Ehab, Maye; Mosaad, Fa ma
A icle — Published Ve sion
In o mal employmen in he heal h sec o : Examining
gende dispa i ies
In e na ional Jou nal o Social Wel a e
P o ided in Coope a ion wi h:
John Wiley & Sons
Sugges ed Ci a ion: Ehab, Maye; Mosaad, Fa ma (2024) : In o mal employmen in he heal h sec o :
Examining gende dispa i ies, In e na ional Jou nal o Social Wel a e, ISSN 1468-2397, Wiley,
Hoboken, NJ, Vol. 34, Iss. 2,
h ps://doi.o g/10.1111/ijsw.12704
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ORIGINAL ARTICLE
In o mal employmen in he heal h sec o : Examining
gende dispa i ies
Maye Ehab
1,2
| Fa ma Mosaad
3
1
Ins i u e o Employmen Resea ch
(IAB), Nu embe g, Ge many
2
Chai o Sociology, a ea Social
S a i ica ion, Uni e si y o Bambe g,
Bambe g, Ge many
3
The Ame ican Uni e si y in Cai o, New
Cai o, Egyp
Co espondence
Maye Ehab, Ins i u e o Employmen
Resea ch (IAB), Regensbu ge S asse,
104, Nu embe g, Ge many.
Email: [email p o ec ed]
Funding in o ma ion
Ca negie Co po a ion o New Yo k
Abs ac
This pape in es iga es he associa ion be ween in o mal employmen as a
o m o non-s anda d employmen and he p e alence o in-wo k po e y o
women in he heal h sec o . We measu ed in-wo k po e y using a bina y indi-
ca o ha p o ides in o ma ion on whe he an indi idual has ea nings abo e
o below he low ea nings h eshold. The indica o akes in o accoun house-
hold size and whe he o he household membe s a e also in paid wo k. Using
da a om he Egyp Labo Ma ke Panel Su ey o he yea s 2012 and 2018
and logi models, we ound ha being employed wi hin he heal h sec o
inc eased he likelihood o in-wo k po e y among non-s anda d employees,
bo h men and women. Howe e , highe isks o in-wo k po e y we e wi -
nessed among women wo king in o mally in he heal h sec o compa ed o
o he sec o s. This inc eased isk was pa icula ly obse ed when compa ing
non-s anda d employmen in he heal h sec o o non-s anda d employmen
in non-heal h sec o s. Fu he mo e, ma i al s a us plays a c i ical ole in eco-
nomic wellbeing, wi h ne e -ma ied women being mo e suscep ible o in-
wo k po e y compa ed o e e -ma ied women.
KEYWORDS
emale employmen , heal h sec o , in-wo k po e y, non-s anda d employmen , p eca ious
employmen
INTRODUCTION
In ecen yea s, he dualiza ion o he labo ma ke in o
s anda d and non-s anda d employmen and i s e ec on
economic wellbeing ha e ecei ed inc easing a en ion.
Non-s anda d employmen e e s o empo a y, pa - ime
and ma ginal employmen , as o ms o ex e nal and in e -
nal lexibili y (De Cuype e al., 2009;Lohmann&
Ma x, 2018; Wo ld Heal h O ganiza ion, 2019). Despi e
being conside ed a s epping s one (Boo h e al., 2002;
Gash, 2008), esea ch has shown ha non-s anda d employ-
men , pa icula ly empo a y employmen , has nega i e
e ec s, including highe le els o insecu i y, lowe wages
and inc eased social inequali y, namely po e y isks
(Fause & Gebel, 2023;Gash&McGinni y,2007;
Gebel, 2009;Giesecke,2009;Giesecke&G oß,2003;
McGo e n e al., 2004; Wes ho , 2022).Thenega i ee ec s
a e also gende ed, wi h he isk o po e y ending o be
highe o women in non-s anda d employmen , and lowe
Abb e ia ions: ELMPS, Egyp Labo Ma ke Panel Su ey; LFP, labo
o ce pa icipa ion.
Recei ed: 2 Sep embe 2023 Accep ed: 20 Sep embe 2024
DOI: 10.1111/ijsw.12704
This is an open access a icle unde he e ms o he C ea i e Commons A ibu ion License, which pe mi s use, dis ibu ion and ep oduc ion in any medium, p o ided
he o iginal wo k is p ope ly ci ed.
© 2024 The Au ho (s). In e na ional Jou nal o Social Wel a e published by Akademike ö bunde SSR (ASSR) and John Wiley & Sons L d.
In J Soc Wel . 2025;34:e12704. wileyonlinelib a y.com/jou nal/ijsw 1o 15
h ps://doi.o g/10.1111/ijsw.12704
o women in coun ies wi h a weake male-b eadwinne
model (Giesselmann, 2015; Jaeh ling e al., 2014).
