Is Glass Ceiling a Myth or Reality? A Systematic Review in Healthcare Sector

As females are actively participating in every sector, the obstacles faced by them in their careers attracted the attention of researchers. The main purpose of this study was to systematically review the literature about the glass ceiling in the healthcare sector, published between the years 2000 to 2019, with no geographical limitations. Additionally, the barriers resulting from the glass ceiling were also explored. For this purpose, literature was searched from various databases, and grey literature was also used for the review. After applying all the steps of inclusion and exclusion criteria, a total of 32 studies were evaluated for this paper. Results were obtained by mainly focusing on the existence of a glass ceiling in healthcare and the barriers/factors of the glass ceiling. The findings showed that although the number of females is increasing in the healthcare sector, there is still an underrepresentation of females in senior positions. The existence of a glass ceiling is the main reason for this. The main barriers to the glass ceiling in the healthcare sector that are obstructing the way of females are organizational, societal, and personal. There is a long way to go for females in the healthcare sector.


Introduction
In the modern global economy era, there is a high demand for human resource talent. Both qualified males and females are needed for the growth of the economy. However, the pipeline that supplies an educated workforce is chock full of women at the entry-level, but when it comes to filling the leadership positions, that same pipeline is stocked with men. They are equally capable and have potential human resources as males. However, they get low wages, underrepresentation in top positions, gender stereotypes, unfavorable social status, fewer opportunities for growth, and many more obstacles even after having the same abilities and capabilities as males (Bahri, 2020). Women are underrepresented in top leadership positions; the presence of females at top positions is significantly less as compared to males in almost every sector and country (Baxter & Wright, 2000;Abraham, 2013;Parcheta et al., 2013;Purcell, 2013;Öztürk & Şimşek, 2019;Makarem & Wang, 2020;Carpenter et al., 2021;Mousa et al., 2021). There are gender disparities in workplaces. Although females are equal to or even more qualified and skilled than their male counterparts, they continue to be underrepresented in senior positions and overrepresented in lower positions and low-skilled jobs, with negative consequences for their physical and mental health and work-family conflict (Castaño et al., 2019). A study by Ford and Kiran (2008) found that biasness prevails among male and female leaders, as male leaders receive more favors than female leaders.
Females constitute almost half of the population in every society. The glass ceiling problem is not limited to poor or undeveloped countries; it affects people worldwide (WEF, 2021). Various global, regional, and country-level efforts are performed to promote women's empowerment and gender equality. However, still, the situation remains the same, and a very number of females attained senior positions (ILO, 2012). Women also possess equal specialization, so the management should pay great attention to gender equality not only because it is a human right but also to utilize their talent in an optimum way without any wastage of their talent due to gender discrimination (ILO, 2012). For this purpose, a workplace with gender equality along with social corporate responsibility, organizational ethics, and sustainability are required for the adequate growth of each employee regardless of gender (Di Fabio, 2017). But this kind of equal workplace environment has not been achieved yet where there is no discrimination based on gender for attaining senior-most positions for women. Females working in senior positions believe that they must do well in order to be acknowledged, but they are frightened that doing so would lead to failure, so they would rather keep their achievements to themselves (Kaur & Mahajan, 2021). Women are reluctant to voice their opinions since they make up a small portion of the board, and they don't appear to have had a say in any significant choices. It is clear that the principle of resource dependency is not applied. The scenario is the same in every sector; the healthcare sector is also not untouched by this gender discrimination.
Medical education institutions are full of female students, and females constitute a large proportion of the healthcare workforce (Hoss et al., 2011;Muraya, 2019). However, when it comes to senior positions in the healthcare sector, the number of females is drastically low as compared to their male counterparts, and females are underrepresented in top managerial positions and overrepresented in lower positions (WHO, 2008;Downs et al., 2014;Muraya, 2019). Females face unseen barriers that impede their career advancement. Glass Ceiling is an invisible barrier that keeps women from progressing in their careers (Carli & Eagly, 2001;Ridgeway, 2001;Powell & Butterfield, 2015;Sharma & Kaur, 2019). Although there is a large number of existing pieces of literature documenting these barriers faced by female leaders and aspiring leaders, hardly any evidence is related to the complete evaluation of these factors/barriers resulting in a glass ceiling in the healthcare sector. Therefore, the current study is to perform a systematic literature review of the existing body of literature regarding the glass ceiling in the healthcare sector to explore the barriers to attaining top positions, remedies, and signs of breaking the glass ceiling in the healthcare sector at the global level. The main objective of this study is to understand more clearly the situation and representation of females in healthcare and the difficulties in attaining managerial positions. For this purpose, literature published in reputed and peer-reviewed journals between 2000 and 2019 was taken.

