The math seems to be off, in the equation of health and healing. Official data suggests women constitute almost half of all of India’s health workers. Yet, only 18% of them make it to the top of the pyramid, reaching leadership positions across health panels, committees, hospitals, colleges and ministries. That means for every woman, there are more than four men in a health setting.
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Emerging research is putting the health sector’s worst-kept secret on display: diversity gaps. The cone of the pyramid has an “over-concentration” of not just men, but of doctors, individuals from Delhi-NCR, and bureaucrats, according to a new analysis of India’s National Health Committees between 1943 and 2020. The over-representation of privileged actors and lack of diversity indicates a “centralisation” of the health policy. If power is concentrated in circles — with gender, geography and socio-economic markers at their compass — it risks creating skewed health systems ridden with inequality, experts note.
This constitutes a very middle-class, or an upper-middle-class elite set of policymakers, making decisions for 70% of people whose lives they don’t understand, says Vandana Prasad, a public health professional associated with Public Health Resource Network. In another reality, with a more equitable representation from stakeholders, “the policy, program and implementation will all be different and the outcomes will be much better. The lack of participation is one of the reasons we are not arriving at the outcomes we want.”
The gender question
The present study was the first to analyse the composition of India’s National Health Committees — a sort of sitting of health elders that a body that recommends what policies to introduce and how to implement health programs across the country. Gender, experience and location of decision-makers are known to impact their decisions, wrote authors Disha Agrawal, Parth Sharma and Vikash Keshri. Only 11% of women were present in 23 health committees, and there was no woman present in 36% of the committees studied.
Take the Devi Shetty Committee formed for the Prevention and Management of COVID-19 Third Wave in 2021. Public health expert Prashanth N. Srinivas pointed out the committee is primarily led by male clinicians, lacking the diverse expertise needed to tackle a global health crisis. The committee, initially comprising only men, added two women after facing criticism. Agarwal et. al. found that gender diversity improved marginally in committees formed post-2000, rising from 9% to 15%, with some panels formed to discuss “broader perspectives on healthcare...thus reflecting more diversity”.
Diversity impacts the nature of policies made, “because you are looking only from a certain lens”, says Dipa Sinha, a professor at Ambedkar University with a focus on public health and gender. “The committees can have well-meaning people, but if these are all upper-caste, privileged men located in urban areas”, it stymies the level of detail, care and attention needed for inclusive health policies. When officials started deliberating on rising anaemia and malnutrition levels among women, the public health messaging was to encourage women to eat better: green, leafy vegetables, or eggs. “There was no recognition that women might not be able to afford it and even if they do, there is an intra-household difference,” says Dr. Sinha. If a woman were on these committees from the start, she says, ‘experts’ might have realised earlier that women’s experience of food is gendered.
Photo Credit: “Who drives the health policy agenda in India? Actors in National Health Committees since Independence” (Dialogues in Health, June 2024)
The gender gap in health is like any other sector, Dr. Sinha says. “As you go higher, you have to fight for your views and your voice.” Outside of health committees, the representation looks equally bleak: there has been only one woman out of the 16 directors of the All India Institute of Medical Sciences, New Delhi; only three women executive directors of the 18 new AIIMS proposed by the Ministry of Health and Family Welfare, a Lancet journal paper noted.
The institution is designed in a way that women are concentrated at the frontline low-paid positions at the lower end of the hierarchy, and find limited opportunities to climb the ladder. Women make up 29% of doctors, 80% of the nursing staff, and nearly 100% of Accredited Social Health Activists (ASHAs) in the country. Moreover, their job is classified as ‘care work’, not technical enough, further devaluing their knowledge. Women across the workforce, on average, earn 34% less than men, according to another report by Dasra NGO.
In the present study, the only committee with six nurses in attendance was the High-Power Committee on Nursing and Nursing Profession. “There is a lot of mansplaining...Women will need much more evidence and support to say the same thing as a man to get heard,” says Dr. Sinha. “They also often fall into the trap of being blamed for bringing up these ‘sensitive’ or gendered issues.”
This perception fuels a larger discrimination against women’s abilities and leadership potential. I
Culturally, a “system of patriarchy definitely seems to affect women”, says Dr. Prasad. Choices are often made based on norms, childbearing and familial expectations; careers interrupted to meet the demands of gender. The National Sample Survey Office found that around 31% of women with medical education in 2018 were out of work because they were engaged with household tasks. Medicine itself, with long working hours and demanding rotas, is seen as being untenable for women who are the primary caretakers in a family. Scholar Joan Acker contextualised workplace inequality: job demands “are structured on the assumption that the ordinary worker is a man... who has few obligations outside work that could distract him from the centrality of work”. Instead of ‘glass ceilings’, Ms. Acker suggested ‘inequality regimes’ as a more accurate metaphor for the challenges women face in advancing in their careers. Dr. Prasad notes, “There will be fewer women, and they’ll be less visible, but that’s not because of any inherent lack of skills or interests. That’s the way the society is gamed.”
Step back, and the trend reflects globally: 70% of CEOs and board chairs across 201 global health organisations were men, and just 5% of leaders were women from low- and middle-income countries. A report from Women in Global Health found women occupy only 25% of senior positions and 5% of leadership roles in the healthcare sector, despite making up 70% of the overall global health workforce. The underrepresentation of women in medical leadership sets in motion a cycle: fewer women, fewer mentors, and fewer safe spaces for women to work and air their concerns. “Current leadership structures are failing to address issues of low or no pay, procedures and protective equipment are tailored to male measurements and sexual abuse and harassment is too common in the workplace” pushing women out of the health workforce, said executive director Roopa Dhatt. It also “severely impacts” health delivery and health security.
