Gender inequality in healthcare leadership: the challenges women face in breaking through the glass ceiling | BMC Health Services Research

This qualitative exploratory study aimed to uncover the challenges women in Pakistan encounter in their pursuit of healthcare leadership positions and the factors that help them overcome these challenges.

One of the prominent themes that emerged from our research was the existence of an unsupportive work environment. Women participants consistently described encountering biases, gender stereotypes, resistance to authority, a lack of equal opportunities, and a lack of representation. Participants recounted instances where they felt stereotyped or pigeonholed based on their gender, age, and attire, rather than being evaluated on their professional merits. This stereotyping and discriminatory behavior stems from deeply ingrained misogynistic cultural beliefs that erroneously label women as inherently weak, emotionally unstable, less competent, or ill-suited for leadership roles [13,14,15]. Several studies conducted in the USA, UK, Nigeria, and Egypt found that the difficulties encountered by female healthcare professionals in these nations were fundamentally tied to socio-cultural factors, consistently echoing the sub-theme of stereotyping [16,17,18]. Many participants discussed how the existing power structures and top leadership positions are predominantly occupied by men. Studies conducted in India and China have also revealed a pattern where women predominantly occupy low and mid-level positions, with men dominating the top leadership roles [19, 20]. This male-dominated hierarchy has a detrimental impact on women in two significant ways: first, the prevalence of male-centric policies and decision-making processes, and second, a preference for men over women when opportunities arise. Additionally, a scarcity of female role models and mentors can make it difficult for aspiring women leaders to envision themselves in high-level roles. Mentorship enables women to effectively navigate existing professional hierarchies [21]. Participants noted that women in healthcare leadership roles often receive less recognition and compensation than men in similar positions. According to Desai et al., women earned less than their male counterparts, even when they had equivalent levels of productivity, work volume, academic qualifications, and professional experience [22]. The pay gap not only affects women’s financial well-being but also sends a disheartening message about their worth and contributions to the organization. Participants also shared experiences where their decisions were questioned or challenged more often than their male counterparts. This observation also resonates with the established body of literature on female authority [14, 23], and may be attributed to cultural upbringing and entrenched traditional gender norms, which have historically positioned men as the primary figures of authority [24].

In Pakistani culture, women are often seen as the caregivers and nurturers of the family [25]. All ten participants identified family responsibilities, particularly taking care of young children, as the foremost hindrance to the advancement of women. It was likewise discovered in a multinational study that women assumed greater responsibility for parenting and domestic duties compared to men [26]. While women in Pakistan have increasingly pursued education and careers, traditional gender roles and societal expectations can limit their opportunities outside the home. These opportunities include networking, official tours, relocation for work, meetings with stakeholders after work hours, working overtime, etc. A systematic review revealed that women prioritize their medical careers over family and choose to delay having children [27]. Contrary to that, all the participants in our study claimed that family is their priority. Many women opt for extended career breaks to manage their caregiving responsibilities, resulting in significant setbacks to their professional careers. In a survey conducted in Japan, 38% of female surgeons adjusted their career plans to accommodate childcare responsibilities, while 11% chose to resign from their positions [27]. Participants also frequently cited instances, where they perceived their decision-making autonomy was curtailed, with men in their households assuming control over their work-related decisions.

Leadership is often associated with qualities like confidence and assertiveness, which are considered masculine traits. In Pakistani culture, women are frequently confined to their homes and have limited social interactions with the opposite sex. This, along with the absence of women’s leadership development opportunities within organizations, is a significant contributing factor to the lack of confidence and leadership skills among women. This finding is consistent with the established body of literature that indicates that women are often denied significant development opportunities by their superiors. They often experience self-doubt, and when they endeavor to assert themselves, they may risk being perceived as unlikable [14, 23, 28, 29].

Practical approaches emerged as a crucial theme in our study, with participants shedding light on the importance of continuously honing their skills, acquiring relevant knowledge, and demonstrating exceptional competence in their healthcare leadership roles. A study conducted among Pakistani female surgeons similarly found that being skillful and competent helped women thrive in a male-dominated field [30]. Women are accorded a high degree of respect in our society, and there are certain behaviors that men are expected to refrain from when interacting with women. By strategically capitalizing on these gender norms, women can establish themselves as leaders, break down barriers, and garner the trust and support of their teams. Participants highlighted the significance of clear and empathetic communication in building relationships, resolving conflicts, and conveying their vision to their teams. They also stressed the importance of women being adaptable because society often does not favor women with inflexible or assertive personalities [31].

Despite repetitively declaring family responsibilities as obstacles to leadership, participants emphasized that family support played a crucial role in helping them overcome work-related challenges. This contrasts with the outcomes of prior research, which typically identified unsupportive families as barriers to women’s progress [19]. The data also unveiled an unconscious bias among women against women, hinting at internalized misogyny as a potential factor hindering women’s progress to leadership positions [24]. However, many participants discussed that women can only make their mark in a male-dominated society by having each other’s backs. An intriguing aspect of the study’s findings is that despite Pakistan’s international image often being associated with conservative beliefs and Islamic extremism, none of the interviewed women leaders reported religion or societal conservatism as obstacles to their advancement. The participants reiterated examples of Muslim women leaders on several occasions to underscore Islam’s endorsement of women’s progress. Most participants believed that once you’ve acquired your leadership position and proved your mettle, the challenges reduce.

Finally, various organizational interventions that participants believed could assist women in reaching leadership positions encompassed mentorship programs, leadership training initiatives, family-friendly policies, daycare facilities, women-exclusive support groups, equal pay practices, feedback and evaluation, transparent promotion processes, safe reporting mechanisms, and flexible career paths for women within healthcare organizations. Existing literature widely agrees that focusing on these aspects holds the potential to dismantle barriers and promote gender equality in healthcare leadership [14, 18, 23, 27, 32, 33].

This study has certain limitations. Firstly, all participants were doctors and dentists, excluding other healthcare professionals, which along with societal and cultural variations may limit the generalizability of the identified themes to female healthcare leaders on a global scale. Secondly, there is a potential for participants to provide responses they deem socially desirable, potentially influenced by the feminist theory. Additionally, the study did not explore how factors such as foreign qualifications, socioeconomic status, or influential family backgrounds affect gender dynamics in leadership. Future research should encompass a more diverse group of healthcare professionals and should also incorporate the viewpoints of male healthcare leaders to acquire a more comprehensive understanding of the intricate gender dynamics that operate within the healthcare system in Pakistan.