Literature Review
The glass Ceiling is a term initially used in 1990 to explain the inability of females and other minority groups to attain senior positions irrespective of their qualifications and capabilities. It is an invisible barrier that keeps females away from reaching top managerial positions as well as their access to prestige and revenue. In other terms, the Glass ceiling is the barrier, namely personal barriers, organizational barriers, and societal barriers that stop women and minorities from getting promotions in the organizational hierarchy (Cotter et al., 2001;Acker, 2009;Choi & Park, 2014;Glass & Cook, 2016;Feng & Sumettikoon, 2022;Salahuddin et al., 2022). The glass ceiling stretches through every career field. The term Glass Ceiling was first defined by Carol Hymowitz and Timothy Schellhardt in their special report in the Wall Street Journal in March 1986. They defined that the glass ceiling was not something that could be seen in business meetings; instead, it was originally an invisible barrier that stopped women and minorities from reaching the upper level of the organization. In 1991 the U.S. Department of Labor also used the term Glass Ceiling in response to a study of nine fortune 500 organizations.
The investigation confirmed that women and minorities experienced significant glass-ceiling barriers in their professions. It is related to women's access to top hierarchical positions as well as their access to revenue and prestige. Implicit prejudice has been viewed as a significant component of hiring discrimination (Kleinberg & Raghavan, 2018;Espinosa & Gardeazabal, 2020). Since the prejudice in question is inadvertent and unnoticed, it is unnecessary to explain how it might continue to exist in the labor market. This would also help to explain why there are glass ceilings if unconscious gender preconceptions are more prevalent at the top of business hierarchies. The glass ceiling effect may appear in management positions or lower positions in a workplace. Studying gender disparity in the workplace is very important to understand the situation of females and minorities.
Indeed, females are equally qualified as males, but they cannot easily reach top managerial positions (Lyness & Thompson, 2000). Females are underrepresented in top senior positions (Powell, 2015). The glass ceiling stretches through every career field. Öztürk and Şimşek (2019) found that the main variables for the glass ceiling effect such as females' duties assigned by culture and society, twin responsibility of family roles and business life, organizational policies, and some other organizational factors that pose an obstacle in climbing the career ladder for females in academia. The barriers of the glass ceiling can be seen in the healthcare sector (Tracey, 2006). Females are working very hard to get equality and liberty. Females feel that the selection process is very subjective and there is a difference in getting growth opportunities. Presently a day we can see a move in social and cultural practices, particularly about discernment for women who work that is moving from traditional attitudes to modern thoughts.
According to Federal Glass Ceiling Commission USA, the glass ceiling is "the unseen, yet unbreakable barrier that keeps minorities and females from rising to the upper steps of the corporate ladder, regardless of their qualifications or achievements."

Organizational Barriers
The organizational barrier exists in the organizational practices and keeps women away from top positions. The main reason for these barriers is biased recruitment and selection practices, lack of equal training opportunities for females, lack of support from top management, adverse working environment, lack of mentor or role models, lack of equal employment opportunities, biased methods of performance appraisal, etc. Due to these reasons, there is a fewer number of females in senior positions.

Social Barriers
Our society is male dominated. Males are considered primary bread earners, and females' earnings are considered secondary income. They are confined to household work and considered homemakers. After marriage, females have to perform twin responsibilities. They are expected to work at home as well as at the office. As they have to concentrate on household tasks, it becomes difficult to concentrate on their career altogether. In this way, performing the twin responsibility simultaneously puts a huge burden on the shoulder of females. Factors like gender stereotypes/discrimination, male-dominated society, lack of family support, and twin responsibility are social barriers that affect the carrier advancement of females.

