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Participant characteristics
This qualitative phenomenological study was conducted through in-depth telephone interviews with six female health leaders in three regional states of Ethiopia. The education of all participants was related to bachelors in health sciences. The average total number of services employed by participants was nine years. However, the participants had been in management positions for about two years (Table 1).
Analysis of the qualitative data revealed four themes and thirteen categories (Table 2).
Topic 1: individual behavior
This theme emerged from four categories of data analysis results. Participants in this study described individual behaviors such as being visionary, an empathetic listener, honest, and applying judicious use of limited resources that make a woman an ideal candidate for a leadership position in primary health care settings. In addition, participants described the importance of leadership experience in achieving better outcomes in work and family life.
Category 1.1: being a visionary
Research participants explained that a leader with a clear vision has the potential to achieve better results, and they tend to self-initiate their own rise to leadership positions in their organizations. The following excerpt, which is verbatim, illustrates the commitment of a visionary woman on her path to a leadership position in healthcare.
I want to be successful in my educational career and in business. I dream of being a successful healthcare leader. I am sure that one day I will serve as a role model for the young girls around me. Participant #1.
Category 1.2: empathy and honesty
Participants in this study stated that female healthcare leaders spend significantly more time listening to their staff than their male counterparts. This behavior enables women to advance their way into leadership and management positions. Participant #3 described his efforts to build a culture of honesty in the Ethiopian health system:
I am reliable and honest with my staff and organization. I guarantee that there is no corruption in the health center. Therefore, I am among the few effective health leaders. That’s why I was able to stay in a leadership position, even in difficult times. Participant #3.
Category 1.3: reasonable use of resources
Participants believed that women were more likely to engage in the judicious use of healthcare facilities’ resources. This behavior made women the preferred leaders of the health care system. Participants #5 and #6 described how this behavior helped them rise to leadership positions.
Almost all women have experience in managing and leading their households. A woman can easily identify her child’s needs and address them in the best way possible… these management practices and experiences enable women leaders to effectively utilize available resources in health facilities as well. Participant #5.
Category 1.4: leadership experience
In this study, participants stated that women who had leadership experience were more likely to volunteer for leadership positions in their organizations. A participant illustrates how her experience influences her current leadership role.
I was a supervisor of health professionals, a student representative at the university and received leadership training; they all enriched my experience. I am a strong woman by nature. Growing up in a rural area with many problems has helped me to become resilient and able to handle challenges easily. Using my experience, I manage my daily activities very well and the work of my health center is very good. Participant #4.
However, there are challenges that negatively impact women’s ascension to leadership positions in primary health care units in Ethiopia. In this study, participants described their lived experiences of reluctance to delegate leadership positions combined with micromanagement by supervisors as barriers. In addition, the experience of sexual harassment in the workplace was reported as a challenge for women in advancing to leadership positions. One female leader describes these challenges as follows:
Previously, officials empowered women leaders but were deeply involved in fulfilling their responsibilities. Because I had these discouraging experiences, I often avoided applying for leadership positions. I also know of cases of sexual harassment that women leaders have faced. This not only affects their work but can also affect their personal family life. I missed several opportunities because I was afraid to go through such trials. Participant #2.
Topic 2:- social support
Participants often described the positive effects of support from spouses, grandparents, and colleagues on their journey to leadership positions. Subject social support was identified from the categories of close family and peer support.
Category 2.1: close family support
Almost all participants in this study mentioned that women who received support from their spouse or close family members were more likely to advance to leadership positions. Participant #6 describes the support of her close family members as follows:
My husband encourages and supports me in developing my leadership career. I had discussed the leadership opportunity in my organization with my husband and got his input before I decided to compete for the position. Participant #6.
Similarly, some participants in this study often stated that women who bear the burden of housework and who lack support from close family members would avoid holding leadership positions. A female leader recalls her experience of avoiding leadership positions due to lack of family support, saying:
After I had two children, my mother and mother-in-law advised me to quit my job and focus on household chores. I was responsible for taking care of my children, cooking and feeding them, washing clothes and managing all other aspects of family life. ….for a woman like me, leaving the children with their father or other family members for long periods of time was not possible and so I rejected the opportunities that came my way. Participant #5.
