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Lessons from Uganda for a safer, more equitable health sector.
Sexual harassment is a seemingly ubiquitous, intractable problem that prevents many women around the world from advancing in the workforce. To end it, we must understand how it operates.
In 2017, for example, the Ugandan Ministry of Health conducted a study—with support from IntraHealth International’s USAID-funded Strengthening Human Resources for Health Project—to better understand the nature of sexual harassment and why it so often went unreported.
The study found:
Sexual harassment appeared to be pervasive and systemic in Ugandan public health workplaces, with few mechanisms to regulate it. This made it difficult for workplaces to meet even basic management standards for their employees, such as supportive supervision. Women seeking economic security or career growth found that sexual harassment and professional advancement were often tied to one another.
The Ugandan Ministry of Health understood that these work conditions were unacceptable and they used these study results to operationalize Uganda’s 2012 Sexual Harassment Regulations in the health sector.
But what did the Uganda study findings suggest about how workplace sexual harassment operates? First, most of the contributing factors existed at sociocultural and organizational levels. Women’s presence, economic independence, and equal place in an organization can be a political issue that leads to exclusion and reassertion of male authority. In Uganda, demeaning and sexualizing talk served to routinely remind female health workers of their sexual (rather than professional) roles, and retaliation held them back or drove them out of their jobs.
Some of the study findings also substantiated gender harassment—sexist verbal and nonverbal behaviors that convey hostility, objectification, exclusion, policing, or second-class status. Female health workers were often intimidated and punished if they refused advances. When we understand how sexual harassment protects hegemonic masculine status and identity, even unwanted sexual attention is visible as a way to maintain subordination.
How can we create a safer, more equitable health sector?
Employment and labor laws must ensure that health workers’ rights to violence- and harassment-free workplaces are protected. Uganda’s 2006 Employment Act already provided legal protections. Where law is weak or non-existent, a country can start by ratifying the ILO Convention 190 on violence and harassment and integrating its recommendations into national law or sectoral and organizational policies.
If applied, anti-violence and -harassment policies can shift gender power relations toward gender equality. One of the first, low-cost steps the Uganda Ministry of Health took to do this was to use the experiences of study participants to define and provide illustrative examples of sexual harassment in policy implementation guidelines.
Unchecked, subjective, and arbitrary authority perpetuates sexual coercion and subordination. This must be curtailed through systems that regulate supervisory power, such as standards of conduct and rigorous onboarding processes. The Uganda Ministry of Health’s sexual harassment guidelines now also require a third-party presence and consent for physical examinations in clinical settings.
Ending harassment requires visible leadership commitment and may require changing an institution’s hierarchy or its composition. For example, Harvard and Tel Aviv University researchers have noted, “We already know how to reduce sexual harassment at work, and the answer is pretty simple: Hire and promote more women.” Gender parity may provide the authority, strength, and safety to (re)shape non-sexist organizational norms, especially in combination with other programs such as bystander interventions.
Reporting sexual harassment often comes with risk of secondary harm. Organizations should not depend on individual complaints to determine if there is a problem. A workplace climate survey used as a prevention and monitoring tool would take the onus of stopping harassment off of victims. There should be formal, informal, and anonymous reporting channels and reports of sexual harassment should be investigated through mechanisms independent of the organizational hierarchy.
Sexual harassment is often confused with flirtation and is commonly understood as an attempt at romantic or sexual cooperation. But sexual harassment in the Uganda study demonstrated unwelcome sexual attention, coercion, and bullying. When a person has no choice in a sexual encounter, or has reason to fear the repercussions of refusal, the interaction has moved into the realm of intimidation and aggression.
These understandings should be reflected in definitions of sexual harassment, the way we design policies to prevent it, and training efforts that prevent the abuse of power. A common definition of sexual harassment, at least at national and organizational levels, will help improve measurement and intervention design.
There is still much to learn about sexual harassment in the health sector, including its prevalence and cross-cultural nature. How does it manifest in the health workplace and how do sexual coercion, unwanted attention, gender harassment, and other forms of gender discrimination intersect in various settings?
Can well-designed training contribute to changing organizational culture? How can we apply theory (such as hegemonic masculinity) in prevention programs that enlist allyship? Along the way, we must find ways to hold perpetrators accountable—efforts that are often met with defensiveness, hostility, and deflection.
We also need to know more about how COVID-19 and technology are changing the nature of workplaces and the new forms of online harassment that may emerge or disrupt old patterns.
Organizational leaders who want to create a safer, more equitable health sector that offers decent work must end sexual harassment. The first step is to implement laws and policies that deliberately aim to shift power relations toward gender equality.
Read more about the 2017 Uganda study and policy initiative in this new publication in the Human Resources for Health Journal Gender Equity Thematic Series, titled Uganda’s response to sexual harassment in the public health sector: from “Dying silently” to gender‑transformational HRH policy.
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