How lack of support and biases create a glass ceiling in health care

The fact that women are not reaching leadership positions means they are not able to influence decision-making on public health, Lancet article shows

The barriers for women in health care to assume leadership positions in India are the same as those faced by their peers in North America, although they vary in their intensity, an article published in the Lancet journal pointed out.

Women leaders in India agree that health care remains uniquely positioned as a female-dominated sector, but skewed in terms of representation at the top.

In public health care, only about 30 per cent are doctors, while the rest include nurses, midwives, auxiliary nurse midwives, Asha (accredited social health activist) workers who form the frontline workforce, points out Preeti Kumar, vice-president, public health system support, at the Public Health Foundation of India. There are more than 800,000 Asha workers, who are not represented in leadership positions, she adds. “There is a vast base of frontline workers, but leadership positions are very few.”

Shagun Sabarwal, one of the authors of Lancet’s August article titled “Comparing barriers and enablers of women’s health leadership in India with East Africa and North America”, points out that unlike other sectors, women account for nearly three-fourths of the workforce in health care. But the fact that women are not reaching leadership positions means that they are not able to influence decision-making on public health.

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The study pointed out that “universal themes emerged around factors enabling (mentors, professional networks, leadership based in empathy and team building) or impeding (overt bias and family responsibilities) women across all contexts”.

Among three top barriers, it found higher percentages of women in India reporting lack of female role models, as well as gender discrimination and/or harassment in male-centric cultures than in North America. On the other hand, more women in North America complained of harmonising personal responsibilities with work as a barrier than in India. Women in East Africa reported the highest percentages for all three barriers.

“It is a global trend, where the transition is not happening into leadership positions for women,” says Sabarwal, South Asia and monitoring, evaluation, and learning director at WomenLift Health, a non-profit funded by the Bill and Melinda Gates Foundation. “When it comes to C-suite representation, the number is barely 5 per cent. Women representation from low- and middle-income countries is even lower,” she adds.

What stood out in their study were the commonalities across regions and universality of themes, says Sabarwal.

“In India and East Africa, the lack of female mentors was a specific problem. And the lack of access to professional networks is specifically a problem for women because the way networking spaces work retains the idea of old boys’ clubs.”

According to her, organisations should invest in mentorship and leadership building opportunities.

WomenLift Health, which has presence in the geographies covered in the study, carries out programmes to build leadership with a focus on training mid-career women.

“Women are more likely to think about barriers, so it’s very important to get them exposed to certain critical concepts like emotional intelligence, confidence, negotiation and managing conflicts,” Sabarwal says, explaining the focus of their training programmes.

The onus should not be on women alone, she says. “Institutions should recognise unique gender barriers, go beyond tokenism, and create networks and opportunities.” WomenLift Health also wants to address the societal aspects, push the discourse around women and create role models.

In India, it has worked with 30-odd women who represent hospitals, non-profits, government institutions as well as philanthropic bodies.

Kumar of PHFI says, “Sadly, the top leadership, including the women who have worked hard to reach there, have a disconnect with the mid-level leadership”.

While in rural areas, women face greater challenges in terms of opportunities, social milieu, or gender sensitivity, these issues are not absent in urban areas, says Kumar.

Women’s own perceived capacity and capability are also a lasting and significant barrier. “Women’s desire to have work-life balance, gender discrimination in terms of opportunities, and how much agency they can exercise are barriers that are at the organisational as well as individual levels.”

According to Kumar, women need actual support more than mentors to overcome structural barriers. “The barriers have to be broken with male allies in an organisation. And, why only in a cisgender equation; what about transgenders? So, a support structure should be extended to transgenders as well as those with disabilities, apart from women.”

Collectivising is one way to aim for better representation and empower women in health care.

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Kalpana Nagpal, senior consultant, department of ENT and head and neck surgery, Indraprastha Apollo Hospitals, New Delhi, long felt the need for organising women ENT specialists.

The Association of Otolaryngologists of India, which has thousands of registered members, did not offer adequate opportunities for all at its conferences, she says. The Women’s Association of Otolaryngologists of India (WAOI) was thus formed in 2021.

“Women multitask and face challenges particularly in extended families, as they are not encouraged to go for surgical procedures. So, I thought we should be a strong support group for rising ENTs or even medical graduates who are indecisive about specialising,” says Nagpal.

The WAOI held its first conference last month, in New Delhi, which 110 women ENT surgeons attended.

Among its stated objectives are networking and collaborating. “People also trust you more when you are in a group rather than practise solo. I have seen junior colleagues crying because they have been made fun of over low pay. It's tough for beginners because doctors have no age limit and can practise even in their 80s. So, guiding and mentoring is essential and it becomes both a financial and emotional support for young doctors. It also helps face medicolegal cases better,” Nagpal explains.

She, too, stresses on improving work conditions to help women aspire for bigger roles.

As women get empowered, it is not so much about gender biases as about work conditions that set them back, according to her. “There are no daycare facilities, for instance, which should be mandated everywhere. Then young women can work without the stress of caring for children at home.”