We are delighted to announce Pamoja Communications have been working with the Monitoring & Action for Gender & Equity project (MAGE) to develop their brand identity and website.
MAGE is a partnership between Johns Hopkins University and the Global Financing Facility for Women, Children and Adolescents (GFF), a multi-stakeholder partnership housed at the World Bank that is committed to ensuring women, adolescents, and children can survive and thrive. The project undertakes this work through the advancement and strengthening of gender- and equity-intentional monitoring and evaluation.
Pamoja Communication has worked with MAGE on the initial planning for the project and has now moved on to create a brand and a logo that accurately represents their work. That branding was then developed into the design for a website with appropriate text and illustrations that reflect the brand of the partnership, along with appropriate metadata, database and SEO.
In this blog post by Kate Hawkins, Saugat Pratap KC, Shreeman Sharma, Sophie Witter, Karen Miller, Jo Raven and Shophika Regmi, we report from the HERDi learning site in Kapilvastu, Nepal where ReBUILD for Resilience is implementing embedded health systems research.
“Nobody could have imagined the impact that COVID-19 created. I have been working as a paramedic for 25 years – I have seen floods and outbreaks. We did have small disaster management plans, but we were not prepared for the pandemic.” Siddhartha Kaji Bajracharya, Health Post in-charge
A recent visit to Kapilvastu, one of the districts in Lumbini Province of Nepal was an opportunity to hear from municipal elected officials of Kapilvastu Municipality (including mayor, deputy mayor and ward chairs) and health workers on their experiences during the early months of the COVID-19 outbreak in 2020. Their stories demonstrate the resilience of a local health system under strain, as well as the challenges of emergency planning, especially in a decentralised context, and important recommendations for institutional and structural changes.
When the pandemic hit, Kapilvastu, along with many local government authorities all over the world, found itself unprepared – in terms of human resources, medicines and supplies, infrastructure and information systems, with no obvious mechanism to generate the types of evidence that could help guide the emergency response.
Initially there was little federal guidance on how to respond. In this liminal space, local people had to make quick decisions about how to manage the crisis – innovating and adapting as COVID-19 unfolded.
Governance and communication
At the start of the pandemic there were no official updates through the usual federal government channels. In the absence of formal guidance, health workers and managers found information online, through Facebook and other global sites. While there is the potential for this type of source to broadcast dis- and misinformation, health workers were struggling with how to respond and counsel their constituencies. It was through online sources that they learned about aerosol transmission and isolating people suspected of having COVID-19.
They described chaos in their decision making in a context of rapid threat and information and resource gaps. To overcome this, local-level decisions had to be made by elected representatives as the situation evolved. Some of these decisions may not have been strictly compliant with the federal level but local actors were trying to avoid ‘unmanageable human catastrophe’, and this was made more challenging by the open border with India.
Kapilvastu Municipality formed two Rapid Response Teams that each comprise five team members. One was led by a health facility in-charge having a large catchment area, and another was led by a municipal health coordinator. The other team members included a nurse, a lab technician, a health assistant and an auxiliary nurse midwife who worked closely with the ward chair. Kapilvastu Municipality has 12 wards. The ward chair is the chair of the Health Facility Operation and Management Committee (HFOMC) in each health facility at ward level, and the Health facility in-charge is the member secretary of HFOMC, and together they quickly mobilized the Female Community Health Volunteers (FCHV). Municipality and ward offices, in coordination with local health facilities, enforced COVID-19 strategies at the local level. For health communication, FCHVs were mobilized, having the support of their communities and particularly close relationships with women and children given their work on maternal health and immunization.
Medicine and supplies
Sourcing test kits and PPE during the initial stages of the pandemic was challenging. Local stakeholders didn’t even have masks at first, and were conducting house visits while frightened of potential infection and the possibility of harming their own families. They described attending patients without even a thermometer to assist with diagnosis. When test kits finally did come through, the PCR results were processed in Kathmandu and took 30 days to come through and this long timeframe hindered planning and action. When PPE did arrive it wasn’t fit for purpose. Health workers described taking 300-400 swabs a day in 35 degree heat inside stifling PPE that couldn’t be removed until the day was over.
