African Women Surgeons Reshape Healthcare, Break Gender Barriers

Kigali, Rwanda — Approximately five billion people in low-resource areas lack access to safe surgical services, risking catastrophic health expenses, with an estimated need for 143 million additional surgeries, particularly in resource-constrained countries that house two-thirds of the global population, according to an Operation Smile study titled Breaking the Glass Ceiling: A Multiregional Study of Mentorship and Leadership in All-Women Surgical Teams.

Four cleft surgical programs were conducted in Morocco, Peru, Malawi, and the Philippines in 2022 to evaluate the experience of healthcare providers in Operation Smile all-women surgical programs and the impact of participation on leadership and mentorship opportunities. The results were striking as 97% of respondents reported improving technical and non-technical skills, while 82% were motivated to pursue leadership positions. 99% of women who participated in all-woman teams sought mentorship from other women.

But is gender equity the answer to healthcare accessibility?

Workforce shortages, especially in surgery and anesthesia, are a significant barrier, exacerbated by gender inequities. Women, who make up half the world’s population, represent only 47.4% of the global workforce, facing hurdles such as unpaid labor, gender discrimination, and pay inequality, reports the World Bank. Despite delivering the majority of healthcare – 80% of nurses and 90% of midwives are women – they remain underrepresented in leadership roles, with less than 40% of the surgical workforce being female. Women in surgery often face bias, limited mentorship, and inflexible work arrangements, relegating them to lower-paid, lower-status roles, according to Women in Global Health.

In low- and middle-income countries (LMICs), women dominate unpaid or underpaid healthcare roles, contributing significantly to GDP, yet nearly half of their work remains unrecognized.

Surgery has long been a male-dominated field, but across Africa, women are increasingly breaking barriers and reshaping the landscape of healthcare.

The first women plastic surgeons in Africa, such as Dr. Francoise Mukagaju in Rwanda and Dr. Metasebia Abebe in Ethiopia, paved the way, inspiring other female plastic surgeons to enter the field. In Africa, women plastic surgeons have the unique opportunity to transform healthcare by addressing these challenges and leveraging existing achievements. Despite challenges such as gender bias, limited access to training, and societal expectations, women surgeons are making remarkable strides in an area where they are significantly underrepresented.

Four surgeons were on a panel at the Pan African Surgical Conference – Dr. Naikoba Munabi, a plastic and reconstructive surgeon, Dr. Metasebia Abebe, Ethiopia’s first female plastic surgeon, Dr. Francoise Mukagaju, Rwanda’s first female plastic surgeon, and Professor Salome Maswime, an associate professor and the Head of Global Surgery at the University of Cape Town – sharing their insights on the role of academic institutions, NGOs, and private industry in driving gender equity in surgery. The panel was moderated by Dr. Mumba Chalwe-Kaja Surgeon, Zambia’s first woman urologist.

The discussion was rich with personal experiences and professional reflections and addressed the challenges and triumphs women face in a male-dominated profession while stressing the transformative potential of gender-inclusive policies and initiatives.

Fostering gender equity

“I would argue that pursuing gender equity is important, not just from an equity standpoint, but also from an economic and business standpoint,” said Dr. Munabi. “Advancing the participation of women in healthcare is crucial for achieving our goals of providing safe surgery to the 5 billion people worldwide who need it.” According to Dr. Munabi, 18 million more healthcare providers are needed worldwide, with women representing the largest untapped demographic.

She pointed out that women, particularly in low- and middle-income countries, represent the largest untapped demographic to fill this gap. “By 2030, one billion women worldwide will not be participating in any form of formal employment, and over 90% of those women exist in low- and middle-income countries,” she said.

Dr. Munabi said that initiatives promoting women’s development and education could have the most significant impact. However, women must first know that opportunities exist and see them as feasible.

She said that biases and societal norms often prevent women from entering the field.

Reflecting on an eye-opening experience with Operation Smile’s Women in Medicine program in Morocco, Dr. Munabi shared “I remember one mother said, ‘I was scared for my child. I thought that the surgery was not going to work because there are only women here.’ Another woman told us, ‘I had always been told my whole life that women can’t do anything without men.'” These biases, Dr. Munabi said, “run deep and can prevent women from participating.”

Despite these challenges, she found hope in the positive reactions of many participants. “By seeing women here, I was inspired… I want to get an education. I think that I could potentially be a member of healthcare as well.”

