Equity in Practice: Exploring Gender Disparities in Ethiopian Healthcare Employment Contents Acknowledgement .......................................................................................................................... 3 Introduction .................................................................................................................................... 4 Rationale for the Diagnostic Exercise ............................................................................................. 5 Results ............................................................................................................................................. 7 Motivation and Satisfaction ........................................................................................................ 7 Performance Management ....................................................................................................... 11 Compensation ........................................................................................................................... 13 Training and Capacity Building.................................................................................................. 13 Gender Norms ........................................................................................................................... 14 References .................................................................................................................................... 17 Acknowledgement This note was prepared by a team led by Zahid Hasnain (Lead Governance Specialist), Ayesha Khurshid (Public Sector Specialist), and Turkan Mukhtarova (Consultant). The team would like to thank Arturo Herrera Gutierrez (Global Director), Roby Senderowitsch (Practice Manager), Manuel Vargas (Practice Manager), Vikram Menon (Senior Public Sector Specialist), and Charlotte Pram Nielsen (Senior Health Specialist) for their support and overall guidance. The team would like to express its gratitude to government officials in the Government of Ethiopia’s Civil Service Commission for their support in the implementation of this exercise. Finally, the team is grateful to the civil servants across the Ethiopian Civil Service that participated in the survey and shared their experience that made this report possible. Introduction Ethiopia, Africa’s second most populous country, has made significant strides in economic growth and human development over the past two decades. Between 2010 and 2018, GDP per capita more than doubled, and since 2000, life expectancy has risen steadily, surpassing both regional and global averages for low-income countries.1 However, these gains have not translated into equitable access to essential services, particularly in health care. The country continues to rank among the lowest globally in human capital development. In 2020, Ethiopia placed in the bottom decile of the 174 countries assessed in the World Bank’s Human Capital Index, with a score of 0.38.2 Gender disparities persist as well, with Ethiopia ranking 129 out of 170 countries in the UN’s Gender Inequality Index. These challenges are particularly evident in the health sector, where workforce shortages, imbalanced distribution of professionals, and gender disparities hinder progress toward universal health coverage. Ethiopia’s health sector faces a severe shortage of qualified professionals. As of 2018, the country had only 1.0 health worker per 1,000 people—far below the WHO-recommended threshold of 4.5 per 1,000 for achieving Universal Health Coverage and the global average of 3.05 per 1,000. Beyond the overall shortage, there is a mismatch in workforce composition. While nurses are relatively abundant, the country faces a critical shortfall of doctors, midwives, anesthetists, pharmacists, and laboratory technologists. This skills imbalance limits the health sector’s ability to provide comprehensive and specialized care (Ethiopia Ministry of Health, 2022). Gender disparities further exacerbate these workforce challenges. Women, despite making up most frontline health workers, remain underrepresented in leadership and specialized roles, restricting their influence on decision-making and policy formulation. While Ethiopia has introduced gender-sensitive workforce policies, gaps persist in recruitment, training, and career advancement, leaving women with fewer opportunities for professional growth. Workforce management remains another critical bottleneck. The Human Resources Information System (HRIS), introduced in 2009, has not yet functioned effectively at all levels, leading to fragmented workforce planning. Regional governance challenges—including unclear responsibilities, financial constraints, and weak coordination—further impede efforts to address staffing shortages and strengthen service delivery. The World Bank is supporting Ethiopia’s civil service reforms through both operational and analytical engagements. The Governance Modernization to Enable Efficient Service Delivery Project seeks to strengthen public administration by promoting data-driven human resource management, competency- based recruitment, and improved institutional coordination for civil servant capacity building. This note examines HRM policies and systems in Ethiopia’s health sector from gender lenses, drawing on primary data collected by the Bureaucracy Lab at the World Bank. By capturing the experiences of female healthcare administrators, the note identifies key barriers to career progression and highlights areas for policy intervention to improve gender equity in public sector employment. 