Participant characteristics
This qualitative phenomenological study was conducted through in-depth telephone interviews with six female leaders in health in three regional states of Ethiopia. The educational background of all participants were linked to bachelors of sciences in health studies. The average overall services tenured by the participates was nine years. However, the participants had been in leadership positions for about two years (table 1).
The qualitative data analysis revealed four themes and thirteen categories (Table 2).
Theme 1: Individual behavior
This theme emerged from four categories of the data analysis results. The participants of this study described individual behaviors such as being a visionary person, an empathetic listener and honest, and applying wise use of limited resources as making a woman an ideal candidate for a leadership position within primary health facilities. In addition, the participants described the importance of having experience in leadership for achieving better results in work-family life.
Category 1.1: Visionary
The research participants explained that a leader with a clear vision has the potential to achieve better results and they tend to self-initiate their rise to leadership positions in their organization. The following extract which is verbatim, illustrates the commitment of one visionary woman on her path towards a leadership position in health.
I want to be successful in my educational career and business too. It is my dream to be a successful healthcare leader. I am sure one day I will serve as a role model for young girls in my vicinity. Participant #1
Another female health leader expresses her vision to lead beyond her organization by saying:
I am a strong woman and the best health leader among all primary healthcare unit directors in the [name] zone. I believe in myself and I am capable of leading beyond the primary healthcare unit level . Participant #4
Category 1.2: Empathy and honesty
Participants of this study stated that female leaders in health spent a lot more time on listening to their staff than men. This behavior is an opportunity for women to progress in their path towards leadership and management positions. The participants also described their efforts towards building a culture of honesty in the Ethiopian health system. Participant #1 and participant #3 explainid:
As a female leader, I used to listen my subordinates and try to solve their problems. In addition, I was known by staff for being transparent and an effective communicator in the health center. Participant #1
I am faithful and honest with my staff and organization. I am sure that there is no corruption in the health center. Therefore, I am among a few effective health leaders. That is why I survived holding the leadership position even in difficult times. Participant #3
Category 1.3: Wise use of resources
Participants perceived that women are known for their wise use of health facility resources. This behavior made women the preferred health system leaders. Participant #5 and #6 described how their behavior in this regard assisted them to rise to leadership positions.
…. women are known for preventing malpractices and corruption in the management of health facilities and for encouraging subordinates to perform well in accordance with health system standards. Participant #6
Almost all women have experience in managing and leading their households. A woman can easily identify the needs of her child and can properly address it in the best way.. … having such household management practices and experiences capacitate women leaders to use available resources efficiently in health facilities too. Participant #5
Category 1.4: Leadership experience
In this study, participants stated that women who had experiences on leadership skills, were more likely to volunteer to hold leadership positions in their organizations. Three participants illustrate their shared experiences on leadership.
I was inspired by the leadership skills of my grandmother. When she faced a challenge, she considered it as part of life. I took a lot from her problem-solving skills. Participant #1
When I was a college student, I was serving as a student council president and facing many challenges because of my courage to correct malpractices observed inside the college compound. I believe this experience built my leadership capacity and became a springboard for engaging in higher level roles and responsibilities. Participant #3
I was a health extension worker supervisor, students’ representative at university and undertook leadership training; all of which have enriched my experiences. I am a strong woman by nature. Growing up in a rural area with a lot of problems helped me become resilient and cope with challenges easily. By using my experience I manage my day-to-day activities very well and my health center’s performance is very good. Participant #4
However, there were challenges which influenced the women’s ascension to leadership positions at primary health care entities in Ethiopia. In this study, participants described their lived stories of delegation of leadership positions combined with micromanagement by supervisors. In addition, experiences of workplace sexual harassment was expressed as a challenge for the women in their rise to leadership positions. A woman leader describes this challenges as follows:
Previously, officials used to give authority to female leaders but would be deeply involved in the execusion of their responsibilities. Because I was having these discouraging experiences, I would often avoid putting myself up for leadership positions. Participants #2
I know cases of sexual harassment that occurred among female leaders. It not only affects their work, but can also impact their private family life. I have missed few opportunities because I was afraid of going through similar ordeals. Participants #2
Theme 2:- Social support
Participants frequently described the positive effects of support from spouses, grandparents, and colleagues in their paths towards leadership positions. The theme social support was identified from close family and peer support categories.
Category 2.1: Close family support
Almost all participants of this study mentioned that women who had received support from their spouse and close family members continue to advanceme in leadership positions. Participant #4 and #6 describe the support of close family members a follows:
My mother encourages and supports me by taking care of my children. This enables me to fully focus on my office work. Participant #4
My husband encourages and supports me in my leadership career development. I had discussed the leadership opportunity at my organization with my spouse and got his input before I decided to compete for the position. Participant #6
Similarly, some participants of this study frequently stated that women who had the burden of household chores and who do not have support of close family members would avoid assuming leadership positions. A female leader recalls her experience of avoiding leadership positions due to lack of family support by saying:
After I had two children, my mother and my mother-in-law advised me to leave my job and concentrate on household chores. I was responsible to taking care of my children, cooking meals, and feeding them, washing clothes, and managing all other aspects of family life. …. For a woman like me, leaving children with their father or other family members for a long periods of time was not possible and therefore, I declined to take opportunities. Participant #5
Category 2.2.: Peer support
In this study, participants linked their preparedness for leadership roles to the support they received from their supervisors which were expressed as trainings, mentorship, coaching, and feedback. Participants # 3 and #5 expressed their peer support positive experiences as follow:
Since I am known for my commitment, courage, confidence, and being fearless about public speaking, my supervisor has great trust in me handling and managing things in his absence. Participant #3
…. when I was a family health department coordinator, [a colleague] supported me to build my confidence in handling more than my current responsibilities. Before I assumed my current post, I discussed it with my best friend and it is because of her encouragement that I took on the leadership position. Participant #5
Participants attributed lack of peer support as the main reason for women avoiding leadership positions. Participant #1 explains that lack of peer support negatively influenced her career development decisions saying:
My colleagues laughed at my decision to assume a leadership position while having children who need my full-time care, and they discouraged me to continue my career development. Participant #1
Another woman leader expresses her decision to decline a leadership position due to lack of support from her supervisors:
My supervisor was not understanding. When I would request permission to seek medical care for my child, he refused to give me permission. Because of the lack of support from my supervisor, I decided to decline a leadership position. Participant #5
Theme 3:- Organizational support
Leadership development is a process of capacitating health workforces by adhering to principles and guidelines of an organization. The theme organizational support emerged from four categories, namely: principles and guidelines, training and mentoring, succession planning, and development partners’ support.