In addi ion o empo a y and pa - ime employmen ,
in o mal employmen is ano he aspec o non-s anda d
employmen ha is ex emely ele an wo ldwide and
speci ically o lowe -middle income coun ies. In o mal
employmen among women is widesp ead wo ldwide
(55%), wi h he majo i y o such employmen occu ing
in lowe -middle income coun ies (83%) (In e na ional
Labou O ice, 2024). Ne e heless, impo an aspec s o
in o mal employmen emain unde s udied due o a lack
o good da a, wi h some excep ions in he li e a u e on
wellbeing and heal h (Ehab, 2023a; Ka abchuk &
Sobole a, 2020; Pi ani, 2017). Wage penal ies exis no
only o empo a y employmen (Gebel, 2011), bu also
o in o mal employmen (Tansel e al., 2020). Despi e
his, wo- hi ds o wo ke s in de eloping coun ies su e
om ex eme o mode a e po e y (In e na ional Labou
O ice, 2017). The high sha e o in o mal employmen
and he associa ed high isk o in-wo k po e y aise con-
ce ns abou he ex en o in-wo k po e y aced by
women. In-wo k po e y, a si ua ion which desc ibes he
wo king poo , p o ides in o ma ion on whe he an indi-
idual has ea nings abo e o below he low ea nings line.
The indica o conside s he size o he household and
whe he o he household membe s a e also in paid wo k.
These disad an ages end o be highe in sec o s wi h
high le els o ho izon al and e ical seg ega ion o
women, such as he heal h sec o (Meulde s e al., 2010).
Globally, he heal h sec o is a majo sou ce o employmen
o women, ye many o hese jobs a e cha ac e ized by low
wages and empo a y employmen (Schlenzka e al., 2020;
Wo ld Heal h O ganiza ion, 2019). Women make up 70%
o he heal h and social ca e wo k o ce (Wo ld Heal h
O ganiza ion, 2019), making i a emale-domina ed sec o .
These women wo k in essen ial and indispensable occupa-
ions, as demons a ed du ing he pandemic (Palomino
e al., 2020). In addi ion o ho izon al seg ega ion, women
in he heal h sec o a e concen a ed in low-paid jobs, a
sign o e ical seg ega ion (Meulde s e al., 2010;Wo ld
Heal h O ganiza ion, 2019). The majo i y o doc o s and
pha macis s a e men, while he majo i y o women wo k
as nu ses (Wo ld Heal h O ganiza ion, 2019). A gende
wage gap o 26% in high-middle income coun ies and 29%
in uppe -middle income coun ies is p e alen in he
sec o , which is also highe han in o he economic sec o s
(Wo ld Heal h O ganiza ion, 2019). Non-s anda d employ-
men , in he o m o empo a y employmen , is also
common. Wo ldwide, one in i e wo ke s in heal h and
social ca e wo k ope a e unde in o mal condi ions.
This issue is mo e p e alen in low- and middle-income
coun ies, whe e 30.5% o wo ke s ace in o mal employ-
men , compa ed o only 10.4% in high-income coun ies
(In e na ional Labou O ice, 2024). Ye , a ecen li e a u e
e iew o 170 s udies ound ha li le is known abou he
si ua ion in low- and middle-income coun ies in he
heal h sec o (Wo ld Heal h O ganiza ion, 2019).
Egyp is an excellen case s udy o lowe -middle
income coun ies o se e al easons. Egyp ian wo king
women a e highly concen a ed in he heal h sec o ,
simila o women in o he coun ies (K a &
Ehab, 2023). On a e age, Egyp ian women a e o e ep-
esen ed in heal h and social se ices compa ed o men,
wi h a ising sha e o hei employmen in his sec o
(Fedi e al., 2019). Women employed in he heal h sec o
accoun o 19% o o al emale employmen in Egyp
(Open Access Mic o Da a Ini ia i e, 2019). Heal hca e
jobs a e one o he nine job ca ego ies in he Egyp ian
p i a e sec o wi h a high concen a ion o women
(Assaad & A n z, 2005).Ye ,59%o womenin heca e
sec o su e om highe isks o in-wo k po e y com-
pa ed o 49% o men (K a & Ehab, 2023). In he pe iod
2015–2017, he p opo ion o women o mally employed
in Egyp 's p i a e heal h and social ca e sec o was 47%,
a decline om 74% o he pe iod be ween 2009 and
2011 (Economic Resea ch Fo um & Uni ed Na ions
Women, 2020).
Un il ecen ly, he majo i y o jobs in he Egyp ian
heal h sec o we e s anda d employmen due o he
p e alence o public sec o ec ui men (K a &
Ehab, 2023; Economic Resea ch Fo um & Uni ed Na ions
Women, 2020). Wo king in he public sec o , which usu-
ally en ails a o mal and pe manen employmen con ac ,
is he mos p e e ed op ion o women (Ba soum, 2019,
2020). Howe e , in ecen yea s, a end o con ac ing
hi ing in he public sec o has eme ged (Assaad &
Ba soum, 2019). As a esul , jobs a e ins ead being c ea ed
in he p i a e sec o , leading o an inc ease in non-
s anda d employmen ac oss he economy, including in
ca e employmen which ex ends o he heal h sec o
(K a & Ehab, 2023). A decline in social secu i y insu -
ance co e age has led o a de e io a ion o wo king condi-
ions. The p oli e a ion o in o mal jobs in he Egyp ian
labo ma ke and he heal h sec o is conce ning, espe-
cially in ligh o he de e io a ion o he wo king condi-
ions in he ca e and heal h sec o s and he p oli e a ion
o he ca e pay gap, despi e e o s o imp o emen
(K a & Ehab, 2023). The inc ease in in o mal jobs in
he heal h sec o exace ba es he p oblem o insecu i y,
especially o women (K a & Ehab, 2023). On op o he
ca e pay gap, in o mal employmen o en lacks p o ec-
ions, bene i s, and s abili y, lea ing wo ke s suscep ible
o exploi a ion and po e y (Assaad, 2009; Assaad
e al., 2019; Assaad, K a , & Yassin, 2020). The ising
in o mal employmen and de e io a ing wo king condi-
ions aise conce ns abou he e ec o employmen in
2o 15 EHAB and MOSAAD
his sec o o women, who ace mul iple disad an ages
due o in o mal employmen (Ehab, 2022; K a &
Ehab, 2023).
