Introduction: A Contemporary Leadership Challenge         Oppressive forms of leadership among government funded hospitals, more specifically related to lack of gender equality has proven to be a contemporary challenge, including but not limited to Canada, where high-level management is still dominated by males. In Canada, men are two to three times more likely than women to be in a senior healthcare management position (Soklaridis, 2017). Although women make up approximately 78 per cent of the healthcare workforce, there remains a significant gender gap in senior management and executive leadership (Lanz, 2008).         Underrepresentation of women continues to be evident within healthcare governance of government funded organizations which may reflect a societal gender bias. Nevertheless, despite economic and social changes in the role of women, certain beliefs regarding women in leadership roles seem to persist and these beliefs apparently continue to flourish across cultures (Jonsen, Mazevnski & Schneider, 2010).  Lee and James (2007) postulate that stereotyping exists because it makes our life easier, we stereotype based on familiar women’s roles (mothers, wives, nurses, etc.) and the characteristics they embody, which are currently inconsistent with those that traditionally define a good business leader. Pinpointing inequalities in the competing relationships between women and their male counterparts in hospital leadership roles may prove problematic to unpack. A study done by Toronto researchers of female hospital CEO’s revealed how difficult it is for some women CEOs to identify gender bias themselves (Soklaridis, 2017). Their male counterparts have created their own specific ecosystems in regards to their leadership styles that may prevent women from emulating this desired style if promoted to an executive position. Devillard, Sultan and Werner’s (2014) survey strongly suggests that prevailing leadership styles among top managers and performance models stressing that executives make themselves available 24/7 can be important barriers to women’s advancement.         The environment leaders in the Canadian Healthcare system exist within is easily wrought with fiscal restraints and growing population needs with little government assistance. Decision makers at the executive level are now being forced to consider operating within an ethical framework to make decisions instead of being driven solely on monetary demands and personal agendas. Daniels and Sabin have proposed an ethical framework (1998) for priority setting in health care institutions called ‘accountability for reasonableness’ which has become a leading international model for ethical decision making under limited resources (Reeleder, Goal, Singer, & Martin, 2006). In this less than ideal ecosystem, hospital leaders remain unaware or consider gender disparities in executive leadership as low on their priority list as evidence by the conspicuous absence of women in leadership roles.         A critical literature review will be discussed based on how ethical and ecosystem leadership approaches assist leaders to respond to such challenges. A systematic approach was used to review the literature to identify relevant research utilizing three databases; ProQuest, Google Scholar and PubMed. Three recurrent themes were identified in the literature when looking at how ethical leadership responds, but not limited to, the Canadian healthcare ecosystem leadership realm, regarding gender diversity issues. The three recurrent themes are; Few formal accountability processes in place to monitor ethical governance; Stereotypes and gender bias effect women occupying executive positions;  Perpetual, global underrepresentation of women in healthcare leadership. This report will synthesize and evaluate the existing research (literature and media) on gender issues in the contemporary hospital leadership environments.Ethical and Ecosystem Leadership on Gender Diversity in Hospitals: Literature and Contemporary Media Review         Currently media scrutiney involving the #MeToo Movement has garnered attention on   leadership and the ethicalities that should be binding within these portfolios. Social Learning Theory shows that ethical leadership is likely to stimulate and transfer ethical norms and behaviors (Kalshoven, VanDijk, & Boon, 2016). Contrastingly the research shows, regarding this watershed movement of women coming forward with sexual harrassement claims, that employees will emulate their leaders behaviour if they are perceived as ethical and would deem the behaviour appropriate. Sometimes leaders assume that their employees know how to behave appropriately and let formal codes, policies, and training do the talking for them as a substitute for ethical leadership (Brown, 2007). It would seem ethical leadership is best defined through the eyes of their subordinates but