Category 3.1: Affirmative action
All participants identified and explained the importance of adherence to principles and guidelines in increasing female leaders in health organizations. Clear principles and guidelines from health leaders solve complaints from staff and simplify future activities. Participants #1 and #5 illustrates the importance of adherence with guidelines as follow:
The human resources manager follows pre-defined guidelines in the processes of selecting the best candidates for advertised posts. Though some candidates raised issues of fairness on the selection processes, the core process owner was able to check for consistency and reliability on the points given to each participant.. Participant #1
The affirmative action taken by the government is an important action to increase women leaders. Participant #5
Category 3.2: Training and mentoring
In this study all participants attested to feeling more capable following the leadership training and mentoring sessions. The following three participats stated the benefit of the leadership training incapacitating women health leadersby saying:
The leadership training in which I took part benefited me a lot. It helped me prepare myself to cope with any challenges I faced. Furthermore, while I was implementing my project, the coaching sessions helped me adapt some revisions that had been made on leadership, management and governance practices, experience sharing and developing do-able actions. Participant #1
....the leadership training enhanced my presentation and communication skills and facilitated my promotion to a leadership position. Participant #5
Arranging continuous training and development activities on leadership, facilitate the experience sharing events or shadowing of junior staff with experienced once and sharing the stories of successful women leaders could help us to develop the capacity and capabilities as we are among the next generation health care leaders. Participant #1
Category 3.3: Succession planning
In this study, participants explained that women who were identified as future leaders by their immediate supervisors and got prepared to face new challenges before assuming leadership positions were successful in their career development. Participants #1 and #5 describe the benefits of engaging and preparing women for leadership positions in advance, as follows:
Women are busy both in the household and with work related activities. We are not always eager to take on additional responsibilities in the workplace. But with proper succession planning, one can be familiar with the principles, guidelines, and workload of a role and be adequately prepared to be a future leader in the health system. Participant #1
In my current organization, my immediate supervisor encourages me to build my confidence and courage, and practice my leadership and management skills. He always delegates me when he has other commitments outside. This has a huge impact on my self improvement and in helping others achieve better results. I am also really motivated to work towards leadership when my supervisor delegates me, and the support from my colleagues (especially women) helps me recognize my shortcomings and enables me to work on them. Participant #3
Category 3.4: Recognition
To encourage more women to assume leadership positions, the health system should recognize and motivate the role models in the health system. In this study, participant #2 and #4 explain the importance of exercising recognition for best performing women in increasing leaders.
Recognizing current leaders will encourage more women to take on senior leadership positions. I was encouraged and motivated by a model female leader in my zone’s health department. Participant #4
……to attractwomen to leadership positions, there should incentives and recognition like offering continuous education... Participant #2
Category 3.5: Development partners’ support
All participants stated that their leadership capacity, competencies, and capabilities were enhanced with the support of development partners. The verbatims of participant #1and #6 shows the role of development partners on women leadership development,
I thank [name] for their support. I took leadership training which prepared me for my day-to-day activities in leadership. Participant #6
As a result of the leadership training of [name], I now understand the importance of moving from a gender neutral environment to a gender transformation one in any organization. This motivates me to face gender inequalities in access to power and opportunities. Participant #1
Theme 4.: Gender stereotype
Gender stereotypes are the generalized views of the community about the roles played by men and women and can affect how women assume leadership positions. Gender stereotyping was identified from two categories i.e. status quos (norms) and self-image.
Category 4.1: Status quos and norms
All six participants stated societal norms hinder women from assuming leadership positions. The following are verbatims from participants #1, #3, and #6 which summarize the opinions of the rest of the respondents.
In my district, the social norms favor men and there is limited support for women to progress in their career development. Women are expected to manage all household matters and are perceived as weak in leading organizations. Participant #1
As a felame leader, I have not been particularly affected by the problem, but the community gives priority to male leaders. There is a preconception in the community that the leadership skill of a woman is lower than that of a man in nature, and even those who are empowered to lead an organization are seen as exhibiting male traits. Participants #4
…community members including trained professionals think of women as too weak to lead complex organizations. The workload of a leadership position, a busy home life, and the expectation of staff can sometimes create frustration …. Participant #6
Category 4.2: Self image
In this study, four out of six participants explain that lack of self-image and confidence are among reasons for women being hindered in their leadership career development. Participants #4 and #5 state that lack of confidence and self-image are barriers to assuming leadership positions.
[Women] lack confidence in our leadership capacity. We think that we cannot overcome the work-life/home burden and avoid taking on leadership positions. Participants #4
… I consider myself as weak and someone who cannot handle a lot of responsibilities…this is why I declined leadership positions three to four times - because of the fear of failure. Participants #5