“If we truly want to build health systems that serve everyone, we need to redress the inequality that has side-lined women from leadership and start listening to women.”Roopa Dhatt
The Women in Global Health report recommended a host of measures. Hiring, promotion and rotating doctors decisions should be made taking into account identity-based challenges; efficient, anonymous systems to report misconduct; adapting systems to “encourage women doctors and medical leaders with dedicated resources and flexible working arrangements that promote work-life balance...to shatter glass ceilings and glass fences”.
In an Indian context, Dr. Sinha and Dr. Prasad also recommend reserving seats for women and people from marginalised social locations on health committees, similar to the women’s reservation in the legislature. There are glass ceilings and inequality regimes to tackle, but affirmative policies will give them a starting point. Governments, they suggest, need to include people with deliberate policy and deliberate intent, “not just lip service”. “There are women who would be appropriate [for leadership roles]. They may have to travel further, they may have to be encouraged to come....but efforts need to be made to find them,” Dr. Prasad adds.
A ‘top-down approach’
India’s National Health Policy, read in tandem with Niti Ayog’s ‘Vision 2035’ white paper on public health surveillance, promotes diversity in political, policy, technical, and managerial leadership at both national and state levels. However, there is a “larger leadership competency gap” in Indian health policy, which has many dimensions, and gender is a part of it, a Lancet paper noted.
The present study did not include an analysis of the caste and ethnicity composition of national health committees or panels, citing a lack of data.
While there is a global gap, India is unique on two accounts: medical leadership is concentrated in Delhi-NCR (with almost half of the members present there), and there is a high degree of influence from doctors and government officials. “The hilly areas of the North-Eastern states have very low representation in the committees, while the metropolitan cities are disproportionately represented,” Agarwal et. al. pointed out. Different places arguably have different needs: a public health centre in Bastar or the northeast is very different from one in, say, Delhi or Chennai. The present study noted that post-2000, committees are getting more diverse, in including women, NGOs and non-medical academia. At the same time, centralisation has increased too, from 53% before 2000 to 83% in the recent years.
Photo Credit: “Who drives the health policy agenda in India? Actors in National Health Committees since Independence” (Dialogues in Health, June 2024)
From the Central Government, there is a “top-down” approach and an insistence to apply a “uniform pattern”, says Dr. Sinha. Take the policy on ambulance services. In some parts of the country where ambulance buses don’t work, you might need a boat, or, a person may need another mode of conveyance to connect them from the village to a road. “You get only [this perspective] when you have diversity in decision-making,” says. Dr. Sinha. Both are important: more diversity in central committees, but also a decentralised processes “so that policies are not made by eight people sitting in another city.”
The research also pointed to a noted “domination” of doctors in health committees. Scholars Julie Davis and Kamal Gulati wrote in an article noted that doctors often reach executive leadership roles “based on seniority without ever receiving formal management training”, suggesting that people in health leadership “lack appropriate management and leadership competences and practices”.
On the matter of government influence, Dr. Prasad notes their presence is important as the managerial arm of the government, but their “main task is to represent the Health Ministry, and they may or may not have a full understanding of ground realities or technicalities”, or the necessary experience in the sectors” they are charged with forming policies on. They are often perceived as “controlling”, playing a “policing role” in the way discussions unfold. “A lot of times we find that even in the minutes [of the meeting], dissenting views are not recorded,” she says. It impacts how transparent the proceedings are, and who gets to speak. “Even how much time is given to people to speak is regulated,” Dr. Prasad adds.
What is more important than people being or not being there is the balance of power, Dr. Prasad notes, adding that “the bureaucracy wields much more power than any individual or expert coming in.” Some experts have voiced concerns about conflicts of interest in the composition of national committees. The Alliance for Sustainable & Holistic Agriculture (ASHA) report alleged a “conflict of interest” in the committee charged with deciding India’s fortified food programme, noting that some stakeholders were “profiting financially” from expanding fortification drives, and imperilling the health of marginalised communities in the process.
The Devi Shetty Committee on COVID-19 management, headed by an entrepreneur and a doctor, bunched philanthropists with the public policy sector, and suggested resource allocation through an “agency” for equity, commented Dr. Prashanth in an X post. While recommending solutions for vaccine booking, the report fleetingly mentioned “rural communities” may need help with slot booking. This showed a “lack of understanding of both software or its social realities,” he said.
“Industry members directly profiting from a certain decision should not be allowed in a decision making capacity.”Vandana Prasad
Redefining policy making
The composition of India’s health committees reveals more than its gender or geographical make-up. A tendency to view public health from the lens of clinical medicine only. It’s always disease not dignity, cure not care. Diseases like malaria and tuberculosis got their vertical programs early on in; their social determinants, or how gender or caste impact transmission and treatment, still fight for attention. The “neglect of preventive care” reflects in how nurses are treated, how ASHAs are paid, and how medical doctors are over-represented in these committees, says Dr. Sinha.
Medical experts are important, but equally significant are those who look at health from a population point of view.
A missing piece in who makes our health policies, also, is the people themselves. “We’ve started to think in terms of men and women, even geographical representation, but are still not thinking about representing directly affected people,” Dr. Prasad points out. When making policies on food fortification, the 80 crore people who are going to be handed the rice through government schemes deserve representation, she adds. Larger bodies of patient organisations, including the Consortium of Accredited Healthcare Organisations, advocate for hospitals to institute Patient Advisory Councils to promote patient involvement and safeguard their health rights.
It comes down to intent. “What do we want to do? Do we only want to create an illusion?” she asks. And, “If we wanted to know the truth, to take good action, there’s no other way but to ask and include people,” Dr. Prasad adds.
