Ethiopia has embedded its community health worker program in the broader health system.

  •  Programming includes both curative care and preventive care.
  • 40,000 professional Health Extension Workers, supported by another 3 million part-time volunteers, work in their communities to change norms and improve health. 

In 2004, Ethiopia launched an unprecedented pair of initiatives to improve its dismal health indicators.

First, the government drastically increased the number of health centers across the country with the Accelerated Expansion of Primary Health Care Coverage.

Second, recognizing that even with this expansion, the government still did not have the physical and human infrastructure to meet demand for healthcare, it expanded the footprint of this brick and mortar network by training 30,000 villagers (40,000 by 2015) to work in the 15,000 (16,000 by 2015) newly established health posts as Health Extension Workers. Two Health Extension Workers were assigned to work in each Health Post, a modest structure erected by the community with government support. The pair of Health Extension Workers (HEWs) in each Health Post served 3,000-5,000 residents.1

These Health Extension Workers functioned as the lowest level of the formal national health system and were Ethiopia’s bold attempt to provide its citizens, no matter where they lived, with primary health care. It is important to realize that these workers didn’t just sit in the health post waiting for, and treating, patients. In fact, they were expected to spend about 75 percent of their time out in the community initially, though this changed over time. Much of the HEWs’ work outside their health post involves visiting families in their homes to create demand for healthcare in communities that have been accustomed to functioning without it. In the early days of the program, this involved educating communities about good health and hygiene practices that prevent illness, like exclusive breastfeeding. As demand for healthcare increased, some of the behavior change communication work shifted from Health Extension Workers to part-time volunteer members of the Health Development Army.

A Health Extension Worker visits a mother and baby in their home in Ethiopia.
A Health Extension Worker visits a mother and baby in their home. The HEW program is part of Ethiopia’s attempt to provide citizens with health care, no matter where they live.
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A 2017 study found that Ethiopia’s simultaneous combination of investments in primary health care facilities and low-level, community-based staff was critical to the success of its health sector and, ultimately, to achieving the health-related MDGs.2

There are a number of programmatic elements that made the Health Extension Program particularly impactful in the Ethiopian context. We discuss each in this section:

Health Extension Worker Profile and Training

Global and domestic research informed Ethiopia’s standards for the profile and training of Health Extension Workers (HEWs). All HEWs are female, because villagers view women healthcare workers as more acceptable and approachable than male healthcare workers. HEWs have at least a tenth-grade education and live in the communities they serve. Once selected by their fellow villagers, HEWs receive one year of full-time training in a Ministry of Education technical and vocational training school before they begin work in their local health post. As full-time government employees, they receive a monthly salary of up to $120.3

At the introduction of the Health Extension Program, HEWs received primarily classroom-based training and emerged with limited practical skills. An independent 2007 evaluation identified shortcomings in the performance of HEWs and recommended they receive more frequent practical training and regular supportive supervision focused on improving their clinical competencies. Another 2007 independent evaluation found that 78 percent of HEWs felt the types of duties and responsibilities they were expected to perform required more training than they had received.4

Initially, NGOs jumped in to fill these gaps by offering in-service training programs. These uncoordinated efforts resulted in redundancies in training, skill gaps, and a disruption of the delivery of care.

How the Ethiopian government handled this problem is another example of their adept coordination of donors and other development partners. The government restricted NGOs from providing direct training to HEWs, but convened partners to develop an in-service integrated refresher training (IRT) curriculum in 2009. What emerged was a 30-day training module that improves HEW's knowledge of the basic service package, updating them on new service elements.

“Before IRT was introduced, every NGO program developed their own training materials. For every training, HEWs were called to attend… as many as 15 trainings a year, some for five days; almost one-third to fifty percent of the HEWs’ time was spent to come for training in cities…”

- Research participant from the NGO sector

Now, HEWs are eligible to take additional integrated refresher trainings that last 15-30 days, every two years. A study found that from 2011-2014, more than 80 percent of HEWs had completed IRTs in the management of possible severe bacterial infection, iCCM and maternal, newborn, and child health, while a smaller percentage had received re-training on other topics.3 However, quality of care remains a pressure point for the program. 