To ill his gap, we asked: a e he e any gende di e -
ences in in-wo k po e y o hose wo king in he heal h
sec o compa ed o o he sec o s? In addi ion, we ocus
on s anda d and non-s anda d employmen ela ions.
This pape adop s an employmen axonomy ha clas-
si ies jobs acco ding o hei o mali y (whe he o no
he e is a con ac ). Thus, we classi y employmen as
s anda d i he job is o mal and as non-s anda d i he
job is in o mal, in o de o p o ide a be e pic u e o
he si ua ion in lowe -middle income coun ies. To
answe ou ques ion, we used he Egyp Labo Ma ke
Panel Su ey (ELMPS) o he yea s 2012 and 2018 and
es ima ed logi models. We examined he ela ionship
be ween non-s anda d employmen and in-wo k po e y
by gende . Unde s anding he ela ionship be ween non-
s anda d employmen and in-wo k po e y is c ucial o
designing e ec i e policy in e en ions, especially in sec-
o s such as heal h ca e whe e women a e disp opo ion-
a ely a ec ed. Ou indings a e p esen ed as pa ial
co ela ions, p o iding insigh s in o associa ions a he
han claiming causal ela ionships.
Ou main con ibu ion o he li e a u e is wo old.
Fi s , we in es iga ed he ela ionship be ween non-
s anda d employmen and in-wo k po e y in a lowe -
middle income coun y, conside ing in o mal employmen
as non-s anda d employmen in he heal h sec o . This
esea ch is pa icula ly ele an in he con ex o Egyp ,
whe e in-wo k po e y was epo ed o be 57% in 2018
(Said, 2012;Saide al.,2022). We del ed deepe in o he
p eca iousness o hese non-s anda d jobs o in es iga e
he le el o economic p eca iousness in e ms o in-wo k
po e y. Second, we looked a he gende ed implica ions,
which ha e no been s udied in such de ail in he heal h
sec o .Focusingon hissec o isc ucialgi eni s olein
women's employmen wo ldwide in gene al and in Egyp
in pa icula .
BACKGROUND AND HYPOTHESES
Women in he Egyp ian labo ma ke
Women in Egyp ha e signi ican ly imp o ed hei educa-
ional a ainmen and closed he gende gap (Assaad,
Hendy, e al., 2020; K a & Ke le, 2019). Howe e , his
gende equali y in educa ion is no e lec ed in hei labo
o ce pa icipa ion (LFP). In 2018, he LFP o women was
21%, compa ed o 76% o men (K a e al., 2022), which
emains one o he lowes labo o ce pa icipa ion a es
o women globally (In e na ional Labou O ice, 2017).
P e ious esea ch has shown ha 57% o women in
Egyp ansi ion om school o inac i i y (Heyne &
Gebel, 2014). This pa e n is also obse ed in o he coun-
ies bu usually a e women ha e aken on g ea e am-
ily esponsibili ies, gi en he p e alence o he adi ional
di ision o labo (Moen, 2016). Fu he mo e, in Egyp ,
he ansi ion back in o he labo o ce is limi ed. The
majo i y o hose who ansi ion o inac i i y o amily
easons do no e-en e he labo ma ke (In e na ional
Labou O ice, 2016).
S anda d employmen is he mos p e e ed employ-
men o Egyp ian women. Women p e e o wo k in he
public sec o , which is usually a s anda d job in e ms o
o mali y and inde ini e con ac du a ion (Ba soum, 2019,
2020). Job s abili y and cha ac e is ics o o mal jobs, such
as a ailabili y o social insu ance a e he main ea u es ha
imp o e women's job sa is ac ion (Ezza & Ehab, 2019).
In addi ion, he ansi ion om non-employmen o in o -
mal employmen has nega i e e ec s on women's heal h
(Ehab, 2023a).
Howe e , due o dec easing employmen oppo uni ies
in he public sec o , he s anda d employmen si ua ion in
he Egyp ian labo ma ke and he de e io a ion o wo king
condi ions in he p i a e sec o ha e esul ed in a sho age
o s anda d employmen (Assaad & Ba soum, 2019;
Assaad, Hendy, e al., 2020; Assaad, K a , & Yassin, 2020;
Ba soum, 2019,2020). This si ua ion has esul ed in limi ed
access o o mal o pe manen jobs. Thus, he access ha
women ha e o employmen oppo uni ies is p edomi-
nan ly ei he empo a y o in o mal in he p i a e sec o
(Ame & A allah, 2022; Assaad & K a , 2015; Roushdy &
Sie e ding, 2015). The p e alence o in o mal employmen
cha ac e izes he segmen a ion o he labo ma ke in
Egyp , which places women a high isk. Non-s anda d
employmen , especially in o mal employmen , is associa ed
wi h poo job quali y such as i egula i y, lack o access o
paid lea e and heal h insu ance, o social p o ec ion in
gene al (Assaad, 2009;Assaade al.,2019; Assaad, Hendy,
e al., 2020; Assaad, K a , & Yassin, 2020).
