As highlighted in our June 2025 blog on The Care Gap, women in low- and middle-income countries (LMICs) systematically access healthcare less often than men. This gender difference in healthcare-seeking may have drivers on both the ‘demand’ (patient) and ‘supply’ (health system) sides. In our recent blogs, we zoomed in on the demand side of women’s healthcare, examining factors at the individual level (such as empowerment, behavioral aspects), household level (financial means, power dynamics) and societal level (religion, culture and stigmas). In this blog, we shift focus to the supply side of the story, asking whether there are aspects of the health system that discourage women from seeking care.
Underrepresentation of female doctors
A key structural feature of health systems in LMICs is the predominance of male doctors. Less than 25% of doctors are female in countries such as Afghanistan, Togo and Ethiopia – a pattern that is observed in many other developing countries. This imbalance is also prevalent in some upper-middle- and high-income countries like Seychelles (33%) and Georgia (35%).Yet, these figures likely underestimate the extent of gender disparity as a significant majority of developing countries do not report sex-disaggregated data on physicians to the World Health Organization (WHO).
Even if there is gender parity among doctors in more developed settings, there may be a concern of underrepresentation of female doctors in certain fields of medicine. In the United States, women make up almost half of residents but only about 29% of active surgeons, with slow growth in most surgical specialties (Kurapti et al. 2024). In the United Kingdom, female representation varies widely across surgical specialties. Some such as trauma, orthopaedics or cardiothoracic surgery have fewer than 10% female consultants, and gender parity in these specialties may not be reached for several decades (Newman et al. 2022).
Figure: Gender composition among doctors, selected countries, 2023
Source: World Health Organization (WHO).
How female patients experience health systems
Mirroring broader social norms, staff at health facilities may treat women as inferior – adding to the demand-side factors that make women hesitant to seek treatment. In their qualitative study of healthcare-seeking behaviors among women and men in Vietnam, Johansson et al. (2000) investigate the role of staff attitudes and quality of health facilities with regard to tuberculosis. Based on focus group discussions, it is found that across genders, public health facilities for the disease did not meet patient expectations both in terms of material resources and human competence – with women being more sensitive to poor facilities and negative staff attitudes1. The researchers call for gender-sensitive strategies in healthcare and an improved understanding among health workers of the sociological and gender aspects of disease control, in addition to technical aspects. There ought to be a continuous process of assessing and improving the quality of care, with a focus on communication, management, and leadership – alongside working environment, equipment, and facilities.
Besides, in settings where patients are not very well-off or educated, the doctor-patient relationship may be characterized by power imbalances. In their research in central India, Fochsen, Deshpande and Thorson (2006) observe that medical encounters are dominated by the knowledge and expertise of doctors. From the doctors’ perspective, patients are ignorant and incapable of understanding the information being provided to them. This is exacerbated in cases where the patient is female: the “dependent, vulnerable, and neglected” status of women in the family and society seems to be reproduced in the doctor-patient relationship as well. During consultations, it is mainly the accompanying family members talking to the doctors and the female patient remains passive and submissive. At the same time, doctors largely consider this necessary based on the belief that women are reluctant to disclose information and incapable of providing a proper account of their condition. Despite male patients being considered as less cooperative, doctors express the view that it is easier to establish a relationship with them, leading to effective communication and treatment adherence. The authors infer that such power imbalances may be less prominent when the doctor and patient belong to the same gender. Improving the work conditions of doctors, ensuring sufficient staffing to manage patient load, and providing support and training, can alleviate the authoritarian approach of medical personnel. In particular, training in interpersonal and communication skills and patient counseling should be incorporated in medical education and also be arranged for practicing doctors.
Gender match between doctors and patients
Research in developed countries has demonstrated that physicians do not practice solely based on science; their behaviors and choices are also driven by values, beliefs, race, and gender. For example, Malhotra et al. (2017) find that patient–provider gender discordance is associated with lower rates of breast, cervical, and colorectal cancer screening, even after accounting for racial and ethnic concordance. In China, Si et al. (2025) examine the impact of physician-patient gender match on the quality of healthcare2. To isolate the impact of physicians on outcomes, the researchers adopt a “standardized patients” (SP) method wherein SPs are study participants who are trained to present their illness symptoms to physicians and respond to questions in a similar manner and to later record their interaction in detail. In the study setting, the random pairing of SPs with physicians is ensured given the walk-in nature of primary healthcare. Two gender-neutral illnesses are chosen – unstable angina and asthma – which are such that the initial statements by SPs may be consistent with multiple underlying illnesses, and appropriate history-taking and examinations should lead physicians to the correct diagnosis and treatment. The measures of healthcare quality considered are consultation length (proxy of provider effort), medical costs (consultation, medical tests, medicines prescribed), correct diagnosis, and correct drug prescription.
Overall, the study finds little difference by the gender of the physician in terms of the quality metrics. When the gender of the patient is taken into account, it is seen that physicians treating male SPs obtain a higher rate of accuracy in diagnosis and drug prescription – even as consultation times and medical costs remain consistent. Comparison of the four pairs of physician-patient gender matches demonstrates that female physicians treating male SPs was associated with a higher likelihood of prescribing correct drugs but also higher costs. Based on testing of various potential mechanisms, the authors deduce that female physicians may have stronger motivation to defend themselves when treating male patients and try harder to avoid the risk of misdiagnosis. Cultural gender norms favoring males may drive the provider to prescribe more unnecessary medical tests to reduce decision uncertainty. The evidence suggests that the training of healthcare providers in effective communication and innovative interventions that enhance patient centeredness can improve outcomes in healthcare.
