How did Ethiopia implement?
Ethiopia began development of its community health worker program using a problem-driven approach to program design, and then tested its findings and assumptions in a rigorous, extended pilot.
- The program did not exist on the fringes of the healthcare system and instead, was embedded in the system and promoted by top political leaders as the government’s flagship health program.
- Implementation and management were decentralized with local authorities empowered with both the authority and budget to roll out the program, plan programming, conduct measurement and evaluation, and ensure quality.
A Problem-Driven Approach to Designing the Program
Ethiopia followed a problem-driven approach, developing programming precisely designed to address the most pressing health challenges specific to rural areas of the country.
Problem-driven approaches can be broken down into three steps:
Clearly diagnose specific problem
In the case of Ethiopia, the problem was not just poor health indicators. At its root, the problem stemmed from both low health-seeking behavior in rural areas, and a lack of access to health care facilities and workers. Four out of 10 Ethiopians had no access to basic primary care. Drilling down deeper, Ethiopia examined its disease burden, and saw that nearly half of all deaths in the country, such as those from malaria, diarrhea, rotavirus, and pneumonia, were preventable.
Analyze why problem exists - digging down to understand institutional dysfunctions, stakeholder interests, and other structural factors
For Ethiopia this meant recognizing the mismatch between the existing health facilities and the population. Health facilities and trained health providers were concentrated in urban centers, while the country’s population was concentrated far from those urban centers (Ethiopia is more than 80 percent rural). This was compounded by a poor road system that prevented people from accessing the care they needed.
Additionally, the health system - focusing on treatment, not prevention - had not built a network of clinics in rural areas. Further, most doctors did not want to live in remote communities. Finally, the government did not have funding to spend on training, hiring, and equipping thousands of doctors or nurses to live and work across rural Ethiopia. Those factors affected the availability of care, but there were also factors that affected the demand for care. Rural communities often opted for traditional care with local healers who were known to them, and who practiced healing in a more familiar and traditional manner. The formal health system was often difficult to access, both in terms of distance and cost, and it was often not reliable. A sick individual could make the arduous journey to an urban health center only to find the doctor unavailable, the clinic closed, or the wait for care to be interminable. Furthermore, many women simply did not know about modern birth control, the benefits of immunization, or best practices for feeding a baby, and cultural practices around the absence of care often incentivized poor health choices. For example, if a woman traveled to a city to give birth in a clinic, she would have to forgo the traditional blessing her newborn would receive if she gave birth in her home, with her community’s religious leaders in attendance. 1
Identify ways forward, including how to initiate change through incentives and policies that can help overcome identified challenges
In the case of Ethiopia, this meant bridging the gap between the health system, which largely began and ended in urban areas, and rural communities. Given the other challenges identified, Ethiopia recognized it needed to do this largely without the involvement of expensive, highly-trained doctors - which was not a huge hurdle, since the diseases that killed nearly half of Ethiopians were easily treated or prevented. Following this problem-driven approach to programing, Ethiopian officials realized that their solution needed to be relatively inexpensive and delivered by modestly-educated community members who would serve as community health workers and support the shifting of community norms.
In this way, the Health Extension Program was developed to reflected challenges and solutions specific to Ethiopia’s rural areas.
Political Commitment at the Highest Level and Across Government
Health policy reform is as much a political issue as it is a technical one.
A key element that made Ethiopia’s Heath Extension Program successful was high-level political support.
High-level political support enabled coalition-building within the Ministry of Health and across other ministries, and in federal, regional and district levels of government. It also ensured the required financing from the nation’s budget, encouraged pooled and earmarked funding from donors, facilitated the rapid scale-up of the initiative, and placed the Health Extension Program at the center of key health sector reform policies. Vocal, high-level political support also communicated a dedication that ensured accountability and regular evaluation.
The Health Extension Program’s high-level supporters included:
- Former Prime Minister Meles Zenawi, who positioned the Health Extension Program as one of his administration's flagship programs.
- Former Minister of Health Dr. Kebede Tadesse (2001-2004), who was a vocal advocate for the program.
- Dr. Tedros Adhanom Ghebreyesus, the state minister of health in the Tigray region (where the HEP was piloted), who later went on to serve as minister of health from 2005 to 2012, where he guided the national expansion of the initiative that he helped pilot. He also served as chair of the Global Fund to Fight AIDS, Tuberculosis, and Malaria, from where he also supported the initiative.
