Ethiopian Community Health Worker Programs

By: Rose Zulliger

Summary

Background

The first cadre of Health Extension Workers (HEWs) was trained in 2004. In the following years, Ethiopia expanded its PHC programs in hope of achieving universal health coverage. Human resources that serve at the community level in Ethiopia include: HEWs, voluntary CHWs, and Community Health Promoters (CHPs), now called Health Development Army (HDA) volunteers.

Case Studies of Large-Scale Community Health Worker Programs was derived from the Developing and Strengthening Community Health Worker Programs at Scale: A Reference Guide and Case Studies for Program Managers and Policymakers, edited by Henry Perry, Lauren Crigler, and Steve Hodgins.

Originally published in May 2014 by USAID’s flagship Maternal and Child Health Integrated Program (MCHIP), it was created in response to the rapid increase in and expansion of CHW programs in low- and middle-income countries over the past decade. In January 2017, a companion document was prepared to provide guidance on 13 case studies, including Afghanistan, Bangladesh, Brazil, Ethiopia, Niger, India, Indonesia, Iran, Nepal, Pakistan, Rwanda, Zambia, and Zimbabwe. CHW Central is serializing the case studies over time.

Summary

Background

Implementation

HEWs are supposed to split their time between health posts and the community. The HDA volunteers’ role is to increase utilization of primary health services through part-time work (less than 2 hours per week) within their communities.

Training

HEWs have more than 1 year of pre-service training conducted by trainers who were taught through a cascade train-the-trainer approach.

Roles/responsibilities

The main responsibilities of HEWs include health promotion, disease prevention, and treatment of uncomplicated and non-severe illnesses, such as cases of malaria, pneumonia, diarrhea, and malnutrition in the community.

Incentives

HEWs are formal employees and are paid a salary. HDA volunteers are not monetarily compensated, but receive nonfinancial incentives such as formal recognition, ongoing mentorship, certificates, and recognition at community celebrations.

Supervision

Supervision is conducted by the woreda (district) supervisory team, which comprises a health officer, a public health nurse, an environmental/hygiene expert, and a health education expert. In 2005, HEWs had an average of three supervisory visits over the course of 9 months.

Impact

Ethiopia is making some of the strongest improvements in health in all of Africa at present. Its declines in under-5 mortality and in maternal mortality, along with dramatic improvements in the CPR, are among the most notable in all of Africa. HEWs are widely seen as the main reason that services have expanded and these results have been achieved.

What is the historical context of Ethiopia’s Community Health Worker Program?

CHWs have a long history in Ethiopia, dating back to around the time of the 1978 Alma Ata Conference on Primary Health Care. One early program in Tigray, during the time of the civil war there in the 1970s and 1980s, trained 3,000 CHWs. These workers were selected by their communities to receive training in maternal, child, and environmental health and in malaria diagnosis and treatment. The Tigray program was suspended in 1991 at the end of the war, but various CHW programs continued throughout the country.¹

In the 1997–1998 fiscal year, the Ethiopian Federal MOH (FMOH) launched the National Health Sector Development Program (HSDP). This program shifted the health system focus from predominantly curative to more preventive and promotive care, and it prioritized the needs of the rural inhabitants, who make up 83% of the Ethiopian population.² A review of the first 5 years of the HSDP found that challenges remained in obtaining universal PHC coverage.³

In response to these unmet needs, the Government of Ethiopia launched in 2003 two programs: the Accelerated Expansion of Primary Health Care Coverage and (2) the Health Extension Program (HEP).⁴ Multiple stakeholders, including the Federal Ministries of Health, Education, Labor, Finance, and Capacity Building, were all involved in the development of the HEW model.⁵ The program was designed to expand health service coverage, particularly in rural areas, using locally available human resources. These included community-based human resources such as HEWs and CHPs, now HDA volunteers.⁴ The first group of HEWs was trained in 2004–2005.⁶ Between 2005 and 2008, the HSDP aimed to deploy 30,000 HEWs in 15,000 health posts with the goal of achieving universal PHC access by 2008.^7,8

There have been numerous recent changes in the HEP. Following the rapid expansion of HEP coverage in rural areas, attention shifted to scaling up these services in urban and pastoralist communities. In 2009, the FMOH launched the Urban HEP, which trained female clinical nurses for 3 months as urban HEWs.⁹ Rural HEWs were initially used in health promotion and disease prevention; in 2010 their services were extended to include treatment of uncomplicated diseases. The CHP Program has also undergone changes and these volunteers are now called the Health Development Army (HDA). Associated with the title change is a shift from an NGO- directed program where each volunteer is responsible for 25–30 households to a government program with one volunteer for every 5 households. HDA volunteers’ new scope of work also includes broader development work beyond health.

