Extension workers drive Ethiopia's primary health care

Abstract

Thousands of community workers are helping Ethiopia to deliver primary health-care services to people living in rural areas. But critics say the training these workers receive is not adequate for them to attend many of the health problems they encounter. Wairagala Wakabi reports. Although it still has some of the worst health indicators in the world, Ethiopia is fast registering impressive successes in extending affordable primary health-care services across the country. These achievements are largely attributable to the Health Extension Programme which has been implemented since 2003, and through which the country hopes to achieve universal access to primary health care by 2009. Coverage of publicly-funded health care has risen from 61% in 2003 to 87% in 2007, whereas total coverage—including services provided by private health facilities—has grown from 70% to 98% over the same period. The Health Extension Programme, which has enabled this success, aims to improve access and equity through provision of essential health interventions at the village and household level, with a focus on sustained preventive health actions and increased awareness. The initiative deploys two salaried health extension workers at each village health post. Most of these workers are women who are recruited from the local communities in which they will work. New recruits complete a 1-year training course, which includes fieldwork, before taking up their posts. Luwei Pearson, head of the health department at UNICEF Ethiopia, told The Lancet that a review completed last July by independent consultants with the input from WHO, the UN Population Fund, and UNICEF, showed that the Health Extension Programme had achieved great successes, helping to prevent communicable diseases and enabling effective community participation in the planning and implementation of health care. The care given under the programme covers disease prevention and control, hygiene and sanitation, family health services, and health education. According to the evaluation of the Health Extension Programme, the training and deployment of the health extension workers have been progressing according to plan. Some 24 534 workers gave been trained and deployed, representing 82% of the target. “From several studies carried out so far, it appears the community engagement of the HEWs [health extension workers] in a number of regions is highly appreciated and seems effective. In those regions, HEWs work together with community health promoters, health workers, religious leaders, and community leaders”, says the evaluation report. Most of the workers were said to be well organised in their activities and divided their time between the community and activities at health posts. Female-headed households reported monthly visits by the extension workers and had received health education on various topics such as housing, food hygiene, waste disposal, immunisation, and family planning. However, not all the news is positive. Tewodros Adhanom, Ethiopia's minister of health, says that workforce shortages still hamper delivery of health care. And analysts point out that the ability of the extension workers to deliver services will remain limited because of delays in the construction of health posts and the distribution of health kits, as well as inadequate supervision within the programme. At the national level, the Health Education and Extension Centre is mandated to coordinate and monitor the activities related to the health extension programme. It is also responsible for the preparation of national health education standards and materials. But its effectiveness has been under question, and it is one of the departments that health minister Adhanom has said will be reformed. Critics also say that the training which extension workers receive is not adequate for them to attend to many of the health problems they encounter and that the interaction between the workers and their referral health centres needs to be strengthened. But despite these problems, the Health Extension Programme is largely seen as a big success. Adhanom says his country is on course to achieve primary health care for all by 2010, and praises the HEP for contributing to this milestone.