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Healthcare work as women's work: parallels and analogies between domestic care and paid caregiving.

Introduction

This article reports on a study analyzing the structure, characteristics and distribution of employment in the healthcare sector in the province of Cordoba, Argentina. (1) This research project applied a gender perspective to the complex institutional and socioeconomic interactions entailed in the provision of healthcare services at the local level, examining the differences in the working conditions for women and men and the relationship between policies on public health and those on human resources. The study also evaluated how job quality affected quality of care at the local level, distinguishing between the provincial and municipal jurisdictions and analyzing the working conditions in staterun public facilities, private clinics, charity hospitals and local-level public facilities.

A participatory methodology was designed, based on a triangulation of quantitative and qualitative data, incorporating the opinions and expectations of the women workers who took part in the study, in order to build consensus in the formulation of labor policies with gender equity. Special attention was placed on the sexual division of labor within the home and how this work affects the ways in which women are involved in the healthcare field. In other words, emphasis was placed on drawing attention to women's contributions in health care, both through their actions as paid workers as well as their efforts as volunteers, like the "public health agents" who work at the grassroots level. Armed with a basic training in primary care, these women play a strategic role--especially in the areas with the highest rates of unmet need--by visiting the homes and evaluating the health situations of the families; they are a very important link between the population and the healthcare system. The unpaid labor of the public health agents is very much like all the other "social work" that women perform, tasks that undoubtedly take up most of their productive time, but which are unremunerated. Even the attempt to emphasize the importance of the public health agents as key players in the process of primary health care has had no political repercussions.

The following article shares the primary findings from the qualitative phase of the study that looked at the subjective aspects of the healthcare work carried out by women in facilities treating the poorest sectors of the population. (2) These clinics are located in outlying neighborhoods and provide care for the poorest inhabitants of the Argentinean city of Cordoba, the capital of the province of the same name. All these institutions endure problems related to infrastructure, lack of human resources and supply shortages. Most of those seen in these centers are women, and 75% of all the healthcare workers are also women, and so from a gender perspective, it appears that "women are caring for women." The medical specializations in which women tend to be concentrated (pediatrics, general medicine, gynecology, psychology, social work and nursing) are all linked to caregiving and to reproductive work that channels them to locations closer to poverty and to meeting basic needs.

The Extension of the Domestic Role in Remunerated Work

Traditionally, Latin American women would seek paid work outside the home only when the salary of the "man of the house" was not enough to support the family, following a model of the "sole provider" in the domestic sphere. If she were untrained or uneducated, a women would look for employment that echoed the work that she performed within the home, i.e., domestic work. If she were more qualified, then she could obtain other work, but always for less pay than a man, following the model of gender discrimination in wages.

In this fashion, and following the model of occupational segregation, women were channeled into employment related to caring for others. Women were understood as possessing a set of qualities that made them more appropriate for performing these tasks that are "reproductive" productive work.

In recent years, various studies have analyzed women's multiple roles, the gender inequalities associated with the distribution of domestic work and the impact of this situation on women's health.3 It is widely understood that women workers shoulder a "double workday" and continue to be responsible for most of the domestic work in their own homes, even though they have paid jobs outside. Research has also revealed the negative impact on women's health due to the burden of domestic work, which depends on the needs of the family and the resources available to meet these needs, plus the burden of remunerated work and the stress of balancing professional and family lives. (4)

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This article explores other aspects of the relationship between paid and unpaid work, as related to the way in which gender conditions women's behavior on the job, with the objective of describing the emotional impact of a specific fashion of exercising their profession (nursing, medicine, psychology or social work) in caring for a marginalized population. The basic hypothesis of the study was that women healthcare workers perform their caregiving tasks as if their remunerated jobs were an extension of their domestic role.

The way in which gender conditions health care is linked with the care provider's: 1) identification with the patients; 2) self-sufficiency, guilt and the need to meet the needs of the population; 3) inability to compartmentalize, in other words, as the healthcare workers themselves state: "women mix everything together, their professional lives, their emotional lives"; (5) 4) the experience of motherhood: the doctor is a mother so she "understands" and identifies with the patient-mother whom she is treating; 5) stress and overwork. (6)

Subjectivity in Health Care

In a traditional relationship between doctor and patient, the healthcare provider attempts to overcome subjectivity. The physician treats the patient as "the sick," as the object of a discourse on illness in an aseptic relationship generated between a technician and a layperson. Thus, the "official practice" of medicine tries to generate a notion of difference in which the emotional implications are minimal.