- Dr. Kesete Admasu, who championed the program during his tenures as director general of the Health Promotion and Disease Control Directorate (2007 to 2010), and as state minister for health programs (2010 to 2012) and minister of health (2012 to 2016).
“If there was no government commitment, it could not be carried out. The centerpiece is the decision at very beginning to establish it. It was made by the head of government. This has been part of the government communication even beyond health sector. The Health Extension Program is now our brand.”- Official within the current Ministry of Health, on the importance of political leadership to the Health Extension Program
These vocal, high-level champions ensured support from a wide range of ministries, regions, and levels of government. Further, other leaders within Ministry of Health, such as the chief of planning and directors of other health programs, as well as leaders of the regional health bureaus, championed the Health Extension Program for more than 20 years.
Embed the Program in the Primary Health Care Sector
Health Extension Workers connect Ethiopia's rural communities with the broader health system.
From the perspective of a rural resident, the front door of the health post, staffed by two Health Extension Workers, is the entry point to the entire federal health system.
Health Extension Workers are embedded into the health system in three key ways:
- They make and receive patient referrals
- They are supervised by health staff at local clinics
- They collect routine health information about their patients and integrate it into the federal health management information system
Even from a budgeting perspective, the Health Extension Program is fully integrated into the national health plan, budget, and reporting system, meaning there is no separate plan, budget, or report for the Health Extension Program.
The Health Extension Program serves as the base of Ethiopia’s three-tiered health care structure. Five health posts report up to one Health Center. And Health Centers report up to Zonal Hospitals, which report to specialized referral hospitals.
The primary health care unit
Ethiopia’s rapid progress in strengthening its primary health care system was in large part due to its ability to attract external resources and manage donors effectively, channeling their investments and expertise to support the country’s flagship program.
The government accomplished this, in part, by communicating to donors a few key messages. These included:
- Ethiopia’s mantra was: “one plan, one budget, one report.” The government developed the plan, created the budget, and issued regular progress reports. This was a government-led, donor-supported program.
- The government would not accommodate donor’s vertical, disease-focused approach. Faced with the systemic failure of the health system, its goal was to develop and implement holistic programming in a systemic manner.
- The government performed a huge amount of research and testing, and led the development of the program. Donors were welcome to add their expertise to the growing consensus.
- The government included donors and NGOs in annual assessments. They were invited to review country data and engage with the government and other partners in meaningful discussions about adapting the program to increase impact and improve performance.
Perhaps the most daunting challenge in donor relations was breaking through the normal funding silos donors often work within. In this regard, Ethiopia had a valuable ally in Tedros Adhanom Ghebreyesus, the visionary regional bureau head for Tigray, who piloted the program and then became state minister of health in 2003, Ethiopia’s minister of health from 2005 to 2012, and then chair of the Global Fund to Fight AIDS, Tuberculosis and Malaria, from 2009 to 2011. Under his leadership, not surprisingly, the fund bought into Ethiopia’s vision and became one of the largest contributors to the program.
Other donors were initially skeptical of the Health Extension Program and HEWs’ ability to provide quality, meaningful services that could move the needle on the greatest health burdens facing Ethiopia.
“The government was not open to [development] partners during the design of [the Health Extension Program]. Once they came up with the program, we were asked to support [it]… most [development] partners, we had concerns. We did not think it would be a success.”- NGO research participant
The donors were quickly proved wrong. And they came on board once they recognized the government’s commitment to the program and witnessed the program’s quick roll out.
As donor interest and involvement increased, the government of Ethiopia took steps to coordinate spending and policy discussions and reduce reporting requirements.
In 2005, the government developed the Code of Conduct to Promote Harmonization in the Health Sector, with signatories that included the African Development Bank, United Nations agencies, the World Bank, DFID, and USAID. The Code coordinated donor engagement, reduced administrative transaction costs and channeled the majority of donor support toward one plan: Ethiopia’s Health Sector Development Program - III, of which the Health Extension Program was a key part.
In 2007, the government developed a Health Sector Development Plan (HSDP) Harmonization Manual. The manual helped the health sector at the woreda, zonal, regional and federal levels, as well as NGOs and other stakeholders manage donors’ requirements. The manual created absolute clarity for all actors to understand timelines, roles and responsibilities, as well as coordination structures for implementing national planning, reporting and budgeting cycles.
