Introduction

Many countries take inspiration from the UN agenda for sustainable development [1], especially from Sustainable Development Goal (SDG) 3 on health and well-being and SDG 5, dedicated to gender equality. Modern strategies for health system development try to empower women and promote gender equality in governance and management at the macro (society and policy), meso (communities and institutions), and micro (social interaction in departments) levels [2]. The World Health Organization’s (WHO) approach to gender mainstreaming [3] refers to projects and institutions striving to build capacities in developing gender equality, promoting the use of sex-disaggregated data and gender analysis, and establishing accountability. Since women account, on average, for 70% of the health workforce [4], gaps in health workers will decrease only by addressing the gender dynamics of the workforce. In its 5-year Strategy (2019–2023), WHO [5] is committed to empowering countries for gender equity and a human rights approach in the health sector’s day-to-day activities. A recent review [6] pointed out that female health workers who deliver most of the care in all settings face barriers that their male colleagues do not. This situation not only undermines their well-being and livelihood but also constrains progress on gender equality and negatively impacts health systems and the delivery of quality health services. Gender parity in health management differs from country to country, but men always prevail in the top health services positions [7]. Similar disparities between females and males apply to work reimbursement; women are usually underpaid [8]. We use the term "Responsibilities" here to refer to the level of positions held by women.

To speed up interventions for gender equality, in 2017, WHO established the Gender Equity Hub (GEH), co-chaired by WHO and Women in Global Health under the Global Health Workforce Network umbrella. The GEH brings together key stakeholders to strengthen gender-transformative policy guidance and implementation capacity for overcoming gender biases and inequalities in the health workforce—in support of implementing the Global Strategy on Human Resources for Health: Workforce 2030 [5]. Gender analysis, empowerment, and mainstreaming became significant cross-cutting issues in developing capacity for health system management. Much evidence confirms that a lack of gender parity in higher-level decision-making positions and leadership [9] can influence the efficiency and quality of health services. In contrast, discrimination in health service settings can compromise Universal Health Coverage [6].

Still, gender inequalities hinder progress and influence women’s leadership in many countries. Gender inequalities in management refer to the unequal treatment or discrimination of individuals based on gender within a management or leadership role [10]. They include unequal pay, limited opportunities for promotion or advancement, and biased evaluations or performance appraisals. The representation of women is not proportional to the overall demographics of the health workforce. Gender inequality in management can negatively impact individual employees and the organization, leading to lower morale, decreased productivity, and a lack of diversity in decision-making processes. In the Kyrgyz Republic, like in many countries, there is a significant gender imbalance in leadership positions in the health sector. Women comprise most of the health workforce but are often underrepresented in management and leadership roles. This situation can lead to gender inequalities in terms of pay, opportunities for advancement, and decision-making power. The specific context of Kyrgyzstan can influence gender equality in management in several ways. One factor is the country’s cultural and social context, which contributes to traditional gender roles and expectations that can impact women’s opportunities for leadership and advancement. Another factor is the country’s economic context. Kyrgyzstan has a relatively low-income economy, and this can limit opportunities for women and make it more difficult for them to access education and training that could help them qualify for management positions.

Additionally, Kyrgyzstan has a history of political instability and conflict, which can create challenges for women seeking to advance in their careers. This aspect includes a lack of access to networking and mentorship opportunities and a lack of support and resources for women-led businesses. While progress has been made in promoting gender equality in Kyrgyzstan, challenges remain. Still, work is to be done until women have equal chances to succeed in management and leadership positions.

The objective of this analysis is to assess the degree of gender disparities at all levels in the health sector management of the Kyrgyz Republic, which can influence efficient health services management, quality, and delivery nota bene: full implementation of the gender-related legislation of the Kyrgyz Republic, equal chances of women and men in competition and appointment, equal remuneration, and job security for women. We look at the policy level, making use of the available governmental documentation and the institutional level through the lenses of stakeholders and directors of health institutions to determine gender equality in governance and management at the macro (society and policy) meso (communities and institutions), and micro (social interaction in departments) levels.

Methods

Results

The health system leadership in Kyrgyzstan takes responsibility for implementing existing gender equality policies.