In o mal employmen plays a majo ole in he
Egyp ian economy, despi e signi ican e o s by he go -
e nmen o educe in o mal employmen as shown by
Wahba and Assaad (2017). They conduc ed a s udy o
examine he impac o in oducing mo e lexible a ange-
men s in a new labo law ha would allow wo ke s
wi hou con ac s o be o mally con ac ed. Using
he di e ence-in-di e ence me hod, hey ound ha he
in oduc ion o he new law would inc ease he likeli-
hood o ansi ioning in o a o mal job o non-con ac ed
wo ke s in o mal es ablishmen s by abou 3%–3.5%
(Wahba & Assaad, 2017). Despi e hese e o s, in o mal-
i y is s ill p e alen in he Egyp ian economy (Assaad,
Hendy, e al., 2020; Assaad, K a , & Yassin, 2020).
INFORMAL EMPLOYMENT IN THE HEALTH SECTOR 3o 15
Egyp ian women, in a ious sec o s, su e om
hi ing disc imina ion ha is o e and no s igma ized
(Ba soum, 2023; Osman e al., 2024). Howe e , hese di -
e ences ha e no been ound in he callback a es o
women, a leas o online job ads, whe e one s udy ound
no di e ences in callback a es by gende o ma i al s a us,
(K a , 2023). Howe e , gende s e eo ypes do exis in ce -
ain occupa ions whe e a high pe cen age o ads o e ly
s a e ha a man is needed o he job (K a , 2023).
Gende di e ences ex end beyond disc imina ion in
hi ing o wage inequali y and in-wo k po e y. Fo exam-
ple, wage di e en ials ha e been calcula ed showing a
gende pay gap. The wage gap be ween men and women
seems o di e ge o e ime, especially in he p i a e sec o .
Wo ke cha ac e is ics do no explain mos o his gap,
e ealing disc imina o y biases and exace ba ing segmen-
a ion based on gende (AlAzzawi, 2016;Bil agy,2014,
2019;Saide al.,2022). This si ua ion is associa ed wi h a
de e io a ion in he ela i e wage posi ion o women in
he p i a e sec o , esul ing in an inc ease in in-wo k po -
e y when compa ing 2012 and 2018 (Said e al., 2022).
The inc ease in in-wo k po e y is also p e alen in he
se ice sec o (which pu s wo ke s' heal h a isk). In 2018,
in-wo k po e y s ood a 56%, a de e io a ion o 14% com-
pa ed o 2012, showing he ise o in-wo k po e y in he
sec o , a ec ing bo h men and women (Said e al., 2022).
Non-s anda d employmen and in-wo k
po e y
To unde s and he ela ionship be ween non-s anda d
employmen and in-wo k po e y, i is impo an o ec-
ognize he di e en ypes o con ac s and wha hey
en ail. Acco ding o psychological con ac heo y, he e
a e ou ypes o con ac s in he labo ma ke (Bea d &
Edwa ds, 1995). T ansac ional con ac s e e o an
employmen ela ionship based solely on he ex insic
aspec s o he job (such as wages) and e lec a sho - e m
pe spec i e. These ypes o jobs p o ide lexibili y o he
employe and inc ease insecu i y o he employee. Rela-
ional con ac s a e con ac s ha include bo h in insic
and ex insic job aspec s in he employmen ela ionship
and in ol e a longe - e m pe spec i e. Such a pe spec i e
esul s in g ea e job secu i y o he employee. Symme -
ical con ac s e e o an equal balance o powe be ween
he employe and he employee. Finally, asymme ical
con ac s a e cha ac e ized by an imbalance o powe
(De Wi e & Näswall, 2003). On he one hand, in o mal
employmen is conside ed an asymme ical and ansac-
ional psychological con ac , which en ails an imbalance
o powe in a o o he employe and a high le el o
insecu i y o he employee (Assaad & Ba soum, 2019;
Kallebe g, 2009). On he o he hand, o mal employmen
ep esen s symme ical and ela ional con ac s, wi h a
balance o powe and mo e igh s and secu i y o he
employee.
The con ac ype migh ha e consequences on he eco-
nomic si ua ion o an indi idual, in pa icula o women.
P e ious esea ch s udied he associa ion be ween empo-
a y employmen and in-wo k po e y a he indi idual
le el. A s udy o 24 Eu opean coun ies in es iga ed ha
ela ionship, aking in o accoun he gende aspec . By
using a logis ic mul ile el model, i ound ha being a em-
po a y employee does inc ease he isk o in-wo k po e y
compa ed o pe manen employees. This inc eased isk o
po e y o empo a y employees was p ima ily a ibu ed
o lowe wages (Van Lancke , 2012). The same esul was
ound in Spain, whe e ixed- e m wo ke s we e ound o be
linked o po e y incidence using Spanish panel da a and
maximum-likelihood bina y models (Amuedo-Do an es &
Se ano-Padial, 2010). On a e age, highe po e y isks a e
expec ed o women who a e in non-s anda d employmen
(Giesselmann, 2015; Jaeh ling e al., 2014).