Category 2.2.: peer support
In this study, participants linked their readiness for leadership roles to the support they received from their supervisors, which was expressed in training, mentoring, coaching and feedback. Participants #3 and #5 expressed their positive experiences with peer support as follows:
…when I was the coordinator of the family health department, [a colleague] supported me to build my confidence in handling more than my current responsibilities. Before I took my current position, I discussed it with my best friend and it was because of her encouragement that I took the leadership position. Participant #5.
On the other hand, participants attributed lack of peer support as the main reason why women avoid leadership positions. Participant #1 explains that a lack of peer support negatively impacted her leadership career development, saying:
My colleagues laughed at my decision to take on a management position while I had children who needed my full-time care and discouraged me from continuing my career development. Participant #1.
Topic 3:- organizational support
Leadership development is the process of strengthening the healthcare workforce while adhering to the organization’s principles and guidelines. Organizational support for the theme stems from four categories, namely: principles and guidelines, training and mentoring, succession planning and support from development partners.
Category 3.1: positive actions
All participants identified and explained the importance of adhering to the principles and guidelines for increasing women leaders in healthcare organizations. Clear principles and guidelines from healthcare leaders resolve staff complaints and streamline activities. Participant #1 illustrated the importance of following the guidelines as follows:
The human resources manager follows predetermined guidelines in the selection processes of the best candidates for the advertised positions. Although some candidates raised questions about the fairness of the selection processes, the owner of the main process was able to check the consistency and reliability of the points given to each participant. Participant #1.
Category 3.2: training and mentoring
In this study, all participants confirmed that they felt more capable after leadership training and mentoring sessions. The following participant stated the benefits of leadership training in the capacity of women health leaders, saying:
The leadership training I participated in helped me deal with the challenges I faced. Also, while carrying out my project, the coaching sessions helped me to adapt some revisions made on leadership, management and governance practices, sharing experiences and developing actionable actions. Participant #1.
Category 3.3: succession planning
In this study, participants explained that women who were identified as future leaders by their line managers and were prepared to face new challenges before assuming leadership positions were successful in their career development. Participant #3 described the benefits of engaging and preparing women for leadership positions in advance as follows:
In my current organization, my line manager encourages me to build my confidence and courage and to practice my leadership and management skills. He always delegates me when he has other commitments outside. It has a huge impact on my self-improvement and helping others achieve better results. I am also really motivated to work for leadership when my supervisor delegates me, and the support from my colleagues (especially women) helps me recognize my shortcomings and allows me to work on them. Participant #3.
Category 3.4: recognition
To encourage more women into leadership positions, the health system needs to recognize and motivate role models in the health system. In this study, Participant #2 explains the importance of exercising recognition for female top performers in growing leaders.
…to attract women to leadership positions, there must be incentives and recognition such as offering continuing education. Participant #2.
Category 3.5: support from development partners
All participants reported that their leadership capacity, competencies and capabilities were enhanced with the support of development partners. This verbatim from participant #6 shows the role of development partners on women’s leadership development:
thanks [development partner name] for their support. I received leadership training that prepared me for my day-to-day activities as a leader. Participant #6.
Theme 4.: gender stereotypes
Gender stereotypes are a community’s generalized views about the roles that men and women play. These beliefs can influence how women take leadership positions. Gender stereotypes were identified from two categories viz. status quo (norms) and self-concept.
Category 4.1: status quo and norms
All six participants stated that societal norms prevent women from holding leadership positions. The following are verbatim statements from participants #1 and #6, which summarize the opinions of the rest of the respondents.
In my area, social norms favor men and there is limited support for women to advance in their careers. Women are expected to manage all household matters and are perceived as weak in leadership organizations. Participant #1.
… community members, including trained professionals, view women as too weak to lead complex organizations. The workload of a leadership position, a stressful home life and the expectations of staff can sometimes create frustration. Participant #6.
Category 4.2: self-concept
In this study, four out of six participants explained that lack of self-esteem and confidence are among the reasons women are held back from developing their leadership careers. Participant #5 states:
…I consider myself weak and someone who cannot handle many responsibilities. That’s why I turned down leadership positions three or four times because of fear of failure. Participants #5.
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