What are Ethiopia’s health needs?

Ethiopia has a large burden of communicable diseases, nutritional disorders and maternal/neonatal conditions, but progress has been made in the past 5 years.¹⁰ Key health issues in Ethiopia include high rates of maternal and child mortality and malaria.¹¹ The MMR for Ethiopia is 470 deaths per 100,000 live births and women have very low prenatal and postnatal service utilization.^12,13 Leading causes of maternal mortality include obstructed/ prolonged labor, pre-eclampsia/eclampsia, and malaria.⁸ The country also has a high IMR of 59 deaths per 1,000 live births and a high under-5 mortality rate of 88 deaths per 1,000 live births.¹³ The leading causes of deaths among children younger than 5 years of age are pneumonia, diarrhea, malaria, neonatal problems, malnutrition, and HIV/AIDS.⁵

Infectious diseases in Ethiopia stretch the health system’s resources and are associated with substantial morbidity and mortality. Ethiopia is among the five countries in sub-Saharan Africa with the highest prevalence of malaria. In Tigray, malaria is the leading cause of hospital admission and death.¹⁴ TB and HIV are important problems. The national HIV prevalence was 2.3% in 2009. At that time, only 8.2% of HIV-positive pregnant women received prophylaxis for prevention of mother-to-child transmission (PMTCT) of HIV. Although the national TB cure rate and treatment success rate are relatively high at 67% and 84%, respectively, it is estimated that only 34% of cases are detected.8 Additionally, environmental factors facilitate disease transmission. For example, 38% of Ethiopian households report no toilet facility.¹³

What is the existing health infrastructure?

The Ethiopian health system is decentralized and has been reorganized into three tiers. Tier 1 is made up of PHC units comprising a health center (one health center for 15,000–25,000 people) and five satellite health posts (one health post for 3,000–5,000 people) along with woreda hospitals, each serving 60,000–100,000 people. Tier 2 includes zonal/general hospitals (one hospital for 1 million to 1.5 million people). And Tier 3 involves specialized/referral hospitals (one hospital for 3.5 million to 5 million people).^8,15,16

In addition to the expansion of HEWs, the Ethiopian government has increased the number of medical students and health officers, some of whom are trained using an accelerated curriculum.¹⁷ This expansion of health personnel is motivated by substantial deficits in human resources. For example, the country has a shortage of 19,489 midwives, and only 3% of births in rural areas are attended by a skilled birth attendant.⁴

What type of program has been implemented?

HEWs are a formally recognized cadre that has strong political support, including from the FMOH and the prime minister.¹⁸ HEWs are supposed to manage the other CHW cadres, but their relationship with these cadres in the field is not clear.^4,7

HEWs are full-time employees who are meant to split their time between health posts and the community. These expectations have changed considerably since the HEW program was initiated. HEWs were originally conceived as links between their local community and the formal health services, dedicating at least 75% of their time to community outreach activities.^19,20 Despite these guidelines, there is some evidence that HEWs spend more time at health facilities, and recent reports indicate that HEWs should spend 50% of their time in the health posts.²¹

There have been four HSDPs since 1997–1998. In 1997, there were 76 health posts, 243 health centers, and 87 hospitals.⁸ Rollout has occurred in steps; the speed of expansion has been influenced by available resources for health posts and presence of eligible women to become HEWs. As of June 2007, the HEP covered 59% of villages (with 17,653 HEWs) and had constructed 66% of 9,914 projected health posts.¹⁹ By the end of 2009, 33,819 HEWs had been trained and deployed and 14,416 health posts had been constructed.⁸