Commonly used measu es o in-wo k po e y in he
li e a u e include income-based h esholds and ela i e
dep i a ion measu es (Delhausse e al., 1993). These mea-
su es o en ely solely on indi idual income le els o de e -
mine po e y s a us, wi hou aking in o conside a ion
household s uc u e o dependency. In con as , ou p o-
posed measu e o in-wo k po e y conside s bo h indi id-
ual and household dimensions. As he numbe o wo king
people li ing in low-income households inc eases, in-wo k
po e y is seen as a phenomenon (C e az, 2015). Building
on his concep , we calcula ed he low-income h eshold.
By calcula ing his h eshold adjus ed o household com-
posi ion, we we e able o p o ide a mo e comp ehensi e
unde s anding o po e y in he con ex o wage employ-
men . This app oach allowed us o cap u e no only he
indi idual's wage ea nings, bu also he household's abili y
o suppo i s membe s, conside ing ac o s such as he
numbe o ea ne s and dependen s. Mo eo e , by linking
ou measu e o he na ional po e y line, we we e able o
assu e i s alidi y and applicabili y wi hin he speci ic
socioeconomic con ex o Egyp . Thus, ou measu e o in-
wo k po e y p o ides a nuanced assessmen ha akes
in o accoun bo h indi idual-le el income and household-
le el ulne abili y, making i pa icula ly well-sui ed o
examining he complexi ies o po e y isks in he
Egyp ian heal h sec o .
Wo king hypo heses
As indica ed in he p e ious sec ion, he li e a u e
mainly di e en ia es be ween pe manen and empo a y
4o 15 EHAB and MOSAAD
employmen in de eloped coun ies. Howe e , wo king in
de eloping coun ies in ol es o he dimensions o inequal-
i y such as he di e en ia ion be ween o mal and in o -
mal employmen (In e na ional Labou O ice, 2013).
Hence, we examined he ela ionship be ween non-
s anda d employmen (di e en ia ing be ween o mal and
in o mal employmen ) and he isk o belonging o he
g oup o he in-wo k poo in he heal h sec o .
Resea ch on he Egyp ian labo ma ke has in es iga ed
he link be ween a ious ypes o non-s anda d employ-
men and heal h ou comes (Ehab, 2023a;Ehab,2023b;
Sha a & Rashad, 2020). Fo example, Ehab (2023a)
has shown how he e ec o ansi ioning om non-
employmen o empo a y and in o mal employmen
di e s by gende . Fo women, mo ing in o o mal employ-
men can p o ide he mos signi ican imp o emen s o
wellbeing, as i ypically o e s g ea e job secu i y, access
o bene i s, and a s able income. This sensi i e posi ion
wi h ega d o he o mali y o he job migh ha e e ec s
ha ex end beyond he heal h ou comes o economic
ou comes.
Some s udies explo ed he ela ionship be ween in o -
mali y and po e y in Egyp o men only. Nazie and
Ramadan (2015) ocused on heads o households who
we e males o s udy hei in o mali y and po e y le els.
By using he EMLPS 2012, hey we e able o in es iga e
he impac o indi idual, socio-demog aphic household
and i m cha ac e is ics, and egional dummies, on he
likelihood o being an in o mal wage wo ke as well as
on he incidence o being poo o a male head o house-
hold. They ound ha being an in o mal wage wo ke in
he p i a e sec o does inc ease he likelihood o being
poo signi ican ly. Howe e , his pape ocuses only on
men's employmen and po e y.
Using he segmen a ion o he labo ma ke in o p i-
ma y and seconda y ma ke s is an app op ia e en y
poin . P ima y ma ke s a e cha ac e ized by o mal and
s able jobs. Seconda y ma ke s a e cha ac e ized by
sho - e m con ac s and uns able employmen (Weiss &
Reid, 2005). Fo women, ma ginal employmen o en
se es as a means o balance wo k and ca egi ing espon-
sibili ies du ing hei employmen yea s. Compa a i e
coho s udies ha e highligh ed he inc easing impo -
ance o non-s anda d employmen as a ool o women
o manage hese dual oles (Bachmann e al., 2020). The
adi ional gende ed di ision o labo means ha
women's employmen pa e ns ypically include mo e
in e up ions and pa - ime wo k due o amily ca e
esponsibili ies, making non-s anda d employmen mo e
likely o women compa ed o men (Moen, 2016). This
concen a ion in non-s anda d employmen could ha e
consequences on women's ou comes, pa icula ly hei
isks o in-wo k po e y.
Gi en he ac ha women a e concen a ed in he
heal h sec o , i is c ucial o s udy hei si ua ion in his
sec o and hei economic wellbeing. Hence, we exam-
ined he a ia ion o in-wo k po e y by gende , speci i-
cally in he heal h sec o in Egyp . This sec o has been
cha ac e ized by a high sha e o o mal employmen , as i
was p edominan ly a public sec o (Ba soum, 2020).
