Introduction

In a recent investigative series, a Canadian newspaper, the Globe and Mail, highlighted a Power Gap [1] between women and men in the Canadian workforce. Their unprecedented analysis of 82 universities revealed that women are outnumbered, outranked and outpaid in the highest decision-making and leadership positions [1]. Compounding this, emerging evidence suggests that the severe acute respiratory syndrome coronavirus 2 (SARS Cov-2) and its mitigation responses (together hereinafter referred to as COVID-19) have perpetuated pre-existing gender-based inequities and disproportionately impacted those already adversely affected by other social determinants of health [2]. Impacts including but not limited to, greater risk of exposure to COVID-19, employment and income losses, increased care demands, increased gender-based violence, and unequal access to education and technology, are creating a systemic human development crisis [2].

Explicit attention to these gendered impacts is directly aligned with Sustainable Development Goal (SDG) 5 calling on all nations including Canada to achieve gender equality not only because it is a fundamental human right but a “necessary foundation for a peaceful, prosperous and sustainable world” [3]. Furthermore, Canada’s approach to planning, including any COVID-19 recovery plans should consider both the direct and indirect impacts on gender and its intersections with other social identities, while also promoting inclusive growth and sustainable development outcomes [4]. It is therefore critical that all Canadian organizations, including those working in global health contribute to this call to action to promote gender equality.

Gender refers to the non-binary social construct of characteristics, experiences and expressions of individuals, inter alia, the manifestation and evolution of roles, behaviours, and attributes [5]. However, beyond gender, multiple systems of power intersect to generate systemic discrimination and structures of privilege that impact individuals and societies. In other words, one must also consider the intersections of gender [6]. In her 1989 paper, Kimberlé Crenshaw defined intersectionality as a lens to understand how aspects of an individual’s social and political identities (e.g., gender, sex, caste, class, religion, disability, physical appearance, sexual orientation) when combined, create different axes of systemic discrimination and privilege [7]. With regards to health outcomes and its extensions, especially in the context of COVID-19, evidence reveals a disproportionate risk of communicable and non-communicable diseases is due to structural inequities that fall at the intersections of unearned advantage (and disadvantage) associated with gender, race, ethnicity, and class [8].

Efforts to promote gender equity in Canada involve a patchwork of approaches including human rights-based policies (e.g., Royal Commission on the Status of Women in Canada; Canadian Charter of Rights and Freedoms) [9]. In 2021, the International Development Research Centre released its 10-year strategy renewing its commitment to gender equality [10] and the Canadian Institutes of Health Research (CIHR)’s strategic plan included a strong and unprecedented focus on the social determinants of health, and on health equity (including gender equity) [11]. These tenets were also reflected in CIHR’s new Global Health Framework [12]. Canada has also actively participated in several international platforms to support gender equality. In 2017, Canada’s Feminist International Assistance Policy (FIAP) was adopted to forward the agenda of gender equality and empowerment of women and girls and their human rights, as part of its international aid efforts and engagement in global health work [13,14]. However, FIAP is not without shortcomings, and there is growing concern that Canada is not doing enough to address women’s rights in Canadian global health institutions domestically or within our partnerships abroad [15]. According to Cadesky (2020), the FIAP simultaneously over-politicizes and depoliticizes feminism, gender, and gender equality to suit prevailing environments, while shifting the spotlight away from structural issues of social and economic justice that contribute to gender inequities [15]. Moreover, the absence of decolonial feminism theory within national policies further threatens Canada’s progress on SDG 5 and international relations efforts.

In the Canadian context, global health is rooted in and influenced by ongoing effects of colonialism; though there are concerted efforts to decolonize global health research [16–19]. This narrative review examines institutional gender inequities and inequalities in Canadian global health research, policies and practices. We recommend four priority actions for Canadian institutions to transform gender equality and equity within the workplace (Actions 1–3) and their work internationally (Action 4), in the wake of COVID-19.

Methods

We conducted a narrative review to summarize existing literature, illustrate points of debate and highlight knowledge gaps on gender equity in Canadian global health. To inform our search strategy, we performed an initial review of grey literature including institutional documents and websites related to gender equity in global health purposefully identified by project team members. We then developed a search strategy for MEDLINE (Table 1) using keywords, limiting results to the Canadian context and English language articles published after the year 2000 (Search date: July 22, 2022). Titles and abstracts were reviewed to capture empirical or conceptual studies related to gender, institutional domains and activities in the Canadian global health ecosystem. After eliminating duplicates, we included 16 articles. From these articles and grey literature, we derived actions related to current data and policies, representation in leadership and governance, and workplace conditions. This study did not receive nor require ethics approval, as it does not involve human and or animal participants.

