Feminization of the Primary Care Medical Workforce: A Systematic Review and Case Study of Implications for Pay-for-Performance for Chronic Disease Management in Context of Universal Health Coverage

The prevalence of chronic non-communicable diseases is increasing rapidly worldwide. To address the growing challenge of chronic disease prevention and management, performance incentives for patient-centred care are increasingly common in many health organizations. While studies suggest feminization of the primary care physician workforce contributes to changes in practice patterns, there has been no comprehensive investigation of its impacts on the effectiveness of pay-for-performance (P4P) for patients with chronic disease. This research aims to address the knowledge gap from global to local perspectives. First, we perform a systematic review of the literature on impacts of P4P for chronic disease management in systems of universal health coverage – and the extent to which physicians’ gender is considered or influential in the results. Second, we conduct quantitative analysis of the gender-specific effects of P4P by physician uptake of a diabetes practice incentive in New Brunswick (Canada), a context of single-payer universal health insurance. The review aligns with Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines, with the preliminary search yielding 2090 records from 10 databases and other sources. After applying inclusion and exclusion criteria to focus on studies measuring outcomes most relevant to patients and policymakers, none of the record titles highlight the effects of workforce feminization. Full-text articles will be screened for the variable of interest. For further insights from a local perspective, we present a case study from New Brunswick, where the proportion of female family physicians increased from 38% to 45% over the decade 2006-2015. We use a quasi-experimental study design drawing on linked population-based health administrative datasets, with propensity score matching for physician’s gender and other characteristics. Results are expected to enhance the evidence base on the effectiveness of “one-size-fits-all” P4P schemes to improve population health and sustainability of health system investments with feminization of the physician workforce.