Gender imbalance in executive management positions at the Mexican National Institutes of Health

Gender hierarchy in the healthcare professions is a complex sociological phenomenon. For decades, it has been argued that medicine is a patriarchal enterprise headed by men to maintain women in a subordinate position. According to these theories, men have consistently used gender exclusionary strategies to maintain a male monopoly [29]. Then, during the 1920s and 1930s, aspiring women doctors increased their participation in male-dominated professions [30, 31]. Since the 1970s, the numbers of women in medicine have increased significantly around the world [32].

It is well documented that even if women’s awareness of the importance of their active participation in healthcare professions is growing, they still struggle with the lag of many to accept them, which leads to obstacles to access and promotion to leadership positions and to the training needed to qualify for this access, as well as to an already mentioned inequality in working conditions and wages [33‐39]. Such disparity is more pronounced in academic medicine, especially in the cardiac and surgical specialties (i.e., in high-paying specialties) [40, 41].

Studies on gender differences about preferences, attitudes, and skills are often contradictory. It is indeed difficult to assess the reasons why leadership positions are assumed in some health institutions. The most common are believed to be mainly related to personality, character, labor merits, social and political relations, and prestige, as well as to academic and administrative inclinations [42].

The concept of self-efficacy to leadership offers a potential resolution of this contradiction. Various theories argue that effective leadership is the result of the appropriateness or fit between particular behaviors (being someone well trained and willing) and particular situations (being in an appropriate and welcoming context) to the functional necessities of each leadership organization. Hence, instead of placing barriers to high-level training, organizations must design and include effective policies to prepare and encourage women’s leadership if they want to be inclusive [37, 43, 44].

In Mexico, command posts in hospitals, health ministries, universities, or medical academies have been in charge of men for hundreds of years already. These higher management and director positions require full-time dedication and have often been filled by 50 plus-year-old men. This could be explained by the fact that the feminization of medicine in Mexico has been a recent phenomenon so that time has not allowed for women’s leadership to become common [42].

If we analyze the Area Director position and the size of each MNIH, we found that in the INGer, which is the smallest institute with only 19 (2.4%) executive managers, woman and man are found in the same proportion, while the largest institutes, like INSP or INCMNSZ, showed an apparent gender gap; for example, in the INSP, 36% are women and in INCMNSZ only 11%.

On the other hand, in the Deputy Director position, gender gap is more evident and could be related to antiquity of MNIH. For example, in 10 of the 13 MNIHs (some of the oldest institutions), this position is occupied predominantly by men. In the INCICH (the eldest of all), historically, women have never been represented in this position, while in two more, INger and INPer are occupied by women more frequently.

In this research, we found that executive positions in MNIHs are significantly lower for female than those of male executives and that the wage gap exists mainly in the lower ranks of the hierarchical order, where women are relatively highly concentrated. This phenomenon has already been reported in other cases [45].

Consistent with our finding, other studies have shown that while the majority of the healthcare workforce is female, women are still underrepresented in healthcare leadership positions [46‐49]. Women represent 70 to 80% of the total of the workforce; however, only 24% reach senior executive positions, and furthermore, only 18% of women occupied general manager positions in hospitals [50, 51].

Another example of this situation is the health boards, where women represent only 14% of the population [52]. This is the case of the World Health Assembly, where women occupied a quarter of the Managing Director position, even though they represent three quarters of the total health workforce [3].

In our results, the gender imbalance in executive management positions apparently was not affected by temporal changes; however, other studies have demonstrated that temporality or antiquity could determine the organizational policy and greater access to the leadership position, especially those determined by the legal environment [53].

A number of traditional and critical theories have been put forward by various institutions, organizations, authors, scholars, researchers, and development practitioners, somehow, to explain or contextualize the issue of gender equality and lower female empowerment.

In the twentieth century, perspectives given by sociological research and gender studies have provided some relevant frameworks aimed to explain why women are underrepresented in executive management positions [54].

In what follows, we will present and discuss some of these:

Inequality theories, the apparent universal subordination of females over the centuries (supposedly a biological explanation): Structural functionalism argues that gender roles were established aimed at keeping the division of labor and family system functioning properly because men typically took care of responsibilities outside of the home, and women typically took care of domestic responsibilities [54].

