Terms of Reference for National Consultant / Firm to undertake Study on Gender Equality in Health Sector (Women in Health Leadership) in Pakistan
Pakistan has a comprehensive health system comprising of an elaborate Health Regulatory machinery, health surveillance system, and a network of health facilities including Rural Health Centers, Basic Health Units (BHU), secondary and tertiary hospitals. While some hospitals work directly under the administrative control of Health Departments, there are a number of health facilities working under Employees’ Social Security Institutions in each Province. Apart from a large Public sector health network, there is an equal number of private health facilities. In 2019, the Government of Pakistan initiated a process to provide ‘Universal Health Coverage’ to all citizens – starting from KP Province (completed in 2020) and now expending in Punjab Province.
As per 18th Constitutional Amendment, the Federal Health Ministry was devolved to the Provinces. While there are strong Health Departments in each Province, there is a Federal Ministry for National Health Services Regulation and Coordination – primarily to deal with international matters and coordination.
Gender Equality in Health Sector (Women Leadership in Health) in Pakistan
For the past several years, the International Labour Organization (ILO) has built a case for higher representation of women in decision-making positions. ILO’s global report on “Women in Business and Management: Gaining Momentum” presents the business case for gender diversity, provide information and data on the evolving situation of women in management and boardrooms and showcase good practice examples from enterprises on their measures and strategies to shift the status quo. Improving gender diversity in the workplace does not only benefit women. Mounting evidence shows that it is a boon to societies, economies and enterprises themselves. The ILO in its Centenary Declaration called for a human-centred approach to the future of work, which includes the effective realization of gender equality in opportunities and treatment.
The health sector constitutes an important and growing employer for women and can greatly contribute to gender equality. The United Nations Secretary-General High-Level Commission on Health Employment and Economic Growth in its ten recommendations to transform the health workforce for the SDGs called for maximizing women’s economic participation and foster their empowerment among others through institutionalizing their leadership.
Gender inequity in health and social care work remains a challenge. Women are overwhelmingly the decision makers for meeting the health needs of their families, making four-fifths of health purchases. Given this, it would seem beneficial for all if women were strongly represented in the senior leadership of health systems. Yet this is not the case. Despite women’s employment as doctors, nurses, pharmacists, midwives, Lady Health Workers, and other health care personnel, available data consistently shows a lack of gender parity in leadership and decision-making positions. Women comprise an estimated 70 percent of the global health workforce but hold only 25 per cent of senior roles. 69 per cent of global health organizations are headed by men, and 80% of board chairs are men. The gender leadership gap in health is inequitable, a barrier to health systems and holds back achievement of the SDGs and Universal Health Coverage.
Besides the fact that women make up a large part of the health workforce, their role as drivers of health is often not acknowledged. It is also common in South Asia that women play an important role as frontline workers (e.g. Lady Health Workers in Pakistan, ASHA workers and Anganwadi workers in India, and Community Health Volunteers in Nepal), they lack recognition as workers and they do not enjoy the rights and entitlement in relation to their work. Globally, women experience a disproportionate burden of disease and death due to inequities in access to basic health care, nutrition, and education. In the face of this disparity, it is striking that leadership in the field of global health is highly skewed towards men and that global health organizations neglect the issue of gender equality in their own leadership. Randomized trials demonstrate that women in leadership positions in governmental organizations implement different policies than men and that these policies are more supportive of women and children. Other studies show that proactive interventions to increase the proportion of women in leadership positions within businesses or government can be successful. Therefore, the authors assert that increasing female leadership in global health is both feasible and a fundamental step towards addressing the problem of women’s health. In addition, women also carry a largely unacknowledged burden of unpaid health and social care work. It is estimated that women’s unpaid care work represented 6.6 per cent of global gross domestic product (GDP), while men’s contribution amount for 2.4 per cent of global GDP.
