Understanding women’s leadership in health sector; findings of a qualitative study in Kerala, India

Background

The lack of women's representation in health and medicine, especially in leadership positions, is a major global challenge. An exception to this is the state of Kerala in India, where female representation is high, defying national trends. We undertook a study to understand the contexts undergirding women's rise to leadership in Kerala and their experiences in leadership.

Methods

We employed a qualitative research methodology like in-depth interviews. We identified 16 women by peer nomination (respondent-driven sampling) or from public records as leaders in health, working in Kerala's health system, in civil society or political leaders dealing with health issues. Following informed consent procedures, interviews were carried out seeking to understand the work-life balance, challenges, gender norms, motivation and leadership styles of participants. Transliterated English transcripts were analyzed by three researchers using a thematic analysis approach and Atlas.Ti8 software.

Results

Participants were aged 42 years and older, with between 19 and 60 years of occupying senior managerial positions in different levels. Most emphasized family members' influence and support for their leadership roles. Their work in communities and in primary care was described as formative. Women leaders reported a combination of leadership styles to accommodate and adapt to varying circumstances, emphasizing motivation and coalition building. Challenges like false allegations, non-recognition of competence and discrimination were overcome through self-determination and perseverance.

Conclusions

Kerala women leaders have faced hardships and challenges and rely on reflexive and variable strategies. They have climbed up the ranks and developed their leadership styles mindful of and benefitting from the maintenance of community and family relationships, suggesting a different kind of leadership model altogether.

Key messages

Women leaders from Kerala’s health sector have faced unique challenges. Women leaders from the health sector have addressed different challenges by developing a hybrid, distinct leadership style.

Intersecting gender inequalities in non-communicable disease risk factors in Kerala: A primary study

Evidence globally and in India indicates intersecting gender inequalities in Non-Communicable Diseases (NCDs) risk factors. These are understudied in Kerala, which is at an advanced stage of an epidemiological transition. We estimated sex differences in self-reported prevalence and screening coverage of blood pressure (BP) and blood glucose (BG) grouped by the socio-economic status. A multistage cluster random sampling survey of 3398 women and 2982 men was conducted in 4 districts of Kerala from July to October 2019. Descriptive, Relative Concentration Index (RCI) for age, wealth and education and Population Attributed Fraction (PAF) for caste/tribal groups and religion were computed using Stata 12 and WHO's Health Equity Assessment Toolkit (HEAT) Plus. More women reported BP and BG screening than men (BP - W: 90.3%; 95%CI: (89.1, 91.4) vs M: 80.8%; 95%CI: (78.5, 82.9); BG- W: 86.2%; 95%CI: 84.9, 87.4 vs M: 78.3%; (95%CI: 75.9, 80.6)).BP prevalence was significantly higher among women than men (BP - W: 11.2%; 95%CI: (9.0, 13.9) vs M: 7.9%; 95%CI: (6.6, 9.6). BP screening was concentrated among less educated women (WRCI: -0.2: 95%CI: -0.2, -0.1), older (WRCI: 0.3: 95%CI: 0.2, 0.4; MRCI: 0.5: 95%CI: 0.4,0.7) and wealthier populations (WRCI: 0.1: 95%CI: 0.03, 0.2; MRCI: 0.3: 95%CI: 0.1, 0.4).High BP was concentrated among more educated women (WRCI: 0.9: 95%CI: 0.1, 1.6) and less educated men (MRCI: -1.6: 95%CI: -2.6, -0.6). High BG was concentrated among less educated women (WRCI: -1.6: 95%CI: -2.4, -0.8) and more educated men (MRCI: 0.9: 95%CI: -0.1, -1.6). Religion inequality in high BG among women was -19.1(95%CI:-28.0, -10.2).We found distinct patterns of sex related inequalities in NCD risk factors in Kerala. There is a need for greater screening among men but also sub populations of women who may be under-served by screening services. These patterns require further exploration to understand contexts and pathways to ensure program design leaves no one behind.

Key messages

Intersecting gender inequalities in prevalence and screening coverage of NCD risk factors in Kerala, India. NCD screening should reach all gender equitably despite of their social economic status.

Burden of mental health disability in Kerala: A secondary time trend analysis from 2002 to 2018

The fourth target of Sustainable Development Goal (SDG) 3 advocates for the promotion of mental health and wellbeing. The Indian state of Kerala is recognized for its gains in health and development but has substantial burden of mental health ailments. Historical analysis is vital to understand the pattern of mental health morbidity. The current study focusses on comparable estimates available from three largescale population-based surveys in India to explore trends in prevalence of mental health disorders over the years and map resources and infrastructure available for mental health care in Kerala.

We undertook a secondary analysis of national demographic surveys from 2002 to 2018 which reported information on mental health and availability of health infrastructure and human resources. Data were collated and descriptive analyses were conducted. We compared the national and state level estimates over the years to study the trend in the prevalence of mental health disability.

The prevalence of mental retardation and intellectual disability in Kerala increased from 194 per hundred thousand persons in 2002 to 300 per hundred thousand persons in 2018, two times higher to the national average. The prevalence of mental illness increased from 272 per hundred thousand people to 400 per hundred thousand people in sixteen years. The prevalence was higher among males (statistical significance was not indicated) in mental illness and mental retardation. 2018 data showed that the public sector had 0.01 hospitals and 5.53 beds per hundred thousand persons available for mental health treatment.

Results showed a substantial increase in mental health illness over the 16-year study period that has affected males and females, as well as all social classes of the state. The current health infrastructure and human resources in the public sector of the state are inadequate to meet the current burden of the problem and to ensure universal access to care for its population.

Key messages

The trend in prevalence of mental health disorders in the state is increasing across the years. There is a mismatch between the extend of the problem and resources available in public sector.