The manual established the Annual Review Meeting - a joint event bringing together representatives from federal and regional government agencies, selected woreda health offices, development partners, NGOs, professional associations, universities, the private sector and local and international consultants. The meeting is used to review progress, examine new evidence and data, and to plan for the coming year. Donors can also take advantage of the gatherings to assess and influence the national health policy process and planning for the Health Extension Program. Minutes of an Annual Review meeting can be found here. [add link]
The government also used pooled funding, which combined contributions from a variety of donors, to provide more flexibility in spending the money and reduce administrative burden and transaction costs of donor funding. From 2006 to 2010, the Health Extension Program and the Accelerated Expansion of Primary Healthcare received more than $180 million from pooled funds.
In 2008, Ethiopia become one of the first developing countries to sign on to the International Health Partnership Plus (IHP+) Compact. This formalized the path that Ethiopia had already set out, to align agendas of donor countries with aid recipients.
OVERVIEW OF HEALTH FINANCE CHANNELS
Ministry of Finance
Ministry of Health
Outside of GoE Oversight
|Percentage of health funding||
Promoting Basic Services
M/SDG Performance Fund
A Structured Pilot Period
Ethiopia’s success with developing, implementing, and refining one of the largest community health worker programs in the world has its roots in the lessons it learned during a half century of community health worker programming and pilots.
Ethiopia had long realized its future would be defined by poverty and hunger unless it could unleash the potential of rural communities. Community health worker programs appeared to be one critical tool towards that end.
Ethiopia’s first experience with community health workers was back in the 1950s, when traditional birth attendants and health assistants at rural clinics engaged communities during outbreaks, vaccination campaigns, and in school health programs. The CHWs in this early program, however, were not appropriately resourced and lacked effective community participation. The community did not select health workers, did not have a role in informing what health workers focused on, and did not monitor their performance.
During the Derg military regime in the 1980s, 5,000 CHWs selected by their communities to receive three months of basic health training, worked part-time promoting immunization for pregnant mothers and children under two, providing general health education, mobilizing people to use health facilities, and addressing childhood mortality through distributing ORS, antibiotics, and fighting malaria. Pay varied, as did their dedication. A study found that only between 30 and 62 percent of them were actively serving their community. They reported being demotivated by the absence of supervision, training, and remuneration.2
During the Ethiopian Civil War (1974 to 1991), the Tigray People's Liberation Front established a primary health care system in Tigray in which community residents helped plan and implement health services with health committees and CHWs. The CHWs in this program were trained in and provided a basket of services that included maternal and childcare, nutrition, environmental sanitation, safe water, and the control and treatment of epidemic diseases and malaria. CHWs were managed by district health department staff, who visited CHWs every three months. When available, chloroquine, paracetamol/acetaminophen, and bandages were distributed to CHWs.3
In the 1990s, NGOs introduced several CHW programs that relied on volunteer staff. At one point, 25 different NGOs had implemented and were managing 25 different CHW programs, each with different or overlapping foci, such as malaria, TB, trachoma, or child survival. With inconsistent training and focus, these programs could not be relied upon by communities for the broad primary care they needed. Furthermore, the programs could not be sustained after NGO funding or interest ended.
During this same time period, again in Tigray, a community-based malaria control program was launched, building on the strengths of the previous CHW program during the war, and incorporating grassroots participation and supervision. Community members and district and regional health staff participated in electing CHWs, in implementing program activities, in regular and systematic supervision, and in evaluating CHW and program performance.3 The primary objectives of this program were to reduce malaria morbidity and mortality and protect pregnant women from malaria through early diagnosis and treatment.
In 1998, Tigray authorities began to adapt and expand this program both geographically and beyond the prevention and treatment of malaria. Over the next four years they tested various approaches and staffing arrangements, such as training CHWs to the level of junior nurses, while expanding the program to eventually cover the entire region of Tigray, with its population of five million. They developed guidelines and protocols and, given Ethiopia’s decentralized approach, made a point of sharing their learnings often within the region and across the country. This proved prescient.