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Table 1. Search strategy.

https://doi.org/10.1371/journal.pgph.0001105.t001

For the purposes of this paper, we define Canadian global health institutions as Canadian-based public or private sector organizations. This includes Canadian-based multilateral and bilateral development institutions, non-governmental organizations and civil society partners, funding bodies, higher-education or research institutes which advance global health research, policy, and practice globally (Panel 1). We further draw attention to Canadian-based women leading global health research, policy, and practice initiatives internationally. In doing so, we also recognize that disparities are amplified for gender non-conforming people and people navigating multiple intersecting forms of social exclusion (e.g., racism; ableism; ageism; classism).

Navigating power dynamics in Canadian global health institutions

Progress on SDG 5 is sluggish globally [20]. As the impact of the COVID-19 pandemic continues to be felt, closing the global gender gap has increased by a generation from 100 years to 132 years, according to the 2022 World Economic Forum Global Gender Gap Index, which benchmarks 156 countries on global parity [21]. Canada ranks above the global average at 25^th; however, Canada has fallen six spots since 2020– primarily due to poor performance in two of four subindices: 1) political empowerment (from 25^th to 31^st) and 2) economic participation and opportunity (from 30^th to 43^rd); health and survival and educational attainment indices have remained stable [21]. Metrics reveal widening gaps in participation, advancement and remuneration between men and women, related to the “glass ceiling” and “glass cliff” (Panel 1) [21]. Despite gender parity in Canada’s COVID-19 task force [22], there is no shortage of examples of both phenomena, especially with regards to Canadian women’s economic participation and political empowerment in global health leadership [23]. Several women are the face of public health measures in Canada to control COVID-19 at the national, provincial, and local level. While they have been praised for their exceptional leadership, they have also been the subject of criticism, harassment, and racial discrimination [24,25].

Within the academy, the lack of gender parity in Canadian-led global health research in terms of production of global health knowledge and representation on editorial boards is apparent [26]. A review of over 23,000 CIHR grant applications between 2011 to 2016 concluded that grants led by women principal investigators were evaluated less favourably, despite similar quality of proposals led by men and women [27]. Likewise, an analysis of Lancet Global Health publications (between June 2013 to Nov 2018), indicated women constituted only 34% of all Canadian authorship lists. A key caveat is the assumption of gender with regards to authors (i.e., those who self-identify as women), as most journals do not require gender declarations upon submission. This proportion was significantly lower for women in low- and middle-income countries [28]. Further, numerous examinations into scholarly publishing during COVID-19 suggests a substantial decline in authorship for women, but an increase for men; highlighting additional barriers to academic career advancement that are bound up in women’s multiple roles in the household [29].

Socio-structural factors create workplace demands and cultures which tend to reflect life patterns and gender roles of men. Such patterns are often at odds with the time and resource constraints that women usually face as primary caregivers. The disproportionate burden of unpaid care work for family [30], combined with structural disadvantages associated with having children (or “child penalty”) and limited support systems such as accessible day care, all contribute to women’s cumulative loss in lifetime earnings, productivity and opportunities [31]. Despite accounting for the majority of the global health social workforce [32], the lack of social protections and job security for Canadian women, especially Black, Indigenous and Persons of Colour (BIPOC) women, is persistent for those working in global health, especially internationally-based global health practice and humanitarian aid and relief organizations [33]. This situation is further aggravated by the lack of publicly available data on pay transparency and the gender wage gap, with Canada ranking among the worst Organisation for Economic Cooperation and Development countries in 2020 [34,35]. Importantly, these data do not accurately capture the disparities which may exist in disaggregated data and the vast number of women in precarious part-time or temporary jobs, which were largely lost during COVID-19 [30]. Despite Canada’s values and aspirations to advance a ‘feminist agenda’, the lack of collective action to dismantle the layers of colonialism and systemic advantage afforded to men, continue to perpetuate the Power Gap that disadvantages women.