I also e lec s he si ua ion o women in Egyp who
s ill p e e wo king in he public sec o due o he na u e
o i s wo k a angemen s, namely o mali y and inde i-
ni e con ac s (Assaad & Ba soum, 2019; Ba soum &
Abdalla, 2022). Said e al. (2022) conduc ed a s udy using
he ou wa es o he ELMPS and ound ha eal wages
declined o wage wo ke s in Egyp . Women we e mos
a ec ed by his decline, especially in he p i a e sec o
and su e ed om inc easing in-wo k po e y.
Women bea he g ea e sha e o domes ic and ca e
wo k as hey y o econcile amily and wo k, bo h in
Egyp and in o he coun ies (Adda i e al., 2018;
Assaad & K a , 2021; Uni ed Na ions, 2019). This econ-
cilia ion ends o lead o hei concen a ion in jobs and
occupa ions ha o e lowe wages (Kallebe g, 2009;
Mandel, 2012; Uni ed Na ions, 2019). This means ha
women, in gene al and in he heal h sec o , a e concen-
a ed in o occupa ions ha end o o e g ea e lexibil-
i y bu a e associa ed wi h low wages (Wo ld Heal h
O ganiza ion, 2022). Hence, we expec ha he magni-
ude o he associa ion be ween wo king in he heal h
sec o and in-wo k po e y o be highe o women com-
pa ed o men (Hypo hesis 1).
The si ua ion is expec ed o be wo se o women
employed in in o mal employmen compa ed o women in
o mal employmen . Women p e e o mal employmen ,
gi en ha i p o ides bene i s such as sick and ma e ni y
lea es, which a e a necessi y in ligh o he an icip-
a ed wo k in e up ions o women caused by p egnancy
o ca egi ing esponsibili ies (Assaad e al., 2022;
Selwaness & K a , 2021). In o mal employmen , on he
con a y, does no p o ide hese bene i s, making i ha de
o women o make ends mee du ing pe iods o sick lea e
o ma e ni y lea e and migh lead o wage penal ies in
compa ison o o mal employmen (Tansel e al., 2020).
Hence, ou second hypo hesis is ha he ise in he isk o
in-wo k po e y is highe o hose employed in in o mal
employmen compa ed o o mal ones (Hypo hesis 2).
On a e age, women ha e a highe a e o ansi ion o
non-employmen , especially a e a majo li e cou se an-
si ion (Ehab, 2022;Heyne&Gebel,2014;Selwaness&
K a , 2021). Ma iage signi ican ly inc eases he likeli-
hood ha women will ansi ion o non-employmen
(Ehab, 2022; Selwaness & K a , 2021). This ansi ion
ypically occu s a ound he ime o ma iage, wi h a
no iceable inc ease s a ing in he yea be o e ma iage,
INFORMAL EMPLOYMENT IN THE HEALTH SECTOR 5o 15
sugges ing an an icipa ion e ec (Ehab, 2022; Selwaness &
K a , 2021). A ecen s udy showed ha he e is a ma -
iage p emium in he Egyp ian labo ma ke and no e i-
dence o an occupa ional penal y a e ma iage o
childbi h (Ehab, 2023b). This inding indica es ha ma -
ied women a e a a he selec g oup wi h good employ-
men ajec o ies and a e expec ed o ha e be e
economic ou comes. Mo eo e , he adi ional gende di i-
sion o labo means ha a woman's income is seen as a
supplemen o he household's income a he han as he
main sou ce o income. O e all, ma ied women in he
Egyp ian labo ma ke a e a a he selec g oup wi h good
employmen ajec o ies. The e o e, we expec he magni-
ude o he associa ion be ween non-s anda d employmen
and in-wo k po e y o be highe o single women han
o ma ied women (Hypo hesis 3).
DATA AND METHODS
Da a
To answe ou esea ch ques ions, we used epea ed c oss
sec ions om he ELMPS o he yea s 2012 and 2018.
1
The ELMPS is he mos sui able da ase o ou analysis
since i is na ionally ep esen a i e, ollowing households
and indi iduals (K a e al., 2021). I includes se e al
modules such as employmen , cha ac e is ics o he main
job, ma iage and e ili y ha a e ele an o ou
esea ch. The ELMPS 2012 co e ed 12,060 households,
consis ing o 49,186 indi iduals (Assaad & K a , 2013),
while he ELMPS 2018 co e ed 15,746 households wi h
61,231 indi iduals (K a e al., 2021).
Sample weigh s we e used in he desc ip i e s a is ics
and he mul i a ia e analysis. Since he scope o he pape
ocuses on in-wo k po e y in he wo ounds o he ELMPS
2012 and 2018, we included only wage wo ke s, aged om
15 o 64 yea s old. Hence, he inal sample includes 24,171
obse a ions o men and 5522 o women.
2
Va iables
The main dependen a iable o he indi idual in-wo k
po e y isk is a bina y a iable indica ing whe he he
indi idual's wage is below he low ea nings line. Being
in-wo k poo is seen as a measu e o po e y ha
add esses bo h he indi idual and household dimensions.
