Essential but vulnerable: a model for understanding how macro–meso–micro-level factors combine to impede the sustainability of female health providers

Purpose Global health discourse has increasingly focused on achieving universal health coverage, yet the occupational health needs of the workforce delivering these services remain systematically neglected. This paper aims to address the systematic neglect of the occupational health needs of female health-care providers – principally nurses and midwives – in low- and middle-income countries (LMICs). The paper makes particular reference to Sub-Saharan Africa. It develops an integrative multilevel conceptual model that explains how this neglect is produced, transmitted and amplified and proposes implementable multilevel responses. Design/methodology/approach The study uses a structured integrative literature review, reported in line with the PRISMA 2020 statement, and conducted for the purpose of conceptual model development. Eighty-six sources retained from six databases and grey literature repositories were synthesised through a codebook-style thematic analysis. It draws on the Social Determinants of Health (SDH) framework, Moral Injury Theory, the Job Demands–Resources (JD-R) model and the Health Equity Framework. Findings The synthesis suggests that macro-level structural determinants are proposed to produce the foundational architecture of provider neglect. Meso-level organisational factors are proposed to transmit macro-structural neglect into the lived realities of individual providers. Micro-level clinical stressors appear to amplify the intermediate consequences experienced by individual providers beyond what structural and organisational factors alone imply. Gendered structures operate as a cross-cutting context conditioning every level of the model. Feedback loops link deteriorating health system outcomes back to macro- and meso-level conditions. Dismantling provider neglect is therefore proposed to require simultaneous interventions at all three levels of the model. Research limitations/implications As a conceptual paper, the proposed model is not empirically tested. It requires empirical validation through quantitative and qualitative studies across different health-care settings, particularly in LMICs. Cross-national comparative studies across Sub-Saharan African, South Asian and Latin American contexts would test the model’s generalisability. Longitudinal studies tracking the same provider cohorts over time would help examine the proposed sequence and feedback loops. Practical implications The paper emphasises the necessity for national governments, health ministries and institutions and policymakers to establish comprehensive occupational health programmes, dedicated health insurance schemes for providers, workplace wellness initiatives, mental health services and financial protection mechanisms. It specifies responsible actors, implementation priorities and measurable outcomes for each recommendation. International development partners, global health donors and multilateral organisations should integrate health-care workforce welfare into health systems-strengthening investments. Social implications The study reframes health-care providers as a vulnerable population whose health needs are often overlooked within health-care systems. It contributes to sustainable development goals 1 (end poverty in all its forms everywhere), 3 (ensure healthy lives and promote well-being for all), 8 (productive employment and decent work and economic development for all), 10 (reduce inequality) and 16 (provide access to justice for all). Originality/value To the best of the authors’ knowledge, this is the first study to integrate macro-, meso- and micro-level explanations of health-care provider neglect within a single conceptual model that embeds gender-specific mechanisms and feedback loops in its connecting structure. It reframes this neglect as an equity and social justice issue rather than a management problem. It extends Moral Injury Theory into the domain of occupational health exclusion. It repositions the SDH framework as a tool for analysing occupational health inequalities among the health workforce itself.