Lower wages and discrimination come out as important features of the challenges women employed in the health and care face, according to an ILO study. But, the study barely makes any mention of the situation of workers in India’s health and care sector. The working conditions of India’s ASHA, whose work was recognised only recently by the WHO, find no mention in the study.

Women working in the health and care sector earn nearly a fourth less than their male counterparts – a larger gender pay gap than in other economic sectors, two UN agencies said in a new report on Wednesday.

The gender pay gap in the health and care sector: a global analysis in the time of COVID-19, was published by the International Labour Organization (ILO) and the World Health Organization (WHO).

It documents a raw gender pay gap of roughly 20 percentage points which jumps to 24 percentage points when factors such as age, education and working time are taken into account.

Silence on ASHA Workers

Surprisingly, there is no mention in the ILO-WHO study of India’s community-based health and care workers, the million-strong force of accredited social health activists or ASHA workers. ASHA workers, considered the foot-soldiers of India’s National Rural Health Mission are not paid a fixed monthly salary – rather they are given an honorarium and programme-based incentives.

ASHA workers are not described as employees of the government – instead, they are supposed to be honorary volunteers in bureaucratic jargon. But the nature of their engagement is anything but voluntary – for instance, the government has not hesitated to enforce the Essential Services Maintenance Act (ESMA) to quell their protests for salaries.

In fact, the WHO had recently praised the work by ASHA workers and recognised their outstanding services during the COVID-19 pandemic.

Drawing attention to their “abysmally low payment”, ASHA workers in Delhi even put their distress on record when they said, “….while the world has acknowledged out efforts, our very own governments do not admit our contribution.”

Discrimination a factor 

While much of this gap is unexplained, the agencies said it is perhaps due to discrimination towards women, who account for nearly 70 per cent of health and care workers worldwide.

The report also revealed that wages in the health and care tend to be lower overall when compared with other sectors, which is consistent with the finding that wages often are lower in areas where women are predominant.

Furthermore, even with the pandemic, and the crucial role played by health and care workers during the crisis, there were only marginal improvements in pay equality between 2019 and 2020.

“The health and care sector has endured low pay in general, stubbornly large gender pay gaps, and very demanding working conditions. The COVID-19 pandemic clearly exposed this situation while also demonstrating how vital the sector and its workers are in keeping families, societies and economies going,” said Manuela Tomei, Director of Conditions of Work and Equality Department at the ILO.

Bangladesh figures among 18 of the 54 countries among which the mean hourly gender pay gap in the health and care sector is estimated to be at least twice as high than in other sectors of the economy – 14.8 per cent compared with 6.9 per cent.

Working mothers penalized 

The report also found a wide variation in gender pay gaps in different countries, indicating that these gaps are not inevitable and that more can be done to close the divide.

Within countries, gender pay gaps tend to be wider in higher pay categories, where men are over-represented, while women are over-represented in the lower pay categories.

Mothers working in the health and care sector also appear to suffer additional penalties, with gender pay gaps significantly increasing during a woman’s reproductive years and persisting throughout the rest of her working life.

The study found the gender pay gap increasing around the age of child-rearing (30–35), while the proportion of full-time work declines for women but not for men at around the same age.

“It would not be surprising to find that more women workers compared with men workers (both with family responsibilities) find it difficult to cope with the demands imposed by the sector,” the study says and gives the example from India where nurses with children and family responsibilities found it significantly more difficult to cope with regular morning, evening and night shifts, resulting in significant deterioration of their own health.

A more equitable sharing of family duties between men and women could lead to women making different job choices, according to the report.

The analysis also examines factors that are driving the gender pay gaps in the health and care sector.

Dialogue and action 

Differences in age, education and working time, as well as the difference in the participation of men and women in the public or private sectors, only address part of the problem.

The reasons why women are paid less than men with similar labour market profiles remains, to a large extent, unexplained by labour market factors, the report said.

Tomei expressed hope that the report will spark dialogue and policy action as there will be no inclusive, resilient and sustainable post-pandemic recovery without a stronger health and care sector.

“We cannot have better-quality health and care services without better and fairer working conditions, including fairer wages, for health and care workers, the majority of whom are women,” she said.

Jim Campbell, WHO’s Director of Health Workforce, added that the report contains success stories in several countries, including wage increases and political commitment to pay equity, which point the way forward.

“Women comprise the majority of workers in the health and care sector, yet in far too many countries systemic biases are resulting in pernicious pay penalties against them,” he said.

“The evidence and analysis in this ground-breaking report must inform governments, employers and workers to take effective action.”

ILO’s Manuela Tomei and WHO’s Jim Campbell say in their foreword to the report, “Not only is the gender pay gap large in the health and care sector, low pay is also prevalent and working conditions very demanding.”