“…the awareness of the community is increasing. Educated young people… seek more services, quality services… in some areas, the awareness of the community is greater than the HEW’s. There is a need to upgrade the HEW to nurses (Level IV). The demand from the community is very challenging and rapidly evolving.”

-  Multilateral development partner

To address this, and offer HEWs opportunities for career advancement, the government is further expanding training available for HEWs. HEWs interested in expanding the services they offer can enroll in a second year-long training program focused on providing more sophisticated curative services. As of 2017, nearly 30,000 HEWs had completed the additional training.5 The Ministry of Health has set the goal of upgrading a total of 35,000 HEWs.6 These more highly trained HEWs earn a higher wage. They are called level IV HEWs, while regular HEWs are known as level III HEWs.

Health Extension Workers, like this young worker preparing to measure the weight of a six-month-old baby, live in the communities they serve. 
©Gates Archive

Basket of Services

Complete Health Extension Program Service Package

Service Packages Specific Activities Preventative/Curative

Hygiene and Environmental Sanitation

Building and maintaining a healthful house PREVENTATIVE
Construction, usage and maintenance of sanitary latrines  PREVENTATIVE
Control of insects, rodents and other biting species PREVENTATIVE
Food, hygiene and safety measures PREVENTATIVE
Personal hygiene PREVENTATIVE
Solid and liquid waste management PREVENTATIVE
Water supply safety measures PREVENTATIVE
Service Packages Specific Activities Preventative/Curative

Family Planning

Education and access to contraceptives (e.g. pills, condoms, injectables, IUDs and implants) PREVENTATIVE

Maternal Health

Early identification of pregnant women PREVENTATIVE
ANC exam and information for pregnant women PREVENTATIVE
Home visits and referrals for pregnant women with health problems CURATIVE
Postnatal care services for lactating mothers on infant care, nutrition and breastfeeding PREVENTATIVE
HIV counselling and testing for lactating mothers and their partners PREVENTATIVE
Maternal death surveillance and response PREVENTATIVE
Fistula detection PREVENTATIVE
Uterine prolapse detection PREVENTATIVE
Distribution of misoprostol for mothers to take at home after delivery to reduce the risk of post-partum hemorrhage PREVENTATIVE

Newborn Care

Care for healthy newborns PREVENTATIVE
Care for sick newborns CURATIVE
Health education on newborn care CURATIVE
Tetanus Toxoid (TT) vaccination PREVENTATIVE

Child Care

Care for sick child: Fever CURATIVE
Care for sick child: Diarrhea CURATIVE
Care for sick children: Malnutrition CURATIVE
Care for sick children: Cough CURATIVE
Care for sick child: Referral for seriously sick children PREVENTATIVE
Child vaccination PREVENTATIVE
Health education on child care PREVENTATIVE


Mother, Infant, and young child nutrition services PREVENTATIVE
Growth, monitoring and promotion PREVENTATIVE
Service Packages Specific Activities Preventative/Curative

HIV/AIDS and Tuberculosis Prevention and Control

HIV/AIDS - Condom distribution PREVENTATIVE

Maternal Health

Health education on HIV/AIDS and other STIs PREVENTATIVE
Voluntary counselling and testing PREVENTATIVE
Post exposure prophylaxis PREVENTATIVE
TB case detection PREVENTATIVE
Multi drug resistant TB suspect identification and referral PREVENTATIVE
TB DOTs giving medicines CURATIVE
TB DOTs defaulter tracing CURATIVE

Malaria Prevention and Control

ITN distributions PREVENTATIVE
IRS campaign/prophylaxis for high-risk groups PREVENTATIVE
Vector breeding site identification/environmental management PREVENTATIVE
Malaria test and/or treatment (>5 years) PREVENTATIVE
Health education on malaria PREVENTATIVE