Local-level decision-makers were tasked with opening quarantine centres for people who they suspected were infected with COVID-19. But this was easier said than done as they had no existing infrastructure to use and they were unsure how to isolate people. In the end, they used the school buildings that were closed due to lockdown and quarantined more than 5,000 people in 12 wards. When the weather allowed, people from the isolation centre could stay in the fields outside, but when the heat and rains came there was a serious lack of space inside the building. They also had to run toilet facilities where none had previously existed plus the schools were not accessible for people with disabilities. Caring for Nepali migrant returnees from India was also a challenge as they didn’t have family members to bring them food every day, or had care takers who lived far from Kapilvastu. This problem was compounded by food shortages at that time. The health workers were also impacted by this and had to work throughout the day fuelled just by fruit, with most shops closed during the lockdown.
On the Nepali-Indian border the arrival of people from India was also an issue. Potentially infected Nepali people were returning home and needed to be tested and cared for, so a new border health check was created at Krishnagar border. At the peak of the pandemic, staff (who themselves fell ill) tested around 300 returnees each day, issuing each infected person with care information. Unfortunately, the majority probably got straight on to public transport, spreading the infection further. This testing facility continues to run, supported by international NGOs, the EU and Kapilvastu Kids, however the nearby new quarantine facility remains unopened due to a lack of funds. (Another problem was migrant returnees entering Nepal via unofficial, unregulated transit points and not being tested.) The border health desks still test for COVID-19, TB, malaria and HIV but on a purely self-referral basis, and samples still need to be sent to Kapilvastu for screening, raising questions over patient and contact tracing and treatment.
Human resources for health
The COVID-19 response relied heavily on the health workforce; a workforce already understaffed and under strain. When these health workers themselves got infected with COVID-19 this was a significant challenge. In one of the health posts all of the staff were infected and it had to be shut down altogether. The Nepal Police helped with the response, managing the food provided in the quarantine centre and how funds were allocated for this. There was adaptation in the absence of guidance to try and ensure that the poorest were targeted, but because of the lockdown it wasn’t possible to launch a multi-sectoral approach and NGO staff stayed at home until much later in the pandemic.
Local health facilities struggle to provide routine health services on a good day and this was further aggravated when there is an emergency. For instance, Kapilvastu Municipality has five primary health centers, but not all sanctioned positions have been filled. Also, around 40% of the municipality’s population live in just four of twelve wards, and with just two health workers to deal with around 9,000 people in each ward the situation is very challenging. Furthermore, Kapilvastu is prone to disease outbreaks due to several socio-economic and geographic issues. During shocks like COVID-19, local health systems have trouble meeting routine health demands with such emergencies exacerbating the issue. Therefore, the resilience of the local health system is a pressing issue in Kapilvastu Municipality.
Looking to the future
The health system was heavily impacted by the pandemic. Immunisation, family planning and nutrition services – the foundations of primary health care – were all put on hold for more than three months. Data collection ceased. When services did resume they took time to get up to speed. In rebuilding the health system, lessons from the outbreak have been incorporated into practice and longer term aspirations:
Communication during the pandemic cemented the importance of mobile phones. Now the health posts have access to the internet which was not a priority before. Better communications are a key priority for the future.
In terms of infrastructure and medical supplies, the first stage of the emergency highlighted the need for greater testing and lab capacity, and the scarcity of oxygen in the second phase taught the importance of strengthening hospital care.
The pandemic highlighted how health emergency decisions by federal governments, such as the decision to impose a lockdown, may have hampered local level coordination and action. Stay-at-home orders prevented a truly multi-sectoral approach and led to a reliance on the police and army where other sectors might have been more appropriate. Restrictive measures based on the local context may be more appropriate.
During the emergency, the mayors had informal conversations and there was a formal inter- and intra-municipal sharing process. However, there were no mechanisms for sharing lessons learned across municipalities and communicating these stories of adaptation from one local level to another local level and from local level up to the provincial and federal governments. This is still lacking.
Most of the local level health budget is conditional and this potentially restricts decision making space which is vital in emergencies (although there was a pot of flexible emergency funding that could be used in emergencies). Progressive flexibility could be considered in times of extreme hardship.
ReBUILD with HERD International will continue to document the lessons from the COVID-19 experience, working with municipal partners to identify ways to strengthen the resilience of the local health system, building on the capacities identified and the gaps (for example, around communication), and to share those lessons with other areas and with the district, provincial and national authorities.