Key dimensions of gender inequity and leadership gap in health included among others gender pay gap; gender based disparities in job recruitment, induction, retention and promotion procedures and policies in the health sector; gender insensitive and discriminatory work place environment including violence and harassment at the work place; lack of gender responsive policies and systems; and unequal opportunities for capacity building. Workplace gender biases, discrimination, inequities, and gender disparities are persisting and COVID-19 continues to exacerbate existing inequalities and place a disproportionate burden on women, including in health-care settings. Women health workers are faced with increased workloads, a gender pay gap, shortages of personal protective equipment that fits them, increased care responsibilities at home, and harassment and violence as they respond to the pandemic on the frontlines. Women deliver global health while men design and lead it. Women remain largely absent from national or global decision-making on the COVID-19 response.
Though Pakistan has a long history with health workforce regulation, especially for physicians and dentists, the system needs a thorough review and strengthening with updated practices. Health workforce information is fragmented and incomplete. Registration data of the professional councils is not updated and does not provide information on the status. There is inadequate research, which is critical for health workforce planning, implementation and monitoring. A national HRH Vision 2030 was launched in 2018 and provincial health workforce strategic plans are being developed.
At the moment, there is no comprehensive baseline study identifying gender situation in health leadership – particularly, women’s leadership role on health system in Pakistan. In this background, the ILO through the joint ILO-OECD-WHO ‘Working for Health (W4H)’ Programme in Pakistan undertakes and supports a study on ’Women Leadership in Health Sector’. The study will look at women’s leadership in health sector in all avenues including within health institutions and within hierarchies in public health institutions, in staff associations and trade unions, and in other settings.
This analysis is undertaken within and in support of the implementation of the ILO-OECD-WHO ‘Working For Health’ (W4H) Programme – funded by ‘Working for Health Multi-Partner Trust Fund.’ Findings of this study will be submitted to the Government for considering possible improvements in health regulations and creating more opportunities for women’s leadership.
This analysis contributes to the Pakistan Decent Work Country Programme 2016-2020 (extended to 2022), Priority Area 4: “Extending Social Protection”, with international Labour Standards being a cross-cutting theme.
Globally, this work contributes to Outcome 2 “International Labour Standards and authoritative and effective supervision” and Outcome 8 “Comprehensive and sustainable social protection for all” as envisaged in the ILO Programme and Budget for 2020–21. This work will also contribute to Outcome 6: Gender equality and equal opportunities and treatment for all in the world of work. Output 6.1 addresses: Increased capacity of the ILO constituents to promote investments in the care economy and a more balanced sharing of family responsibilities – under which health personnel falls as well.
In turn, the work would contribute to UN Strategic Development Framework 2018-2022 (Pakistan), Outcome 10 “Social Protection” and the SDG target 1.3
Objectives of Study
The Study will achieve the following objectives:
- Assess Gender Equality in Health Leadership in Pakistan at institutional, structural, policy and service delivery level
- Provide recommendations to address Gender Equality and Leadership Gaps in the health sector in Pakistan at all level
Specific objectives/ Areas of Inquiry:
- Assess to what extent gender equality and non-discrimination is promoted in national laws, policies, programmes and institutional mechanisms, including in job recruitment, induction, retention, training opportunities and promotion procedures and policies in the health sector;
- Provide a detailed situation analysis of health workforce in Pakistan with gender-disaggregated data, and information about their employment status, and health leadership positions at Federal and Provincial level;
- Discuss women health workforce career progression and challenges in accessing leadership opportunities and in engaging in health priority setting, health governance and management;
- Provide a gender situational analysis of key leadership positions and their selection/promotion procedures to identify any structural or administrative gaps for promoting gender equality;
- Identify the inherent barriers and facilitators to women’s advancement and leadership journeys in the health system;
- Recommend policy options to improve gender equality in health sector, including women’s representation in leadership in Pakistan.
The study will provide baseline information on women’s leadership situation in the health sector (line management as well as in other areas e.g. staff associations and trade unions) and identify the factors inhibiting and favouring the leadership journeys of women in health in Pakistan, who have successfully made it to the top, to help develop policy interventions enabling women to reach to leadership positions more easily.
Scope of Study and Required Work for National Consultant
The study is primarily a desk review of secondary data with some key informant interviews and consultation for data validation and collection of primary data of qualitative nature. The assessment report would provide both qualitative and quantitative analysis of dimensions given in areas of inquiry.