First Aid

First aid - Delivery CURATIVE
First aid - Referrals CURATIVE
First aid - Health education PREVENTATIVE
Non-communicable Diseases Cardio vascular disease, hypertension, diabetes, asthma, cancer, other NCDs health education PREVENTATIVE
Cardio vascular disease, hypertension, diabetes, asthma, cancer, other NCDs screening and referral CURATIVE
Cardio vascular disease, hypertension, diabetes, asthma, cancer, other NCDs surveillance PREVENTATIVE
Neglected Tropical Diseases Neglected Tropical Disease prevention and control PREVENTATIVE

Mental health

Counselling, screening, referral, surveillance for mental health PREVENTATIVE
Service for drug/substance abuse CURATIVE
Service Packages Specific Activities Preventative/Curative

Health education and communication

Collect vital elements and surveillance data; Prepare and submit reports PREVENTATIVE
Determine health needs, conduct advocacy and promote community mobilization on identified health needs PREVENTATIVE
Train model families PREVENTATIVE

At the outset of the Health Extension Program, Health Extension Workers (HEWs) were tasked with a package of 16 preventive services - all of them drug-free.7 In addition to guarding against any possible misuse of antibiotics, the initial focus on drug-free prevention minimized program costs - critical for Ethiopia’s economy, still struggling at the time. Each preventive service was a response to a major disease that remained unchecked in rural communities, demonstrating Ethiopia’s problem-driven approach to program design.



Proper and safe excreta disposal system

Proper and safe solid and liquid waste management

Water supply safety measures

Food hygiene and safety measures

Healthy home environment

Arthropods and rodent control

Personal hygiene

HIV/AIDS prevention and control

TG prevention and control

Malaria prevention and control

First Aid

Maternal and child health

Family planning


Adolescent reproductive health


Data source for table: Bilal, 2014; Wang, 2016; Perry, 2016; Perry, 2017; USAID, 2017; Ramana and Workie, 2014; El-Saharty, 2009

Within a few years of launch, domestic and international research and pilot testing proved HEWs could safely provide curative services, including first-line antibiotics. At the same time, donors gained confidence in the program and began to support it. With this new research, increased funding from donors, and an increasingly robust economy, Ethiopia decided to expand the basket of services to include key curative services that more precisely mirrored rural Ethiopia’s disease burden. HEWs began treating the leading causes of preventable deaths across rural Ethiopia: malaria, pneumonia, diarrhea, severe acute malnutrition, HIV (with PEP), and TB (with DOTS).

Later, community-based newborn care, which includes antenatal and postnatal visits to identify and treat sepsis, and long-acting contraceptives were added to HEWs' services.8 The final basket of services provided by HEWs is another example of Ethiopia’s problem-driven approach to program design.

The inclusion of these curative and more sophisticated services has increased the complexity of HEWs' tasks. Not surprisingly, as their responsibilities multiplied, HEWs began reporting feeling overburdened. Experts worried the system was overtaxed and might begin to fray. The government responded by adding powerful new allies for HEWs: model families and the Health Development Army.

Model Families and the Health Development Army

In 2006, the government of Ethiopia magnified the reach of the Health Extension Program by adding a new element: model families.

This concept was based on an earlier Ethiopian Agricultural Extension Worker Program, which trained locally elected farmers (two per village) as agricultural development agents.9 Selected farmers worked in their communities to model improved agricultural practices and provide training on modern farming methods, such as the use of fertilizers, and improved seeds.10 The program improved agricultural production, increased food security, and sparked sustainable economic growth that many see as the foundation of Ethiopia’s current robust economy.

The agriculture program was influential because of its unique theory of change, based in part on the premise that farmers, just by publicly modeling best practices, would influence the behavior of their neighbors. This approach of training villagers to actively model best practices to their peers was adapted to inform the development of the “model family” in the Health Extension program.

Volunteer model families have become a critical part of the Health Extension Program. They receive 96 hours of training in healthy practices such as exclusive breastfeeding of newborns, and in themes like the importance of immunizations.11 Their main task is to serve as positive outliers in their community. These early adopters of best hygiene and health practices encourage their neighbors to follow and as a result, slowly change their community’s norms for the better. The scale of this program is important to appreciate. As of 2011, nearly 70 percent of all households across the entire country have received model family training.