1 World Development Indicators, DataBank, World Bank. Accessed at: https://databank.worldbank.org/source/world-development-indicators 2 Human Capital Index 2020 Update: Human Capital in the Time of COVID-19. Accessed at: https://openknowledge.worldbank.org/entities/publication/93f8fbc6-4513-58e7-82ec-af4636380319 Rationale for the Diagnostic Exercise Women are consistently overrepresented in the public-sector workforce, despite having lower labor force participation rates. Globally, women account for 46 percent of public sector workers, compared to only 33 percent in the private sector. Across many developing countries, particularly public healthcare has historically been one of the few accessible employment opportunities for women (Yassin and Langot, 2017). This trend is evident in Sub-Saharan Africa, where women constitute 55 percent of the public sector health workforce (Figure 1). Figure 1: Females, as a share of public paid employees in healthcare Source: Worldwide Bureaucracy Indicators, latest data available per country However, women remain underrepresented in leadership and management positions even in frontline service delivery roles (World Bank, 2024). For instance, while women account for 84 percent of the 28.5 million nurses and midwives globally, they are still outnumbered by men in physician and specialist roles (Boniol et al., 2019). Only 35 percent of public sector managers across all sectors worldwide are women (World Bank, 2024). Ethiopia reflects these global trends: despite recent efforts to promote women’s empowerment in the health sector, structural and cultural barriers remain, particularly in accessing leadership positions. In addition to these representation gaps, women in the public sector often earn less than their male counterparts. This wage disparity is shaped by a combination of gender bias, occupational segregation, and entrenched social norms. While public employment is generally viewed as offering equitable compensation and favorable working conditions, gender-based wage gaps continue to persist (Figure 2). Figure 2. Gender wage premium in the education and health sector (compared to male workers) Source: Worldwide Bureaucracy Indicators, latest data available per country To better understand and address these disparities, a survey was conducted in Ethiopia to systematically assess key organizational and human resource management (HRM) practices within the civil service. While legal frameworks, childcare demands, and prevailing social norms all contribute to gender inequality in public employment, one often overlooked driver is the lack of meritocracy in HRM systems. When recruitment, promotion, and pay decisions are not based on transparent and objective criteria, they can unintentionally reinforce gender bias. By investigating how these systems function in practice, the survey identifies critical challenges that affect women in the health sector. These insights can inform the design of more inclusive HRM systems and policies that promote equity not only in participation, but also in advancement and recognition. The survey covered three administrative levels: federal, regional, and woreda (district) administrations. All respondents were public servants; contract workers were not included in the sample. The sample at the federal level included 122 employees (70 women, 52 men). The regional level included 279 health administrators (113 women, 166 men), while the Woreda level had 127 administrators (46 women, 81 men). The survey collected information on respondents’ educational attainment and job responsibilities. While both male and female respondents reported relatively high levels of education, clear gender disparities emerged in employment roles (Table 1). Women were more likely to hold technical or support positions, whereas men were more frequently found in managerial roles. This structure may point to the possible gender-specific challenges in career progression within the sector. Table 1: Demographic Characteristics of the Respondents Source: Ethiopia Civil Servants Survey, 2024. Only Health Sector Respondents Results The findings in this section systematically examine gender dynamics and workforce management within Ethiopia's public health services. The analysis specifically focuses on perceptions toward job satisfaction, employee motivation, wage fairness, and performance evaluations, as well as experiences related to recognition, training, career advancement, and prevailing gender norms. Motivation and Satisfaction Frontline worker motivation in the public sector is shaped by a combination of intrinsic and extrinsic factors that influence commitment, effort, and overall performance. Intrinsic motivators—such as a sense of purpose, opportunities for professional growth, and the ability to contribute meaningfully to society—play a particularly strong role in sectors like health, where many employees are driven by a desire to serve others. At the same time, extrinsic factors, including salaries, financial incentives, career advancement opportunities, and recognition, are critical for maintaining job satisfaction and retaining skilled personnel. The balance between these factors varies across individuals, but gendered patterns in motivation, satisfaction, and career outlook suggest that men and women experience and respond to these drivers differently. Women are more likely than men to choose and remain in public sector jobs—a trend that has been consistently documented across multiple contexts. Research by De la Rica et al. (2007) found that unemployed and inactive women show a marked preference for public employment, and more recent studies continue to affirm this pattern. Despite the declining overall share of public employment in many countries, the public sector remains especially attractive to women due to its perceived stability, predictable career pathways, and supportive policies related to maternity leave and work-life balance (Barsoum and Abdalla, 2022). This persistent overrepresentation of