Personal Barriers
Sometimes females themselves become an obstacle in their career advancement. From early childhood days, females are taught some rules, like they are emotional, soft-hearted, and dependent on males, which makes their mindset a weaker section. Being too ambitious is still considered a male trait. In this way, females start discriminating against themselves. This leads to a lack of confidence and enthusiasm, a lack of initiative for taking challenging jobs, and a fear of administrative and leadership positions in the organization. These are the major contributing factors that hamper the career progression of females.

Data collection and transformation
Women make up 75% of the healthcare workforce, but the number of women in top positions in healthcare is just 38%. When it comes to family healthcare needs, women are the primary caretakers, but even after having the specializations, they are still underrepresented when it comes to leadership in the healthcare industry (Lantz, 2008;Hoss et al., 2011;Hopkins et al., 2006;Bismark et al., 2015;Inam et al., 2020). An article documented that in 2014-15, 51% of women joined medical colleges for studies. But when it comes to the number of medical professionals, the ratio of women is significantly low compared to men. In hospitals, females are responsible for 70-80% of the care provided in hospitals. But females comprise only 25-35% when it comes to senior leadership and administrative positions (TOI, 2016). Yedidia and Bicke (2001) documented scarcity of women in leadership positions in academic medicine has persisted despite their increasing numbers in medical training. The study also found the existence of barriers to the advancement of women and proposed a spectrum of approaches to address them. Females face a lack of opportunities compared to their male counterparts, and it is perceived that males acquire leadership qualities and styles more than females (Muraya et al., 2019;Wolfert et al., 2019). According to a 2012 study by the American college of healthcare executives' women attained CEO positions at half the rate of men, and only about 26% of CEOs overseeing U.S. hospitals were women. In a survey conducted in 2011, females earned about 20% less than their male counterparts despite having nearly the same amount of experience and level of education. The American College of healthcare executives concurs: "it is not simply one barrier at the very top, but rather myriad obstacles at many junctures. To promote gender diversity and help ensure a pool of qualified women candidates for the most senior positions, healthcare organizations need to look not only at policies affecting the promotion of women to the C-suite or the top leadership positions but also at policies affecting the development and retention of female executives at every level." Most women believe that being a female is disadvantageous to their career, and they have to act like a man for career growth. It is true that female doctors bring quality to their services and represent the great majority of the specialized workforce in the healthcare sector, but there is a need to further enhance and support their leadership needs (Newman, 2011;Fjeldsted, 2013).
Similarly, a review study by Inam et al. (2020) and Mousa et al. (2021) also found that females face discrimination in healthcare leadership. A study found that the number of females in top management positions has increased from 13% to 36% from 1993 to 2001; however, the representation of males in management positions is still more than females (ACHE, 2001). The recent report on women in healthcare leadership in 2019 documented that there is still a long way to go for women to achieve top positions equally compared to their male counterparts. In the healthcare sector, "Females in healthcare" is no longer an issue but a problem: "Females in healthcare leadership."

Research Questions
The main purpose of the study is to gather the published literature on the glass ceiling in the Healthcare sector at the global level; evaluate what factors/barriers are resulting in the emergence of the glass ceiling in healthcare. Following are the research questions expected to be answered within the scope of the current study: a) Is there still a glass ceiling that exists in the healthcare sector? b) What are the barriers affecting the perception of the glass ceiling in the healthcare sector? c) What do existing studies recommend breaking the glass ceiling in the healthcare sector?

Methodology
This is a systematic literature review based on published data from previous studies on the glass ceiling concept in the healthcare sector. A systematic review is a way of collecting information from existing studies/published materials on a chosen topic. It can also be said that systematic review means "summarize the body of knowledge on a particular topic" (Aveyard, 2014). The review was performed by two authors independently by following the proper inclusion and exclusion criteria for selecting the literature to be reviewed.

Research Strategy
The main keywords used for searching the articles were "glass ceiling," "barriers," and "healthcare." The articles were searched from online databases, including Google Scholar, Scopus, PubMed/Medline, and Cochrane Library. The journals were also searched through Emerald, Wiley, JSTOR, Research Gate, Science Direct, and SAGE search engines. Grey literature was also used in this study that was found from the references and citations. The scope for searching the literature was kept broad, not setting any geographical limits in the databases to be comprehensive as possible in retrieving the literature on the glass ceiling in the healthcare sector at the global level.