In 2011, as HEWs’ responsibilities proliferated and surveys showed the need for further modifications in how they worked, the government of Ethiopia added yet another layer of support for HEWs: the Health Development Army. These three million volunteers, who have gone through the Model Family training, provide a more formal mechanism for influencing behaviors. The Health Development Army engages groups of households in their communities to engage in weekly meetings to discuss issues related to children’s health, hygiene, nutrition, antenatal care and maternal health.12 They also support HEWs with lower-level tasks, immunization campaigns, community mobilization, managing appointments, household visits, and record keeping.7 Included in the Army were previously existing but uncoordinated reproductive and family planning volunteers. The Health Development Army works with large numbers of Ethiopian households - nearly one in six - within the Health Extension Program’s scope.

Health Development Army members meet at the Germana Gale Health Post in Ethiopia.
Health Development Army members meet at the Germana Gale Health Post.
©Gates Archive




~40,000 (2017)

~3,000,000 (2017)


  • 1 HEW: 2,500 people. 2 HEW: Health Post. 1 Health Post: 5,000 people.
  • 1 women’s development group (WDG) = 5 one-five networks. Each one-five network includes a leader who is defined as the health development army volunteer. One of these leaders also leads the WDG.
  • 1 health development army volunteer: 25 people.
  • Female, secondary school graduates (10th grade), 18-30 years old, knowledge of the local language and willingness to remain in the village and serve the community.
  • Pastoralist program allows men and those with a 6th to 8th grade education to serve.
  • Trained as a model family which includes maternal health, malaria prevention and control, and hygiene and environmental sanitation service packages; able to implement these packages after the training; and able to influence their relatives and neighbors to adopt the same practices.
  • Selection is conducted by a committee comprising members nominated by the local community and representatives from the woreda (district) health office, the woreda capacity building office, and the woreda education office. 
  • Selection is conducted by women’s development group and one-five network members with input from the Kebele village council. 
  • Pre-service: 1 year of training and completion of a competency exam delivered at technical vocational education centers or health science colleges with practical training at health centers (1,632 hours of classroom-based learning and 320 hours of internship/practical experience).
  • In-service: 15-30 days of integrated refresher training every 2 years (See training curriculum table for additional information). 
  • 96 hours of training which emphasizes high-impact maternal and newborn health services.
  • The training is facilitated by HEWs with support from woreda health offices.
Services Offered
  • Delivery of 16 health packages across four program areas which include: Hygiene and environmental sanitation; disease prevention and control; family health services and health education and communication (See service package table for additional information).
  • Community mobilization
  • Health promotion
Roles + Responsibilities
  • Full time - Generally work 6+ hours per day.
  • Spend 50% (25% before introduction of HDAV) time at health post and 50% time at household.
  • At health post, manage operations and deliver basic curative services.
  • At household level, in collaboration with HDA volunteers ,conduct home visits and outreach to provide preventive and promotive services and mobilize demand for primary health care services.
  • Provide referral services to Health Centers and follow up on referrals.
  • Identify, train and collaborate with health development army volunteers for household outreach.
  • Provide progress reports to the health center.
  • Attend meetings with PHCU team and Kebele village council.
  • Part time- Generally work a 3-5 hours per week.
  • Establish and lead a one-to-five network or WDG.
  • Monitor the implementation of the local health development army plan developed with HEWs.
  • In collaboration with HEWs, disseminate health messages to peers to encourage adoption of healthy behaviors.
  • Gather status report on the one-to-five networks every two weeks. Analyze data and identify bottlenecks and solutions; share best practices among the network members as well as with others.
  • Enable HEWs to spend more time at the health post.
  • HEWs are salaried government civil servants. Monthly salaries have varied from $90-120 per month as the program has evolved. HEWs also may receive formal social recognition, opportunities for career advancement, and benefits such as annual leave. In some areas, community members and local government actors build residences for HEWs.
  • Community recognition.
  • In-kind gifts from community members.
  • In some areas, HDAVs also perform activities that enable them to earn a small profit. 
  • This PHCU team meets monthly with the HEWs at the health center.
  • PHCU team includes: a Health Officer, a Public Health Nurse, an Environmental/Hygiene Specialist, and a Health Education Specialist.
  • One of these team members (primarily Health Officer) supervises approximately 10 HEWs each.
  • WDG leaders are supervised by HEWs with accountability to Kebele village council.
  • One-five network leaders are supervised by the leaders of the WDG.
  • The Kebele village council creates a coordinating body, which draws representatives from many different groups such as women, agricultural and schools. This group monitors implementation of the health development army activities.
Data source for table: Bilal, 2014; Wang, 2016; Perry, 2016; Perry, 2017; USAID, 2017; Ramana and Workie, 2014; El-Saharty, 2009