The objective of this research was to explore midwives’ experiences working on the frontlines of the COVID-19 pandemic in British Columbia, Canada. It is a qualitative study involving three semi-structured focus groups and four in-depth interviews with 13 midwives. The research took place during the COVID-19 pandemic in British Columbia, Canada from 2020-2021. Qualitative analysis surfaced four key themes. First, midwives faced a substantial lack of support during the pandemic. Second, insufficient support was compounded by a lack of recognition. Third, participants felt a strong duty to continue providing high-quality care despite COVID-19 related restrictions and challenges. Lastly, lack of support, increased workloads, and moral distress exacerbated burnout among midwives and raised concerns around the sustainability of their profession.
Lack of effective support for midwives during the initial months of the COVID-19 pandemic exacerbated staffing shortages that existed prior to the pandemic, creating detrimental gaps in essential care for pregnant people, especially with increasing demands for homebirths. Measures to support midwives should combat inequities in the healthcare system, mitigating the risks of disease exposure, burnout, and professional and financial impacts that may have long-lasting implications on the profession. Given the crucial role of midwives in women- and people-centred care and advocacy, protecting midwives and the communities they serve should be prioritized and integrated into pandemic preparedness and response planning to preserve women’s health and rights around the world.
The COVID-19 pandemic has disproportionately impacted women and vulnerable groups, magnifying existing gender inequalities. To prevent inequalities from further widening, countries must urgently address and mitigate the gendered impacts of the pandemic. In this report, we outline the gendered impacts of the pandemic in Kenya, summarise measures taken by the Kenyan government to address these impacts, and offer recommendations to strengthen the pandemic response.
Our analysis of the gendered impacts of the pandemic comprises both primary and secondary impacts. Primary impacts refer to immediate, direct impacts of the pandemic, such as COVID-19 infections and deaths. Meanwhile, secondary impacts refer to longer-term social, economic, and non-COVID-19 health impacts. Through our analysis, which drew on government publications, academic journals, grey literature, and news articles, we found that:
In Kenya, men comprised 56.4% of confirmed COVID-19 infections and 64.8% of COVID-19 deaths, as of 15 February 20221.
There is no publicly available sex-disaggregated data on nationwide COVID-19 vaccinations and testing rates, nor on hospitalisations and intensive care unit admissions.
Unvaccinated women were less likely to try to get a COVID-19 vaccine compared to unvaccinated men, even though vaccine acceptance is similar between both groups.
Nationwide, two in three adults who lost all their income in 2020 were women, with the most affected category being women working in the informal economy and depending on daily wages.
The government’s financial assistance for businesses, such as lower interest rates and tax relief, were targeted at the formal sector and thus did not benefit many women.
Cash transfer programs barely reached those who needed them most. Only 5% of households in Nairobi’s informal settlements received cash transfers in the first phase of the program between April and November 2020.
Over 50% of young women who were unable to meet their basic needs reported depressive symptoms.
Women disproportionately shouldered the increased care work resulting from school closures and taking care of the sick: 76% of women and only 24% of men helped to home school their children.
Nationally, adolescent secondary school girls were twice as likely to become pregnant and three times more likely to drop out of school because of school closure during lockdown.
Gender-based violence reported through the national helpline 1195 recorded a sharp increase of cases from 86 in February to 1,100 in June 2020.
Kenyan health care workers, the majority of whom are women, reported inadequate personal protective equipment and training on COVID-19 management, understaffing, long hours, burnout, deteriorated mental health, isolation from family, social stigma, lack of comprehensive medical cover, and inadequate risk allowance and compensation, among other grievances.
Women are greatly underrepresented in COVID-19 leadership. For example, the National Emergency Response Committee on Coronavirus only included four women (19% of membership).
Trust is the bedrock of all relationships and is a key ingredient to establishing effective relationships between different players, be it researchers, communities, countries, policymakers or scientists. In this blog Lynda Keeru shares a discussion between Prof Doris Schroeder, Lauren Paremoer and Ethan Greenwood in the Trust, Trustworthiness and the COVID-19 pandemic webinar, organized by the Global Health Network. The blog captures lessons, best practices and processes in build and maintaining trust in international research particularly in the face of epidemics.
Doris defined trust, trustworthiness and explained to the webinar participants on the difference between the two. Trust is given while trustworthiness needs to be earned. Public health authorities and governments need to earn trust of the population they serve and the population/citizens on the other hand should give trust.