Article Selection Criteria
In systematic literature review-type studies, the reliability and validity of the study are based on the quality of articles selected for the review. The search strategy identified 553 articles from databases and 65 from grey literature. In the first phase, all the duplicated articles were excluded. After this, all the selected articles were initially assessed based on their title and abstract. Finally, both reviewers evaluated the articles that passed this stage independently. The reviewer applied the inclusion and exclusion criteria to full-text articles. The articles that did not discuss the glass ceiling and its barriers in the healthcare sector were excluded. After this process, 32 research articles were selected from this systematic literature review study. The process of inclusion and exclusion is shown in the PRISMA flow chart in Figure 1.
The articles for this study were selected on the following criteria that ensure the quality of the systematic review. The inclusion Criteria and Exclusion Criteria are as follows: 1. The study included only those studies based on the glass ceiling and its barriers in the healthcare sector. The articles that did not discuss the glass ceiling and its barriers in the healthcare sector were excluded.
2. The study only included peer-reviewed articles from recognized journals discarding books and dissertations.
3. All studies were considered, i.e., research and review-based studies.
4. The selection was limited to research articles published from 2000 to 2019.
5. Only articles published in English were taken for the study.

Glass Ceiling in Healthcare Sector
The existing literature clearly shows a glass ceiling in the healthcare sector, as shown in Table 2. These studies were based on both primary and secondary data. Primary data were collected through questionnaire surveys and interviews, and secondary data were collected from databases and previous studies. The glass ceiling acts as an invisible barrier that impedes the career advancement of females. The studies state the increase in the number of females in medical colleges and the healthcare workforce, but there is still an underrepresentation of females in senior positions (Bismark et al., 2015;Abelson et al., 2016). Women constitute almost 75% of the healthcare workforce; however, they hold only 12% of chief executive officer positions in US hospitals (Hoss et al., 2011). Bismark et al. (2015) clearly stated that males dominate senior management positions in the healthcare sector.

Included Eligibility Identification
Women in hospital medicine in the United Kingdom: glass ceiling, preference, prejudice or cohort effect?
To assess from official statistics whether there is evidence that the careers of women doctors in hospitals do not progress in the same way as men.

Data from various sources
There is little evidence of a "glass ceiling" for women doctors in hospital careers, and the current paucity of women consultants primarily reflects historical trends in the numbers of women entering medical school; there is evidence in some cases of disproportionate promotion that is best interpreted as direct or indirect discrimination.

Reed and
Buddeberg-Fischer (2001) Career obstacles for women in medicine: an overview The study described the position of females in the medical field.

Previous studies
The study found that females are underrepresented in top positions and the main reasons for this situation are domestic responsibilities, rigidity in career structures, and discrimination. Hoss (2006) Women in Hospital Chief Executive Officer Positions:

Fact or Fiction
The study analyzed the representation of females in hospital CEO positions.

Questionnaire
The female gender in the healthcare systems across the country is proving its capabilities daily, and everyone is taking notice. This research contributes to the advancement of women to senior executive positions. Tracey (2006) The glass ceiling in Irish healthcare: a nursing perspective This study explored the perspectives of top-level nurses holding the formal position of director of nursing in the Irish healthcare system.

Semistructured interviews
The results showed that the organizational Structure in healthcare is changing, but the power base remains the same. There is no change in the submissive behavior of female nursing and the dominance of general management over top management.  The study investigated the link between women's health with the advancement in leadership positions and their slow progression toward senior positions.

Previous studies
The study found that the main reason for slow and less progression toward senior leadership positions in academic medicine was the glass ceiling.
Hoss et al.
Reasons and remedies for the underrepresentation of women in medical leadership roles: a qualitative study from Australia This study addressed the views of medical leaders on the underrepresentation of females in medical leadership roles and remedies for it.

Semistructured interviews
The number of females in medicine is increasing. However, gender disparities impede women's abilities to climb the career advancement ladder. There still exists male dominance in medical leadership roles. The study examined the underrepresentation of females in academic leadership in healthcare.