healthcare executives seem to prefer the heirarchy accountability platform which has kept women from advancing. Research has found that justice is particularly important to employee evaluations of organizational authorities in general (Alexander & Ruderman, 1987) and to role modeling in particular (Scandura, 1997). By engaging in transparent, fair, and caring actions, and by creating a fair working environment, the leader becomes a legitimate source of information about appropriate conduct, and a target of identification and emulation (Browne & Travino, 2006). Governing bodies that lack gender diversity are not modeling inclusivity which could in turn perpetuate the conspicuous abscense of women in leadership roles which is the opposite of healthy ecosystem leadership. The literature review reveals there is very little information on who is ‘policing’ the ethical governance of our hospitals and corporations. Although there is a significant need to understand the implications of increasing demographic diversity for leadership, surprisingly little research has been conducted on the topic (Mason, Ruderman, & Nishii, 2013).  Governance is a core pillar of health systems and greater parity and gender responsive, transformative leadership are essential in our efforts to strengthen health systems and meet the gender-and health-related strategic goals  (Langer, 2015).   Women make up the vast majority of those working in the field of global health, but are seriously underrepresented at the institutional decsion-making level, in global policy and governance forums and in leadership panels and venues (Global Health Council, 2016). Fundamentally the trend in the literature reflects no consensus in how the governing bodies are going to ethically solve this issue. Little has been done to systematically develop an ethical leadership constuct necessary for testing theory about its origins and outcomes (Mihelic, Lipicnik, & Tekacic, 2010).  Although research has produced various theories: whether or not the approach to leadership differs between men and women as distinctive biological groups; whether this difference is one of style or substance; whether it is real or perceived; whether one leadership approach is more or less effective than the other and which is more likely to lead to success (Applebaum, Audet, & Miller, 2003). These theories reflect the Transformational Leadership Theory, which has been widely researched (Hoch, Bommer, Dulebohn, & Wu, 2018) and will not be discussed in this review,  which has similar characteristics that embody ethical leadership behaviours in successful organizations.         Unconscious gender bias (also referred to as implicit or second?generation gender bias) occurs when a person consciously rejects gender stereotypes, but still unconsciously makes evaluations based on stereotypes (Madsen & Andrade, 2018). Empirical research suggests that even women CEOs themselves, embedded in the subtle everyday norms and practices within the workplace have difficulty naming and explaining gender bias explicitly or explaining the challenges in understanding how it might affect a woman’s career path (Soklaridis, 2017). Facebook’s COO Sheryl Sandberg was quoted in an interview regarding the #MeToo Movement as saying, “Women don’t get the top job as it is perceived as risky because of the sterotypes, but now maybe men are a risky bet, and people are asking about the risk of not having women in power” (McGregor, 2017).  Conversely, empiric studies have shown that people’s perceptions of ethical leadership have nothing to do with gender. Brown and Travino (2006) conducted a study that found ethical leadership is positively related to affective trust in the leader and negatively related to abusive supervision, but it is unrelated to either rater demographics or perceived demographic similarity between leader and subordinate.  Ecosystems where leaders foster the growth of other leaders are still skewed in terms of gender diversity. Even after we have more egalitarian, gender-neutral views toward leadership allowing an increased representation of women in lower and middle level manager positions, it may take considerable time for the networks to emerge that allow women to gain equal access and to function effectively as top-level leaders (Hogue & Lord, 2007). The issue that lies within the research is denoted in the qualitative and potential subject interpretations of the research identified as containing empirical data. Surveys and data collection questionaires may bring about the subject’s own personal bias that may be unkowningly wrought with inconsistencies or err. Scholars have found published articles on gender bias and race bias and established that articles on gender bias are funded less often and published in journals with a lower Impact Factor (Garfield, 1996) than articles on comparable instances of social discrimination (Cislak & Formanowicz, 2018). This contributes to the ongoing need for further investigation into this contemporary leadership issue.         