While Tigray was getting excellent results from its community-based approach, Ethiopia was beginning to confront the failure of its national health system. In 2001, Ethiopia conducted a mid-term evaluation of its Health Sector Development Program launched in 1997. The program had set forward health development targets to be met by 2002.4 And, just as importantly, it had specified a rigorous monitoring schedule that forced reassessments of progress, strategies, and tactics every two to three years. The national 2001 mid-term evaluation revealed not only that Ethiopia was off track to meet its targets, but also that if it continued following its existing approach, it was unlikely to achieve any of its targets.
“When that was evaluated in 2001… most of the targets were not met... and when the analysis was done, it was because of structural challenges of the health system. So most of the health facilities the country had were concentrated in the urban areas. I think, at the time, there were like 300 or 400 health centers which were primarily based in urban areas while 85 percent of the population lived in rural areas.”- Former senior ministry of health official
Officials recognized the urgent need to try a different approach.
SELECTED HSDP I (1996-2004) TARGETS AND PROGRESS IN 2002
|INDICATOR||ASSESSMENT||BASELINE (1997)||TARGET (2002)||RESULT (2002)|
Maternal Mortality Rate
DID NOT MEET
Infant Mortality Rate
|DID NOT MEET
|Contraceptive Prevalence Rate||DID NOT MEET
|Immunization Coverage (DPT3)||DID NOT MEET
|Primary Health Service Coverage
||DID NOT MEET||45%||55-60%||52%|
|Skilled Birth Attendance Rate||MARGINAL INCREASE||9%||N/A
|ANC Coverage||MARGINAL INCREASE||28%||N/A||34%|
|HIV Adult Prevalence
|Doctor-Population Ratio||WORSE OUTCOME
|Outpatient Visits/PP/PPT||WORSE OUTCOME
This opened a window of opportunity for the Tigray pilot project. Tigray officials had been proactively sharing their learnings and progress. During a regional workshop in 2001, district leadership and senior staff shared their progress and developed guidelines and a manual for the Health Extension Program. This manual provided a framework for the regional expansion of the program. A national workshop organized by the Ministry of Health in 2002 to discuss the Tigray pilot further helped build political and technical support.5 This buy-in for the Tigray pilot project positioned it as a natural solution to Ethiopia’s pressing health delivery challenges.
In 2003, The Federal Government determined to move forward with further adapting and scaling the Tigray pilot project nationally.
The heavily consultative pilot period helped create a CHW model that was ready for national implementation, with flexibility built in to respond to local context. Specifically, the pilot period helped build political support by:
- Allowing for engagement with critical leaders within the federal government, regional governments, and regional health officials.
- Allowing time to demonstrate impact through monitoring.
- Allowing time for the development of guidelines that helped officials better understand how the program would be implemented.
The federal government moved forward guided by key lessons from the country’s experiences with CHW programs:
- The CHWs should be paid and provided with standardized and significant training for services that provide the highest return on investment.
- The CHWs should be incorporated into the broader health system to provide opportunity for referrals of patients whose needs exceed CHWs’ skills. Incorporating the CHWs into the health sector also allows for formal supervision of CHWs by trained health staff such as nurses.
- The CHWs should be government employees to standardize training, treatment, and reduce duplication of efforts and gaps in coverage.
- The program should be responsive to the community.
Engage Non-Health Institutions in Scale Up
To expedite implementation and clearly establish the initiative as a national imperative that every government official needed to be working towards and supporting, Ethiopia designed a program that built on existing institutions and delivery mechanisms across federal ministries.
The Federal Ministry of Health worked with the Ministries of Education, Finance and Economic Development, Public Works, and Urban Development to help roll out and expand the HEP. The Ministry of Education provided technical and vocational educational training and resources, including teachers, to train the Health Extension Workers (HEWs). And the Ministry of Public Works and Urban Development’s subnational offices facilitated the construction of health centers and health posts by providing contractors and supervision and ensuring the quality of the construction. The Ministry of Finance and Economic Development engaged the HEWs as civil servants and paid their salaries from block grants transferred to the regions and woredas.
Build Sub-National Government Ownership and Responsibility
In Ethiopia’s decentralized system, a large part of the responsibility for planning, designing, implementing, funding, managing, monitoring, and reporting on the Health Extension Program falls to regional and local authorities.
Again, by spreading responsibility for the Health Extension Program to multiple levels of the government, the program was seen as every official’s responsibility.