Community engagement and various other exercises should be included in research processes to increase trust in international research. Doris noted that it is not often that the trustworthiness is examined and emphasized and that this should be done regularly. She reflected on the key things that should be done to strengthen trust and identified fairness, respect, care and honesty as key values. They are not only ethical values, but also personal characteristics. To this end, you can assess whether a person acts with fairness, respect, care and honesty; or whether they act out of the opposite which is self-interest, manipulation, hypocrisy and dishonesty. During the COVID-19 pandemic, significant distrust was observed among countries during the pandemic. Unfortunately, it requires a lot of courage to point out when leaders are operating from a point of self-interest. A closer relationship between ethicists and psychologists would help pinpoint particular topics and issues; like manipulation in social media that hampers COVID-19 efforts.
Doris shared best practices from a project she was involved in that aimed to build trust in international research despite significant resource differentials. She indicated that a majority of leaders were from low- and middle-income countries (LMICs) and the majority of team leaders were women. They had two communities from Kenya and South Africa involved from the start who gave input on exploitation risks. They documented 88 such risks. They then analyzed and mapped them out into ethical value. All of them zeroed into fairness, respect, care and honesty. This work has been translated into a practical framework for others to use.
Lauren’s presentation focused on social citizenship and the idea that states have an obligation to realize the welfare of citizens. This could mean their health but also their welfare in other dimensions including education. States are positioned differently in the global political economy in terms of ability to realize this obligation. Historically, LMICs have struggled to realize the social rights of their citizens and one of the key drivers of this has been the lack of access to public monies and resources in order to deliver on the promises of social inclusion.
A long view by political scientists locates this lack in historical dynamics, particularly colonial dynamics. The incorporation in the global political economy has led to developing states focusing more on extractivist modes of production, to prioritize their foreign obligations more that their social obligations towards citizens. For this reason, even with COVID-19, many citizens have felt abandoned by their states and having abandoned prioritization of their wellbeing in the service of growing the economy and serving needs of global capital. On a concrete level, this is reflected in disinvestment of systems, particularly public health systems and the increasing privatization of care. These are some of the structural issues that made it hard for citizens to access care during the pandemic; and this was experienced both in the global north and south.
In LMICs, problems with trust are not necessarily only with the state, but also with the global political economy. A concrete example of this is that in November 2021, South African scientists undertook excellent surveillance on COVID-19 mutations and they identified the Omicron variant and were transparent in their communication. They said that it was highly contagious and because of where South Africa is positioned in the global political economy, they received a lot of blows including border closures and stigmatization. Owing to this, when we think of trust, we should not think of it only in terms of government versus citizens.
Ethan shared a presentation with a focus in the context of the pandemic. Just when the pandemic had begun and lockdowns were in full swing, trust in scientists across the world increased in every region except for Sub-Saharan Africa, Russia and Central Asia. Trust generally increased in all types of institutions including doctors and governments. One explanation for this might be since all people were in this crisis, they had no choice but to trust what they were told. People interviewed stated that they trusted doctors and nurses the most, then health organizations, closely followed by governments. Despite the high trust in scientists, only a quarter of people felt that their governments valued scientific advice.
Trust in what science creates in terms of trust in vaccines is very much linked to trust in scientists but it is not a black and white issue and it varies. In France for instance, trust in scientists is high and distrust in vaccines is also quite low. The correlation generally does stand. In LMIC’s, trust tends to be high and whether or not there was trust for vaccines, it did not make a difference.
In order to increase trust, scientists must and should listen and understand the needs of the public. Trust among the public really does vary within countries. In about 80% of countries where people said that they were living comfortably, they were more likely to trust scientists than those who said that they did not were just getting by or struggling. It is important for governments and other partners to be perceived as competent and reliable. Consistent communication is also crucial.
