ABSTRACT:
Title Health Without Borders, Yet Unsafe at Work: Gendered Power, Structural Inequality, and the Unsustainability of Primary Health Care Systems in Tanzania Authors and affiliations Lorraine Mathias(PhD)¹, ¹Sally Mtenga(PhD), Irene Mashasi (PhD) Background and objective Global commitments to “Health Without Borders” emphasize equity, inclusion, and sustainability, yet these ideals remain largely aspirational for women working within under-resourced health systems in low- and middle-income countries. In Tanzania, primary health care (PHC) delivery is heavily feminized, with women disproportionately concentrated in lower-paid, lower-status cadres such as nursing, midwifery, and community health work. These women operate at the intersection of weak labour protections, entrenched gender norms, and hierarchical power relations, rendering them especially vulnerable to workplace violence and chronic threats to well-being. This study examines how national policy frameworks in Tanzania addressendered workplace violence in PHC settings and the implications for equity and system sustainability.

METHODS:
A structured review of national policies across the health, labour, and gender sectors was undertaken, guided by health policy and systems research and feminist institutional analysis. Policies were examined for definitions of workplace violence, recognition of gender-specific risks, and the presence of accountability, coordination, and implementation mechanisms at national, district, and facility levels. Key findings The review reveals profound policy silences and fragmentation. Workplace violence is rarely explicitly named, gendered risks facing female health workers are minimized or rendered invisible, and institutional responsibilities are dispersed across sectors with limited enforceability. These failures disproportionately disadvantage women, normalizing insecurity as part of feminized care work and undermining workforce retention, morale, and resilience in PHC.

CONCLUSIONS:
The Tanzanian case demonstrates how women in under-resourced health systems remain systematically exposed to harm despite global equity commitments. Addressing gendered workplace violence as a core governance and sustainability issue is essential for building inclusive, resilient primary health care systems.