Fo he indi idual dimension, he indi idual is a wage-
ea ne and he e o e ea ns a wage. Fo he household
dimension, his wage may no be su icien , conside ing
he s uc u e o he household, namely he numbe o
ea ne s and he numbe o dependen s in he household
(such as child en unde 15 and senio ci izens o e
65 who a e no wo king). To accoun o he household
s uc u e, we ollow he me hodology o Said (2012) and
Said e al. (2022) o iden i y indi iduals a isk o in-wo k
po e y by calcula ing he low-income line. This line is a
escaling o he na ional po e y line by he mean o he
a io o dependen s o ea ne s in each household. Indi-
iduals a isk o in-wo k po e y a e hen hose who a e
in paid employmen bu all below he low-income
h eshold. This po e y measu e does no ully cap u e
household in-wo k po e y, which conside s household
income. Howe e , i is s ill an indica o o in-wo k po -
e y a he indi idual le el as i is ancho ed o he
na ional po e y line.
Ou wo main independen a iables a e bo h bina y
a iables. The i s is being employed in he heal h sec o ,
which is de ined based on he indus y and occupa ion
de ini ion. I akes 1 i he indi idual wo ks in he heal h
sec o and 0 o he wise.
The second is non-s anda d employmen , which is
de ined as in o mal employmen (no-con ac employ-
men ) while o mal employmen ep esen s he s anda d
employmen in his case. I akes 1 i he indi idual is
wo king in an in o mal job and 0 o he wise. I is impo -
an o no e ha gi en he small sample size o empo a y
employmen ha is o mal in he heal h sec o in he
ELMPS da a, i is imp ac ical o pu i in a sepa a e ca e-
go y. The e o e, we ha e decided o di e en ia e only by
he o mali y o he job and no by he leng h o he
con ac .
O he co a ia es a e accoun ed o in he models.
These include e e ma ied (which akes ze o i he pe -
son is cu en ly single and ne e ma ied be o e and
1 o he wise), ha ing kids, wo king in he p i a e sec o ,
he numbe o wo king hou s, age as a ca ego ical a i-
able, di ided in o 15–29, 30–44 and 45–64 age g oups,
educa ion, gende , occupa ion (ISCO-3 digi s), li ing in
u al a eas and heal h s a us. Fu he mo e, a dummy a -
iable o 2018 is also con olled o . Table 1shows he
summa y s a is ics o all he a iables used in he models
sepa a ed by sec o and gende .
Empi ical s a egy
To answe ou esea ch ques ions, we ely on bo h
desc ip i e and mul i a ia e analyses. Using da a om
he 2012 and 2018 ELMPS, we es ima e he associa ion
1
ELMPS's da a collec ion is conduc ed e e y 6 yea s (K a e al., 2021).
2
Egyp ian women a e concen a ed in unpaid amily wo k wi h abou
58% o wo king women. The ocus o ou esea ch excludes women who
a e no in wage wo k, ha is, in unpaid amily wo k.
6o 15 EHAB and MOSAAD
be ween in-wo k po e y and being employed in in o mal
jobs using logi models. The logi coe icien s a e ans-
o med in o a e age ma ginal e ec s. In addi ion, p e-
dic ed p obabili ies a e p esen ed o ease o compa ison
be ween o mal and in o mal employmen and be ween
heal h and non-heal h sec o s o men and women.
The ollowing models we e calcula ed sepa a ely o
men and women, as shown in Table 2. Models 1 and
2 include in o mal employmen , heal h sec o and all
con ol a iables o men and women, espec i ely.
The heal h sec o coe icien is he coe icien o in e es
o es ing he i s hypo hesis. Models 3 and 4 add an
in e ac ion e m be ween in o mal employmen and
heal h sec o o he male and emale subsamples, which
add esses he second hypo hesis. Models 5 and 6 add, in
compa ison o he Models 3 and 4, a iple in e ac ion
be ween in o mal employmen , heal h sec o and ma i al
s a us, again o men and women, which is used o es
he hi d hypo hesis. I should be emphasized ha his
pape ocuses on he heal h sec o in compa ison o o he
sec o s. Ne e heless, we p o ide analysis o he disag-
g ega ion o he non-heal h sec o s in o indus y, ag icul-
u e and o he sec o s in addi ion o he heal h sec o o
he ull sample (Model 7).
TABLE 1 Desc ip i e s a is ics o heal h and non-heal h sec o s.