The main role of the HEW is in health promotion, disease prevention, and treatment of uncomplicated and non-severe illnesses such as malaria, pneumonia, diarrhea, and malnutrition. HEWs provide a range of services, including prevention, health promotion, and health education; support role for outreach health services; distribution at the community level of commodities whose use does not involve clinical judgment; clinical case-management that involves exercising clinical judgment; ongoing care or support to assist people with a chronic illness (e.g., HIV/AIDS); and participation in and support of campaign-type activities. They also provide immunizations, injectable contraceptives, basic first aid, diagnosis and treatment of malaria and diarrhea, and treatment of intestinal parasites.¹⁵

The role of HDA volunteers is to increase utilization of primary health services. They work less than 2 hours per week within their communities. Their services include prevention, health promotion, and health education; support for outreach work by health services; and participation in or support of campaign-type activities. They are expected to be model community members and to share health information with others in their communities. This includes information on latrine construction, waste disposal, personal hygiene, ANC, immunization, infant feeding, and FP.²² Other cadres that provide community-oriented services include community counselors, peer educators, and home-based care providers who provide HIV-related services.²⁰

What about the community’s role?

Village health committees are involved in the selection and oversight of HEWs. In some geographical areas they are also engaged with HDA volunteers. Additionally, the kebele (ward) council is supposed to be involved in every step of the HEP, from program planning through to evaluation.²³

How does Ethiopia select, train, and retain Health Extension Workers and Health Development Army Volunteers?

HEWs are adult women who have completed 10th grade. HDA volunteers can be male or female and must be older than 15 years old and, preferably, literate. However, the literacy level in Ethiopia is very low: 51% of women have no education and only 29% of rural women are literate.^8,13This necessarily limits the number of eligible women in each community.

HEWs and HDA volunteers are also supposed to work in or close to their community of origin or their permanent residence, yet the first HEWs largely did not meet this criterion. Only 8% of interviewed HEWs were assigned to work in the village where they were born, and 52% were from urban areas. Many trained HEWs preferred to be placed in a community other than that in which they were born, and only 16% expected to stay in the kebele where they were currently employed for more than 3 years.⁷

HEWs have more than 1 year of pre-service training conducted by trainers who have been taught by a higher level of trainers.²⁴ HEW training is a collaboration of the MOH and the Ministry of Education and occurs at 40 technical and vocational education training schools.

HEW training includes didactic and clinical training in modules on (1) family health services, disease prevention and control, (3) hygiene and environmental sanitation, and (4) health education and communication.⁴ HEWs also recently received a one-time 1-month in-service training provided in response to identified inadequacies in their initial training. As of 2007, 4,772 HEWs had completed integrated refresher training conducted by woreda health offices and health center staff.23 A 2007 study of this continuing education for HEWs found that most HEWs underwent multiple continuing education trainings on malaria and reproductive health, among other subjects. There was, however, little coordination of these trainings, and HEWs expressed a desire for additional training on basic nursing care, home delivery, and care of children with common childhood diseases.²⁵

Before CHPs became HDA volunteers, they received an initial training conducted by the HEWs. CHPs were given 96 hours of training on prevention of communicable diseases, family health, environmental and household sanitation, and health education.⁶

Compensation for the two cadres of health workers is as follows: HEWs are regular government employees with a regular salary and benefits, while HDA volunteers do not receive financial compensation. A range of nonfinancial incentives has been effective with CHPs and now HDA volunteers, including formal recognition, ongoing mentorship, certificates, and recognition at community celebrations.²²

How does Ethiopia supervise its Health Extension Workers?

HEW supervision has varied throughout the history of the program, and it currently varies from one geographical location to another. In 2005, HEWs had relatively high levels of supervision: each HEW had an average of three supervisory visits over the course of 9 months.⁷ There are supposed to be multiple levels of HEW supervision, including by the woreda supervisory team that comprises a health officer, a public health nurse, an environmental/ hygiene expert, and a health education expert.²³ HEWs supervise the cadres such as HDA volunteers as well as TBAs and community-based reproductive health agents.²⁶

The program has extensive monitoring and evaluation (M&E) systems that include routine reports and monitoring of indicators for maternal, neonatal, and child health; disease prevention and control; nutrition; and hygiene and environmental health. Among the indicators that are reported are contraceptive acceptance rate, deliveries attended by skilled birth attendants and by HEWs, TB case detection and cure rates, and proportion of households using latrines.²¹

How is the Health Extension Program financed?