Database of AAMC, FACTS, FAMOUS and GME
The results showed an increase in female entrants in medical schools despite an underrepresentation of females in senior leadership positions.

Impact of glass ceiling on women employees in hospitals
This research aimed to examine the effect of the glass ceiling on female employees in hospitals.

Questionnaire and scheduled interview
This study is evidence of the existence of a glass ceiling and its effect on organizational performance. Even after having the required abilities and experience, women are unable to reach top positions.
Ellwood et al.
The shattered glass ceiling and a narrowing gender pay gap in NHS foundation trusts: Gender and salaries of chief executive The study aimed to examine the glass ceiling and whether there are changes in the gender pay gap in the healthcare sector over the period from 2012 to 2018.

Database of NHS From 2012 to 2018
The glass ceiling still exists in the NHS, but the gender pay gap has narrowed. However, there is still a gap, i.e., statistically insignificant but significant in monetary terms.
Wolfert et al.   Weil and Mattis (2003) To shatter the glass ceiling in healthcare management: who supports affirmative action and why?
The study examined the evidence of a national survey of healthcare executives that showed 90% of women but only 53% of men favored efforts to increase the proportion of women in senior positions.

Questionnaire
Female healthcare executives are much more supportive than males. Three major barriers: 1. Gender stereotyping and male dominance 2. Exclusion of women from informal networks of communication Senior leadership positions fail to the advancement of women. Hoss (2006)

Executive Officer Positions: Fact or Fiction
The study analyzed the representation of females in hospital CEO positions.

Questionnaire
The study found that the main barriers to career advancement for females are perceived male stereotypes and preconceptions of females' roles and abilities by others. Eiser & Morahan (2006) Fixing the system: Breaking the glass ceiling in health care The study examined the major barriers impeding females' advancement to higher positions in healthcare Previous studies The study found five major barriers: 1. Organizational culture norms and values that favor men over women 2. Gender stereotyping 3. Exclusion from informal networks 4. A lack of effective mentors The challenges of work-life balance Zhuge et al. (2011) Is There Still a Glass Ceiling for Women in Academic Surgery This study documented the existence of a glass ceiling and some barriers impeding the career advancement of females in academic surgery.

Previous studies
Despite the increased entry of females in maledominated fields of the healthcare sector, their underrepresentation in senior leadership positions remains the same. Traditional gender stereotype roles, gender discrimination in healthcare, and lack of mentors are the main barriers to the glass ceiling in healthcare.
Women in leadership and the bewildering glass ceiling The study addressed the glass ceiling in healthcare leadership Previous studies The study found the existence of a glass ceiling due to the following barriers: 1. Conscious and unconscious biases 2. Lack of mentality to pursue leadership 3. Lack of mentors, role models, and sponsors 4. Lack of policies that support work-life balance 5. Work-life integration challenges 6. "Lean-out" phenomenon 7. Lack of internal and external networks, recognitions, opportunities, or resources Bots et al. (2018) Women in Translational Medicine: Tools to Break the Glass Ceiling The purpose of the study was to find ways to break the glass ceiling

Previous studies
The study addressed some approaches to breaking the glass ceiling in medicine: 1. Unbiased selection 2. Proper coaching and training 3. Integration 4. Gender equity Gilavand (2018) Investigation of the barriers of the promotion to managerial positions of female faculty members of Ahvaz Jundishapur University of medical sciences, in southwest Iran The study investigated the main barriers to promotion to managerial positions.

Questionnaire
The results found that organizational structure, personal factors, social factors, and organizational culture are the major barriers impeding the career advancement of female faculty members.
Gender is not even a side issue...it's a non-issue': career trajectories and experiences from the perspective of male and female healthcare managers in Kenya.
This study was performed to elicit female healthcare leaders' views on career advancement in the healthcare sector.

Interview
Gendered factors play an important role in the underrepresentation of females in top positions. Women's twin responsibility between family and career and gendered societal expectations impedes their way to career advancement.
Wolfert et al.