Local governments, as the entities that pay Health Extension Workers, have built in leverage to ensure that the HEWs are responsive. This allows local authorities to ensure that HEWs work with them to collaboratively develop village-level health and hygiene plans. Finally, once appointed, HEWs sit on the Kebele (local) Council, making the program a key part of local government.
“The goal was to put knowledge and power - and, ultimately, responsibility - in the hands of local people.”- Kesete Admasu former Ethiopia Minister of Health.1
Remuneration and Profile of HEWs
Government guidelines specify that Health Extension Workers (HEWs) should be
- Paid and full-time employees
- Residents of the community they serve
- Between the age of 18 and 30, with a minimum 10th-grade education
- Selected by their community
Paid and full-time employees
Informed by earlier CHW efforts in Ethiopia, the regional pilot in Tigray, the agricultural extension program, and insights from CHWs in other countries, the government concluded that HEWs would be salaried workers integrated into the health system. Given the costs of adding a large number of healthcare workers to the wage bill, Ethiopia decided to train and employ versatile community health agents instead of nurses or even junior nurses (who were used in the Tigray CHW pilot). Task-shifting to a cadre with lower salaries and a less sophisticated skill set increased the prospect of scaling up the HEP with reduced training and remuneration costs. HEWs are paid a monthly salary that, over the course of the program's evolution, has ranged between $90-120 per month.
Estimates of how much the government of Ethiopia spends on salaries for HEWs differ, although one study from 2012 estimates an expenditure of $13.6 million per year, or about 21 percent of recurrent government health expenditures and 32 percent of woreda-level recurrent expenditures (although this varies between woredas).6 Another study from 2017 suggests the government of Ethiopia spends around $31.7 million per year on HEW salaries.
Mandating HEWs work as full-time employees ensured they dedicated their days to serving their communities with limited competing interests.
Local and international experience indicated women health care workers are often more acceptable and approachable to local communities than their male counterparts.
The decision to hire women as CHWs also reflects the government’s expectation that most patients would be women and children, and that female HEWs would be most accessible and responsive to them.
Lastly, using women community health workers also serves to promote women’s empowerment by providing gainful employment of women as civil servants and by recognizing women as decision makers for health-related concerns within their families.7
Selected by their community
Representatives from community associations and members of local government select HEWs - a system designed to ensure the chosen person is acceptable, respected, and responsive to the community. This also positions the HEW as someone of importance selected by local leaders. HEWs' roots in the community they serve ensures they are familiar with the culture, language, and traditions of their clients, and are aware of any community dynamics. HEWs can then leverage community trust to promoted improved health behavior.
Research shows that CHWs’ relationships with the community are strong when CHWs themselves are selected from and by their communities.8 The nature of the CHWs' work - promoting improved health at the household and community level - makes good relations with the community critical for impact.
HEWs must be between age 18 and 30, and must have at least a 10th-grade education, though in the more deprived pastoralist areas, only an eighth-grade education is required, since there are simply not enough women with a 10th-grade education in these communities.9
HEP PROGRAM CHARACTERISTICS TABLE
|CHARACTERISTICS||HEALTH EXTENSION WORKER (HEWs)|
|Roles + Responsibilities
Continuously Adapt the Program
While many programs are monitored and refined as necessary to improve impact, Ethiopia’s Health Extension Program is unusual in that the government established multiple monitoring mechanisms functioning at various levels, from the family level to the village level on up, and used timetables for sharing data, with the expectation that this feedback would ensure opportunities for continuous improvement.
At the family level, every HEW tracks all treatments provided to every one of the 2,500 people (500 families) they serve. The information is sorted by family and by village, and includes pregnancy due dates, use of family planning services, or immunization status, along with household information, such as whether the household has access to safe drinking water or a latrine. This information is shared with the kebele council (local government), and with the woreda health office, and with the team supervising the HEW. The information is then used to make local government planning decisions, adjust health and non-health specific programming, and review performance and impact.
If one of the 2,500 people a HEW serves does not come to the health post for care at least every two months, the HEW is tasked with visiting the individual at their home.
In addition to the data generated by frontline staff, the program also collects and reviews data on procurement, staffing, supplies, etc.