The HSDP has been financed by national and sub-national government entities, bilateral and multilateral donors, NGOs, private contributions, and user fee revenues. Current HSDP funders include the GAVI Alliance’s Health System Strengthening Program; the Global Fund to Fight AIDS, Tuberculosis and Malaria; and the Carter Center, among others.¹⁷

The total per capita health expenditure in 2007–2008 was $16.09.8 A costing exercise determined that an additional $11.96 per capita per year for 5 years (totaling $8.83 billion) would be required to meet Ethiopia’s health-related MDGs. This investment would reduce under-5 mortality by 32% and maternal mortality by 55%. Forty-five percent of the budget would be allocated to sustain and strengthen the HEP. There is, however, a substantial gap between the amount required to achieve the MDGs and the current level of funding.⁸

The costs of HEWs are as follows: $234 for 1 month of training; $178 for the apprenticeship; and $84 monthly for the salary of one HEW.¹⁶ At the local level, financing and planning are decentralized and the woredas receive block grants to cover the expenses of the HEP.²⁰

What are the program’s demonstrated impact and continuing challenges?

By 2008, 24,534 HEWs had been trained to provide services, leading to substantial increases in health service coverage. The percentage of the population that is served by the program has increased from 61% in 2003 to 87% in 2007.²⁷ The program has also demonstrated success in health service areas such as increased use of ITNs.¹⁹ The percentage of pregnant women and under-5 children using an ITN was over 40% in malarial regions.⁸ Significant, positive associations were also found between exposure to the HEP and child vaccination uptake, ITN use by children and pregnant women, utilization of ANC early in pregnancy, and proper disposal of babies’ fecal matter.²⁸ Additionally, some regions have achieved increases in institutional deliveries and tetanus vaccination coverage.²⁹

In 2009, ANC coverage was 68% and PNC coverage was 34%. The percentage of deliveries performed by HEWs was 11% and the percentage performed by skilled health personnel increased to 18.4%. Full immunization coverage reached 66%,⁸ and HEWs were found to be making an important contribution to improving the effectiveness of TB control at a modest cost.³⁰

The HEP has faced a number of challenges in its implementation, including delayed construction of health posts, delayed provision of health kits to HEWs, inadequate supervision for HEWs, and deficiencies in training.²⁷ The reach of HEWs is also limited in some settings.¹⁹ Additionally, a survey of HEW knowledge of maternal and neonatal health, skills, and confidence in providing services found substantial gaps.

HEWs are often younger women who may not be trusted by the community to assist during delivery.²⁶ A recent analysis of strengths, weaknesses, opportunities, and threats identified numerous weaknesses in the HEP, including low health service utilization; weak referral systems; low service quality; shortage of drugs, medical supplies, and equipment; and lack of a career trajectory for HEWs.⁸ The analysis also raised a concern that the increasing number of tasks allocated to HEWs and their growing workload will compromise their ability to complete their tasks. Finally, additional challenges for the HEP include high levels of staff turnover and lack of integration of services.⁹

In spite of many operational challenges to the operation of the HEP, Ethiopia is nonetheless making very impressive progress in achieving its health-related MDGs. The under-5 mortality has declined from one of the highest in the world in 1990 (204 per 1,000 live births) to 68 in 2011, enabling Ethiopia to reach the MDG for child health—one of the few African countries to achieve this so far.³¹ The MMR has declined from 950 per 100,000 live births in 1990 to 350 in 2010 and is expected to come close to achieving the MDG for women’s health by 2015.³² In addition, Ethiopia has achieved one of the “most rapid and unprecedented” expansions of contraceptive prevalence in Africa and, in fact the world, with the CPR increasing from 8.2% in 2000 to 28.6% in 2011 (based on national Demographic and Health Surveys [DHSs]).³³ The HEWs are widely seen, both within and outside of Ethiopia, as one of the major reasons these remarkable results have been achieved.

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