Analysis

The Innovation (CHW Program)

• 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

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)

• 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)

• 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

• 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

• 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

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