Ethical considerations

The research protocol was reviewed and approved by the Ethiopian Society of Sociologists, Social Workers and Anthropologists (ESSSWA) ethical review board (Ref No. ESSSWA/L/AA/0452/2023). The research team developed informed consent and assent forms for key informants and focus group discussants. Informed consent was obtained from all respondents before conducting interviews and discussions. Participation in this study was voluntarily without any implication to the study participants in their community. All the information from participants is kept confidential and presented anonymously.

Study setting

Ethiopia is a low-income country located in the Horn of Africa [19] and the health system of the country has three tiers, namely, primary, secondary, and tertiary. The population of Ethiopia has an estimated population of more than 120 million of which a high majority live in rural areas [20]. Gender assessment was conducted in diverse contexts, including agrarian, agro-pastoral, and pastoral contexts, and encompassed nine woredas from eight regional states: Afar, Gambella, Oromia, Sidama, Central Ethiopia, South Ethiopia, Somali, and South West Ethiopia Peoples’. These agrarian, agro-pastoral, and pastoral contexts have differences in infrastructure access, health service access, livelihood, culture, and religious beliefs. The study involved Primary Health Care (PHC) facilities and surrounding communities from August to September 2023.

Theoretical underpinnings and design

Despite the commitment of government and development partners to address gender disparities in primary healthcare settings, the influence of gender intersectionality on women’s access to and use of essential health services is an untapped research agenda in Ethiopia. Unequal, unfair, ineffective, and inefficient gender inequities in the health and health system have remained a major public health challenge [21]. Understanding the reason for the unequal and unfair conditions and context-oriented intervention approach to curb the disparity is a critical agenda [21,22] that needs systematic exploration and program re-designing. Hence, we used a descriptive qualitative study design [23] to explore gender disparities in women’s access to essential health services in the primary health care system in the agrarian and pastoral contexts of Ethiopia [21,22]. A multifaceted pragmatic meta-theoretical framework [24–26] was used to guide the study to understand gender disparities and their impact on access to and use of essential health services. The gender disparities were assessed mainly based on five USAID Transform Primary Health Care gender-analysis domains [27,28] that consolidated with other theoretical and implementation frameworks: namely cultural norms and beliefs; division of labor; access to and control over resources; patterns of power and decision; and health system. This study utilized the consolidated criteria for reporting qualitative studies framework [29] to ensure comprehensive reporting of the methods and results.

Sampling methods

The maximum variation sampling technique was applied to recruit Key Informant Interviews (KIIs) and Focus Group Discussions (FGDs) participants to examine a diverse range of cases relevant to the gender analysis. Diverse experiences and opinions related to gender influence the transformation of gender- and social- norms and affect access to and use of Reproductive, Maternal, Newborn, Child, and Adolescent Health and Nutrition (RMNCAH-N) services by women, girls, and persons with disability in rural agrarian and pastoral contexts. The study participants were recruited through consulting kebele leaders, HEWs, and traditional birth attendants to identify appropriate persons for gender analysis. Community members, gender focal officers from nine woredas, the Ministry of Health, Ministry of Women and Social Affairs, who have active key roles and responsibilities RMNCHAH-N were eligible for the KIIs. Of these, targeted participants who were unable to give consent for participation due to physical and/or mental illness during the study period (August to September 2023) were excused from the study. KIIs were conducted with a wide array of different focal persons, including at the federal level (MoH and MoWSA) and a focal person from the regional health bureau (RHB), woreda health office, woreda gender focal person, service providers from health centers and health posts, HEWs, religious or clan leaders, Women’s Development Union (WDU), adolescent girls out of school, adolescent boys in school, and married adolescent girls and boys. FGDs were conducted with six to twelve discussants, for women and men groups at kebele levels.

Data collection methods

Data collection guides were developed for KIIs and FGDs through reviewing relevant literature. The interviews and discussion guides were developed guided by the desk review of relevant documents including published articles and validation by relevant stakeholders. Semi-structured interview guides were used to collect qualitative data through KIIs with experts and FGDs with representatives from government organizations, non-government organizations, community, and service providers. Experienced and trained qualitative research assistants were deployed to collect qualitative data and take handwritten notes. Relevant data were extracted from relevant policy and program documents using a data extraction template and complemented by the primary study. All the interviews were conducted using local dialects and took an estimated 45–60 minutes for the interview and up to 90 minutes for focus group discussions at their vicinity and convenient time. HEWs, TBAs and kebele leaders helped the data collectors to identify the entry points and access the FGD discussants.

