Framework for change

Leadership advancement among women is a product of imparting the necessary skills, leveraging their strengths and providing resources to circumnavigate barriers, embedded in a setting where organisational and systemic change facilitates and accommodates women’s leadership [21]. Effective leadership interventions that progress women’s leadership are generally characterised by an organisational component that is channelled through changes in organisational processes, creation of awareness, mentoring and networking, leadership training, support tools and resources [22]. Closing the leadership gap in health can only be done by addressing the systemic barriers women face [10]. A policy action paper by the World Health Organization, the Global Health Workforce Network and Women in Global Health, proposed a framework for change in supporting women’s leadership [10]. The framework emphasizes the centrality of addressing workplace systems and culture, and the use of deliberate measures to enable women to achieve [10]. Addressing workplace systems and culture to promote the leadership of women can be done by visible and accountable senior leadership, targets and quotas for gender parity in leadership, sensitisation of men to engage with and lead gender transformation, gender-transformative and retention strategies and adoption of an equality and family friendly policy [10]. Conversely, strategies which empower women to lead comprise development of networks for leadership advancement, increasing public visibility of women in decision-making, tracking and publishing key metrics on representation, developing peer support mechanisms and mentoring women [10].

Aims and objectives

Against this backdrop, this study aims to implement a package of interventions to address the organisational and individual barriers to the advancement of women to leadership positions in the Tanzanian health sector, and to evaluate the influence on leadership competencies and career advancement actions of the female health workforce. More concisely, the project seeks to address gendered leadership by advancing systems and structures through collective leadership, networks, and mentorship. Specific objectives of this project are to:

1. Determine the current gendered leadership characteristics and barriers in healthcare across three selected regions in Tanzania.
2. Co-design and implement a mentorship, networking and leadership support programme for women healthcare workers across the three Tanzanian sites.
3. Document and share programme resources, learning and best practices for supporting women’s leadership in healthcare.

Gender transformative research

Gender transformative research (GTR) aims to foster gender equality and empower women and girls as a strategy to transform gender power dynamics and aligns relevant structures within communities and societies [23]. The proposed work will not only implement a programme for female healthcare workers but also garner support from government officials and sectors, with the purpose of confronting the intrapersonal and structural barriers which disempower women’s leadership.

Gender transformative research explores research questions pertinent to social norms, attitudes, behaviours and social systems that support gender inequality [23]. This approach actively engages groups in the process of critically examining, challenging and scrutinising gender norms and power relations [23]. Gender stereotypes and biased practices in the workplace will be assessed in realisation of this GTR principle.

Emerging insights on efficient utility of a gender transformative approach that will be incorporated in the research include clear and initial understanding of the context, getting men and women to jointly engage in critical reflection and identify options for change and building strong relationships between critical actors such as researchers, government officials, men, women and youth in local communities [24]. Finally, all data collected will be disaggregated by sex [25].

Co-design

Co-design is the involvement of multiple stakeholders in the design and development of products, services or systems, with the goal of creating relevant, effective and acceptable solutions for the end-user [26]. This process goes beyond user consultation but partners with stakeholders as co-creators, where community and user experiences are at the core of the design process [26]. Co-design is an empowerment mechanism for individuals and communities to develop ideas, knowledge and skills in the resolution of issues that influence their lives [27].

Central to co-design is that project outcomes are agreed upon following in-depth analysis of the context, and research aims are aligned to policy [28]. Co-design captures experiences of patient and healthcare staff, ensuring that researchers, leaders and policy makers understand the reality and challenges faced by service users and deliverers [26]. There is accumulating evidence that co-design is likely to result in more sustainable change [28]. Co-design is particularly suited to studying gender and for gender transformative research, which emphasises participant critical engagement and contribution.

Implementation science

Implementation science is the scientific study of methods that promote uptake of research, which is distinct from seeking to establish efficacy of a clinical innovation [29]. The methodology aims to pinpoint barriers and facilitators across various levels in the implementation context, and thereafter apply strategies to address the barriers and enhance factors which facilitate uptake of the innovation [29]. Notably, implementation science actively engages with the context pertinent to the innovation to unveil the optimal implementation strategy [29]. In implementation research, operational partners such as healthcare system leaders, administrators and healthcare providers are full partners in the research [29]. The project at hand will engage with these actors at various stages including, research design, intervention co-creation, participant recruitment, implementation and sustainability conception.

Context of the research

In Tanzania the health system structure parallels the political-administrative hierarchy [30] (see Figure 1). National Hospitals are the highest specialised referral point in the country; secondary to this are zonal hospitals which serve the five zones [30]. Both national and zonal hospitals are generally teaching hospitals and provide complex healthcare which requires advanced technology and skilled personnel [30]. The regional referral hospitals service the 26 Tanzanian regions [30]. Regional hospitals provide a wide range of services including specialised care, and public health preventative programs [30]. Regions are further subdivided into districts which are served by district hospitals [30]. Regional hospitals differ from the district hospitals because they are larger and offer more specialised care [30].

