Gender equity in neurosurgery requires structural reform

Women remain severely underrepresented in neurosurgery, constituting approximately 7% of the global neurosurgical workforce. Global disparities in women neurosurgeons are shaped by interconnected systems of infrastructure, governance, and education that differ substantially between high income countries (HICs) and low- and middle-income countries (LMICs). While HICs have formalized residency pathways, institutional mentorship frameworks, and professional societies dedicated to gender equity, LMICs face systemic barriers including inadequate surgical infrastructure, limited training capacity, scarce mentorship, and insufficient gender equity policies. Moreover, the brain drain phenomenon disproportionately affects female physicians from LMICs, who migrate to HICs seeking better compensation, safer working conditions, and professional advancement, thereby reducing local neurosurgical capacity. However, comparisons of a country's economic status and global gender gap index-a measure of gender disparity-to its female neurosurgical workforce have revealed that disparities remain in HICs and there are lessons to be learned from progress in LMICs. Africa demonstrates the highest proportional representation of women neurosurgeons globally at approximately 15% yet has wide inter-country variability and the smallest neurosurgical workforce in the world, making percentages heavily influenced by the presence of even a few women neurosurgeons. Underrepresentation becomes self-reinforcing: women lack advocates and mentors to advance through training pathways and into leadership positions without women in surgical leadership. National Surgical, Obstetric, and Anesthesia Plans (NSOAP) are country-led building blocks aimed at strengthening surgical systems and offer a structured framework to address these inequities systematically.