In this country narrative, Last Mile Health detailed the evolution of Ethiopia’s Health Extension Program utilizing two frameworks: WHO ExpandNet1 and Primary Healthcare Performance Initiative (PHCPI).2 The WHO ExpandNet framework enabled Last Mile Health to systematically explore the scaling-up process of Ethiopia’s HEP. Through the lens of ExpandNet, the project investigated specific elements of the Primary Healthcare Performance Initiative (PHCPI) framework, most notably governance and leadership, health workforce, health financing, facility infrastructure, and service delivery. Last Mile Health also assessed and analyzed the often-unrecognized contextual factors that have influenced the process of HEP expansion, including political, social and economic factors.

Below, we lay out our findings using the ExpandNet and PHCPI frameworks.

EXPANDNET PHCPI ENABLERS OF SCALE

The Innovation (CHW Program)

Service Delivery 
  • Diversified Service Package: Program incorporated an effective balance of curative and preventive services
  • Comprehensive Training: Combination of pre-service and integrated refresher training leveraged existing MOE infrastructure and development partner technical expertise
  • Career Advancement Opportunities: Level III to level IV upgrading program supported addition of new services and maintenance of existing skills
Inputs 

Comprehensive Investment in Health Systems: Simultaneous investments in human resources and physical infrastructure

  • Health centers, health posts
  • Health extension workers (full-time salaried CHWs)
  • Health development army (volunteer CHWs)
System
  • Structured Pilot Process: Built on existing community infrastructure and learning from past CHW programs and regional innovations
  • HEP Introduced Within Existing Health Sector Planning Processes: Major impetus for HEP was suboptimal results of HSDP-I mid-term evaluation conducted in 2002. This demonstrated challenges in achieving health service coverage of key interventions and a continued high-disease burden in readily preventable and treatable conditions (e.g., pneumonia, HIV, TB, diarrheal diseases, and malnutrition and pregnancy related complications)
  • Integrated Program Design: HEP service delivery, program management, supervision structures and referral systems are integrated into the broader public health system
  • Government Led Program: HEP continuously supported by government leaders
  • Community-based Program: HEWs must be residents of the community they serve, selected by the community and engage in community structures (e.g., kebele village council)
User organizations (Adoption)   
  • High-Level Political Leadership: Prime minister Zenawi, health leaders such as Dr. Tedros, Dr. Kesete and other leaders within MOH championed HEP as a major priority to build consensus and mobilize resources
  • Sub-National Political Leadership: EPRDF leaders on regional, district and kebele councils tasked to prioritize and provide support to the program
  • Non-Health Ministries: Non-health ministry leadership (MOE, MOFED) engaged early in the scale-up process, which helped contribute important resources and expertise
Resource team (Scale)  
  • MOH: Continuous leadership from the MOH and the EPRDF during the scale-up and maintenance stages of HEP
  • Development Partners: Development Partners assess and influence national health policy process through annual review meetings and monthly health sector related meetings
Environment
 
  • Decentralization: Devolved fiscal responsibility, human resource management, physical infrastructure and health planning helped build local accountability in line with national frameworks and systems
  • Complementary Investments: Pro-poor investments in education, agriculture and economic development likely strengthened impact of HEP

Scaling-up Strategy
 

Overall Strategy:

  • Scope: Focused scale-up in agrarian regions where majority of population resides. Differentiated HEP for urban and pastoralist regions after initial scale-up
  • Speed: Rapid scale-up from 2005-2010 to achieve HSDP targets. Gradual adaptation over time to incorporate new services
  • Management: MOH provides overall direction complemented by decentralized planning, monitoring and evaluation at regional, woreda and kebele levels. HEP is institutionalized through HSDP mechanism

Dissemination and Advocacy:

  • Used Evidence for Program Adaptation: Continuous use of domestic and international evidence enabled gradual introduction of new services, CHW cadres and training
  • Linked Evidence to Learning Exchanges: Senior government leaders visited countries with well-established programs to benchmark their efforts to HEP prototype. Development partners engaged government leaders on international learning exchanges to introduce new services

Organizational Process:

  • Built Local Government Ownership and Accountability: Decentralized planning, management and financing of HEP built foundation for local ownership, accountability and sustainability of effort
  • Embedded CHW Program into Health Sector Planning: HEP made a key pillar of the HSDP processes which helped ensure funding, high-level political commitment and continuous adaptation of program
  • Developed Enabling Policy Environment: Various policies such as the civil service policy, vocational education policy and health policy helped develop the necessary policies to ensure the rapid scale-up of HEP

Costs and Resource Mobilization:

  • Fostered Local Government Fiscal Responsibility: Districts allocated specific financing for HEP, which improves local ownership and accountability
  • Demonstrated Significant Financial Commitment: By committing to salary civil servants and earmark funds for HEP in the health sector development plan, political leaders signaled importance of effort to international funders
  • Harmonized Planning, Reporting and Financing Mechanisms: HSDP harmonization manual, code of conduct and IHP+ improved coordination of health sector financing
  • Incorporated CHW Programs into Pooled Funding: By promoting pooled funding, Ethiopia sought to reduce administrative burden and transaction costs, increase quantity and predictability of primary health care financing, and ensure overall sustainability

Monitoring and Evaluation:

  • Family Folder: Enables monitoring of demographic profile and implementation status of HEP at household level
  • HEW Action Plans: Each HEW develops an annual action plan, which is monitored monthly and forms the basis of the kebele and woreda planning processes
  • Health Sector M+E: HEP implementation, financing and performance are measured on an annual basis through sector-wide planning process

 

A graphic to show the scaling up strategy for CHW programs.

Social determinants & context (political, social, demographic, socioeconomic)

Data Source: World Health Organization (WHO) ExpandNet
  1. 1World Health Organization, ExpandNet. Nine steps for developing a scaling-up strategy. World Health Organization, 2010, accessed 17 December 2018, http://www.expandnet.net/PDFs/ExpandNet-WHO%20Nine%20Step%20Guide%20published.pdf.
  2. 2Primary Health Care Performance Initiative (PHCPI) Methodology Note, PHCPI, updated September 2015, accessed 17 December 2018, https://phcperformanceinitiative.org/sites/default/files/PHCPI%20Methodology%20Note_0.pdf.

Data and evidence