women is largely shaped by supply- side dynamics: women actively seek out public sector roles, rather than being recruited through targeted gender policies (Gomes and Kuehn, 2025). Survey data from Ethiopia reinforces this trend. Seventy percent of female respondents indicated a desire to remain in public service for the rest of their careers, compared to 57 percent of male respondents. When asked about their reasons for staying, both men and women most cited job security, limited opportunities in the private sector, and alignment with personal values—particularly the desire to contribute to society (Figure 3). However, this strong attachment to the public sector among women may also reflect constrained labor market mobility. Fewer women (24 percent) than men (33 percent) believed they could easily find a job outside the public sector, suggesting that structural barriers may limit women’s perceived or actual opportunities elsewhere. In this light, women’s continued presence in public employment may be driven as much by necessity as by preference. Figure 3: Reasons for staying in the public service Source: Ethiopia Civil Servants Survey, 2024. Only Health Sector Respondents Overall job satisfaction among public health workers is high for both men and women, with 80 percent of men and 83 percent of women reporting satisfaction. Satisfaction is especially strong among women working at the Ministry of Health (MOH), where 91 percent report being satisfied, compared to 79 percent of their male counterparts. However, satisfaction declines noticeably at lower administrative levels, particularly for men—suggesting that working conditions and perceptions of value may differ across the health system hierarchy. Despite a strong sense of purpose among health workers, compensation remains a major source of dissatisfaction, with fewer than 3 percent of men and women reporting satisfaction with their salaries (Figure 4). This discontent is reinforced by broader wage disparities: health workers earn less than public administration staff, even after controlling for education and experience (Figure 5). While public sector jobs often offer a wage premium over private-sector roles, this premium is uneven within the sector. Although many health workers remain committed to their roles—driven by intrinsic motivators such as a sense of societal contribution—low and unequal compensation can gradually erode morale, especially in the absence of meaningful career progression or recognition. The burden is even greater for those deployed in under-resourced areas, where challenging working conditions are not matched by financial or professional support. Figure 4: Satisfaction with job, salary, and non-salary benefits Source: Ethiopia Civil Servants Survey, 2024. Only Health Sector Respondents Figure 5: Public sector health workers are paid less compared to public administration workers Source: Worldwide Bureaucracy Indicators (WWBI), latest data available. Most countries are from ECA and LAC regions. Variation in satisfaction with non-salary benefits reveals disparities across gender and administrative levels, offering insight into how compensation structures are perceived and experienced throughout the health system. Men report especially low satisfaction with these benefits at the regional (4 percent) and woreda (11 percent) levels, with a significantly higher rate at the MOH (35 percent). Women report slightly higher overall satisfaction (25 percent), particularly at the MOH where 51 percent are satisfied. However, satisfaction among women also drops sharply at subnational levels—falling to 12 percent at the regional level and 17 percent at the woreda level. These patterns suggest that benefit packages—such as housing allowances, transportation subsidies, or family support policies—may be more comprehensive, accessible, or clearly communicated at the central level. They also point to persistent gaps in how compensation-related policies are experienced across gender lines and administrative settings. Addressing these disparities will require more equitable distribution of benefits and stronger HR communication channels, particularly in remote areas where worker satisfaction is most fragile. Perceptions of wage fairness provide insight into underlying issues of equity in compensation practices across different administrative levels. While majority of both men (59 percent) and women (55 percent) feel they are paid relative to peers with similar responsibilities, these perceptions vary by administrative level. At the Ministry of Health (MOH), confidence in pay equity is relatively high—over 60 percent of both genders believe they are compensated fairly. However, perceptions of fairness decline in decentralized settings: at the woreda level, only 53 percent of men and 48 percent of women report feeling that their pay is equitable. Although the gender gap is modest, these figures reflect deeper concerns about transparency, consistency, and perceived recognition in more remote or under-resourced facilities. The slightly lower rates among women suggest they may be less likely to receive equitable treatment in discretionary compensation decisions. Survey results further shed light on gendered dynamics of workforce retention, highlighting both common drivers of attrition and distinct patterns in how men and women navigate career dissatisfaction. While baseline motivation remains high, both male and female workers report a decline in motivation since entering the civil service. This decline is slightly steeper among men (a 14-percentage- point drop compared to 11 points for women), aligning with their higher stated intent to leave the sector—28 percent of men plan to exit within the next two years, compared to 18 percent of women. The reasons cited are consistent across