However, the practice of health care is affected by gender socialization. While this may be gross generalization, it does appear that men want the relationship between the healthcare professional and the patient to be a strictly technical relationship with the exchange between the two under the control of the doctor. For women healthcare professionals, however, there is another implicit demand, something that escapes their understanding or ability to change: the patients have a need to be heard, to be supported, to be acknowledged; there is a cry for help that comes from suffering rather than illness. Women who work in the healthcare field respond to this implicit demand in a maternal fashion, caring for others in a way that is typical of the female identity in patriarchal society. The work of these caregivers is rooted in the female stereotypes of "self-denial," "charity," "dedication" and "generosity." (7) In the face of a medical discourse that divides people, women's response is to become even more involved emotionally and to identify with the patient. Women healthcare workers defend some forms of these relationships as "more humane" or "more sensitive." They explain that becoming emotionally involved makes them more vulnerable. "We are all in the same boat, those who provide care and those seeking treatment."

If the relationship between the healthcare professional and the patient deteriorates, patients react by being non-compliant, both the healthcare professional and the patient are dissatisfied and the patient is usually "blamed." It is fairly common for the healthcare professional to identify the patient as "responsible" for the bad relationship, to label them as a "bad patient" and to feel a certain degree of hostility or resentment towards them, thus justifying the "dehumanization" of the relationship. However, it is also common for the healthcare professionals to eventually doubt their effectiveness as physicians, questioning their own abilities at the professional and even personal levels. They may lose their self-confidence, emotional stability and their ability to work with their colleagues, finally blaming themselves for the failure of the therapeutic relationship with their patients.

Healthcare workers--both women and men--confront serious difficulties in trying to forge an "intersubjective" practice of health care. It is difficult for men because they deny the subjective aspects of their profession, but it is also hard for women because they tend to focus excessively on these aspects.

Despite medicine's attempts to exclude emotion from healthcare work, emotional interactions frequently occur in the healthcare sector. While women could exercise medicine just like their male colleagues, according to the stereotypes, this behavior wouldn't exactly be desirable. The application of a gender perspective to medical practices would democratize and overcome asymmetries in knowledge and power these practices. According to Rovere (2006), there is a very interesting debate between two concerns of quality: one focuses on fulfilling technical standards, the other on placing oneself in the other's shoes, on empathetic listening, on comprehending the needs of the patient. Both aspects are necessary for obtaining quality services. (8)

The Extension of Domestic Work in the Practice of Health Care

Among other things, domestic work is characterized by personalized care, the randomness of the tasks (there are no fixed schedules), constant routine (tasks are carried out with repetitive monotony) and a lack of differentiation between leisure time and work. In addition, domestic activities are not seen as valuable and are not acknowledged either by others in the family group or by society.

All these aspects, typical of the private sector, translate almost directly and permeate the organization of the public healthcare centers that we studied and the medical practice itself. Countless other indicators support this affirmation, including the fact that women workers fulfill multiple tasks and functions: in addition to a specific job, they also sometimes cover for administrative personnel, receptionists or cleaning staff. The excessive demands on each health clinic condition the organization of the work; it's difficult to organize the schedules, to carry out tasks of promotion and prevention. Caregiving is seen as monotonous and routine, and the work processes are barely defined or regulated by protocols. Unlike hospitals, health clinics do not have an organizational structure. Task are not assigned but are "appropriated" spontaneously. Women and men tend to take on very different tasks, and these decisions are clearly influenced by gender socialization. (9)

At the same time, there is no healthcare "profession" in the health clinics as in the hospitals, and therefore, there are no expectations of promotion or professional development. Rather, there is a stratification of tasks permeated by mechanisms of gender segregation. This situation gives evidence of a disjuncture between the social recognition of health care and the design of the model of care. While the model of care establishes the initial level of treatment (the clinics) as the foundation of the system, greater recognition and professional prestige are accorded to those who work in the areas of greater complexity (the hospitals). According to the culture of traditional medicine, the primary-care clinics do more social work than modern medicine. This attitude belittles the healthcare professionals and technicians who are responsible for treatment in these facilities and their work in the healthcare field and also fails to acknowledge the importance of primary-care clinics, which are also viewed by women healthcare workers as "less desirable" workplaces.

