World Report

Extension workers drive Ethiopias primary health care

Thousands of community workers are helping Ethiopia to deliver primary health-care services to
people living in rural areas. But critics say the training these workers receive is not adequate for
them to attend many of the health problems they encounter. Wairagala Wakabi reports.
Although it still has some of the
worst health indicators in the world,
Ethiopia is fast registering impressive
successes in extending aordable
primary health-care services across
the country. These achievements
are largely attributable to the Health
Extension Programme which has been
implemented since 2003, and through
which the country hopes to achieve
universal access to primary health care
by 2009.
Coverage
of
publicly-funded
health care has risen from 61% in
2003 to 87% in 2007, whereas total
coverageincluding services provided
by private health facilitieshas
grown from 70% to 98% over the
same period. The Health Extension
Programme, which has enabled this
success, aims to improve access and
equity through provision of essential
health interventions at the village
and household level, with a focus on
sustained preventive health actions
and increased awareness.
The initiative deploys two salaried
health extension workers at each
village health post. Most of these
workers are women who are recruited
from the local communities in which

Panos Pictures

The printed journal

includes an image merely
for illustration

Health education forms part of the Health Extension Programme

880

they will work. New recruits complete

a 1-year training course, which
includes eldwork, before taking up
their posts.
Luwei Pearson, head of the health
department at UNICEF Ethiopia, told
The Lancet that a review completed
last July by independent consultants

...Ethiopia is fast registering

impressive successes in
extending aordable primary
health-care services across the
country.
with the input from WHO, the UN
Population Fund, and UNICEF, showed
that the Health Extension Programme
had achieved great successes, helping
to prevent communicable diseases
and enabling eective community
participation in the planning and
implementation of health care. The
care given under the programme
covers disease prevention and control,
hygiene and sanitation, family health
services, and health education.
According to the evaluation of
the Health Extension Programme,
the training and deployment of the
health extension workers have been
progressing according to plan. Some
24 534 workers gave been trained and
deployed, representing 82% of the
target.
From several studies carried out
so far, it appears the community
engagement of the HEWs [health
extension workers] in a number of
regions is highly appreciated and
seems eective. In those regions,
HEWs work together with community
health promoters, health workers,
religious leaders, and community
leaders, says the evaluation report.
Most of the workers were said to
be well organised in their activities

and divided their time between the

community and activities at health
posts.
Female-headed households reported
monthly visits by the extension
workers and had received health
education on various topics such as
housing, food hygiene, waste disposal,
immunisation, and family planning.
However, not all the news is positive.
Tewodros
Adhanom,
Ethiopias
minister of health, says that workforce
shortages still hamper delivery of
health care. And analysts point out that
the ability of the extension workers
to deliver services will remain limited
because of delays in the construction
of health posts and the distribution
of health kits, as well as inadequate
supervision within the programme.
At the national level, the Health
Education and Extension Centre is
mandated to coordinate and monitor
the activities related to the health
extension programme. It is also
responsible for the preparation of
national health education standards
and materials. But its eectiveness has
been under question, and it is one of
the departments that health minister
Adhanom has said will be reformed.
Critics also say that the training
which extension workers receive is not
adequate for them to attend to many
of the health problems they encounter
and that the interaction between
the workers and their referral health
centres needs to be strengthened.
But despite these problems, the
Health Extension Programme is
largely seen as a big success. Adhanom
says his country is on course to achieve
primary health care for all by 2010,
and praises the HEP for contributing
to this milestone.

Wairagala Wakabi
www.thelancet.com Vol 372 September 13, 2008