According to the Conflict theory, society is driven by a struggle for dominance among social groups, men as the dominant group and women as the subordinate group, and the social problems are created when dominant groups exploit or oppress subordinate groups. Feminist theory considers that the patriarchal family is realized by perpetuating male dominance. Symbolic interactionism aims to understand human interaction by analyzing the created behavior related to the interpretation of masculinity or femininity characteristics which may help us understand societal labeling, institutionalized sexism, and gender disparities [54].

Recently, gender theories have received a great deal of attention, in particular the ones dealing with gender barriers and disparities in the corporate suite. Androgyny theory, or feminization of management, states that females and males could possess both masculine and feminine traits. Gender stereotyping theory states that managerial roles should be masculine occupations or in any case reserved for older females. The perpetration of such ideas from the corporate world does not seem far from what happens at higher managerial and directive positions in healthcare systems [55].

Expectation states theory argues that gender leadership style is deeply embedded in status, beliefs, and organization’s social hierarchy because of the rules of the gender system. Also, advantaged groups (as males) are seen in society as having greater competence and social significance than disadvantaged groups (as females); this belief, in turn, becomes grounded in inequalities. Role congruity theory takes into account an individual’s gender role, its congruity with other roles [55]. Well-documented more specific theories, related to stereotype-based cognitive bias, social dimension, individual dimension, and institutional dimension, explain the barriers and various contextual factors that impede women’s opportunities for leadership positions in work organizations. Figure 3 shows a conceptual model of structural of multilevel gender barriers.

Stereotype-based cognitive bias may take two forms:

Explicit barriers are related to clear personal beliefs about women, such as believing that women are less committed to their careers than men and believing that women are worse leaders than men. Women also encounter additional explicit hurdles in becoming leaders, and they face a double bias by the reason of motherhood or by the color of skin [56].

Implicit barriers refer to unconscious stereotypes or attitudes which are harder to see, but they still influence judgment and actions towards women. The stereotype-based perspective towards women has been used to explain their supposed lack of fit for leadership roles in medicine. These stereotypes center on perceived characteristics, skills, and aspirations of women and how they have been perceived to not coincide with what it has been declared valuable for effective leadership, e.g., “how can a woman be the leader of a large hospital?” the challenges can be “too much” for her [39, 57, 58].

Contemporary theories of gender as a multilevel or structural system also explain the problem in terms of additional dimensions, as follows:

Social dimension (homosocial reproduction) suggests that decision-makers tend to appoint leaders like themselves in terms of gender, race, age, and background; in-group favoritism leads men to prefer other men for high-level promotions and appointments. Hence, male directives will train and elect other males to succeed them. Social hierarchies are hence part of the reason why the so-called glass ceiling phenomenon exists [37, 38, 55].

Individual dimension suggests that women face significant limitations on their individual ability to display typical leadership qualities. To counter this burden, some women have de-emphasized her gender status when interacting with male colleagues, training to be assertive, driven and/or competitive in spirit, without failing to emote more stereotypically feminine qualities such as warmth and passivity [37, 59].

Institutional dimension includes some processes that take place within the workplace that can limit the access, recruitment, retention, promotion, and advance of women to leadership positions. Also, these mechanisms are well reported in the literature termed as the glass cliff, the decision-maker diversity, and the savior effect [44].

Also, by looking beyond individual actors and behaviors, a structural sexism perspective highlights the discriminatory character of institutional arrangements. Let us consider some possible mechanisms that may be present in healthcare systems [60].

Barriers related to the access and recruiting are as follows:

Gender-segregated social and professional networks. It has been discussed that men are more likely than women to have access to more abundant and timelier information about job openings, which gives potential female applicants a handicapped position since they may lack critical information about job availability relative to their male counterparts [44].

In-group preferences. Gender stereotypes strongly influence decision-makers’ evaluations of job candidates, in contexts where traits required for performance tend to be stereotypically masculine. This ideas are related to those of homosocial reproduction theories, already mentioned [44].

Barriers related to the retention and promotion are as follows:

Glass ceiling phenomenon refers to an invisible barrier to women’s promotion to top positions by means of other implicit mechanisms, such as lack of quality mentoring, strong professional networks, social ties to elites, workplace support, and insider information [37, 38].