Twin Responsibility
Females are achieving CEO positions with their capabilities and hard work in the healthcare sector, but there is still a long way to go (Hoss et al., 2006). LaPierre and Zimmerman (2012) analyzed the situation of females for career advancement in the healthcare sector. The study revealed that females face the situation of a glass ceiling. Male employees get promotions easily, and females face obstacles in the promotion to senior management even after having the same qualifications and characteristics. Over time, the organizational structure of the healthcare sector has changed. However, the power is still in the hands of males (Tracey, 2006). Glass ceiling is the reason for the slow career progression for females in healthcare (Reed and Buddeberg-Fischer, 2001;Andrew, 2007;Carnes et al., 2008;Millath et al., 2017). They face hurdles to attain senior positions. Ellwood et al. (2019) conducted a study to examine the existence of a glass ceiling in NHS. For this purpose, the NHS data related to remuneration of senior-most positions were taken from 2012 to 2018. The results showed that gender disparity still exists in NHS, but the gender pay gap has narrowed in the analyzed five-year period.
Similarly, Wolfert et al. (2019) examined the glass ceiling for female neurosurgeons in Europe. It was stated that several female neurosurgeons are almost one-half of practicing physicians, but males dominate the field regarding entry into neurosurgery. There are inequitable promotions of females even after having the same capabilities as their male counterparts (Reed and Buddeberg-Fischer, 2001).

Barriers or Factors of Glass Ceiling in Healthcare
Various international research found barriers or factors that impede women's career advancement in climbing the leadership ladder. These barriers are organizational, interpersonal, cultural, and societal. The studies showing the barriers of the glass ceiling are given in Table 3.
In this systematic review, the authors found various barriers hampering women's career advancement in the healthcare sector. Organizational barriers included: lack of equal training and development, lack of opportunities, lack of role models or mentors for women, lack of support from seniors/colleagues, Exclusion from informal networks, Lack of internal and external networks, recognitions, opportunities, or resources (Weil and Mattis, 2003;Eiser & Morahan, 2006;Hoss et al., 2006;Longo & Straehley, 2008;Johns 2013;Spina & Vicarelli, 2016;Bismark et al., 2015;Chisholm-Burns et al., 2017;Millath et al., 2017;Bots et al., 2018;Wolfert et al., 2019). Interpersonal barriers blocking the way to career advancement are a Lack of self-confidence in women, self-doubts for not being able to handle senior leadership positions (Eiser & Morahan, 2006;Johns, 2013;Spina and Vicarelli, 2015;Bismark et al., 2015;Chisholm-Burns et al., 2017;Millath et al., 2017). When talking about societal or cultural barriers, the studies found that gender stereotypes, a maledominated society, societal expectations from women to perform twin responsibilities between family and career, and females considered as less able and suitable to perform leadership roles are also the main hurdles in the career progression for females in the healthcare industry (Eiser & Morahan, 2006;Hoss et al., 2006;Longo & Straehley, 2008;Johns 2013;Spina & Vicarelli, 2016;Bismark et al., 2015;Chisholm-Burns et al., 2017;Millath et al., 2017;Muraya et al., 2019;Wolfert et al., 2019).

Recommendations for Breaking the Glass Ceiling
The literature revealed that females are still underrepresented in senior positions in the healthcare sector. Females are working hard to achieve top positions. Existing studies have recommended various suggestions to break the glass ceiling. Reed and Buddeberg-Fischer (2001), Zhuge et al. (2011), andWolfert et al. (2019) stated that there should be equitable practices for males and females. Females should be provided with mentoring and development programs. Along with these females, they need to raise their social capital by developing support networks and seeking mentors and sponsors at the workplace (Bots, 2018). There is a need to make a committee that can address the issues of females and provides them equal opportunities.
The Healthcare sector needs to change outdated cultural norms and gender stereotyping. They should encourage females' enhanced leadership development and greater effectiveness (Eiser & Morahan, 2006). It is required to design leadership development approaches to help females identify their strengths, increase their confidence, and develop leadership skills. Millath et al. (2017) suggested that the hospital sector should continuously motivate and train its employees. Attention EJBE 2022, 15(30) must be paid to preparing females for senior positions by providing the required training, work experience, and networking within organizations and with governing boards for female hospital CEO successors (Hoss, 2006;Zhuge et al., 2011). Muraya et al. (2019) suggest that there is a need to provide social support to females to fulfill their responsibilities in a better way and advance their careers. This will boost their confidence to perform more efficiently in career advancement. Similarly, Inam et al. (2020) recommend that policymakers and the government pay attention to this issue and take necessary steps to overcome cultural barriers to equal growth of male and female surgeons.