“If women are seen and their presence is encouraged, more women will actually follow,” she said. “Only 25% of healthcare leaders worldwide are women, and that’s even lower in low- and middle-income countries.”

She called for programs that promote women’s leadership, which she believes will create a ripple effect, addressing inequality while strengthening economies, promoting education, and reducing poverty. “If the question is how do we actually solve the global health problem and the global surgery problem, get healthcare workers, the answer definitely includes women,” she said.

Dr. Abebe agreed that academic institutions must go beyond just creating space for women – they must actively support and nurture their growth.

“It’s not just about creating physical space for women; it’s about ensuring they thrive,” she said.

Reflecting on her experience as the first College of Surgeons of East, Central and Southern Africa (COSESCA) woman fellow from Ethiopia, Dr. Abebe questioned whether increasing numbers alone were enough. “Is it always about the number that we’re talking about? Is it about the physical space? It shouldn’t be,” she said. “Academic institutions lie in a very special place where they can actually witness gender equity opportunities, collect data, and provide that information.”

She shared her personal experience as a resident, recalling the challenges of sharing night shift rooms with male colleagues. “Even now, my residents face the same issues I did years ago,” she said.

“It’s not about just existing. It’s about thriving. It’s also about retaining them.”

Dr. Abebe called for institutions to go beyond tokenism and actively support women surgeons. “Academic institutions are in a unique position to collect data, identify gaps, and implement solutions,” she said. She also praised NGOs like the Association of Women Surgeons and Operation Smile for providing opportunities and mentorship but stressed the need for these programs to be more widely accessible.

Discussing the role of NGOs, she acknowledged the support of organizations like the Association of Women Surgeons, and Operation Smile in funding women in surgery. However, she insisted that such opportunities need to be expanded. “As more women train, they need to know these opportunities exist. They need to come and actually occupy the space and become part of the whole situation,” she said.

Dr. Mukagaju echoed these sentiments, praising her country, Rwanda, for taking steps to promote gender equity.

“When you are born in Rwanda and you are a lady, the first day, you are already lucky,” she said. She said that women in the country are given space to demonstrate their abilities rather than being pushed into roles.

“If you are a woman in Rwanda, definitely gender equity is taken care of.”

She shared examples from her hospital (King Faisal Hospital) and university, where there is a strong focus on recruiting women into various medical fields, including surgery. “The space is given, but it’s not just about being given space; it’s about showing what we are capable of when we have the support and encouragement to succeed,” she said.

Dr. Mukagaju said that through organized meetings and sponsorships, women are empowered and encouraged to pursue careers in medicine. She described initiatives like the Women in Surgery Chapter Symposium, where young girls in secondary schools are invited to learn about surgery and see successful women surgeons. ” The hospital helped us, the university helped us to go to those secondary schools and pick young girls who are in sciences so that they can come and see what is happening in surgery, see that there are women that have made it and now are surgeons,” she said.

She credited Operation Smile for supporting her journey to becoming Rwanda’s first female plastic surgeon. “If I’m sitting here as the first female plastic surgeon in Rwanda, it’s because of Operation Smile that has believed in me and put effort into training me,” she said. “When I enrolled to train, I didn’t think it would be this big, but I’m grateful for Operation Smile and other partners and NGOs that believe in women and give space so that we can show what we can do.”

Measuring impact

Professor Salome Maswime, who has been a champion for women in the surgical field, said that while increasing the number of female registrars in surgery is important, true transformation goes beyond numbers. “We used to have one female registrar, now we’ve got 20 and over time. But it’s not just about the numbers, it’s about the experience the women have,” she said. “When young students see a professor who looks like them, it tells them they can also become that.”

She said the critical role of undergraduate students in shaping surgery’s future and how their early experiences influence their career paths. “How you treat them, first of all, whether you inspire them to specialize in surgery or not, that’s the way it all happens,” she said. She pointed out the damaging impact of subtle discouragement, such as telling women they don’t look like surgeons. “The messages that we tell them, ‘You can’t be a surgeon, you don’t look like a surgeon,’ trying to get them not to specialize – these soft messages on the corridors will determine how people do,” said Professor Maswime.

Maswime stressed the importance of setting clear goals for transformation.

“If you want to transform anything, if there isn’t a goal, an objective, so many diversity and transformation strategies fail because there was never a target. We said we want to change everything, but we didn’t put actual numbers,” she said. However, she urged a human-centered approach beyond numerical targets. “Beyond the numbers, let’s be human,” she said.