Glass cliffs scenario suggests that women will be appointed to leadership in poorly performing firms that are struggling, in crisis, or at risk to fail because they are viewed as superior interpersonal managers and more capable of taking the blame for failure. As a result, women leaders often experience shorter tenures, and again, the men associates are the ones perceived as ideal managers for successful firms [37].

Labyrinth theory suggests that women and men use different routes to climb the corporate ladder. Women break impermeable barriers in small numbers, such as in a labyrinth. The labyrinth represents the possible multiple routes that women follow in their career, because routes do exist for females, they are just not direct routes, but entangled ones [55].

Barriers related to the advance and postpromotion are as follows:

Token status suggests it is believed that those who comprise less than 15% of a group’s total are expected to experience a variety of hardships in the workplace, leading to weaker social and professional networks; reduced organizational support, information, and assistance from peers and subordinates; heightened visibility and scrutiny; exaggerated stereotypes; and exclusion and isolation. As a result, token women leaders often experience reduced performance and lower job satisfaction [37, 38, 55].

Role incongruity theory suggests that the association of leadership with masculinity motivates assumptions about the type of person who can successfully fulfill leadership roles, leading to negative evaluations of women, irrespective of their preparation, ability, or performance [38].

On a related scenario, the so-called savior effect predicts that women will be granted less of opportunities to prove their leadership capabilities within a large organization, so in that cause, they are likely to be replaced by more traditional men leaders who will be brought in to save the firm apparently from poor leadership [37].

Perhaps, the gender gap could be explained by at least two phenomena: the so-called glass ceiling, which is used as a metaphor for the invisible barrier that veiled the advance of women towards higher ranks within the organizations [61, 62], and the implicit bias, which is based on personal believes that act based on unconscious internalized schemes and therefore often act through discriminatory unconscious participants’ behaviors [63, 64].

Other forms of discrimination are wage gap between genders, explained by different working hours or different occupations. There was an analysis based on median wages from the Labour Force Survey data compiled by the International Labour Organization (2000–2018, over 104 countries) where 21 countries showed an average gender pay gap of around 28% exists in the health workforce [51]. In working sectors overpowered by women, work is often undervalued and underpaid; this is the case of the health sector where high-income countries have 26% wage gap and is even higher in middle-income countries 29% [50].

Interestingly, in our case, we found no evidence of the wage gap between genders since gross salaries in the Mexican government is by law fixed for a given position, regardless of the gender or any other characteristic of the position holder; therefore, women in executive management position are remunerated at similar levels to their male counterparts. The only case in which we detected a wage gap was in the Managing Director position (Fig. 2b).

These results are consistent with what Cohen and Huffman reported about female managers associated with lower gender wage gaps, especially when those women were in managerial positions of relatively high status [53]. However, other studies indicated that in many institutions worldwide, women are still extremely underrepresented in leadership positions and also have access to lower salaries on average than their male peers [64‐67].

Other work also reported that a wage gap between men and women (19% less) in leadership positions has been persistent. Additionally, it was noted that women tended to work in specialized areas that are not the usual professional rates for executive leadership positions such as nursing services, planning, marketing, and quality assurance [68, 69].

Strong positive effects have been reported, both on the size of the workplace and in the rise of gender integration [53]. Women underrepresentation in some fields of medicine is critical, because lack of gender diversity in the medical workforce can modify sex-specific aspects, such as the ones related to gender unbalanced financial coverage, patient care, and outcomes [40].

Whether or not this situation has given place to the establishment and perpetuation of gender-based healthcare inequalities is still uncertain. What is not in doubt is that many of these men-designed policies are indeed creating unequal treatment condition of healthcare available to women. One instance that has been recently addressed by our group is related to gender inequalities in public healthcare insurance coverage of myocardial infarction in women [70]. The current situation covers up healthcare security up until 60 years old, both in men and women cases. However, it is well known from social epidemiology studies on myocardial infarctions that women are prone to suffer from cardiac failures later in life (postmenopause), often long after the age of 60 years old [71]. This known fact has been however overlooked by the mostly men-driven public policy-making bodies. Is this inequality a consequence of gender imbalanced directive counsels, we do not know.