Theoretical Implications
This systematic review examined the existence of a glass ceiling in the healthcare sector at the global level and the major barriers of the glass ceiling that impede the career progression of females in the healthcare sector. The study found the existence of a glass ceiling in the healthcare sector as given in existing literature that has been reviewed. While scanning the literature, in this context, the situation of females in the healthcare sector is similar at the global level. It was found that the number of female students in medical colleges is increasing. Even the number of females in the healthcare workforce is also increasing, but males still dominate senior positions. Glass ceiling is the reason for the slow career progression for females in healthcare (Reed & Buddeberg-Fischer, 2001;Andrew, 2007;Carnes et al., 2008;Millath et al., 2017). Weil and Mattis (2003) stated that males are less likely to support females by providing them special efforts to increase their proportion in senior management positions. Almost all studies have found similar barriers to the glass ceiling that are obstructing the way of females in their career advancement. The study explores three main barriers: organizational barriers, societal/social barriers, and personal barriers (Weil and Mattis, 2003;Eiser & Morahan, 2006;Hoss et al., 2006;Longo & Straehley, 2008;Johns, 2013;Spina & Vicarelli, 2016;Bismark et al., 2015;Chisholm-Burns et al., 2017;Millath et al., 2017;Muraya et al., 2019;Wolfert et al., 2019).

Implications for Practice
To break the glass ceiling, existing studies gave some recommendations to eliminate the barriers of the glass ceiling. The healthcare sector has to take action to change these stereotypes and put emphasis on gender equality. The Healthcare sector needs to fully utilize its human resources, but females are underrepresented in senior positions. According to human resource professionals, organizational and societal issues are involved in the lower proportion of women entering the workforce (Saraswathy, 2019). Organizations should take initiatives for gender equality at top positions and provide equal opportunities to females compared to their male counterparts.
Similarly, there is a need to change societal norms, break the old masculine and patriarchal culture, and consider both genders equivalent. Besides, females need to have more confidence in themselves and an optimistic belief in breaking the glass ceiling. They have to be mentally and emotionally strong. With time, the organizational structure of the healthcare sector is changing; however, the power base is still in the hands of males. Females face various invisible barriers at the workplace, like lack of support from top management and male colleagues, unequal advancement opportunities, Exclusion from informal networks, and Lack of internal and external networks, recognitions, opportunities, or resources.
Further, it was found that the selection and promotion process for leadership positions was also influenced by gender discrimination. Males are considered to possess more leadership qualities and styles than females. There are many social/societal barriers like gender stereotyping, male dominance, twin responsibility, etc., and interpersonal barriers to females that stop them from climbing the career ladder. These barriers have been continuing for the past decades till now. The study found that gendered factors play a great role in the underrepresentation of females. Females are expected to play a dual role between family and career; their role as child bearer, domestic responsibilities, and other gendered societal and organizational factors influence their abilities and impede their way to attain senior leadership positions (Eiser & Morahan, 2006;Longo & Straehley, 2008;Spina and Vicarelli, 2016;Bismark et al., 2015;Chisholm-Burns et al., 2017;Muraya et al., 2019). Therefore, the study's findings answer this study's research questions.

Conclusion
The study is a systematic literature review exploring the existence of a glass ceiling in the healthcare sector. The findings of the study show the existence of a glass ceiling by reviewing the existing published literature from the year 2000-2020. Glass ceiling is an invisible barrier that keeps females away from senior positions. Barriers resulting from the glass ceiling are organizational barriers, societal/social barriers, and personal barriers. These barriers or factors of the glass ceiling are obstructing females' career advancement. The study found that even with time, situations are still the same for females as before. The number of females in senior positions is increasing steadily; however, the power is still in the hands of males. Males dominate the top management positions in the healthcare sector. Although the organizations are doing a lot for the upliftment of women, the implementation of these policies needs observation. There is a long way to go for females to attain equality in top management.