genders: dissatisfaction with salaries, limited access to benefits, and weak career development prospects (Figure 6). However, women are more likely to stay despite these challenges. This could reflect stronger intrinsic motivation among women, but it may also point to constrained labor market mobility. Figure 6: Reasons for declined motivation levels compared to when they first joined Performance Management Performance evaluations serve both administrative and developmental functions. Their administrative purposes include raises, promotions, and layoffs, while their developmental purposes include the identification of training needs and areas for employee growth. When implemented effectively, these evaluations enhance job performance, boost employee satisfaction, and improve service delivery outcomes (Tagliabue et al., 2020). However, many public sector organizations struggle with issues such as bias, inconsistent evaluation criteria, and resource constraints, despite statutory or policy requirements for detailed documentation. Persistent challenges in ensuring fairness, standardization, and meaningful feedback have long hindered their effectiveness (Murphy & DeNisi, 2023). Gender disparities in performance evaluations are particularly noticeable in post-evaluation discussions, as men are more likely than women to have opportunities to chat about their performance with direct supervisors. Most respondents—slightly over 80 percent—reported undergoing a performance evaluation in the past two years. Interestingly, a higher share of women than men reported having their performance evaluated (86 percent vs. 81 percent). However, this numeric advantage masks a deeper gap in the quality of engagement: among those who were evaluated, less women reported having a chance to discuss their performance with direct supervisor, compared to men. Among those who did receive informal feedback, men were more likely than women to have had a conversation about their performance with a direct supervisor (30 percent vs. 22 percent). At the Ministry of Health (MOH), 21 percent of women report receiving no informal feedback compared to just 10 percent of men. The gap is narrower but still present at the regional level (43 percent of women vs. 41 percent of men). Informal feedback from supervisors and ongoing performance conversations are just as important as formal evaluations, as they offer timely guidance, reinforce expectations, and help employees build on strengths or address challenges in real time. These interactions also signal managerial support and recognition—key elements that can significantly boost motivation by improving day-to-day working conditions, providing social incentives, and enhancing self-confidence, particularly in environments where formal advancement opportunities are limited (Anseel & Lievens, 2007; Tagliabue et al., 2020; Adams et al., 2024). Without meaningful, two-way feedback, evaluations become a procedural formality rather than a developmental tool. The gender gap in follow-up discussions may reflect underlying biases in managerial engagement, lack of attention to women's career trajectories, or workplace dynamics that make it harder for women to access supervisory support. The lack of meaningful differentiation in performance ratings undermines the effectiveness of evaluations as a mechanism for workforce development. Perceptions of fairness in the evaluation process are generally positive, with 86 percent of respondents believing that their supervisors assess their performance fairly. Additionally, 69 percent believe that evaluations effectively distinguish high and low performers. However, the distribution of ratings suggests otherwise—an overwhelming 96 percent of employees reported receiving either a “good” or “very good” rating in their most recent evaluation. This near-universal positive assessment indicates that performance management systems, while formally in place, may not function as genuine differentiators of employee contributions. This pattern is particularly concerning for women, who may already face barriers to career progression; if performance assessments do not adequately distinguish strong contributors, then recognition and promotion decisions risk being driven by informal networks rather than merit. Performance evaluations in the public sector are primarily used for performance monitoring and motivation rather than direct career advancement or rewards. As shown in Figure 7, most respondents cited "improving performance" and "motivation" as the top uses, with women slightly more likely than men to view evaluations as tools for these purposes (67 percent vs. 60 percent for performance improvement, and 63 percent vs. 60 percent for motivation). While these are valuable functions, the connection between evaluations and tangible career outcomes appears weak. Additionally, 20 percent of respondents reported that performance evaluation results are not utilized in any meaningful way, only 6 percent of respondents noted that evaluations contribute to awarding bonuses, and just 5 percent indicated their role in demotions. Figure 7: Uses of performance evaluations Compensation Financial and quasi-monetary incentives have traditionally played a central role in health worker remuneration, serving both as direct motivators and as signals of recognition for effort and achievement. Beyond simply increasing income and improving one’s standard of living, performance- based financial rewards can reinforce an employee’s sense of value within an organization, fostering motivation and commitment. Conversely, when such incentives are perceived as inadequate or unfairly distributed, they may signal a lack of appreciation, potentially undermining morale and engagement. Although financial incentives are widely recognized as a