While the model of care specifies that clinics should be organized by program, spontaneous demand drives the healthcare services in most of the clinics, and program activities are of little importance. Various lines of analysis explain this situation, including ever-increasing demand, limited resources and general ignorance of the programs. As a result, spontaneous demand is almost always linked to urgent care and acute illness and finally exhausts the scant resources that do exist to the detriment of programmatic activities that could, in the long or mid-term, change the definition of the services offered. At the same time, this response to health care echoes the characteristics of domestic work: it is routine, unplanned, is not gratifying or rewarding, and it revolves around the needs of others.

Women's work continues to increase: in the public sector, in the private sector and in the home. However, as the women healthcare workers explained, "if you just keep going, adding more and more, something has got to give," and what gives is their health. The women feel that they are essential in some respects, and they are unwilling to forsake anything in their effort to fulfill multiple roles and functions, even though they feel the impact on their health, they just can't seem to stop and take a different approach towards their work.

The women healthcare workers also recognize that women and men perform different sorts of work: "Some tasks are more often performed by women: work that demands a lot of patience, going step by step, like beadwork; it's a more domestic task."

The women themselves recognized that their vulnerability in the workplace is due to the following unfavorable working conditions:

i) Conditions of employment: Most of the personnel hired by the municipality also works in the private sector. The clinic directors are named to their positions and receive no extra remuneration for this work, merely a reduction in the number of hours they are required to treat patients;

ii) Environmental conditions: Crowded work areas and waiting rooms; treatment rooms without doors that lock;

iii) Safety issues: Lack of security staff during the day, when women work. There are only security guards from 7 p.m. onwards, when the male personnel are on duty. The women workers say that they have been the victims of violence: robbery, verbal abuse and they have been physically attacked even when the guard was on duty;

iv) Working conditions: The nurses must fulfill multiple functions. Sometimes they carry out administrative tasks; they keep people from blocking the hallways; they make sure everyone takes their turn. But overwhelming demand determines their tasks: no patient can be left unattended, and organizing time is extremely difficult. There are no expectations for promotion or professional development. The work is considered monotonous, routine, unglorified caregiving. Health promotion and preventive medicine face considerable obstacles. Working in sectors of extreme poverty generates feelings of impotence and fatalism;

v) Work process: Unlike in the hospitals that have an organizational structure, with supervisors, directors and schedules that are respected, the work is insufficiently organized in the clinics: "You never know when you will be able to leave." The work continues without a break; the women healthcare workers feel like they "cannot stop seeing patients." There are no performance evaluations or monitoring of results. There is a physical, psychological and emotional overload.

vi) Social and/or organizational conditions: Working in teams is difficult.

We can examine the impact of this situation on the health of the women healthcare workers by looking at their sick leave records to discover the most common health problems of the women workers in comparison with those of their male colleagues.

The Health of Healthcare Workers

Understanding the impact of working conditions on the health of healthcare workers--both women and men--is key to analyzing job quality. The lack of specific measures to protect the health of these workers, the difficulties faced in identifying the health risks to which they are exposed and, above all, the absence of systematized information regarding this phenomenon is striking. In other words, the healthcare concerns of the users of the healthcare system are analyzed, but there are no policies regarding care for women healthcare workers (for example, obligatory mammograms after age 40). This situation occurs at all levels (from the municipality to the provinces to the national healthcare system).

To analyze the health of healthcare workers, information for 2002-2003 was collected on medical leave taken by municipal-level healthcare workers (both women and men). According to the reasons for given for taking sick days, the most common complaints were: i) infectious disease (22%); ii) trauma (16%); surgery (10.8%); digestive disorders (10.2%); respiratory illness (8.6%); and emotional problems (7.5%).

For both women and men, most medical leave was taken for infectious disease or trauma. However, many more men took sick days for trauma than women. Women were more often took time off for emotional problems, while men were more often absent from work due to cardiovascular disease. If the medical leave is analyzed according to the total number of sick days taken, emotional problems rank highest, followed by trauma, surgery and gynecological-obstetric visits.