Va iable
Heal h sec o Non-heal h sec o s
Min MaxMen Women To al Men Women To al
In-wo k po e y 0.36 0.604 0.522 0.294 0.06 0.176 0 1
Ha e kids 0 0.402 0.267 0.001 0.363 0.183 0 1
P i a e sec o 0.198 0.145 0.163 0.789 0.775 0.785 0 1
Job o mali y
In o mal (non-s anda d) 0.105 0.124 0.118 0.661 0.508 0.634 0 1
Fo mal (s anda d) 0.895 0.876 0.882 0.339 0.492 0.366 0 1
U ban 0.578 0.501 0.526 0.420 0.427 0.423 0 1
Job occupa ions (3-digi based on ISCO88) 270 290 283 571 529 558 111 962
Ma i al s a us
Ne e ma ied 0.215 0.139 0.165 0.356 0.208 0.282 0 1
E e ma ied 0.785 0.861 0.835 0.644 0.792 0.718 0 1
Indi idual heal h
Ve y good o excellen 0.471 0.393 0.42 0.377 0.359 0.368
Good 0.488 0.544 0.525 0.506 0.512 0.509 0 1
Fai 0.041 0.053 0.049 0.092 0.105 0.099 0 1
Bad 0 0.009 0.006 0.021 0.02 0.021
Ve y bad 0 0 0 0.004 0.003 0.004 0 1
Educa ion
No educa ion 0.012 0.021 0.018 0.214 0.329 0.272 0 1
P ima y and p epa a o y 0.006 0.015 0.012 0.229 0.201 0.215 0 1
Seconda y and pos -seconda y 0.36 0.565 0.496 0.407 0.339 0.373 0 1
Uni e si y and pos -uni e si y 0.622 0.399 0.475 0.15 0.13 0.14 0 1
Weekly wo king hou s
a
48,318 43,491 45,125 48,339 38,368 46,562 24 72
Age g oup
15–29 0.32 0.503 0.441 0.435 0.452 0.443 0 1
30–44 0.506 0.361 0.41 0.338 0.308 0.323 0 1
45–64 0.174 0.136 0.149 0.227 0.24 0.234 0 1
Obse a ions 172 338 510 14,460 15,051 29,512
No e: Weigh s a e used in he calcula ions.
a
Weekly wo king hou s a e winso ized a 10%.
Sou ce: Au ho s' calcula ions based on ELMPS 2012 and 2018.
INFORMAL EMPLOYMENT IN THE HEALTH SECTOR 7o 15
To inc ease he numbe o obse a ions wi h non-
missing alues in he heal h sec o , we pooled da a om
2012 and 2018. Pooling he da a allows us o inc ease he
sample size, which in u n inc eases he powe o es ima e
accu a e coe icien s and es s a is ics (Woold idge, 2010).
We a e in e es ed in unde s anding he de e minan s o
being a isk o in-wo k po e y a he han he e ec o
he ansi ions in o his s a us o i s long- e m e ec s. I is
he e o e c ucial o explain ou indings as pa ial co ela-
ions a he han in e p e ing hem as causal e ec s.
RESULTS
Desc ip i e esul s
Figu e 1p o ides desc ip i e e idence on he p e alence
o in-wo k po e y ac oss o mal and in o mal jobs o
wo ke s in he heal h and non-heal h sec o s. These ini-
ial esul s show ha ha ing an in o mal job is associa ed
wi h highe in-wo k po e y in he heal h sec o . Those
in in o mal employmen ha e an incidence o in-wo k
po e y o almos 71%, compa ed o 49% o hose in o -
mal employmen in he heal h sec o . Fo o he sec o s,
3
he e is no much di e ence be ween s anda d and non-
s anda d employmen in e ms o in-wo k po e y. The
same end is seen o women (Figu e 2) when compa -
ing o mal and in o mal employmen in he heal h sec o
(77% o 56%, in in o mal s. o mal employmen ).
Compa ing heal h and non-heal h sec o s, men ha e
a lowe isk o in-wo k po e y i hey a e heal h wo ke s
wi h o mal jobs (34%) compa ed o wo ke s in non-
heal h sec o s (36%). Compa ed o women, hei le el o
in-wo k po e y is lowe i hey a e in non-s anda d jobs
in he heal h sec o (54%) compa ed o women in he
same jobs (77%). Women in s anda d jobs in he heal h
sec o ha e highe po e y isks (56%) compa ed o men
in he same jobs (34%). These pe cen ages show ha in-
wo k po e y isks a e pa icula ly highe o women in
he heal h sec o and pa icula ly in in o mal employ-
men compa ed o men.
Mul i a ia e analysis o in-wo k po e y
This sec ion p esen s he esul s o ou analysis o
in-wo k po e y isk and in o mal employmen ac oss
TABLE 2 The analy ical s a egy.
Model Va iables Table Hypo hesis
Models 1 and 2 In o mal employmen , heal h sec o +all con ol a iables, once o men
and once o women
31
Models 3 and 4 Models 1 o 2 +in e ac ion be ween in o mal employmen and heal h sec o 4 2
Models 5 and 6 Models 1 o 2 +a iple in e ac ion be ween in o mal employmen , heal h
sec o and ma i al s a us
53
Model 7 In o mal employmen , sec o s (disagg ega ed), gende +all con ol a iables
o he whole sample
6
71
49
38 40
0
10
20
30
40
50
60
70
80
lam oFlam o nI
Heal h Sec o Non-heal h Sec o
FIGURE 1 Sha e o in-wo k poo wo ke s in heal h and non-
heal h sec o s. Sou ce: Au ho s' calcula ions based on ELMPS 2012
and 2018, weigh ed.
54
34
77
56
40 36
26
51
In o mal Fo mal In o mal Fo mal
nemoWneM
Heal h Sec o Non-heal h Sec o
FIGURE 2 Sha e o wo ke s in in-wo k po e y by gende in
heal h and non-heal h sec o s. Sou ce: Au ho s' calcula ions based
on ELMPS 2012 and 2018, weigh ed.
3
In-wo k po e y, among waged wo ke s, is highes in he heal h sec o
compa ed o he o he sec o s, whe e 51% o he heal h sec o wo ke s
su e om in-wo k po e y.
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