Overview: This Exemplar narrative sought to address the following research question: What are the key factors that enabled the expansion and effectiveness of Ethiopia’s Health Extension Program? Two frameworks were used to broadly organize the research and analysis: WHO ExpandNet1 and Primary Health Care Performance Initiative (PHCPI).2 The WHO ExpandNet framework guided a systematic exploration of the scaling up process of Ethiopia’s Health Extension Program. The PHCPI framework organized the inquiry of program design and the health system along the lines of governance and leadership, health care workforce, health financing, facility infrastructure, and service delivery. Contextual factors that influenced CHW program expansion, including political, social and economic, were considered throughout this process.
Advisory Panel: Last Mile Health assembled a seven-member Technical Advisory Panel of global community health and primary health experts. The Panel selected Exemplar countries and advised on the research methods described below and the country narrative content. For more information on how Ethiopia was selected as an Exemplar in community health worker programming, please click here.
Research Partner: In Ethiopia, Last Mile Health partnered with the International Institute for Primary Healthcare-Ethiopia (IIfPHC-E) who supported the identification of key documents and stakeholders and provided critical input to the country narratives.
Literature Review: To answer our research question, Last Mile Health reviewed more than 100 documents to develop this country narrative. Documents selected focused on the design and impact of the program and contextual factors which influenced program expansion. Documents included peer-reviewed journal articles, published reports, impact evaluations, government and NGO strategy and policy documents, meeting presentations, and other public and private documentation shared by stakeholders who participated in the CHW program design and implementation process. Last Mile Health also analyzed publicly available health financing, coverage and outcome data from demographic health surveys, annual government reporting and other globally recognized data sets such as the Institute for Health Metrics Evaluation, the World Bank and the WHO.
Interviews: Last Mile Health conducted semi-structured interviews with 30 key stakeholders in Ethiopia to obtain additional context regarding the evolution of the community health efforts. Findings from the literature review informed the development of interview guides. The guides included questions about the following topics: program inception, program evolution, success factors, outstanding challenges, and future vision. Furthermore, the guide was tailored to the local context as required. Interviewees were selected through purposive and snowball sampling and included current and former ministry of health leaders and regional bureau directors, leaders of professional associations, international NGO staff, as well as representatives of multilateral and bilateral institutions both in Addis Ababa and in their respective headquarters. Many of the interviewees played a leadership role in the evolution of the Health Extension Program in Ethiopia. When possible, interviews were recorded and transcribed.
Analysis: Last Mile Health’s research team analyzed the transcripts using a thematic approach and in alignment with the topical areas included in the interview guides. Findings from the interviews were supplemented with additional literature review. Using inductive reasoning, Last Mile Health explored key factors that contributed to the successful scale-up and implementation of the Ethiopia Health Extension Program. Last Mile Health followed up with many of the original interviewees to ensure accuracy of the analysis and validity of the findings.
World 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.
Primary 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.