valuable component of performance management, their practical use remains limited. Just 17 percent of female respondents and 16 percent of male respondents reported ever receiving a performance-based bonus. This underutilization suggests that current systems are falling short in leveraging this tool to support workforce motivation and retention. Training and Capacity Building Training and capacity building are key to a strong workforce, especially in service delivery. Training and capacity building are widely recognized as one of the essential elements of a strong public sector workforce. Surveys among public sector staff consistently demonstrate that such training strengthens workers’ skills, improves morale, and increases overall performance (Manzoor et al., 2019; Thaler et al., 2016). In the health sector, training is common but often seen as a formality rather than a tool for skill- building or service improvement. Equitable access to training remains a critical challenge, particularly for women, who comprise a large share of the health workforce. Despite their central role, women face disproportionate barriers to professional development, limiting their advancement. When respondents were asked whether gender influenced the training opportunities they received, most of both women (71 percent) and men (68 percent) disagreed. Most men (95 percent) and women (88 percent) believed that both genders have equal access to educational and training opportunities. However, further data indicates otherwise. Fifty- two percent of men received at least one training opportunity compared to 40 percent of women in the last year and averaged approximately 60 hours of training compared to 51 hours for women. Additionally, 42 more men participated in more than two trainings and attended external training sessions, compared to women. These disparities underscore the need for more inclusive training systems that account for gendered barriers and support equitable career progression. Figure 8: Training opportunities by gender Source: Ethiopia Civil Servants Survey, 2024. Only Health Sector Respondents Gender Norms Most employees do not report experiencing or witnessing gender-based unfair treatment, with 89 percent of women and 92 percent of men stating they have never encountered such issues. However, more women (10 percent) than men (6 percent) say they have faced gender-based unfair treatment at some point in their careers. While these figures suggest that gender bias is not pervasive in most workplaces, they also highlight that a minority—particularly among women—has faced challenges related to discrimination. Gender differences in perceptions of fairness around promotion and career progression are present, though relatively modest in scale. While most employees do not believe gender has influenced their advancement, women are somewhat more likely than men to report experiencing unfair treatment. Specifically, 7 percent of female respondents say they faced gender-based barriers in promotion decisions, compared to 3 percent of men. Additionally, 5 percent of women cite limited access to career development opportunities as a key challenge—suggesting that while not widespread, some women do encounter hurdles to upward mobility, potentially due to implicit biases, exclusion from informal networks, or structural limitations within organizations. Other gender-related challenges were also noted by small shares of female respondents : 4 percent report issues related to hiring practices and work-life balance, and 3 percent mention experiencing dismissive or disrespectful behavior from colleagues. While these figures may seem minor in isolation, they point to subtle but persistent barriers that can compound over time, shaping workplace culture and influencing women's experiences and advancement in the public sector. Interestingly, unfair treatment in compensation is the least frequently cited issue, with fewer than 1 percent of women reporting concerns. This may reflect the fact that public sector salary scales and grading structures are standardized and legally mandated to apply equally to men and women. However, the absence of reported discrimination in pay does not necessarily mean that gender-based disparities do not exist. Rather, it suggests that pay inequities may be driven less by overt discrimination and more by structural dynamics—such as occupational segregation, slower promotion rates for women, and underrepresentation in senior and decision-making roles. Even within uniform pay systems, men may be more likely to occupy higher-grade positions that come with significantly greater salaries and benefits, thereby contributing to an overall gender pay gap. Thus, organizations aiming to build a more equitable workplace should look beyond formal equality in pay structures and actively address the underlying barriers that shape gendered career trajectories. Despite the evident gender disparity in leadership roles, a notable portion of the population does not view it as problematic—53 percent of men and 44 percent of women share this sentiment. Among those who acknowledge the issue, female respondents identify several contributing factors: prejudiced attitudes and stereotypes against women in leadership (34 percent), the perception that women are less available due to family responsibilities (30 percent), and limited access to leadership development opportunities (21 percent) (Figure 9). Furthermore, 24 percent of female respondents and 16 percent of male respondents believe their organizations do not take concrete steps to promote gender equality in leadership positions. Notably, both genders report higher agreement with this statement at the Woreda/local level compared to regional and central levels. 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