Gender is one of the most important dimensions of health workforce. Understanding the structure and dynamics of gender composition of a health system’s health workforce is fundamental to support the safety and wellbeing of health workers and the health of communities and achieve Universal Health Coverage. To be best of our knowledge, this paper is the first study to investigate the feminization of the health workforce in China. Using China’s national health statistics, this study examined the gendered composition of the health workforce in China and analyzed the trend for different types and different professions of health workforce.
Our analysis highlights the following findings. First, the health workforce in China is primarily composed of women, with the proportion of women increasing from 63.8% in 2002 to 72.4% in 2020. Second, the rural health workforce that rank lower in health system and have a lower pay is feminizing at a faster speed than urban counterparts. Third, the health workers in less privileged professions in the hierarchical health system, including those in public health and traditional Chinese medicine, are feminizing at a faster speed than prominent and authoritative professions like clinical medicine.
The feminization of health workforce is beneficial. Gender diversity is able to translate into empowered health workforce and improved patient outcomes. Widespread evidence from other disciplines shows that gender diversity leads to substantial gains in productivity, innovation, and employee retention [18]. Growing evidence shows the way female doctors practice leads to reduced mortality and better patient outcomes[19] [20]. Although gender differences exist in ways of practice, they are not inherent and unchangeable [21], because a gender-diverse environment has the potential to drive innovation and influence behaviors [22].
Our findings of a significant 1.04% AAPC increase in female health professionals are in line with literature from other contexts. The movement of women into healthcare professions has been well documented in high-income countries [23]. In Canada and the United States, female physicians & surgeons increased from less than 5% in 1930 to more than 30% in 2008[23]. In recent years, low- and middle- income countries and regions also reported a similar trend, including Latin America[24], Africa[25], Sultanate of Oman[26], Bangladesh[27]. In Bangladesh, female doctors increased from 47.9% in 2006 to 52.5% in 2015[27]. Shannon et al. estimated that women health professionals annually increased by 5.8% in upper middle-income countries, 4.5% for low middle-income countries, and 1.1% for high-income countries[28]. However, international comparison should be made cautiously since the definitions for doctors are different in various context [29]. The International Standard Classification of Occupations and the World Health Organization have defined General/Specialist Medical Practitioners are required to hold university-level degree in medicine[30, 31]. In the latest version of the Law on Licensed Doctors in China[32], medical students who have no university degree can become licensed assistant doctors after accumulating at least three-year work experience and passing an license examination.
The feminization of health workforce has stimulated wide discussion on its causes, nature, and possible impact[3]. Research has documented sex differences in specialty choosing[33], quality of the care provided[19, 20], research productivity[34]. The feminization of health workforce has prompted concerns over workforce supply and health services provision[35], work patterns[36] [37], specialty imbalances[38], social cognition towards the healthcare profession[23], equity[3, 39, 40] etc. However, in many contexts, sex differences reflect restrictive social gender norms and gender inequalities. For example, research from the United States have found that women are advised against working in some specialties such as surgery during early medical training [41]. In China, medical students still choose specialties based on traditional gender stereotypes, and female students are more likely to choose less prestigious specialties than male, like internal medicine[42]. Women health workforce are facing many challenges [2]. Women are gendered as less skilled and assigned with traditional gender role as caregivers. Higher trained positions prioritize employment of men, such as physicians. Women face greater unpaid domestic burden and difficulties in maintaining work-family balance. Besides, lower positioning in health system leave vulnerability for women, increasing possibilities of abuse, harassment and devaluation for women [2].