There is strong evidence that women’s increased economic and political participation leads to a more developed and healthier world; however, the global health community has not done enough to ensure that the equality we strive to reflect in the planning and delivery of services is seen in the programmatic, policy and leadership levels (Dhatt, Thompson, Lichtenstein & Wilkens, 2017). There is a significant challenge in developed countries for not only women to become CEOs, but to occupy a seat on the board of directors.  Deloitte’s 2015 Global Survey shows the percentage of board seats held by women as: France 29.9%, Germany 18.3%, UK 15.5%, Canada 13.1%, USA 12.2%, China 8.5%, India 7.7%, Brazil 6.3%, Russia 5.7%, and Japan 2.4% (IEDP Editorial, 2017). Scholars have found that in order for organizational executives to increase ethical leadership throughout the organization via accountability (especially self-accountability) and moral competence (Ghanem, 2018) include training organizational leaders to use self-monitoring, reflective leadership, and emotional intelligence. A 2017 study from Fortune (Zarya, 2017) found that women occupy 18% of board seats among the 3,000 largest publicly traded companies, 4% of CEO offices and 11% of CFO positions. And despite women now representing one-third of hospital executives, only 4% of healthcare CEOs are female (Lopez, 2018). Consensus among the literture indicates a deep need for managerial solutions to address the impact that the role of leadership plays in addressing health disparities from a healthcare management perspective (Dotson, Jeter, & Williams, 2012). Research grounds that women work at a steady pace, view unscheduled interruptions as a part of work flow, make time for activities not focused on work, maintain a complex network of relationships, and focus on the “ecology of leadership,” which emphasizes the social dimension, a vision for society, and time for information sharing with others (Chendler, 2011). This review has consistently shown the way ethical and ecosystem leaders in healthcare apporach the issue of gender diversity is by not considering gender balance and inclusion a priority or by not addressing the issue at all.  In summary, research indicates this could be due to the fact solutions to correcting the gender imbalance are not known.Reflection and Conclusion         The analysis of the literature had lead to the conclusion that theories and models have done a great job of outlining contemporary issues related to gender diversity and the imbalance of women in executive positions, but the ethics in leadership is not well understood. Academics agree there is a gap in terms of the way leaders respond to this issue which historically has been identified as a challenge in executive management for decades. It is a global issue not just a local or centralized problem that has become more highlighted within the contemporary media. Male executives tend to naturally flourish in an ecosystem that does not foster the development of women leaders. The literature has shown this to be a combination of influence by societal bias and unconscious bias and feel this issue does not affect the strategic direction of the organizations they lead. As well as the three themes woven throughout the material examined, women that do lead are considered effective, moral and empathic, ethical CEOs. This bodes the rhetorical question of, ‘why not have more women?’         Adding velocity to the process of changing the gender imbalance in healthcare leadership would be to place more focus on the eco-leadership environment. Leaders in hospitals, which have been globally dominated by males, may need women to help shape their idea of what a healthy ecosystem looks like and then build their leadership team with this foundation. 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Retrieved December 17, 2018, from Fortune.com: http://fortune.com/2017/06/07/fortune-women-ceos/ Appendix 1: Media Files Accessedhttps://www.conferenceboard.ca/edu/research/gender-equity-diversity-and-inclusionhttp://learnaslead.com/Article/ecosystem-leader/https://www.bmj.com/Article/Global-Healthcare-Leaders-Not-Taking-Gender-Inequality-Seriouslyhttps://info.qentinel.com/Article/Ecosystem-Leadershiphttps://www.mvma.ca/Gender-Equality-In-The-Workplace.pdfhttps://www.washingtonpost.com/News-Article/Will-the-MeToo-Movement-Speed-Up-The-Number-of-Women-in-Leadership-Roleshttps://www.mckinsey.com/Article-Why-Gender-Diversity-At-The-Top-Remains-A-Challengehttps://www.sciencedirect.com/Article/#MeToo-Movement-An-Opportunity-For-Public-Health.pdfhttps://www.mckinsey.com/Article/Women-In-The-Workplace-2018https://www.youtube.com/watch/video/Assessing-Gender-Diversity-In-The-Workplace