The influence of female medical directive decisions on Mexican healthcare system is special. In recent years (since 1997), out of 13 MINHs, only three Mexican leaders have reached the general direction: Dr. Alessandra Carnevale Cantoni, MD, at INPed (1997–2000); Dr. Teresa Corona Vázquez, MD/PhD, at INNN (2012–2017); and Dr. María Elena Medina Mora, PhD, at INPsi (2009–to date), and for the first time, a woman headed the highest authority in the Secretary of Health in Mexico, Dr. Mercedes Juan López, MD (2012–2016). To add some perspective, there have been up to 85 opportunities to reach the general director status along these years and only three of these have resulted in a woman being elected [42, 72].

There is no doubt that gender differences have been critical in making different decisions about medical care, with a gender perspective, as well as the access and financing process in some areas of the institutional health system. For example, multidisciplinary research with a gender perspective in neuropsychiatric disorders, as well as the study of addictions in Mexican women, has been favored scientific evidence to financing practices for access and care, and has contributed to the formulation of emerging gender and health policies, but also has promoted a greater number of women in decision-making positions and gender professionalization [73‐75].

With this in mind, the vision of the women Mexican health administration, during the 2012–2018 period, was to transform the Mexican healthcare system so that it ensures equitable and effective access to quality healthcare [76]. Within its management, the National Observatory of Health Inequities (NOHI) was formed, and recently, NOHI published its first report on health gaps and differences in access. NOHI has been also proposed to generate knowledge that will allow the Mexican government and its Ministry of Health to achieve a unique, public, free, and egalitarian system. The years to come will witness the efficacy of these relevant actions in the practice [77, 78].

In spite of their large organizational size, there is no evidence of size integrating effects at the MNIHs, as pointed out by our results. In the case of healthcare, occupational segregation still persists with strong disparities on leadership positions, salaries, and working conditions. Most of the healthcare workforce is feminine, and women’s participation in health-related areas is consistently higher than in the bulk of science. However, feminization of the workforce happens in an unequal manner: around 75% of the worldwide healthcare workforce is feminine, but women are disproportionately relegated to the lower cadres of health work [79]. As already discussed, this is the case of the MNIHs supported by our results.

According to the High-Level Commission on Health Employment and Economic Growth, gender biases in the healthcare sector undermine inclusive economic growth, employment, appropriate work conditions, and the achievement of gender equality. There is a consensus that gender equality in science, medicine, and global health has the potential to lead to important health, social, and economic benefits [79]. One goal of the present study is, thus, to provide policy boards and decision-makers with carefully analyzed data to help them make informed choice on these issues.

In August 2018, the president of the World Bank pointed out that human capital, the potential of individuals, will be the most important long-term investment that any country can make to the prosperity and quality of life of people in the future. However, the chronic lack of recruitment, promotion, and retention of women in science and medicine is due to systemic, structural, organizational, institutional, cultural, and social barriers to equity and inclusion. Such barriers need to be dismantled in order to ensure optimal development of the said human capital [11].

Gender imbalance is pervasive in many contexts within medical leadership, but some authors have stated that once uncovered, such imbalance may become malleable. They sustain that possible strategies include a longitudinal approach combined with progressive small-scale training that will be more effective to empower women and may result in durable change towards an increasingly modern and developed society, one with a narrower gender gap [55, 58].

Multidimensional policies in the institutional structures are needed to attain these goals. Gender diversity, particularly the presence of influential women among decision-making ranks, can also impact women’s mobility and tenure, as well as help reduce the impact of gender homophily and token status [37, 44, 55, 80].

It has been argued that annual salary and labor condition reviews with a gender focus, as well as implementation and frequent monitoring systems for harassment and discrimination, can help women not only to survive, but to thrive in the medical leadership field [56].

Socialization processes may improve mentorship, guidance on career goals, and professional advancement of women. Inclusion on social networks to be well informed of job opportunities is also critical [44, 55, 56].

Derived from the previous cases, it is proposed that in order to reduce gender imbalance in the Mexican case, it is critical to design structural policies for access and promotion of equitable leadership positions, based on institutional, cultural, social, and biological differences. Additionally, it is proposed to generate future studies, based on multilevel frameworks for research on the occupational situation, availability of resources, and salaries of health personnel.