Representation of women in policy and services

The Kyrgyz Republic Country Gender Assessment ensures a representation of women and men in different managerial positions at the level of no more than 70% of employees of the same gender. This borderline is surpassed by males in executive positions in Batgen and Osh oblasts and by females in deputy positions in Bishkek and the Issyk-Kul, Naryn, and Chuy oblasts. In the Kyrgyz Republic, according to the E-Health Center data for 2019 [20], 40.5% of women hold higher executive positions in the health sector (Table 1). This percentage is higher in Bishkek and Osh (57.8% and 50%, respectively). However, in Republican institutions, only 35% of women are executive managers. Looking at the regions, there are significant diversities of levels of responsibility. The highest representation of women in the oblasts (i.e., regional districts) is in Chuy, Naryn, Talas, and Issyk-Kul oblasts (55.8, 53.1, 45.0, and 44.1%, respectively). The smallest representation of women at higher levels of responsibility is found in the southern regions of the country, with only 4.0% in the Batken oblast, 25% in the Osh oblast, and 38.7% in the Jalal-Abad oblast. The position deputy head of a healthcare institution is more frequently reserved for females. The average republic presence of women as deputy heads was 60.2%, with the highest representation in Naryn oblast, followed by Chui, and Issyk-Kul oblasts (87.5%, 72.0%, and 71.4%, respectively). The smallest percentage is found again in the Batken oblast (33.3%). In the central offices of the Ministry of Health of the Kyrgyz Republic, as of 01.01.2020, 73 people are employed, of which 46 or 63.1% are females and 27 or 36.9% are males. Looking at the oblast level, almost 40% of the heads of health organizations are women (Table 1), with women mainly represented at the primary level and men at the secondary level (hospitals) [19].

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Table 1. The gender structure of the managerial positions in health facilities of the Kyrgyz Republic, in 2019.

https://doi.org/10.1371/journal.pone.0295239.t001

Gender equality in self-assessment of health managers

Based on the sample of N = 60 health managers, the results reflect the opinion of directors of health institutions, and therefore, further studies among employed health personnel are necessary to avoid the possible bias of generating the desired results based on answers which are adapted to suit national policymakers (Table 2). In addition, it is essential to include gender information in future surveys and reports which would allow for analyzing the reasons for the differences found in Table 1.

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Table 2. Basic results of a sample of health managers in Kyrgyzstan.

(Insignificant results are in italic; percent values are calculated from the sum of YES and NO answers without considering missing answers regarding a specific question (NA)).

https://doi.org/10.1371/journal.pone.0295239.t002

Regarding the problem levels in Gender Equality, questions EK to EX can be grouped according to the macro-level (questions EK to EO), meso-level (questions EP to ES), and micro-level (questions ET to EX). Among the directors answering the question on higher authority’s support (Table 2, question EO) 89,5% expressed the opinion that MoH, regional coordinators, and local authorities fully support the implementation of the Law on State Guarantees of Equal Rights and Equal Opportunities for Men and Women [19]. Nevertheless, a third of respondents (N = 22) considered it challenging to answer such a question. Regarding the inequalities in appointment to leadership positions in health facilities (Table 2, question EL), 80.0% of respondents experienced no inequality problems, but 20.0% did so. Correspondingly 60.4% of the respondents stated (Table 2, question ES) that in their institution the number of women in leadership positions (head of a department, deputy director) increased during the past 5 years (39.6% do not agree). This corresponds to the official data in Table 1, with an almost equal number of women in higher positions (40.5%).

Only 42.9% of the respondents reported (Table 2, question EV) that equality of rights and opportunities are integrated into the job descriptions, and an almost equal number (40.7% in Table 2, question ER), found that commitment to equal rights and opportunities for men and women is reflected in the statutory and other written documents of their institutions.

Analyzing the variables of Table 2 –to this end grouped into five dimensions (I-V)–by a factor analysis shows a two-dimensional plot of variables that are allocated on two factors (axes). Fig 1 shows the results of the factor analysis and the factor loadings, i.e., the correlation of the variables Digitalization (W-Z), Training Usefulness (CD-CH), Computer Workplace (CR-CU), Teaching Qualification (EC-EE), and Gender Equality (EK-EX). Factor 1 (x-axis) could be interpreted as personal aspects i.e., the personal situation. Factor 2 (y-axis) relates to technical aspects. The factor loadings are presented as deviations from the mean normalized to zero (see red lines). High factor values mean strongly positioned above-average values compared to the other variables. A similar interpretation applies to high negative values.

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Fig 1. Factor Analysis with quartimax rotation of the relative positioning of Gender Equality in the management of health services in Kyrgyzstan.

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https://doi.org/10.1371/journal.pone.0295239.t003

https://doi.org/10.1371/journal.pone.0295239.g001

Relationship between Gender Equality, Training Usefulness, Teaching Qualification, Digitalization and Computer Workplace.

