioritising the protection of a minority who engage in abusive behaviour, over the protection of the majority of health workers who just want to carry out their work in a professional manner.

Although SEAH is a violation of human rights, internationally, many countries still lack laws to prohibit work-related sexual harassment. ILO Convention No. 190 (C190) is the first international treaty to recognise the right of everyone to a world of work free from violence and harassment, including gender-based violence and harassment. It was drawn up by the International Labour Organization (ILO) in wide consultation with workers, employers and women’s organisations, and came into force on June 25, 2021. Countries now have a real opportunity to end SEAH in the health sector and beyond by addressing weaknesses in legal and policy frameworks and definitions. To date, only 26 countries have ratified C190. Prioritising its ratification would enable all countries to bring their domestic law into line with the convention.

From the global to the institutional and personal level, we call for establishing the legal foundations for gender equality in the workforce, as well as for a culture change to ensure that perpetrators of abuse are reported and sanctioned. We must end the culture of “open secrets”. Women health workers have put up with enough. It is time for decision-makers to take action in their defence, and finally, reform the systems that pose a threat to their safety.