Gender composition and wage gaps in the Canadian health policy research workforce in comparative perspective

An estimated 67% of the global health workforce are women, but persistent gender challenges mean the promise of “equal pay” for “equal work” remains elusive [1]. The World Health Organization (WHO) advocates for the need to consider gender as a potential driver of social inequalities among human resources for health (HRH)—and therefore to systematically incorporate gender issues in health labour market analyses as a means to ensure the full, effective, and equitable participation of women and men in a high performing health workforce to meet current and future population health needs [2]. Traditionally gendered divisions of labour and social norms may lead to certain professions, including female-dominated nursing and caregiving occupations, being given lower social value and lower pay [3‐6]. Income inequalities and other gender-related problems have also been widely documented among women in traditionally male-dominated health occupations, such as medicine [4, 7‐9]. It is increasingly recognized that health systems should be held accountable to sociocultural imbalances and establish equity benchmarks, but gender considerations often remain neglected in health systems and health workforce research [10‐12]. In a landmark 2019 report, the WHO identified four thematic areas with major gaps in the global HRH data and literature to support gender inclusiveness and equity: occupational segregation, gender pay gaps, decent work, and leadership [13]. An example of such information deficiencies may include gender wage gaps experienced by the very professionals involved in the design and application of gender-responsive health policy.

Differences in compensation for human capital endowments, such as professional qualifications, may help explain gender wage gaps; nonetheless, research persistently indicates simply being a women or employed in an occupation with skewed gender composition are major contributors to wage differentials [14]. The causes of gender occupational segregation and wage gaps among HRH have been linked sociologically and psychologically to historical idealizations defined by and for professional men, who were expected to be authoritative, rational, and committed to their jobs and earning more money; women were typically seen as lacking such traits and thus less committed to employment and becoming professional leaders [3, 5]. Despite social change and women’s increased participation in higher education, the influx of women into previously male-dominated professions has not eliminated differential treatment by gender and may render some jobs less rewarding to men [3, 5, 9]. In many countries traditional gendered hierarchies remain entrenched within health system institutional practices, such that social biases continue to shape compensation policies, professional development opportunities, and productivity evaluations [4, 14, 15]. The result, as argued by Adams, is that women tend to maintain their presence in historically female-dominated occupations (such as nursing), some feminizing professions are internally devalued (e.g., paediatricians), while many higher-paying professions continue to be male-dominated (e.g., surgical specialists) [3]. Such gendered wage relativities may exacerbate HRH shortages if the (female-dominated) health sector is perceived to offer less attractive career trajectories than other sectors (e.g., male-dominated, higher-paying economics and business professions) [5, 6].

Numerous observational studies have found significantly lower earnings for women health workers and feminizing health occupations within and across countries and over time. In an international study of health worker wages from 21 countries, Boniol et al. reported that women health workers earned 28% less than men on average; after adjusting for key labour market variables, a gap of 11% remained for women and men with similar occupations and working hours [1]. A cross-national analysis of health workforce remuneration associated increasing shares of women participating in a given health occupation with a decrease in its wage rank [16]. Based on a time-trend analysis of sex-disaggregated survey data from 25 countries, Shannon et al. suggested that the gender wage gap was widening with increasing feminization of the health labour market, particularly in selected lower- and upper-middle-income countries [17]. In one high-income setting, an analysis of administrative data from the Canadian province of British Columbia indicated significantly lower earnings among women physicians compared with men after adjusting for patient contacts and other factors [18]. In Iran, Rad et al. found that women physician’s salaries averaged 30% less than men’s, with 7% of the wage disparity remaining unexplained after controlling for speciality, work experience, and other measured confounders [19]. A 19% unexplained component to the raw gender wage gap was found among health professionals in Australia, after decomposing gender differences in job characteristics and other human capital factors [14]. From a cross-sector comparative perspective, the evidence is inconclusive as to whether the health sector is more unequal than non-health sectors. In one analysis of data from five countries, gender wage gaps were found to be less pronounced among (male-dominated) science professionals than (female-dominated) nursing professionals, while the association was inconsistent in relation to (female-dominated) education occupations [20].

While wages are central to HRH recruitment and retention, a lack of comprehensive wage information covering the broad scope of health occupations has constrained health workforce strengthening [16]. Studies on the gender wage gap typically focus on service providers. However, an estimated one-third of the global health workforce are composed of health management and support personnel, that is, those who do not provide direct patient care but are essential to the performance of health systems [21]. This may include professionals with clinical backgrounds working outside the healthcare sector. For example, data on physicians in academic institutions in the United States have told of pervasive gender-based salary disparities among early-career and mid-career professionals, even after adjustment for factors such as specialty and academic rank [22, 23]. This wide-ranging category of HRH may also include individuals with non-clinical professional skills employed in the health system, such as those whose core responsibilities involve health policy and programme research and development. Their labour market profile is much less known.