The feminization of the health workforce in China is closely related to China’s fast economic growth and unprecedented social transition [43]. There are three factors that could contribute to the feminization of health workforce in China. The first factor is the transition of women’s social status. Since the foundation of the People's Republic of China, women’s social status has greatly improved. A series of laws and regulations were adopted to protect women’s rights, in which the central one is the Law on the Protection of Women's Rights and Interests (2005), which stipulates that woman have equal rights with men “in all aspects of political, economic, cultural, social and family life”. Increased levels of women’ education also contributed to the feminization of health workforce. Medical schools are preferred choices because jobs in medical fields are considered to be noble, secure and stable in China[44]. More job vacancies in health care sectors contributed to the feminization of health workforce. In China, a relatively well-developed health system has been established over the last century, creating demand for more health workers [11]. Growing private health sectors have also increased the demand for health workers considerably. Changing demographics and increasing health care needs such as the rapidly increasing life expectancy and non-communicable disease burden have increased healthcare needs and contributed to the expansion of the health sector and demand for more health workers[45].
The rural health workforce is feminizing at a faster speed than urban health organizations in China. The feminization of certain medical specialties indicated the horizontal occupational segregation[3]. The reason behind this phenomenon is twofold. On one hand, the status of rural women has increased because they have received more education and social security, and had more job opportunities than before[46]. On the other hand, the rapid economic growth creates more jobs in cities and attracts more men leaving rural areas to pursue more profitable jobs in cities, leaving women to fill the job vacancies in rural health organizations[47].
Specialties in lower position in the hierarchical health system, including traditional Chinese medicine, public health and primary health facilities in rural areas (village clinics and township health centers), have been feminizing at a faster speed than privileged positions. Careers in traditional Chinese medicine, public health and primary health care facilities are less prestigious than the authoritative careers in secondary and tertiary hospitals. In China, traditional Chinese medicine hospitals are less competitive among hospitals, and public health specialty, viewed as secondary to clinical medicine, tends to be marginalized by medical schools [48–50]. The faster feminization in low hierarchy reflects the restrictive gender norms and gender inequity, highlighting an urgent need to improve gender equity at health system level.
More men have started to enter professions that is usually dominated by women, like nurses and positions in maternal and child health hospitals. A survey in 57 countries also demonstrated that there is an increasing share of male health workers in nursing[51]. Gender stereotypes assign women the role of caring and supporting others, but the demand for male nurses has increased greatly and male nurses have good career prospects in China, which may contribute to the increase of men entering the nursing jobs [52]. However, men still remain under-represented in the nursing profession in China and globally.
Our study has implications for policies and research in multiple ways. First, there is an urgent need to consider gender equity in health workforce policies. Gender equity should be considered in policies over the career course for health workforce. Effective gender-transformative policies should be context-specific to support women and foster a gender-equity environment, especially for rural areas, public health and traditional Chinese medicine that have experienced a higher speed of gender diversity. Second, with more women in health care career, the effects of feminization of health workforce on health care services supply needs to be examined. Health workforce continue to face differential responsibilities by their socially ascribed gender roles. Research has found that women often face more pressure to balance multiple roles between employment and domestic responsibilities relative to men, and combined with workplace harassment, unequal payment and opportunity increase burnout and attrition[2] [53]. Studies have suggested to consider gender transition as an influencing factor in health workforce planning[54, 55]. However, research has not examined how women health workers transform their working pattern with more supportive environment and communities.
Despite that women are becoming doctors in greater numbers, female doctors are experiencing differential treatment[56, 57]. According to a cohort of medical graduates, female general practitioners in primary health care facilities had similar wage with their male classmates. However, female doctors in hospitals earned less than their male classmates, and the gap widened over time [58]. This study did not assess differences in pay by gender due to data limitations, but our findings highlighted the need to examine gender pay gap in health workforce as more women joining in the field.
Limitations
This study is subject to several limitations. First, the aggregate data were insufficient to allow for more detailed in-depth analysis, for example: differences in female/male ratio of doctors specializing in surgery and internal medicine; gender differences in levels of career development; and gender differences between regions and provinces in different economic situations. Second, we cannot explore gender pay equity due to data limitation. Studies from the United States have found apparent gender pay gap in dentists[59] [57]. With feminization of health workforce underway, future studies should further explore the gender pay equity, and measure the extent of gender pay gap caused by discrimination in health care field.