Apart from influencing treatment given to patients, medical evaluations impact eligibility for receiving benefits under social insurance programs. Cabral and Dillender (2023) hypothesize that the gender of doctors may play a role in medical evaluations because having similar backgrounds or characteristics improves communication and reduces bias. To disentangle the impact of doctor behavior from patient behavior, the study leverages the random assignment of doctors to patients for medical evaluation in the context of workers’ compensation insurance. This implies that any differences between assessments by female and male doctors are driven by their gender rather than differences in types of patients assigned to doctors. The empirical analysis is based on large-scale administrative data from the Texas workers’ compensation insurance system, with a focus on disputed claims requiring independent medical exams.
It is found that when the patient and doctor have the same gender, there is an increased chance of females being evaluated as having a disability and receiving cash benefits; however, no such effect exists for male patients. It seems that male doctors assess female patients against a stricter standard while female doctors apply similar standards to female and male patients. A survey conducted by the researchers reveals that women more often report having a negative experience, with the doctor not understanding their concerns, assuming something without asking, talking down to them, not believing them, or making them feel uncomfortable. It is concluded that the underrepresentation of female doctors may contribute to gender disparities in medical evaluations.
The power of communication
Siu (2015) underscores the importance of gender in interpersonal communication, including that between patients and doctors. The quality of doctor-patient communication in turn influences treatment quality, compliance and outcomes. Yet, a lot of such evidence comes from the West and this may play out differently in other cultural contexts. The study considers the scenario of female patients with the sensitive condition of overactive bladder (OAB) seeking treatment from urologists, a male-dominated medical specialty in Hong Kong. Based on semi-structured interviews conducted with a sample of patients, it is found that patients feel embarrassed while discussing symptoms with male doctors, and undergoing diagnostic procedures and physical examinations. Often, this hinders honest and effective communication between patients and doctors. Second, patients feel that the urologists do not accord seriousness to their condition, commensurate with the disruption it causes to their physical and emotional well-being. This seems to largely stem from male doctors routinizing or trivializing OAB as a part of middle-aged womanhood, and is compounded by brief consultation times and less emphasis on dialogue. Third, female OAB patients perceive a lack of empathy towards the social and emotional consequences of their condition by male doctors. In a similar vein, recommended treatment regimes fail to take into account women’s dual responsibilities of caregiving, which may make adherence difficult. Finally, given the broader social norm of women not resisting decisions made by males, the patients sense that the doctors do not expect them to have an opinion on how alternative treatment paths may fit into their lifestyles.
Zeroing on the gender of physicians, Roter, Hall and Aoki (2002) investigate the impact on communication during medical consultations. They posit that female physicians facilitate “more open and equal exchange and a different therapeutic milieu” relative to their male counterparts. This is rooted in evidence of interpersonal style varying by gender even outside healthcare, with women encouraging others to talk to them more freely. The researchers conduct a systematic review of studies pertaining to physician-patient communication (non-psychiatric) where communication has been measured via neutral means. It is observed that women doctors communicate in a way that relates more to the broader life context of the patient’s condition. They make an effort to address psychosocial issues via related questioning, counselling, seeking patient input and offering more verbal and non-verbal indicators of attentiveness. Further, there is reciprocity in patient behavior – they talk more with female physicians including sharing psychosocial and biomedical information, and expressing more partnership-building. At the same time, the gender of the physician does not influence the provision of biomedical information in terms of quality and the manner of communication. Overall, female physicians spend 10% more time per patient visit as compared to male physicians, resulting in greater work burden. Based on the findings, the authors advocate for training of physicians to strengthen communication skills such that they are able to deliver quality care within restricted timeframes.
In sum, enhancing the diversification of the medical workforce and provision of support and training in patient-centric care, can improve patient experience and in particular, encourage more women to access healthcare. Higher quality patient-doctor interaction can also lead to better outcomes in terms of diagnosis and treatment.
In the next blog in February, we will explore another aspect of health systems – information interventions carried out under public health programmes. These may have greater relevance for women relative to men, given their lower levels of awareness and access to networks and technology.
FOOTNOTES
1 Drawing a parallel with crime reporting, Iyer et al. (2012) demonstrate that when the quality of women’s interaction with the police improves – in terms of their grievance being taken seriously, among other factors – women are more willing and able to report crime against themselves. In the study, these positive outcomes are linked to greater representation of women at the lowest levels of governance.
2 In school education, Rawal and Kingdon (2010) show that when the teacher is of the same gender as the pupil, there is a positive impact on student performance. This may be caused by the teacher having a greater understanding of the child, leading to more acceptance, understanding and encouragement.
REFERENCES
Cabral, M., & Dillender, M. (2023). Gender Differences in Medical Evaluations: Evidence from Randomly Assigned Doctors. NBER Working Paper No. 29541. https://www.nber.org/papers/w29541
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https://journals.sagepub.com/doi/10.1177/1049732306293776
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Kurapati, S., Moeckel, C., Stegman, M., Yaghy, A., Genao, I., & Shukla, A. G. (2024). A flattened curve: National trends of women physicians and residents in surgery over the last decade. Journal of Surgical Research. https://www.sciencedirect.com/science/article/abs/pii/S0022480424006061
Malhotra, J., Rotter, D., Tsui, J., Llanos, A. A. M., Balasubramanian, B. A., & Demissie, K. (2017). Impact of patient–provider race, ethnicity, and gender concordance on cancer screening: Findings from the Medical Expenditure Panel Survey. Cancer Epidemiology, Biomarkers & Prevention.
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