Addressing the Healthcare Worker Crisis in Ethiopia The effects of gender-based violence and discrimination Tewabech Zewde, PhD; Yimtubezenash Woldemanuel, MD, PhD; Elizabeth J. Kvach, MD, MA; James Conniff, MD; Negussie Deyessa, MD, MPH

2 Activity Disclaimer Elizabeth J. Kvach, James Conniff, Tewabech Zewde, Yimtubezenash Woldemanuel, and Negussie Deyessa have no relevant financial relationships to disclose.

Objectives Review gender inequality in Ethiopia and its effect on the Ethiopian health care system Present the results of a survey of female students and staff of Addis Ababa University - College of Health Sciences (AAU-CHS) investigating experience of gender-based violence (GBV) and discrimination Discuss implications of these results for training of healthcare workers in Ethiopia 3

Ethiopia 4

Ethiopian Human Resources for Health 5 WHO. Global Health Observatory Data Repository

6 Global Healthcare Worker Graduates and Density

Brain Drainin sub-Saharan Africa National vs International Private vs public systems Inadequate training, medical facilities and resources for practice Low salary Lack of incentives to practice in rural areas Repressive governments 7 Hagopian, A., et al. The migration of physicians from sub-Saharan Africa to the United States of America. Human Resources for Health 2004, 2:17

8 Deressa W, Azazh A. Attitudes of undergraduate medical students of Addis Ababa University towards medical practice and migration, Ethiopia. BMC Med. Educ. 2012;12:68. Brain Drain Intentions in Ethiopia

Why focus on gender? Human rights Social justice Economic development Contribution to health care workforce 9

Ethiopian Graduation Trends 10 Ethiopian Ministry of Education, s%20Annual%20Abstract%202006E.C%20% %20G.C%29.pdf

Experience of women in higher education in Ethiopia Marsh, et al (2009): 86.3% of female university faculty and staff reported at least once incident of workplace abuse or sexual harassment in the prior 12 months Arnold, et al (2008): Lifetime prevalence of any GBV for female college students was 59.9%; women reporting any GBV since enrolling in college was 46.1%. Philpart (2009): 24.4% of college males admitted to perpetrating physical or sexual abuse (or both) in the previous 12 months 11

Impact of gender based violence (GBV) Increased rates of depression with suicidal thoughts Poor academic performance Contributes to higher rates of attrition among female students and faculty 12 Gelaye, 2009; Devries, 2011

Addis Ababa University – College of Health Sciences 13

AAU-CHS staff profile 14

Methods Cross-sectional survey –Female students and staff of AAU-CHS –In their respective schools for at least one year –Excluded those who were absent and who were enrolled in extension program Recruited via advertising posters, key informants, and female student representatives May-August

Survey: –Adapted from WHO multi-country study questionnaire and previous work done with similar groups in Ethiopia –Pre-tested –Addressed: Sociodemographic characteristics Substance use Attitudes and beliefs about gender Experience of physical, sexual, and emotional gender-based violence 16

Results: Respondent Characteristics Total of 615 respondents (92% response rate). Mean age 23. Majority were single (59%), Orthodox Christian (67%), undergraduate (76%), from Addis Ababa (70%), and had family living nearby (93%) 32% reported substance use, alcohol most commonly. 17

Results: Prevalence of GBV 18

Results: Perpetrators of GBV 19

Results: Attitudes toward Male Dominance and GBV 63% of women expressed moderate or complete agreement with dominant male roles. 26% agreed that wife beating was justified for at least one reason 58% felt they were unable to refuse sex with a partner in at least one situation 20

Results: Factors associated with Emotional Violence 21 Sociodemographic FactorOdds Ratio, 95% CI Age (0.34, 0.98) 0.57 (0.37, 0.89) Alcohol Use 1.95 (1.29, 2.94) Any Substance Use 1.94 (1.29, 2.92)

Results: Factors associated with Sexual Violence 22 Sociodemographic FactorOdds Ratio, 95% CI Low GPA < (1.04, 9.52) Does not live near family 3.58 (1.38, 9.29) Low monthly income (<500 birr) 4.76 (1.54, 14.7) Very controlling spouse 22.2 (2.86, 171) Alcohol use 3.55 (1.62, 7.74) Binge drinking 1-3 times in last year ≥3 times in last year 2.86 (1.03, 8.00) 5.73 (1.50, 21.8) Khat use 5.18 (1.37, 19.5)

Results: Factors associated with Physical Violence 23 Sociodemographic FactorOdds Ratio, 95% CI Coming from a district town 2.10 (1.15, 3.83) Use khat 5.24 (1.85, 14.86) Moderately controlling or Very controlling spouse 2.06 (1.05, 4.02) 8.79 (1.62, 47.8)

Discussion 1)University instructors and employees are perpetrating a significant amount of emotional violence. 2)Respondents have internalized and normalized a sense of gender inferiority 3)There may be certain high risk groups of students who are at greater risk for GBV 24

AAU-CHS Response to Findings: Gender Equity Action Plan 1)Develop institutional policies 2)Enhance institutional resources 3)Raise awareness 4)Conduct research 25

Strategies to Address Physician Brain Drain 1)Improve and expand local training quality and opportunities, including recruitment and retention of women 2)Recruit students from rural areas 3)Improve health infrastructure 4)Increase incentives for physicians 26 Paang, T, et al. Brain drain and health professionals. BMJ 2002;324:499–500

Conclusion 1)GBV and discrimination are major issues affecting female students and staff at AAU-CHS 2)Efforts should be made to address this to improve the training and work environment for Ethiopian health care workers, and retain women in the workforce. 27

References 28 Arnold, D., Gelaye, B., Goshu, M., Berhane, Y., Williams, M.A.. (2008) Prevalence and risk factors of gender-based violence among female college students in Awassa, Ethiopia. Violence and Victims 23(6), Devries, K., et al. (2011). Violence against women is strongly associated with suicide attempts: evidence from the WHO multi-country study on women’s health and domestic violence against women. Social Science & Medicine, 73, Gelaye, B., Arnold, D., Williams, M.A., Goshu, M., & Berhane, Y. (2009). Depressive symptoms among female college students experiencing gender-based violence in Awassa, Ethiopia. J Interpers Violence, 24, Hagopian, A., et al. The migration of physicians from sub-Saharan Africa to the United States of America: measures of the African brain drain. Human Resources for Health 2004, 2:17 Marsh, J., Patel, S., Gelaye, B., Goshu, M., Worku, A., Williams, M.A., & Berhane, Y. (2009) Prevalence of workplace abuse and sexual harassment among female faculty and staff. J Occup Health, 51, Paang, T, et al. Brain drain and health professionals: A global problem needs global solutions. BMJ 2002;324:499– 500 Philpart, M., Goshu, M., Gelaye, B., Williams, M.A., & Berhane, Y. (2009). Gender-based violence committed by male college students in Awassa, Ethiopia. Violence and Victims, (24)1, World Health Organization (WHO). (2004). Health workforce by gender distribution. Global Health Observatory Data Repository. Retrieved on Feb 21, 2014: WHO & Global Health Workforce Alliance. (2009). Country case study: Ethiopia’s human resources for health programme. Retrieved on Feb 18, 2014: