Women have been demanding for many years that care be valued at an institutional level. The public-private divide is a reality, and its consequences need to be analysed.
Background
For decades now, the feminist movement has highlighted the problem of the public-private divide, namely how gender inequality between men and women has operated to relegate women to the private sphere, to childcare and housework, while reinforcing men's move into public and political life. This public-private divide has been complemented by a patriarchal discourse according to which women have an innate disposition to care for others, to sacrifice themselves for others and to think of others before themselves in order to be seen as a good woman; while men are the ones who must provide for and protect the family, as well as use violence against others in the name of protecting the family.
The problem of the public-private divide is very much alive today in the crisis of public healthcare and in the demands being made for the sector. Although women have conquered public and political life, the mass entry of women into paid employment and higher education in recent years has happened in different and unequal ways for men and women. Moreover, the undervaluing of the activities women do has meant that men have not moved into the domestic sphere.
All these factors affect the conditions of healthcare staff, who are mostly women, since it is women who bear the burden of balancing work and family life and of having to take temporary and flexible contracts, which mean lower pay and more precarious working conditions. And if we take a whole-life approach, we see that these factors come back to haunt women when they retire, because their pensions are lower.
Which women?
It is important to bear in mind that the crisis of public healthcare in Spain is a gender injustice that speaks directly to feminism. The feminisation of public healthcare can be found in administration, cleaning, care assistance, nursing assistants, nursing, medical specialties such as paediatrics or gynaecology, gender-sensitive health research, and many more. According to the Spanish National Health System's 2020 data, women make up 75.3% of the healthcare sector in Spain, compared with 78% at European level according to Eurostat's 2020 data. Although public healthcare has a mostly female workforce, female representation falls in positions of power and leadership while male representation rises. In fact, only three in ten women hold management positions in both public and private healthcare organisations (Redacción Médica). We can therefore speak of both horizontal and vertical segregation of employment between men and women.
The pressure on women to accept temporary work, part-time hours and flexible contracts, together with the undervaluing of activities classed as feminine, are key factors in explaining the gender pay gap in public healthcare. Although the ILO calls for equal pay for work of equal value, wages are influenced by notions of 'effort', 'performance' and 'occupational risk' that give greater social value to highly male-dominated sectors. All this is reflected in the fact that, according to the WHO, women in healthcare earn 24% less than men working in the same sector.
Consequences
For women who care for others, it is a great struggle to look after themselves and to get society to care more about their well-being.
Unfortunately, because of poorer-quality contracts and lower pay, these women are exposed to poor mental and physical health due to stress, lack of free time and leisure, occupational hazards, the risk of sexual abuse at work, trauma or the emotional exhaustion of dealing with patients, patients' relatives, healthcare staff, and so on.
We must remember that it was public healthcare and its staff who had to deal above all with the pandemic crisis, working for hours without a change of shift, being more vulnerable to COVID-19 infection, having to isolate themselves from their families because of their work with patients, and suffering work overload, among other things. There is also now data on the different ways women and men responded to COVID-19 and on the more intense after-effects in women, also known as "post-Covid condition". However, it is also important to stress that underfunding of public healthcare was already a fact before the COVID-19 pandemic, and that there is a lack of generational renewal in some medical specialties (Primary Care, Paediatrics, Emergency Services).
The lack of time to see patients in Primary Care has serious consequences for women. Some of them are: (i) the different patterns of illness between men and women require doctors' time to detect diseases that present differently in women specifically; (ii) gender-based violence: the ongoing follow-up a doctor can potentially have with a patient can be decisive in detecting a case of gender-based violence from the symptoms or in gaining the patient's trust so that she can say what is happening.
Solutions
To address all the health problems women face as a result of all the factors mentioned above, we have a public healthcare network.
Unfortunately, today we are living through an attack on public healthcare that directly affects women. We must be clear that health problems do not affect men and women in the same way.
Historically, healthcare has focused on the problems that affect men and has developed remedies (treatments, drugs, research...) based on them. That is why more research with a gender perspective is needed.
The cuts being made to public healthcare put all this research at risk. Funding is essential to produce sex-disaggregated data, to study the different side effects for women and men, and to better understand the diseases that affect women. The cuts send the wrong message that research with a gender perspective is not important and that other areas must be prioritised
On the other hand, these health problems affect the most vulnerable women, working and poor women, since people with more purchasing power have the alternative of private healthcare. That is why it is necessary to defend quality public healthcare for all women.
Some of the solutions needed to improve the quality of public healthcare involve increasing its budget, so that it can retain people trained in the different specialties and make generational renewal a reality. That budget increase must be founded on valuing work in the social care, health and care sectors, understanding that without these kinds of activities the world stops.
Finally, a crucial solution is education in equality for boys and girls, so that activities traditionally considered feminine are not done only by women and activities traditionally considered masculine are not done exclusively by men either. So the relationship between the feminisation of public healthcare and care is not just about maintaining and investing in health centres themselves. On the one hand, the unpaid care work that women mostly do every day must be valued through public policies. On the other, shared responsibility between men and women must be promoted in housework, in caring for children and, last but not least, in caring for the elderly. The future lies in caring for the women who care.
Written by: Ana E. Marcos and Guillermo Martínez
Edited by: Nuria de Pablo Sánchez