ILO intends to engage a national Technical Consultant or Consulting Firm to undertake a study on Gender Equality in Health Sector, including women’s representation in Leadership positions (Women in Health Leadership), by reviewing existing administrative records, legal and institutional frameworks and conducting key informant interviews with important stakeholders to achieve study objectives mentioned above. The study will cover only Public Sector health system.
The Consultant will be required to map all relevant administrative data and records related to workers in the health sector both in formal and informal employment and draft a detailed review of existing legislation related to health workforce (at Federal and Provincial levels) and how this legislation support or hinders women’s career progression in the health sector. The Consultant will also organize bilateral consultations with WHO; senior health officials, tripartite partners (including government, employers, workers, women workers); existing institutions, and other relevant stakeholders (e.g., health professional associations including All Pakistan Lady Health Workers Association, academia, civil society organizations, etc.) and identify barriers and facilitators for gender equality in health leadership as well as key areas for improvement. The Consultant may also undertake quick online survey on any specific questions (after consulting ILO) to get first-hand information from certain group of stakeholders. The Consultant will be required to study/examine following important measures for the study:
- Review existing laws, policies and regulations related to health workforce and gender equality and assess how they are strengthening or hindering women’s career progression in the public health system;
- Review existing administrative and institutional arrangements as well as technical capacities to ensure equal labour rights, opportunities for growth to women health workers and identify barriers, facilitators and areas for improvement;
- Take the lead in discussing with Government (including Ministry of OP&HRD and Ministry of National Health Services and Provincial Health Departments), employers and workers – including from women workers in formal and informal employment and employers – to assess current level of alignment with provisions related to gender equality and non-discrimination at work and identify areas to be improved;
- Discuss with WHO, academia and civil society organizations – particularly the ones working on the subject of health workforce and gender equality – to identify areas to be improved in line with gender equality and non-discrimination;
- Closely collaborate with ILO Technical Specialists for drafting the comprehensive report analyzing the national health workforce in view of the principles and benchmarks set out in ILO Conventions No. 100 and 111 on non-discrimination.
- Collaborate with ILO Consultant conducting study on Comparative Analysis of ILO C-149 (Nursing Personnel) in Pakistan – for coordination on using common terms, definitions and data in health system.
Terms of References, Tasks & Deliverables:
The Consultant will be required to undertake following tasks :
- Desk review of national legislation, policies, regulations, institutional arrangements, technical capacities, and other related documents to understand how health care is organized, including how decent work, gender equality and non-discrimination are promoted in Pakistan;
- Desk review of laws, policies and institutional arrangements from other countries to identify good practices for promoting gender equality and non-discrimination in the health sector;
- Develop an outline of the study – adequately covering all areas mentioned above;
- Take the lead in organizing individual consultations with all relevant stakeholders including WHO, (Federal Ministries, Provincial Governments, relevant Institutions, Employers and Workers’ Organizations; existing Institutions, academia / experts; and civil society organizations) on current gender situation in health leadership in Pakistan and developing policy recommendations;
- Facilitate a validation workshop (organized by ILO) with all tripartite-plus stakeholders and get feedback;
- Finalize the Assessment Report, following the review of the report by ILO Health Sector Specialists and WHO experts.
Consultant will be required to deliver the following:
- After literature review, share draft ‘Study Outline’ for technical review and inputs by WHO and ILO Health Sector Specialists;
- After data collection and completing stakeholders consultations, draft a synthesis report and draft Study including the description of the national legal framework and its implementation, to be shared with WHO and ILO Health Sector Specialists for review and inputs;
- Develop powerpoint presentation based on the report and facilitate a tripartite validation meeting to discuss key findings of the assessment report and decent work deficits;
- Provide a final assessment report after incorporating all inputs by stakeholders (in validation workshop) and ILO.