Ordered according to their relative importance (see also the table in the legend of Fig 1), Teaching Qualification, Gender Equality, and Computer Workplace are highly correlated to personal aspects (factor 1), and Computer Workplace also to technical aspects (factor 2). Training Usefulness is highly correlated as well. It loads negatively on the first factor and is also negatively linked to the second factor, although insignificantly. However, Digitalization is negatively associated with factor two [technical aspects]. Furthermore, it is noticeable that Gender Equality, Teaching Qualification, and the Computer Workplace are building a kind of cluster of importance under personal as well as technical aspects, whereas Digitalization and Training Usefulness seem to be seen with rather mixed feelings. As mentioned above, it is impossible to indicate statistical evidence by presenting correlation coefficients between these variables because the number of cases is too small to make significant statements.

As concerns SDG 5.5 on gender equality, a detailed calculation of the two indicators 5.5.1 and 5.5.2 is placed in Annex A. These indicators measure achievements of targets described as "Ensure women’s full and effective participation and equal opportunities for leadership at all levels of decision-making in political, economic, and public life" [1]. Indicator 5.5.1 measures the proportion of seats held by women in (a) national parliaments (available) and (b) local governments (not available). Indicator 5.5.2 measures the proportion of women in managerial positions [1].

Adopting the final goal of equal participation of both genders, we calculated the years needed to achieve 50% until 2030 as the last year for the SDG achievement, based on the data for 2015 and 2020 and, alternatively, 2010 and 2020. The analysis results at 7.3 years in delay for indicator 5.2.1a (the baseline year 2015) and 15.25 year in delay (the baseline year 2010). The difference may be explained by the inherited difficult economic and political situation following the 1990ies and extending to the early 2000ds. Regarding Indicator 5.2.2, the analysis resulted in achievement of the target for 7.3 and 7.0 years before 2030, i.e., in 2023.

Discussion

Women’s rights and gender equality in Kyrgyzstan are, to a great extent, a heritage of the Soviet period in the country’s history [28]. The historical promotion of women’s workforce participation supported women’s increased numbers and positions in education, the health sector, and other fields. However, traditional practices and patriarchal attitudes resurged after the changes of the nineties and rolled back many of the gains of the last century [29]. Challenges in achieving gender equality remain, especially regarding limited political representation and unequal pay in comparable positions [30].

However, in recent years, the Kyrgyz Republic has made serious efforts and is developing a culture of equality between women and men. The political will is essential to promote and make organizational change possible. This situation is visible in the national legislation, which supports gender mainstreaming. For example, it is recognized in the percentage of women in managerial positions (SDG 5.5, indicator 5.5.2), which increased from 32.4% in 2010 to 47.4% in 2020, which indicates that the goal of 50% equal participation can be reached by 2023 (Annex A).

Healthcare policies and programs need to take a gender-sensitive approach to ensure that they address the needs and concerns of both men and women and do not discriminate against either group [10]. All Kyrgyzstani health sector documents Manas (1996–2005), Manas Taalimi (2006–2011), Den Sooluk (2012–2018), and the current Healthy Person–Prosperous Country program 2019–2030 [20] have addressed gender equality. The Mana document of 1996 focused on improving the quality and accessibility of healthcare services in Kyrgyzstan but did not specifically address gender equality. Manas Taalimi also focused on improving the quality and accessibility of healthcare services but included a section on gender equality that outlined the importance of addressing gender-specific health needs and promoting the involvement of women in decision-making processes. The ‚Den Sooluk’ document had several specific goals and actions related to gender equality, including reducing gender disparities in access to healthcare services, improving reproductive health outcomes, and increasing the participation of women in the healthcare workforce. The most recent document, the "Healthy Person–Prosperous Country" program 2019–2030 [20], includes several goals and actions related to gender equality, including increased participation of women in the healthcare workforce, improving reproductive health outcomes, and reducing gender disparities in access to healthcare services. However, written policies at the level of healthcare facilities do not exist, and there are no documented cases of violation. Therefore, it is difficult to make a direct comparison of Kyrgyzstan’s approach to gender equality in management with that of other countries, as every country has its own unique cultural, social, and economic context [31,32]. In future surveys of health management in Kyrgyzstan, the following specific responsibilities of healthcare managers should be considered in a gender-sensitive manner at all levels [33], i.e., the macro, meso, and micro-levels:

• responsibility towards the patient, primarily within the framework of modern medicine and the movement to improve the quality of health care, within the best possible evidence and with minimal costs;
• responsibility towards employed healthcare workers, where recognition of their reasonable demands for safety in terms of personal income, adequate working conditions, and promotion, but also fears brought by the uncertainty of positive effects in their work (health outcomes of treated patients);
• the responsibility towards financiers and various interested parties who provide resources for the functioning of the institution;
• responsibility towards the community (public) in determining the way to meet the health needs of the population; and
• self-responsibility, together with the improvement of managerial knowledge and skills, and the readiness to respond effectively in conditions of constant environmental change.