Integration into the Formal Health System

Researchers who systematically reviewed four large community health worker programs in Ethiopia, Brazil, India, and Pakistan, found that Ethiopia’s program was the most thoroughly integrated into the wider health system, benefitting greatly from that integration.13

To understand how Ethiopia’s Health Extension Program is embedded within the larger primary health care system, it is helpful to understand the structure of Ethiopia’s health system.

Ethiopia has a three-tiered health care structure. At the bottom are the health posts staffed by two HEWs. Five health posts report up to one health center. The chain of command rolls up through this basic primary health care unit of five health posts and one health center, through to zonal hospitals, and all the way up to specialized referral hospitals.

Health Extension Workers are the closest to the ground, and are the most widely distributed and accessible part of Ethiopia’s health system. They serve as the key that connects Ethiopia’s rural communities with the broader health system meant to serve them.

Two Health Extension Workers confer at the Germana Gale Health Post. Training and supervision within the program has been central to its integration into the health system.
©Gates Archive

The primary health care unit

HEWs are embedded into the health system in three key ways: they make and receive patient referrals, they are supervised by health staff at local centers, and the routine health information they collect about their patients is integrated into the federal health management information system. This improves patient care and outcomes.

But it would be a mistake to think of them as purely Ministry of Health staff. They are also members of the village council. The layers of supervision HEWs receive reflect their position as critical connectors between communities and the health system. Initially HEWs were supervised by village councils (who help run communities) and district health administrators. Later, yet another level of supervision was added: a team at the nearest primary health care center. This clinical support was added to improve HEWs’ motivation and patient care. HEWs’ clinical supervisory teams include a health officer (who serves as the main point of contact), a public health nurse, an environmental/hygiene specialist and a health education specialist.

This change strengthened HEWs' connections to the wider health system and improved rates of supervision and quality of care. The percentage of HEWs who had been supervised at least once a month increased from 50 percent in 2007 to 96 percent in 2010. The percentage of HEWs who knew how to detect disease and manage complications related to pregnancy increased from 40 percent to 52 percent in the same period. And the percentage of community member respondents who reported that all or most of their needs were being addressed by HEWs increased from 44 percent in 2007 to 61 percent in 2010.3 


Data source for table: HEP National Impact Evaluations: Summary Performance Data Table
Weighted average of Amhara, Oromia and SNNPR regions

Health Post: Service Provision

Percent of health posts staffed with at least two HEWs per the standard 64% 81% 26%
Percent of health posts opened at least five days per week 27% 52% 96%
Health Post: Productivity
Average number of new family planning clients
73 167 129%
Average number of new clients who received antenatal care services
87 129%
Number of new clients attending postpartum care
59 437%
Number of 1 year children immunized against measles
38 117 207%
Health Post: Referrals
Percent of HPs that referred obstetric patients in the year preceding the survey  60% 77% 28%
HEW: Work Planning
Percent of HEWs who have a work plan for their activities  57% 78% 37%
HEW: Training
Percent of HEWs who participated in refresher training attended in the last one year preceding the survey  50% 60% 20%
HEW: Supervision
Percent of HEWs who received regular written feedback during their supervision visit  19% 49% 152%
Percent of HEWs who were supervised at least once in the last three months
78% 30%
Percent of HEWs who were supervised at least once a month
96% 92%
HEW: Competency
Percent of Hews who know how to detect disease and manage complications related to pregnancy  40%
52% 31%
Percent of Hews who new correct actions with obstructed labor
80% 90% 13%
Percent of HEWs with knowledge on counseling for family planning - all methods
60% 76% 27%
Community Perception
Percent of community member respondents who reported that all most of the their needs were being addressed by HEP  44% 61% 40%

Patients can access the entire health system through the health post in their communities, which are staffed by two HEWs. From these modest health posts, they can be referred up to higher level facilities to receive more complex care, as needed.