Health centres resource the division level and are primarily for preventative healthcare and treatment of simple medical conditions, but in some cases, provide reproductive health services and minor surgery [30]. Wards succeed the division administration rank and dispensaries are available at this level. Dispensaries offer basic outpatient care [30]. At the base of this political structure are villages which are served by a community health practitioner who provides health education and basic treatment to people in their homes [30].

Tanzanian study sites

Selection of project sites was based on the proportion of female and males in leadership within Tanzanian regions. High levels of disparity in the numbers of males and females in leadership suggests the presence of barriers that inhibit advancement of women to healthcare leadership, thus regions demonstrating this criterion were selected. The top three regions with the highest disparity in ratio of male to female leadership were Njombe, Kilimanjaro and Kagera (see Figure 2). A minimum of two councils were selected from each region, ensuring representation from urban, semi-urban and rural councils. Councils selected in each of the regions are:

1. Njombe region – Njombe Town Council and Makete District Council
2. Kagera region – Bukoba Municipal Council and Ngara District Council
3. Kilimanjaro region – Moshi Municipal Council, and Same District Council

Mwanza region was selected as a comparison site as it is an urbanised region with moderate variation.

From each selected council, three health centres were purposefully identified, each from an urban, semi-urban, rural or peripheral setting. Therefore, 27 health centres will be included in the research. Four to five women will be selected from each health centre based on their willingness and eligibility to participate.

Approach

The project will be implemented in four phases to allow a logical and comprehensive analysis of organisational and individual barriers to the advancement of women in leadership positions as follows:

Selection criteria for co-design participants

1. Employed as a healthcare worker, such as doctor, nurse or medical officer in the three Tanzanian research regions or;
2. Employed as a healthcare leader or manager whose role entails overseeing or supervising healthcare workers in the three Tanzanian research regions or;
3. Policy makers such as members of parliament or members of the local government such as mayors and councillors who oversee city, municipal and town councils or;
4. Government officials such as permanent secretaries or deputy permanent secretaries who oversee government ministry of health day-to-day activities, and health secretaries who oversee health administrative duties across regions, councils and districts or;
5. Academics who are core team members or affiliated with the project.

The team will endeavour to have two participants from each of the identified categories, with a gender ratio of about 50% men and 50% women. The project is endorsed by the President’s Office Regional Administration and Local Government Tanzania (PO-RALG) which is the body that interprets and implements policy, along with managing district and regional health services. President’s Office Regional Administration and Local Government Tanzania will support the codesign process by inviting government healthcare workers, managers, and policy makers to share their input because the project aims parallel government policy objectives.

Principles that will underpin the co-design process include mutual respect between the research team and co-design partners, inclusivity, flexibility, accountability of the research team, fairness in participation opportunities, and an active participation process [27].

The Generative Co-Design Framework for Healthcare innovation will guide the co-design process [34]. This framework breaks-down codesign into three phases [34]. The pre-design phase commences with contextual inquiry where there the setting of interest is explored [34]. This will be achieved through baseline interviews and surveys mentioned in phase one and two of the research [34]. The next step within the predesign phase is development of informational material for participants to refer to during co-design, selection of participants and facilitators and technology tests [34]. Development of materials for this step is contingent upon analysis of data from phase one and two of the research [34].

The core co-design phase involves sharing ideas with co-design partners such as the design of the prospective innovation, identifying explicit as well as the latent participant needs and thereafter communicating a vision of the work alongside anticipated changes [34]. Specific foci for this co-design phase include specific mentor and mentee roles, associated responsibilities and procedures, identifying training requirements, frequency and timing of programme sessions, project outcome indicators and co-evaluation procedures. The phase that follows this is the post-design phase where data from the active co-design will be analysed, and thereafter theme checking with co-design participants to ensure that the most significant and pertinent ideas are captured [34]. In the final step, the research team and co-design participants identify priorities from the co-design phase and plan for the intervention implementation stages [34].

Phase three

The key action for this research phase is to implement a leadership and mentorship intervention for female healthcare workers in the Tanzanian health sector.

Leadership and mentorship intervention

The final leadership and mentorship intervention for female healthcare workers in the Tanzanian setting will be based on findings from the rapid realist review, baseline surveys and interviews, and co-design process.

The projected intervention will take a collaborative leadership development approach, including tripartite mentorship. The three elements of tripartite mentorship will encompass mentorship from a male influential leader, mentorship from a senior female leader and peer mentorship support.

Leadership training will comprise seminars and workshops delivered by experts (contingent on participants’ needs) to support improved understanding and knowledge of gender and leadership competencies. Ultimately, the seminars and workshops will aim to provide participants with the necessary knowledge and tools to develop their personal leadership style and utilise their strengths to become transformative leaders (see Figure 3).

Figure 3 

Leadership and Mentorship Blueprint.