- Consultant will be responsible to:
- Develop draft list of stakeholders for the ILO approval/amendment;
- Bring/procure required technical expertise for all elements of the study;
- Identify most relevant and recent literature and tools related to the subject;
- Develop mechanisms to effectively consult relevant stakeholders and get adequate information in a respondent-friendly manner;
- In view of travel restrictions and other SOPs due to COVID-19 pandemic, make sure to use appropriate technologies and means of communication that suits the requirements of relevant stakeholders;
- Make a presentation on proposed Assessment Report for validation workshop;
- Ensure timely submission of deliverables;
- Ensure full compliance with ILO and stakeholder inputs in the Assessment Report;
- Share all important legislations, regulations, documents and information obtained during consultancy assignment, which are not available online, with ILO;
- Take all necessary measures to complete the assignment within given resources and timeframe;
- ILO will be responsible for:
- Prepare a contract for the Consultant and making necessary payments on different intervals – based on deliverables;
- Provide an introductory letter to Consultant – which will help him/her to introduce to relevant stakeholders;
- Provide contact details of various relevant stakeholders;
- Where possible, extend support in facilitating meetings with relevant stakeholders;
- Provide technical inputs on outline, and draft Strategy within a reasonable time;
- ILO will facilitate the ‘Validation Workshop’. If, due to COVID-19 lockdown situation, the workshop has to be online, ILO will provide IT platform for meeting. In case of face-to-face meeting, ILO will manage the entire event including content, venue, and logistics etc.
The study will be conducted during July – Oct 2021.
The Consultant / Consulting Firm will be required to identify number of workdays and fee per day for the assignment – keeping in view the scope of work.
- COVID-19: Consultant will be required to fully comply with applicable UN and Government regulations and SOPs for prevention against spread of COVID-19 and organize work in such a way to ensure safety of self and other stakeholders. Vaccination may be required, as per Government policies.
- Security: As per new UN regulations, if the assignment includes traveling to any city other than Islamabad, Lahore or Karachi, the Consultant will have to complete a special Security Training Course (SSAFE) preferably before starting the assignment. ILO will facilitate enrollment of Consultant to the course (and will pay for the course) – but these training days will not be paid by ILO.
- Reporting: Consultant will be required to report to ILO. All materials produced by Consultant will be reviewed by ILO for technical quality assurance and will be shared with Government as ILO product supported by ILO-OECD-WHO Working for Health Programme.
Required Qualification and Experience
The Consultant should have the following qualification and experience:
- Post-graduation in subjects related to gender equality, gender mainstreaming, labour laws, industrial relations, public health or nursing sciences.
- Minimum 10 year experience of dealing with matters related to gender and/or the labour market preferably in relation to the health sector either in Pakistan or abroad;
- Demonstrated research experience on gender related and social studies, and of conducting similar quantitative and qualitative assessments
- Well aware of International Labour Standards and institutional and organizational situations of health system issues in Pakistan;
- Previous work experience with UN System in general and with ILO in particular, will be added advantage;
- Strong competence to use computer and office-related software;
How to submit:
Interested individuals are requested to submit the Expressions of Interest, along with following supporting documents (duly dated and signed) through email to: email@example.com, cc: firstname.lastname@example.org by 10-August-2021.
- Provide CV or profile of the individual or Firm
- Provide brief methodology to carry out the assignment (not more than 1 page);
- Fee per day (in PKR) – exclusive of all taxes and other expenses
Kindly mention the RFQ reference W4H-MPTF/ILO/2021/001 in the subject of email/submission. Any proposal received without this number and received after the official closing time and date will not be accepted.
Questions and replies:
Should you have any questions, please contact us at the latest by date only by email (email@example.com; cc firstname.lastname@example.org) quoting the RFQ reference.
 ILO (2019): The Business Case for Change
 ILO (2019) ILO Centenary Declaration for the future of work
 WHO (2016): Working for health and growth: investing in the health workforce. Report of the High-Level Commission on Health Employment and Economic Growth
 International Finance Corporation (IFC) study “Women Leadership in Health”
 WHO (2019) Delivered by women, led by men: a gender and equity analysis of the global health and social workforce
 US National Library of Medicine (2014): Increasing Women in Leadership in Global Health
 ILO (2018) Care work and care jobs for the future of decent work
 WHO. Delivered by Women, Led by Men: A Gender and Equity Analysis of the Global Health Workforce produced by the Global Health Workforce Network’s Gender Equity Hub, 2019