In Canada, women are overrepresented in health employment and continue to increase their shares in many professions requiring a university degree, including family medicine and health policy research [24]. We are unaware of any studies in Canada (or elsewhere) explicitly addressing gender-related wage gaps in the health policy research workforce. To build the evidence base on wage conditions among health policy researchers, this study investigates the gender composition and relative wages among health policy researchers in the Canadian national context. We address whether gender occupational segregation and wage gaps are issues within the health policy research workforce and compared with other non-health policy domains. We use data from the 2016 Canadian population census to assess and decompose wage disparities among policy researchers in health and other traditionally female-dominated sectors in relation to selected traditionally male-dominated sectors. Econometric decomposition analysis is applied to estimate the explained portion of observed wage differences between women and men as well as any residual “unexplained” component, the latter being commonly interpreted as a statistical measure of gender discrimination [5, 14, 25].

While several HRH studies have examined the persistence of wage differentials between women and men engaged in clinical services, this inquiry represents the first nationally representative analysis in Canada (or, to our knowledge, anywhere) of gendered wage conditions among health policy researchers. Non-clinical professionals represent a large component of human resources in health systems, and policy researchers play an integral role in the development and monitoring of equity-enhancing government and community health policies and programmes. As such, managing gender disparities in health services delivery requires an understanding of underlying gender issues within the workforce itself tasked with policy-actionable research. Echoing global HRH trends in gender composition, the Canadian health policy research workforce was enumerated as predominantly female (74% women). Perhaps not surprisingly, we found evidence of a significant gender wage gap, with women earning 4.8% (95% CI 1.5‒8.0%) less on average annually than men, after adjusting for age, education, and other labour, social, and residential characteristics.

As examinations of health labour markets are enhanced when placed in a more comprehensive perspective that takes into account other sectors [20], we compared wages among health policy researchers with those for selected non-health policy research occupations. Disconcertingly in terms of the relative competitiveness of the health sector for attracting and retaining talent, results from our pooled cross-domain linear regression presented significantly lower wages among health policy researchers (21% lower; p < 0.05) than their counterparts in economics policy research, the only male-dominated occupation under observation (56% men). These results were consistent with research evidence elsewhere of diminishing wage conditions with increasing shares of females in a given occupation. Such findings may express societal devaluation of “women’s work” in the labour market, and replicate and reinforce social perceptions of gendered differences in professional status even for similar types of work [3, 6, 14‐16].

Moreover, the cross-domain regression and Oaxaca–Blinder decomposition analyses showed, of the (observed) female‒male wage differential of 8.1% (95% CI 6.9‒9.2%) in the total policy research workforce, 40% remained unexplained by the measured predictors. In other words, women’s earnings averaged around 3.2% less than men’s due to unexplained factors, an outcome that may be attributed, at least in part, to (unobserved) gender discrimination and other sociocultural and economic structures that hinder women’s labour market opportunities. Significant adjusted wage gaps among healthcare workers have been reported across different national income contexts in studies using decomposition techniques, to provide insight on the residual wage gap that cannot be accounted for by differences in women’s and men’s individual characteristics [6, 14, 19]. The unexplained residual of decomposed wage levels is widely postulated in the literature to capture effects of female‒male differences in societal conventions, unconscious bias, self-selection, and other unmeasured processes leading to a systematic, avoidable, and unfair maldistribution of resources and benefits [6, 16, 25, 31]. It may, however, also denote some degree of estimation bias related to variables omitted from the operationalized model. For example, Vecchio et al. attributed a small part of the wage gap in Australia’s health sector to gendered patterns of unpaid overtime [14]; the lack of a question on expected hours of work in our data source precluded the ability to integrate this potential confounder.

The need for intersectoral collaboration and cooperation is accepted internationally as a critical principle for advancing population health and health equity goals [33]. Our analysis underscored that actions for health workforce strengthening and equity cannot be achieved within the health sector alone. Sectors are largely social constructs, and calls for policy integration are increasing [33]. Alignment of labour market approaches should be considered necessary to improve and sustain the efficiency, effectiveness, and inclusiveness of work conditions among women and men with policy research expertise in the health sector and across interdependent sectors.

Like in many countries and at the international level, Canada’s health policy dialogues are dominated by shortages and imbalances in the health workforce, exacerbated by the Covid-19 pandemic. It is increasingly argued reversing such trends requires investing in female health workers, given that the health sector relies heavily on the recruitment and retention of women [35]. The WHO has long recognized that the people working in planning and setting directions for health systems are indispensable, but often overlooked in HRH data and discussions [21]. Addressing gender inequity and wage differentials across the health policy pipeline is one important element, including among those tasked with bridging information from clinical and community health programmes to evidence-based advice for decision-making. Devaluation of women’s contributions to the performance of health systems should be viewed as an ongoing crisis [9], although denial among researchers and the wider public of persistent gender inequality in the realm of work is widespread [5]. As the present findings need to be tested in other settings, this study aimed to pique interest and advance methodological considerations for more research on wage conditions in the health policy research workforce using an intersectoral and gender-based analysis lens.