Mentorship and resources to support empowerment and advancement of Canadian women in global health

The need for mentorship of women is particularly evident when reflecting on a potential disconnect between Canadian women training in global health and rising to leadership positions [36], especially for BIPOC women. Canadian academic institutions, non-governmental organizations, and professional health societies and associations are well-positioned to lead by example and contribute to the elimination of harmful practices that perpetuate gender and intersectional inequities. Universities educate and prepare the next generation of leaders for roles in global health research, policy, and practice, while non-governmental organizations and health societies and associations are an excellent conduit for continuing education (i.e., practicums and internships), networking and advocacy [37]. However, the vast field of global health encompasses a wide array of disciplines and expertise—ranging from community-based research, epidemiology program evaluation, policy development, and many others—making it difficult for one organization, school or program to provide comprehensive training to well-equip young leaders for a plethora of potential career paths or projects in the field [37]. Additionally, few existing Canadian university programs or Canadian-based global health mentorship programs explicitly focus their efforts on the unique circumstances of women.

To meet a mentorship gap, the Canadian Association for Global Health (CAGH), formerly Canadian Society for International Health, created a formal mentor program, MentorNet [38]. While programs like MentorNet have demonstrated success both at the individual-level (e.g. promoting learning, development, networking, and others) and more broadly (e.g. through contributing to education of a wider array of global health topics and values that are not always communicated in a classroom), the program is not focused on women and only has the capacity to match approximately 30 pairs per year (despite receiving over three- or four-fold this number in applications) [38]. Increased investment in mentorship and sponsorship, especially for women early in their careers could enable more women to transition from their graduate studies and entry-level positions through to mid-career in global health research, policy and practice realms [39].

Canada’s platform for gender-sensitive partnerships and standardizing global gender data and intersectional approaches in research

Gender-related gaps in data manifest in global health research, for example, in data collection, analysis and dissemination and they also exist at the institutional level, in terms of research team composition in Canada and our partnerships globally [4]. In both cases, the lack of gender-disaggregated data and empirical accounts of women’s lived experiences, particularly relating to gender and its intersections, make identifying large-scale issues and tracking change over time more challenging. Contributing to this issue, is the lack of requirement by most journals and funders to mandate disaggregated data by gender, where applicable, or ask for evidence of a gender mainstreaming approach to grantees’ work [40]. The absence of data has become particularly problematic in the context of COVID-19, given its disproportionate toll on women in terms of health and nutrition, loss of education and economic opportunities, experiences of interpersonal violence, and the need to plan national-level responses that take gender and its intersections into account [2,41]. Within Canadian global health research, a lack of disaggregated data means that programmes cannot be as gender-responsive as they should be [4,5].

The Canadian federal government (Global Affairs Canada) created the Department of Women and Gender Equality and national committees and forums, which developed guidance and tools (Gender-based Analysis Plus), and, mandated “no less than 95 percent of Canada’s bilateral international development assistance initiatives will target or integrate gender equality and the empowerment of women and girls” [13]. Moreover, CIHR launched the Institute for Gender and Health to foster research that explores how sex and gender influence health [42]. These actions have yet to result in changed institutional culture and there is limited monitoring and evaluation of gender within Canadian global health leadership and partnerships in terms of gender equity. This impacts our understanding of who leads or forms global health partnerships, and what their roles and opportunities are in those partnerships, including the co-creation of global health research [4,5].

Importantly, the relational skills (e.g., time, trust-building, responsiveness) needed to cultivate collaborative partnerships are gendered and de-valued in tenure, awards, or promotion [43,44] compared to more individually-driven and competitive academic outputs [45,46]. Women in Canadian academic institutions also tend to invest in relational and collaborative ways of working, including building partnerships and informal mentoring that are not always captured by traditional metrics of productivity [43]. There is a role within Canadian institutions for ensuring transformative change relating to partnership building through decolonization [47,48].

Priority actions to gender-transform Canadian global health institutions

Despite governmental commitments to gender equality, Canadian women in global health are underrepresented and underpaid in leadership, management and governance positions in the public and private sector. The coming years present a window of opportunity to decolonize global health through a feminist lens, where a paradigm, leadership and knowledge shift are necessary across Canadian global health institutions to make women and their intersections count. We propose four priority actions to gender-transform Canadian global health institutions (Panel 2).