Data management

Interviews and focus group discussions were audio recorded. The audio records were listened to and transcribed according to the verbatim of the study participants. Transcripts were translated from the local dialect to English following the recommended approaches from existing literature [30,31]. Then transcripts were coded using ATLAS.ti software. The data analysis was conducted using both inductive and deductive techniques. The coded data underwent a blend of content [32] and thematic analysis [33,34] to identify recurring themes and patterns regarding gender dynamics affecting access to RMNCAH-N services. The data analysis was guided by USAID’s five gender domains [28] such as culture, norm, and belief; division of labor, pattern of power on decisionmaking, access to and control over resources, and health system-related barriers.

Cultural norms and beliefs

Culture, norms and beliefs play a paramount role in influencing women’s access to essential primary healthcare services in Ethiopia. The study participants emphasized that gender-related social norms, beliefs, and cultural practices in their communities often favor men than women. Women generally have the freedom to visit health facilities for Reproductive Maternal, Newborn, Child, Adolescent, and Youth Health and Nutrition (RMNCAYH-N), except for family planning. Unmarried adolescent pregnant women; women in polygamous marriages; and women living in rural areas have faced challenges in access to health services due to the presence of rigid gender norms. Cultural norms and religious beliefs restrict communities from having access to family planning and use in most settings of Ethiopia, mainly in pastoral contexts. Study participants, expressed the strongest reservations regarding family planning use, primarily citing religious reasons.

“...Birth control is condemned according to Afar culture and not allowed in Islam.” - FGD, man, Afar

“…Using family planning according to our religion is forbidden.” -KII, religious leader, Jimma

Moreover, these communities perceive that the utilization of family planning is against the basic essence of marriage childbearing and leads to promiscuity.

“…They believe that a girl marries a husband to have a child, so she should not use birth control.”-KII, care provider, Afar

Cultural beliefs played a more significant role in the lower ANC uptake. For instance, respondents from rural Borena mentioned that women tend to avoid seeking ANC because they believe pregnancy should be kept secret. They prefer not to reveal their pregnancy until their belly is visibly prominent, so this delays the initiation of ANC services.

“…if a woman gets pregnant, it is kept secret until six or seven months, known as ‘Ulfi hin lalabamuu’ [pregnancy should not be broadcast]. So, this practice can affect the ANC utilization or result in late initiation of ANC.” - FGD, adult women, Borena

These are deeply rooted in societal structures; existing hierarchal gender norms, cultural beliefs, and practices negatively influence women’s access to and use of health services. According to a religious leader from the community:

“…Our religion dictates that women should be under the authority of their husbands or families. Their roles are limited to domestic activities, and they are not permitted to engage in community activities without the permission of their husband or family.”-KII, religious leader, Afar

The prevailing unsupportive attitude towards family planning is predominantly influenced by demographic considerations and due to recurring conflict between tribes over resources. The cultural norm emphasizing procreation is so deeply ingrained that a husband may even choose to divorce his wife if he discovers that she is using contraceptives.

“The primary reason behind many women’s nonuse of modern contraceptives is the opposition from their husbands, who often do not permit them to use such methods. In some cases, women may resort to using contraceptives secretly without informing their husbands. However, if a husband becomes aware of his wife’s contraceptive use, he may develop suspicions of infidelity and fear that she is engaging in extramarital relationships.” (KII, WDA, Gambella)

Unmarried adolescents’ use of contraception is not socially acceptable.

“… there is a cultural influence that if an unmarried girl uses birth control, she will become a prostitute.” -KII, care provider, Afar

Similarly, cultural norms and beliefs hindered unmarried adolescent girls’ SRH service uptake. The community has a strong objection to unmarried girls seeking SRH services.

“.. if a girl went to the health center and asked for SRH services, the health providers are willing to provide the service. However, the parents are against premarital sex and do not allow their children to go to health centers for SRH services.” -KII, adolescent girls, Gambella

In addition, women did not want to disclose the onset of labor and believed other people’s knowledge of a woman’s onset of labor could prolong the labor. So that they want to keep it secret for the mother to give birth without trouble.