When we study this same information disaggregated by sex, we see a different order: emotion problems are the most common complaint among women (more than three times the sick days taken by men for this concern), followed by gynecological-obstetric visits and trauma. Men more often took leave for the following concerns in descending order of frequency: trauma, surgery and cardiovascular disease. Another interesting aspect is seen in the leave related to cardiovascular illness. While nearly 65% of the municipal health-sector workers are women, men and women request nearly the same number of days for cardiovascular disease.

The most common illnesses among men who work in the healthcare sector are: hypertension, stroke, angina, cardiac insufficiency, lumbago, bronchitis and gastroenteritis. Among women, the most common health concerns are: arthritis, risk of miscarriage, cervicalgia, lumbago, depression, anxiety-related disorders, hypertension, colitis, gastroenteritis and breast cancer. This information provides guidelines for preventive health programs for healthcare professionals, emphasizing cardiovascular wellness for men and mental health care for women.

With regard to the number of sick days requested, 60% of all leave taken by men was for under ten days, while 50% of the women took leave under ten days. Of all the men who requested medical leave, 59% did so only once or twice during the year, while only 42% of the women requested medical leave one or twice in the year. Women requested more days at a time for sick leave and nearly 60% request leave more than twice a year.

In sum, the situation of healthcare workers confirms the relationship between gender and morbidity: women healthcare workers become ill more often then their male colleagues and present more mental health problems than the men, who more often suffer from cardiovascular disease. It should be kept in mind that 65% of all municipal-level healthcare workers are women.

In addition, it should be noted that a considerable portion of these "emotional problems" are related to the difficulties that women face in reconciling their work and family responsibilities. Since there are no specific sorts of leave that allow women and men to assume the caregiving of dependent family members (whether they be children or aging relatives), sick days are often used as a way to get time off to care for others.

The aspects discussed above shed light on the vulnerable situation of healthcare workers of both genders, both in regards to their employment conditions as well as the mechanisms of vertical and horizontal segregation, which have clear but different impacts on the women and men who work in this sector.

As we have discussed above, a series of objective and subjective conditions in which healthcare services are performed--including specific working conditions--threaten the workers of this sector, with different impacts according to gender. Despite this evidence, the issue gets very little attention, whether from policymakers, the workers themselves or union leaders. One of the possible explanations for this situation is fear of being fired, which is among the range of disciplinary actions used in this sector. For these and many other reasons, steps should be taken to improve the working conditions for healthcare workers.

Towards the Transformation of Health Care

We must develop specific labor policies linked with public health policies. These two areas cannot continue to be distant from one another. At the same time, the failure to consider the impact of gender on the healthcare sector is absolutely scandalous. There is an overwhelming need to design policies, specific mechanisms and training programs that include the promotion of skills that would facilitate gender equity by transforming women's own behavior to help them overcome obstacles that hobble their career trajectories, whether in relation to medical specializations or residencies or other levels of competency in the sector. For example, more women "choose" to go into pediatrics or gynecology, while few specialize in surgery, neurology and the like.

Meanwhile, as we explained earlier, primary health care is looked down upon in the medical world, just as some specialties are also seen as "less important." Unsurprisingly, most of the workers in these fields are women. Drawing attention to the sexual division of labor within the healthcare sector would pave the way for capacity building to achieve more efficient systems of referral and counter-referral. Gender also should be understood as playing a key role in the development of specific attitudes, which are taken to be individual predispositions to perform different sorts of tasks.

It is of utmost importance that the relationship between quality of employment and quality of care in health care must be perceived by and promoted among all the relevant sectors. Adequate preventive or curative care cannot be ensured without qualified human resources, who are well paid and motivated to provide these services, nor will there be quality of care in the healthcare sector if there is no gender equity among the workers in this field.