Health professionals should be aware of international agreements on sexual and reproductive health and other areas of women’s health following the human rights approach embodied in these agreements. The Ministry of Health of the Kyrgyz Republic submits a report to the Ministry of Labor and Social Development two times a year. The Ministry of Labor and Social Development monitors the implementation of the action plan and holds joint discussions. However, the National Strategy of Action for Gender Equality, ending in 2020, was predominantly focused on preventing gender-based violence and equality in the family [21] and not on women’s leadership positions.

According to the stakeholder assessment (Table 2), specialists from the Ministry of Health and obstetrician-gynecologists are trained in sexual and reproductive health. They are familiar with international agreements and a human rights-based approach. There is no specific evidence about the situation in other health sectors. Regular continuing education still does not include aspects related to gender inequality and its impact on health and public health. Also, there is no evidence that evaluation for professional certification incorporates criteria related to mainstreaming a gender dimension into knowledge and practices. Gender criteria are not included in vocational assessment questionnaires. Regarding the availability of information, which highlights gender equality, the official website of the Ministry of Health and a Facebook page provides information on ongoing sector activities. However, there are no specialized sections and headings for the population.

Regarding vulnerable groups, there is assistance for victims of gender-based violence at the primary health care level, including clinical protocols, which establish the rules and conditions to ensure confidentiality and protect the rights of marginalized or stigmatized groups. Confidentiality measures are in place to protect the rights of marginalized or stigmatized groups, though evidence about their implementation is limited.

The rapid assessment pointed to still existing gender inequalities in health service, less present at the written policy level of health institutions, and more in implementation. However, the results also showed that the gender equality situation is slightly better in the health services of the Kyrgyz Republic compared to other sectors of society.

There should be a focus on fully implementing and completing the strategic and operational one-year business plan. One of the objectives of this annual business plan will concentrate on implementing written policies regarding health institutions to highlight gender equality in organizational behavior, structure, staff, and management board compositions. It will also monitor the information system in health services, which should provide gender-sensitive reporting (actually not always the case, as seen from this assessment).

With the support of the Government of Switzerland, within the "Health Facility Autonomy project, Phase II (HFA Phase II), a specific module on human rights and gender equality in health care services will be developed and become the composite part of the training strategy: "The human rights and gender equality in health care services" based on the WHO approach [3] and its guidelines leading to gender mainstreaming for health managers. Such a module will train management staff in gender analysis for institutional planning, organizing, staffing, leading, and evaluating controls. The module will provide the Kyrgyz health managers with competencies to deal with health workers to be aware of and exercise their human and gender rights.

Nevertheless, making health organizations gender-responsive needs more time, despite health workers dealing with gender in everyday practice as one of the most critical social determinants of health and diseases [34].

Conclusions and recommendations

At the national health policy level, the Kyrgyz Republic has developed policies and initiatives that support the advancement of women in the workforce and promote gender equity in all areas, including in management and leadership positions. Overall, the Kyrgyzstan health sector documents have become increasingly focused on addressing gender equality over time. Gap analysis pointed to this trend regarding SDGs related to gender issues. The self-assessment revealed that women are less present in the top managerial positions. Also, Gender Equality, Teaching Qualification, and the Computer Workplace are building the cluster of importance under personal as well as technical aspects. Despite this improvement, the gender equality approach needs better integration at the policy level of institutions and implementation in the Kyrgyz Republic. Therefore, the following is proposed:

• to develop a written policy that affirms a commitment to gender equality in organizational behavior, structures, and staff and management board compositions, together with preparing strategic and operational plans of health care institutions;
• to train management staff in gender analysis for institutional planning, organizing, staffing, leading, and evaluating/controlling, but also health workers to be aware and exercise their human and gender rights;
• to integrate gender sensitivity into human resource development for staff at all levels to improve organizational effectiveness, promote non-discriminatory relationships, and respect for diversity in work and management styles;
• to include gender awareness in job performance criteria with striving to increase the number of women in senior decision-making positions and on boards of directors;
• to institute family-friendly policies and create an environment that enables both women and men to balance work and family life together with that, which supports equal pay for equal work;
• to establish a mechanism consistent with the organization’s mission and objectives, which allows proper sex disaggregation of institutional data according to gender approach.

Supporting information