Women fail because they’ve been set up for failure sometimes.

She called for systemic changes, including increasing the number of female students and leaders in surgery. “Changing the gender of the students that come in and ensuring that with time there are more females that come in is important. But also changing the leaders – it doesn’t stop with just getting the surgeons, but your head of department, head of the clinical unit, professors, et cetera,” she said. “When the young students see a professor that looks like them, it tells them that they can also become that.”

However, Maswime cautioned that simply placing women in leadership roles is not enough – they need proper support. “Women fail because they’ve been set up for failure sometimes,” she said. Women need advocates who will “mention your name” and help them access opportunities, she said.

Dr. Munabi strongly agreed with Professor Maswime that promoting the capabilities of women in surgery is important.

“I remember when I was a junior trainee, I had an experience where someone assumed I was a member of the custodial team and not a doctor or a member of the surgical team,” she said. At a time when she was still building her confidence, this was a “very jarring experience.” However, she was fortunate to have strong mentors who supported her, though she acknowledged that such experiences can be difficult.

In addressing the challenge of measuring impact, Dr. Munabi stressed the importance of a clear vision. “To measure impact, you first have to have an idea… that you want to showcase and analyze,” she said. She reflected on her early days with Operation Smile, where she noticed the resilience and talent of women in the field despite pervasive biases.

“Everywhere I went, I encountered at least one woman who was incredibly talented, hardworking, capable, and doing the work with a tonne of grace and resilience, and many times by themselves,” she said. This observation led her to ask, “Why don’t we celebrate these women?”

“Advocacy is important, and most of the time we don’t learn it at school.”

Dr. Mukagadjo said that simply having a great idea is not enough if one cannot articulate it convincingly to decision-makers. “Sometimes you think you have a great idea, but when you are with someone who has to make a decision, you can’t explain it, and it doesn’t serve you,” she said. She advised proactive networking, saying, “If you are in a meeting like this, give yourself a goal to at least know five people, and you never know where you need them and when you need them.”

Professor Maswime spoke out about the importance of women becoming decision-makers to drive systemic change.

“We need to think of the consequences of not changing the table and who is at the table and how they are making decisions,” she said. “We need to hold our leaders accountable, we need to negotiate with them completely, 100%, but there comes a point where we say, but we can’t accept this.”

Maswime shared personal experiences of gender bias in the medical field, recalling how she was questioned for becoming pregnant while a registrar. “I was asked, what was I thinking, falling pregnant as a registrar?” she said. “How do you get those questions? How do you answer those questions? I won’t even share my other stories.”

“At some point in my life I had to think, if nothing changes, I become part of the problem,” she said.

“Some of us didn’t lead because we were attracted to leadership and positions and wanted the fancy seats at the table,” she said. “We chose leadership because we realized that the convictions that we had if we don’t stand up, no one is going to.”

Maswime called for a disruption in leadership structures, saying “Before we change strategies, create policies and all of that, let’s look at whether we need to disrupt the decision-making table.”

“Be there, advocate for it. If you’re not there, then it’s never coming up…”

According to Dr. Abebe, women need to actively advocate for their causes as echoed by Professor Maswime.

“It’s about properly, diplomatically advocating for your cause,” she said. “Sometimes we shy away, as women, we shy away from leadership positions because we feel like some positions are just names or bogus positions just to keep you there.”

She urged women to go beyond just having a seat at the table. “Be there, advocate for it. If you’re not there, then it’s never coming up. But at least if you’re there, if you’re discussing it, if you’re bringing it up, then eventually it becomes a part of the decision,” said Dr. Abebe. “Just be there, and when you’re there, be loud, advocate, again, persistently advocate for the cause.”

She said that there is no one-size-fits-all solution but stressed the value of presence and effective communication. “Instead of just your righteous anger, communicate it in a very diplomatic way so that you get the much-needed equity issue addressed in leadership,” said Dr. Abebe.

“One of the best ways to get a stakeholder at the table is to figure out how to make them understand why your problem is actually their problem,” said Dr. Munabi.

She used childcare as an example, explaining that hospitals rely on their staff’s availability, which is only possible if female employees have access to childcare. “The hospital, for example, wants to have their resident staff and their surgeons available to work. That’s only possible if their female employees have childcare of some capacity,” she said.

Dr. Munabi said that institutions are more likely to invest in such initiatives if they can demonstrate the economic benefits of supporting them. “Making them see how it actually could economically help them out dramatically will make them willing to invest in those types of things,” she said.