Women represent the majority of people working to improve health outcomes in communities, non-governmental and multilateral organizations, both as paid and unpaid health and social care workers. So why is it that when it comes to leadership positions, we have a governance system that privileges men and what can we do to redress the imbalance? This ground-breaking collection explores the leadership roles that women hold in global health, teasing out the routes women have taken to leadership, the challenges they have faced, and what has facilitated their journey. It brings to the fore the stories of women on the frontlines of this struggle from around the world, highlighting and complementing these stories with theoretical and analytical explorations of the structures and systems that help or hinder the process. Among the topics explored:
Gendered Institutions in Global Health
Gender, Peace, and Health: Promoting Human Security with Women’s Leadership
Academic Journal Publishing: A Pathway to Global Health Leadership
Women in Health Systems Leadership: Demystifying the Labyrinth
Women’s Leadership in Global Health: Evolution Will Not Bring Equality
The book is a rallying call to arms to redress gender inequality and celebrate the many ways in which women are taking the lead in supporting the health of their communities internationally.
Women and Global Health Leadership is a must-read for those working in or studying global health. It is also a primer that aims to support other women in their efforts and struggles to succeed in a highly unfair and unequal world. The book will engage ministers of health, policy-makers, practitioners, academicians, students, researchers, healthcare workers, health service managers, and members of multilateral organizations. By highlighting key barriers and facilitators to women in global health leadership, organizations can use this book to help inform the development of institutional policies and procedures to support women in leadership positions across academic, health workforce, and global health governance systems. It also can be used within postgraduate courses focusing on the global heath workforce, leadership and management, and women’s studies.
This book could not have been launched on a more befitting day, International Women’s day 2022. The authors and editors of the book are a bunch of brilliant, erudite women, well versed in global health matters. The book is a rallying call to arms to redress gender inequality and celebrate the many ways in which women are taking the lead in supporting the health in their communities. The launch was a very timely, as it presented an opportunity to celebrate women taking lead in supporting the health in their communities and their historic contribution.
This book is a first of its kind as it fills the gap in the literature. At a time when women are experts in global health but their professional experience and diverse perspectives are not valued sufficiently to guarantee them an equal place in leadership, the launch of this book is incredibly apt. Women held only 25% of leadership roles in health before the pandemic and women from the global south are further under-represented yet they make up 70% of the workforce. The frontline response of the pandemic was 90% women.
The establishment of root drivers of inequality and driving systems’ change are some of the key themes in the book. The book is inspired by partners, movements, organizations and communities that have been working to advance gender equality and spotlight women’s leadership.
A lot of ground has been lost with the onset of the pandemic and since this book went into production. A look at WHO’S Executive Board, the percentage of number of women that hold these seats went from 30% in early 2020, to 6% in January 2022. This is a reflection of where power is being shifted. This book highlights the many forms of leadership and demystifies social norms that reinforce the myths that men are natural leaders and women are destined to be followers.
Women in Global Health propose a four-point framework for change to support women’s leadership. First, governments must build the foundation for equality. Secondly, addressing social norms and stereotypes that drive gendered segregation. Third, is the need to address systemic inequalities and bias in work places and culture that favors men for leadership roles. Finally, enabling women to apply for leadership positions equally and on merit.
The book compiles research evidence examining barriers and facilitators to women’s global health leadership. It showcases personal, professional and political journeys to leadership of women across global health sectors. It additionally offers pragmatic solutions to increasing women’s representation in global health at different levels. It is a labor of love consisting of contributors and interviewees from 17 countries and six regions; hence providing a diversity of voices globally.
The book was inspired by a question that sought to find out:
“Why despite women representing the majority of people working to improve health outcomes in communities, non-governmental and multilateral organizations both as paid and unpaid health and social care workers, the existing governance system privileges men and what can be done to redress the imbalance?”
It takes its readers on an exploration of leadership roles that women currently play in global health and teases out the routes that women have taken to leadership. It also explores the challenges that these women have faced and things that have facilitated their journeys.
It brings to the fore stories of women on the frontlines of this struggle from around the world highlighting and complimenting these stories. It buttresses this with theoretical and analytical explorations of the structures and systems that help or hinder the process. The authors engaged ministers of health, policy makers, practitioners, academicians, students, researchers, healthcare workers, health service managers and members of multilateral organizations.
By highlighting key barriers and facilitators to women and global health leadership, the writers hope that organizations will use this book to help inform the development of institutional policies and procedures to support women in leadership positions across academic, health workforce and global health governance systems.
The editors too had a heartfelt word for their readers:
“We hope that within the pages of this book you will find information, inspiration and hope for how you can play a part in changing systems that no longer serve us well: information about women’s leadership experiences, inspiration from women leaders themselves, and hope for leadership systems and structures which are more equitable and just-leadership which places the most marginalized at the center and purposefully works towards positive change.”