Behavior Change Communication

The Health Extension Program, from its very inception, aimed to accomplish much more than merely vaccinate children, provide pregnant women with check-ups, and treat sick children. The program’s goal included fundamentally changing rural communities' thinking on disease prevention, family health, hygiene, and environmental sanitation.

“The goal was to put knowledge and power - and, ultimately, responsibility - in the hands of local people.”

- Former Health Minister Kesete Admasu14

To foment this change, at the start of the program, HEWs were expected to spend 75 percent of their time in their communities and 25 percent of their time at their health posts. That ratio reflects the importance placed on behavior change communication in the key areas of children’s health, hygiene, nutrition, antenatal care, and maternal health.12

HEWs and, later, Model Family and Health Development Army members, encouraged their communities to take action to improve their health, including building and using pit latrines, separating animal sheds from family housing, breastfeeding their children, improving hygiene and ventilation in their kitchens, seeking antenatal care and giving birth in a facilities with skilled attendants.

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    Last Mile Health key informant interviews.
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    Perry, Henry with Loriade Akin-Olugbade, Aliza Lailari, and Yeri Son. A comprehensive description of three national community-based 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.
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    CNHDE. Ethiopian Health Extension Program Evaluation Study, 2007-2010. Volume II: Health Post and HEW Performance Survey. Addis Ababa, Ethiopia: Center for National Health Development in Ethiopia and the Columbia University Earth Institute, 2011.
  5. 5
    Ethiopia Federal Ministry of Health (FMOH), 2016.
  6. 6
    Zufan, Damtew. Chala Chekagn and Amsalu Moges.. The Health Extension Program of Ethiopia: Strengthening the Community-based Health System. Harvard Health Policy Review, 2016.
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    Wang, Huihui, Roman Tesfaye, Gandham N. V. Ramana, Chala Tesfaye Chekagn. Ethiopia Health Extension Program: An Institutionalized Community Approach for Universal Health Coverage. World Bank Studies. Washington, DC: World Bank, 2016. doi:10.1596/978-1-4648-0815-9. Page 11. License: Creative Commons Attribution CC BY3.0 IGO.
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    Habtamu, Zelalem. The Ethiopian Health Extension Program, July 2016. International Institute for Primary Heath Care in Ethiopia. Addis Ababa, 2016.
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    Yitayal M, Berhane Y, Worku A, Kebede Y. The community-based Health Extension Program significantly improved contraceptive utilization in West Gojjam Zone, Ethiopia. J Multidiscip Healthc. 2014;7:201-208. Published 2014 May 15. doi:10.2147/JMDH.S62294.
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    Belay, Kassa. Agricultural Extension in Ethiopia: the case of participatory demonstration and training extension system. Journal of Social Development in Africa. Vol 18. No 1, 2003.
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    Bilal, Nejmudin et al. Health Extension Workers in Ethiopia: Improved Access and Coverage for the Rural Poor, In Yes AfricaCan: Success Stories from a Dynamic Continent, eds. Punham Chuban-Pole and Manka Angwafo, 2011.
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    Maes K, Closser S, Tesfaye Y, Gilbert Y, Abesha R. Volunteers in Ethiopia's women's development army are more deprived and distressed than their neighbors: cross-sectional survey data from rural Ethiopia. BMC Public Health. 2018;18(1):258. Published 2018 Feb 14. doi:10.1186/s12889-018-5159-5.
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    Zulu JM, Kinsman J, Michelo C, Hurtig AK. Integrating national community-based health worker programmes into health systems: a systematic review identifying lessons learned from low-and middle-income countries. BMC Public Health. 2014;14:987. Published 2014 Sep 22. doi:10.1186/1471-2458-14-987.
  14. 14
    Kesete Admasu in Maternal Mortality: Ethiopia, Goalkeepers 2017,

How did Ethiopia implement?