Notes

(1.) This project was carried out by the Women and Development Department of the UN's Economic Commission for Latin America and the Caribbean (ECLAC), with the support of the German agency for technical cooperation Deutsche Gesellschaft fur Technische Zusammenarbeit (GTZ), under the project, "Politicas laborales con equidad de genero" (Labor Policies with Gender Equity) from 2004 to 2006. For the main results in the case of Argentina, see Mujer y Empleo. La reforma de la salud y la salud de la reforma en Argentina, Nieves Rico and Flavia Marco, eds. (Buenos Aires: Siglo XXI Editores Argentina, ECLAC, 2006).

(2.) The municipality of the capital of Cordoba boasts over 80 healthcare facilities ranging from dispensaries to primary-care clinics to hospitals, organized under the Primary Health Care system. As of May 2004, there were 1,713 healthcare workers employed in the municipality, most of whom were women (65%). A series of municipal programs define priorities for the sector, yet most of the sector's resources are used to care for spontaneous needs unrelated to these programs. At the same time, most of the municipal healthcare facilities (health clinics and primary-care providers) are located in neighborhoods that present a greater concentration of unmet basic needs.

(3.) See, among others, Elsa Gomez Gomez, "Equidad, Genero y Salud: Un reto politico y etico," paper presented at Mercosur (Buenos Aires, 2004) and Maria I. Matamala, Thelma Galvez and Elsa Gomez Gomez, "Desigualdades en salud y enfermedad" (2005) available online at www. equidadchile.cl/documentos/ libro2005/4_genero.pdf. It should be stressed that women's organizations have played a fundamental role in this debate, making a clear impact in the design of healthcare services and in the legal/institutional framework of these services through actions that include the promotion of a gender perspective in reproductive healthcare programs, the fight for the right to health, the denunciation of deficits in care for women living in poverty and in efforts to draw attention to the health impact of domestic violence.

(4.) The social and cultural context has a serious impact on public health and labor policies. Central arguments in this regard have concentrated on different conceptualizations of the health-illness process that include a range of positions, from biological/curative philosophies that address primarily the resolution of the illness to other perspectives that include a social component focusing on prevention and on maintaining and promoting health.

(5.) A female physician interviewed in the context of the project.

(6.) These categories are derived from the qualitative interviews carried out with the healthcare workers (physicians, medical technicians, nurses, etc.) in the healthcare sector of Cordoba, Argentina. The methodology employed focus groups to collect the opinions of the healthcare workers in the municipality of the capital of Cordoba. See J. Burijovich and L. Pautassi, "Calidad del empleo y calidad de la atencion en salud en Cordoba, Argentina. Aportes para politicas laborales mas equitativas," Serie Mujer y Desarrollo no. 60 (Santiago, Chile: ECLAC, 2005).

(7.) As Nancy Folbre explains, women have a legacy of responsibilities in care provision that should make them suspicious of the principle of "every man for himself." Nancy Folbre, The Invisible Heart. Economics and Family Values (New York: The New York Press, 2001).

(8.) Mario Rovere, "Los nuevos y renovados debates en torno de los recursos humanos en salud," in Mujer y Empleo. La reforma de la salud y la salud de la reforma en Argentina, Nieves Rico and Flavia Marco, eds. (Buenos Aires: Siglo XXI Editores Argentina, ECLAC, 2006).

(9.) We are specifically referring to practices and conceptualizations that respond to an asymmetrical power structure that assigns different roles to men and women and is constitutive of gender discrimination.

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Jacinta Burijovich is a professor and researcher with the Instituto de investigacion y Formacion en Administracion Publica (IIFAP, Institute for Research and Training in Public Administration) at the Universidad Nacional de Cordoba, Argentina, and a professor at the Universidad Nacional de Rio Cuarto (UNRC) in Cordoba, Argentina. Laura Pautassi is a researcher with the Consejo Nacional de Investigaciones Cientificas y Tecnicas (CONICET, National Council for Scientific and Technical Research) and the Instituto de Investigaciones Juridicas y Sociales "Ambrosio Gioja" ("Ambrosio Gioja" Legal and Social Research Institute) in the Law School of the Universidad de Buenos Aires, Argentina. She is also a member of the Equipo Latinoamericano de Justicia y Genero (ELA, Latin American Team on Justice and Gender).
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Title Annotation:RESEARCH
Author:Burijovich, Jacinta; Pautassi, Laura
Publication:Women's Health Collection
Date:Jan 1, 2009
Words:4249
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