Solving the leadership gap

Maswime discussed how women face obstacles in pursuing leadership positions and how they can sometimes become the biggest obstacle to themselves. “Sometimes as women, we are our own worst enemies,” she explained, explaining that women often hesitate to apply for leadership positions. She stressed the importance of addressing insecurities and redefining leadership. “Leadership is about service. It’s not about power and all of these things, it’s about service.”

Sometimes as women, we are our own worst enemies…

She encouraged women to rethink their approach to leadership and seize opportunities. “We must desire it. Those who love speaking often make good leaders. We must consider it when opportunities come,” she said. She also pointed out the necessity of stepping up rather than complaining about current leadership: “We can’t sit and complain all the time that my leaders are making bad decisions, but we are part of the problem.”

Professor Maswime said that leadership should not be lonely if proper support systems are in place: “They say leadership is lonely. It shouldn’t be lonely. If we invest in all the support systems, then one is required to be a leader.”

Dr. Abebe initially doubted her ability to become a surgeon due to her physical stature.

“I never told, what I told was I needed to be that tall, that big to become a surgeon. Because that’s what I saw. And I am, fortunately or unfortunately, not big or tall at all,” she said. “We needed to see that women could do it. We knew we could become doctors. But to become surgeons, again, we needed further people to look at, people who have come before us.”

“Seeing people in that position makes you think, I can do it too, I can be there too,” said Dr. Abebe.

Dr. Munabi commented on the difference in how female and male trainees perceive their skills. “…I have found that female trainees thought that their skill level was at the level or below the level that it was at, and male trainees thought that their training was at the level or above. She linked this disparity to societal biases that go back to the way in many cultures “We talk to young women and girls, even before they get to the level where they’re in medical school, training about what they can do, what their talents are.”

She spoke about how societal norms often prioritize appearance over intellect for young girls.

“A lot of times we comment on beauty more than intelligence. And I think that confidence is something that is rooted into young girls early, and it’s not always rooted into young girls,” she said. “On the flip side of that, I would say, is that there is an advantage to that. I think that having humility makes you introspective and self-critical to a certain degree that allows you to improve.”

“Leaders are not born, they are made, but leadership is broad…”

“If you are born a woman in Rwanda, there is a high chance that you can be a leader,” said Dr. Mukagaju affirming the opportunities for women in Rwanda. “If we take an example of the environment, we know how more than 60% in the Chamber of Deputies is women, so that shows how women are allowed to be in leadership roles.”

“Even though there is that saying that leaders are not born, they are made, I realized when I did a course on leadership, I thought maybe they were going to tell me how to talk to the people that are under me, or maybe how to go in the meetings, how to talk to them.” However, she discovered that leadership is much broader. “But I found that it’s more than that, it’s broad, it’s big, and it also includes things that we already do in our daily lives, how you talk to people, even social things as you were saying,” she said.

Dr. Mukagaju believes women’s natural social skills can be advantageous in leadership roles. “As women, we are a bit more social, and I think becoming leaders would be even easier if we are given space.” According to Dr. Mukagaju, this places women in a unique position to excel in leadership roles.

Unlocking opportunities

Dr. Fetiya Awol, an Assistant Professor of Obstetrics and Gynecology at Jimma University Medical Center in Ethiopia, discussed the importance of empowering women in medicine. She described it as a journey of strength, perseverance, and leadership, which required resilience to overcome systemic barriers and societal expectations.

“I asked myself, why not me? A question that has since guided my career,” she said.

Growing up in Ethiopia, Dr. Awol faced societal pressures that discouraged her from pursuing a career in medicine. She recalled, “My high school teacher and even some of my own relatives told me that I didn’t belong in medical school. They said things like, ‘Girls don’t go beyond high school; you have gone too far, and you need to stay home and support your family.'”

Despite skepticism and resistance, she challenged norms and pursued leadership roles.

During her time as Chief Clinical Director, she significantly improved emergency mortality rates, surgical volumes, and the representation of women in leadership positions at the university.

She remains committed to mentoring young professionals and creating an environment where women can thrive as leaders. “This is not about leaving men behind,” she said. “It’s about ensuring that our sisters receive the recognition, opportunities, and support they deserve.”

Dr. Awol said that women should take charge of their futures. “Let us not wait for opportunities; let us create them. Let us not hope for change; let us be the change.”

By Melody Chironda