“…Culturally, the onset of labor should be kept secret. If the labor is known to others, the women will experience prolonged labor.” -KII, adolescent girl, Borena

Division of labor

There are distinct gender roles and responsibilities observed among women, girls, men and boys, and girls. These roles encompass domestic activities, caregiving, livestock-related tasks, child-rearing, marketing, and engagement in off-farm and nonfarm livelihood activities. Women carry a significant burden of household work. It appeared as a primary barrier that women’s healthcare seeking has influenced due to their heavy workloads. Many women struggle to find the time to visit health facilities due to their extensive responsibilities at home.

“…majority of household works are carried out by women and girls, leaving them with limited availability to visit health care facilities. Their visits to health facilities are often scheduled around the rare moments when they have some free time due to their demanding responsibilities.” - KII, WDA, Afar

Despite slow progress in sharing workloads with men and boys, women and girls continue to bear additional time and work burdens related to domestic and reproductive duties.

“…Typically, women shoulder the majority of household chores and responsibilities. Men have relatively fewer domestic duties, with women being responsible for tasks such as cooking, washing clothes, childcare, water collection, wood gathering, and the care and supervision of cattle. Men and Boys’ roles are mainly focused on tasks outside the house, such as tending to cattle and camels.” -FGD, women, Dasenech woreda

The extensive workload that women bear in their households hinders their ability and schedule to visit health facilities. “…she forgets the appointed date due to workload at home.” - FGD, adult women, Sidama

Although women and girls are mainly engaged in routine and tedious domestic tasks, husbands play a crucial role in providing support to their wives, particularly during the delivery process. They ensure that their wives are taken to the health center, offer necessary assistance such as blood donation when required, and accompany them for immunization and post-delivery care.

Access to and control over resources

According to informants, men typically hold a more privileged position when it comes to accessing and benefiting from assets and services. Although women do have some access to assets, they often have limited control over how these resources are used. Women farmers have even faced challenges in controlling resources despite having access to them. Lack of access to resources and control over cash among women was negatively impacting women from use of RMNCAH services, and limited women’s ability to seek health care services, purchase medications or cover other expenses.

“...men typically have access to and control over resources, including land and livestock. Men are often regarded as the owners and primary decision-makers when it comes to these resources. Women are often the ones who access credit services, with their husbands serving as guarantors for the loans from the village savings and credit association. However, even in cases where women access credit services, it is often the men who have control over that money, where men typically hold more decision-making power and control over financial resources.” - FGD, adult men, Gambella

Although access to and control over resources is equal for men and women by principle, men had disproportionality control over the resources. One of the study participants reported that;

“…It’s obvious there is male dominance in any household; there are many households with both males and females having equal access to and control over their resources and assets. There are a lot of improvements in gender equality compared to previous times.” -KII, adolescent boy, Halaba woreda

Patterns of power and decision-making

Decision-making varies substantially across contexts, with notable differences between agrarian and pastoral areas. Women typically seek health care services only when directed to do so by their husbands or when they or their children are severely ill. The majority of the participants in our community share this view.

“…women’s health is the ones women can make decisions… especially in matters like family planning when a common decision cannot be reached.”-FGD, women, Seka Chekorsa woreda,

Although women have made decisions for antenatal care, choice of childbirth place, and accessing PNC, both male and female participants agreed that women typically carried the responsibility and have limited decision-making power on resources. The key informant remarked that:

“…after marriage, I hold the decision-making power in all aspects of our life. If my wife doesn’t comply with my decisions, I may consider divorce. This pattern has been passed down through generations, with my father following the same tradition. Any potential change in these dynamics would require community consensus and increased awareness among its members.”- KII, adolescent boy, Deghabur.

In many cases, the husband or father is the one who makes the final decision regarding health care.

“…if a woman wishes to visit a health facility, she is allowed to do so, but she must inform her husband before. As per Afar culture, respecting the husband’s honor, it is customary for the wife to communicate her intention to visit the health center. Generally, women can receive the necessary care by discussing their needs with their husbands.” - KII, married adolescent girl, Chifra

Women and girls often require permission from their husbands or fathers to seek healthcare. However, there is a disagreement, especially in matters related to family planning. Both male and female respondents from the agrarian areas also emphasized that men play a crucial role in providing various forms of support, including financial assistance and accompanying women for RMNCAH-N services.

“Women take the lead in making health care decisions, but they often consult with their husbands to consider all available options. Women primarily make health care decisions. Nevertheless, in the case of family planning decisions, there should be mutual support and agreement between husbands and wives.” - FGD, women, Buyo Kechema kebele, Seka woreda

Health system-related barriers