Fragile and shock-prone settings (FASP) present a critical development challenge, eroding efforts to build healthy, sustainable and equitable societies. Power relations and inequities experienced by people because of social markers, e.g., gender, age, education, ethnicity, and race, intersect leading to poverty and associated health challenges. Concurrent to the growing body of literature exploring the impact of these intersecting axes of inequity in FASP settings, there is a need to identify actions promoting gender, equity, and justice (GEJ). Gender norms that emphasise toxic masculinity, patriarchy, societal control over women and lack of justice are unfortunately common throughout the world and are exacerbated in FASP settings. It is critical that health policies in FASP settings consider GEJ and include strategies that promote progressive changes in power relationships. ReBUILD for Resilience (ReBUILD) focuses on health systems resilience in FASP settings and is underpinned by a conceptual framework that is grounded in a broader view of health systems as complex adaptive systems. The framework identifies links between different capacities and enables identification of feedback loops which can drive or inhibit the emergence and implementation of resilient approaches. We applied the framework to four different country case studies (Lebanon, Myanmar, Nepal and Sierra Leone) to illustrate how it can be inclusive of GEJ concerns, to inform future research and support context responsive recommendations to build equitable and inclusive health systems in FASP settings.
Throughout the COVID-19 pandemic, as measures have been taken to both prevent the spread of COVID-19 and provide care to those who fall ill, healthcare workers have faced added risks to their health and wellbeing. These risks are disproportionately felt by women healthcare workers, yet health policies do not always take a gendered approach.
The objective of this review was to identify the gendered effects of crises on women healthcare workers’ health and wellbeing, as well as to provide guidance for decision-makers on health systems policies and programs that could better support women healthcare workers.
A scoping review of published academic literature was conducted. PubMed, EMBASE, and CINAHL were searched using combinations of relevant medical subject headings and keywords. Data was extracted using a thematic coding framework. Seventy-six articles met the inclusion criteria.
During disease outbreaks women healthcare workers were found to experience: a higher risk of exposure and infection; barriers to accessing personal protective equipment; increased workloads; decreased leadership and decision-making opportunities; increased caregiving responsibilities in the home when schools and childcare supports were restricted; and higher rates of mental ill-health, including depression, anxiety, and post-traumatic stress disorder. There was a lack of attention paid to gender and the health workforce during times of crisis prior to COVID-19, and there is a substantial gap in research around the experiences of women healthcare workers in low- and middle-income countries during times of crises.
COVID-19 provides an opportunity to develop gender-responsive crisis preparedness plans within the health sector. Without consideration of gender, crises will continue to exacerbate existing gender disparities, resulting in disproportionate negative impacts on women healthcare workers. The findings point to several important recommendations to better support women healthcare workers, including: workplace mental health support, economic assistance to counteract widening pay gaps, strategies to support their personal caregiving duties, and interventions that support and advance women’s careers and increase their representation in leadership roles.
Objective To explore how gender influences the way community health workers (CHWs) are managed and supported and the effects on their work experiences.
Setting Two districts in three fragile countries. Sierra Leone—Kenema and Bonthe districts; Liberia—two districts in Grand Bassa county one with international support for CHW activities and one without: Democratic Republic of Congo (DRC)—Aru and Bunia districts in Ituri Province.
Participants and methods Qualitative interviews with decision-makers and managers working in community health programmes and managing CHWs (n=36); life history interviews and photovoice with CHWs (n=15, in Sierra Leone only).
Results While policies were put in place in Sierra Leone and Liberia to attract women to the newly paid position of CHW after the Ebola outbreak, these good intentions evaporated in practice. Gender norms at the community level, literacy levels and patriarchal expectations surrounding paid work meant that fewer women than imagined took up the role. Only in DRC, there were more women than men working as CHWs. Gender roles, norms and expectations in all contexts also affected retention and progression as well as safety, security and travel (over long distance and at night). Women CHWs also juggle between household and childcare responsibilities. Despite this, they were more likely to retain their position while men were more likely to leave and seek better paid employment. CHWs demonstrated agency in negotiating and challenging gender norms within their work and interactions supporting families.
Conclusions Gender roles and relations shape CHW experiences across multiple levels of the health system. Health systems need to develop gender transformative human resource management strategies to address gender inequities and restrictive gender norms for this critical interface cadre.