SPOTLIGHT ON MONITORING AND EVALUATION - OVERVIEW
Family Folder System
Health Extension Worker Reporting, Monitoring and Evaluation
HEWs collect information using standardized reporting formats and share it with the kebele council and woreda health office
|One Plan, One Budget, One Report
|National Level Health Sector Monitoring and Evaluation
The data is analyzed during regular assessments and shared with government officials, experts, and external partners to inform discussions about opportunities for improvement.
These discussions occur concurrently at multiple levels.
At the federal level, the central joint steering committee, the joint core coordinating committee, the ministry of health development partners joint consultative meeting, and the annual review meeting serve as a forum for robust debate and discussion of the data.
At the regional level, there is the regional joint steering committee with the participation of the ministry of health and regional health bureaus.
At the woreda level there are joint steering committees. And lastly, at the kebele level, there are also meetings.
Program modifications are adopted after extensive evaluation and consultation in collaboration with development partners. Domestic and global evidence is considered, and if need be, officials visit other community health worker programs in other geographies to consider real-world evidence.
Examples of data-driven modifications include:
- The expansion of HEW training, based on evidence that HEWs were ill-equipped to meet community needs
- The introduction of pneumonia treatment in 2009, based on the successful introduction of malaria and diarrhea treatment and emerging international and domestic evidence that CHWs could effectively treat pneumonia
It is important to recognize that the Health Development Army and HEWs not only disseminate information to their communities, but they also listen to community members and ensure the health system adapts to social norms. For example, when women refused to go to hospitals to give birth, HEWs and HDAs learned mothers wanted their religious leaders present to bless their newborns, as was the custom during home births. HEWs and HDAs communicated this up the chain of command and prompted a policy change, allowing religious leaders to attend births in health centers.
Former Ethiopian Minister of Health Kesete Admasu shared another example: women in labor did not want to be carried on a stretcher, because stretchers were associated with death. Often, people who left their village on one, never returned. In response, the government, “designed a new stretcher just for pregnant women. We opened maternity waiting homes where women in their third trimester can stay close to the facility while they wait to go into labor. These were problems and solutions we’d never thought of, but the Women’s Development Army opened our eyes to the community’s needs.”
- 1Kesete Admasu in Maternal Mortality: Ethiopia, Goalkeepers 2017, https://datareport.goalkeepers.org/case-studies/maternal-mortality-ethiopia.
- 2Kloos, Helmut. Primary Health Care in Ethiopia Under Three Political Systems: Community Participation in A War-torn Society. Social Science and Medicine. Vol 46 Nos 4-5, 1998.
- 3Ghebreyesus, T.A., TEDROS 1996 piece on malaria control.
- 4Federal Ministry of Health. 2002 Health Sector Development Programme II (2002/03-2004/05) Addis Ababa.
- 5Gebrehiwot, T, Miguel San Sebastien, Kerstin, Edin, and Isabel Goicolea. The Health Extension Program and its Association with Change in the Utilization of Selected Maternal Health Services in Tigray Region, Ethiopia: A Segmented Linear Regression Analysis. PLOS One. 10(7) 2015
- 6Abt Associates. Health Systems 20/20: Health Extension Program: An Innovative Solution to Public Health Challenges of Ethiopia, 2012, accessed 17 December 2018, https://www.hfgproject.org/health-extension-program-innovative-solution-public-health-challenges-ethiopia-case-study/
- 7Teklehaimanot HD, Teklehaimanot A. Human resource development for a community-based health extension program: a case study from Ethiopia. Human resources for health 2013; 11(1):39.
- 8Amouzou A, Hazel E, Shaw B, et al. Effects of the integrated Community Case Management of Childhood Illness Strategy on Child Mortality in Ethiopia: A Cluster Randomized Trial. Am J Trop Med Hyg. 2016;94(3):596–604. doi:10.4269/ajtmh.15-0586
- 9Henry B. Perry, MD, PhD, MPH, with Loriade Akin-Olugbade, Aliza Lailari, and Yeri Son. A Comprehensive Description of Three National Community Health Worker Programs and Their Contributions to Maternal and Child Health and Primary Health Care: Case Studies from Latin America (Brazil), Africa (Ethiopia), and Asia (Nepal), 2016, http://www.chwcentral.org/sites/default/files/Perry-CHW%20Programs%20in%20Brazil%2C%20Ethiopia%20and%20Nepal-2016.pdf.