For 20-year-old Chaltu Wata and 22-year old Aster Roba, life is anything but easy. The cousins have spent the past several years in a rural area where they initially faced resistance from the local community for trying to teach them healthier ways. They biked or walked for miles each day to visit individual households in order to teach them about sanitation, malaria, immunization, family planning, and the importance of delivering babies at a health facility. Even though they had been born and raised in this area, people from their community often rebuffed or snubbed them. Yet these two young women persevered. As a result of their enthusiasm, commitment, and hard work, they now find themselves in the center of a flourishing community health program. This program, known as the National Health Extension Program, is receiving international attention, as it appears to be successfully contributing to the dramatic improvements in key health indicators in Ethiopia.

Chaltu and Aster are just two of more than 38,000 health extension workers working throughout the country to improve the quality and availability of primary health care services in Ethiopia, particularly in rural areas where 84 percent of the population lives. As part of the Ethiopian Government's National Health Extension Program, these workers who have a tenth grade education and who are trained for a year are paid to provide primary health care in areas of the country where access is limited. The program has been so innovative and successful that during the week of July 18th, 30 policymakers, medical practitioners, and public health professionals from seven African countries (Kenya, Malawi, Mali, Nigeria, Tanzania, Uganda, and Zambia) participated in a USAID-led field observation tour of the program. The tour, which was a precursor to the USAID East Africa meeting in Nairobi on Community Approaches to Family Planning, July 25-29, gave select participants the opportunity to see how a community based health program had been taken to scale. It was designed so that participants could learn from the Ethiopian Health Extension Program and then assess how best to apply lessons learned to their respective country programs.

Dr. David Malwi, director of community medicine at the Ministry of Health in Nigeria, said, “This field observation tour came at exactly the right time. We have learnt so much from the excellent work the Ethiopian Ministry of Health has done. As soon as we go back home, we will move forward with implementing a similar program. There is no option. We need to have a community based program at scale if we are going to see the impact we need.”

The field observation tour took the participants to two regions—Oromia and Southern Nations, Nationalities, and Peoples (SNNP). They visited the woreda(district) health offices, where they were briefed on how the health system was structured; two health centers; and select health posts that each of the two health centers support. One health center oversees five health posts and this constitutes a primary health care unit. The health posts are the backbone of the National Health Extension Program but the Government has also sought to strengthen the health center to ensure the effective continuum of care. If the health centers to which health extension workers refer their clients to do not have the capacity to provide the requisite services, the health extension workers would lose all credibility. Each health post serves a population of 5,000, while the health center has a catchment area of about 25,000.

During the tour, the health extension workers described their catchment area and the services that they provided—both at the health post and in the community. They provided short acting family planning methods, including the injectable that provided protection for three months and some, they said, were now trained to provide the long acting implant that was effective for three years as part of the Government’s efforts to expand the choice of contraceptives in the country. They talked about how they had succeeded in increasing immunization coverage and how they partnered with the traditional birth attendants to ensure women had greater access to clean and safe deliveries in the community. This was an interim measure. Ultimately, all women would deliver their babies at health facilities. That was the national goal.

Participants had the opportunity to meet with local community members and elders. They owned the program, they said. They identified the problems, mobilized the needed resources to solve their community’s problems. It was they, the community, that built the health posts and in certain instances, they even built the houses for the health extension workers on the premises of the health post so that women could come to them at night with ease to deliver their babies.

The field observation tour participants also had the opportunity to engage with community health volunteers who are the eyes and ears of the health extension workers. Because the health extension workers cannot be at all places at all times, about 10 community health volunteers support each health extension worker. The participants also had the opportunity to visit the homes of local “Model Families.” These are families who have demonstrated “model” health behaviors and practices in their daily lives and through example and training share these ideal model behaviors with their neighbors. The idea is that their neighbors in turn would emulate the good and healthy practices of the Model Families.

"It is too difficult to reach every home given the distances, so our system is to use Model Families in different zones. We bring them and give them training, then send them back to the village to train more people," says Aster. "We also tell volunteers to gather the children in one place so that we can do growth monitoring efficiently at the time we visit. We are very happy when there are positive changes in the community. I forget all the difficulties that we have faced. Reducing the unnecessary deaths of our mothers and children….now, that makes me happy!”

More than 38,000 paid health extension workers, almost all of them women, have been trained and deployed throughout the country with 34,382 based in rural areas, 3,401 in urban areas, and 948 in pastoralist areas (the health extension workers in pastoralist areas are male due to the difficult working conditions there).

The Rural Health Extension Program is supported by projects funded by different development partners. The three projects that were showcased during the field observation tour were USAID’s flagship family planning and maternal health project known as the Integrated Family Health Project or IFHP; the Gates Foundation funded Last 10 Kilometers or L10K project; and the Marie Stopes Outreach Program. The IFHP and L10K projects complement one another in their support to the Rural Health Extension Program and are considered sister projects. IFHP works in 286 woredas, while the L10K project is operational in 115 woredas—both work mainly in the four major regions [Amhara, Oromia, Tigray, and SNNP] that account for 80 percent of the country’s population. Marie Stopes Ethiopia is an organization that provides comprehensive reproductive health services within the private sector but with support from the British and others has been supporting the government’s Rural Health Extension Program by providing outreach services for long acting and permanent clinical family planning methods. Tour participants were able to see Marie Stopes Ethiopia’s Outreach Program at one of the health posts that they visited in a remote part of SNNP Region. A large group of clients were present and expressed their satisfaction with the services they had received. Several of the women spoke of how important word-of-mouth was in convincing them to come for family planning at the health post.

The L10K project aims to reinforce the links between Ethiopian families and the formal health care system and tests different models to promote community ownership, which they scale up if they prove promising. "Malaria was the biggest problem in our community," said Aster. "But last year, it wasn’t such a big problem. This is because of the community awareness about bed nets, spray and drains. There was definitely a change. We had zero cases of malaria this past year.”

While the first two days of the tour focused on the Rural Health Extension Program, the third day was dedicated to showing the participants the Urban Health Extension Program in Awassa. USAID’s Urban Health Extension Program supports implementation in five regions and two city administrations, covering 19 towns/cities and benefits 2.6 percent of the country’s urban population. A key difference between the Urban Health Extension Program and the Rural one is that the health extension workers in the Urban Program are trained nurses and are referred to as urban health professionals. These urban health professionals have developed strategies aimed at dealing with the challenges of a city—focusing on initiatives like public latrine construction and community mapping efforts to identify high-risk populations, that is, groups of people whose life styles put them at risk of HIV/AIDS. At the conclusion of the tour, delegates discussed their observations of both the Rural and Urban Health Extension Program with each other and the Ethiopian State Minister of Health, H.E. Dr. Kesetebirhan Admassu. Dr. Kesete provided insights into the next phase of the Health Extension Program that the Government of Ethiopia had planned and also offered the following advice.

“One: Go to scale as quickly as possible if you want to see impact. Have a learning phase but get rid of pilots! Two: Be ambitious. Most people thought training 30,000 health extension workers was an impossible feat. Some even laughed at us. But we not only did it, we surpassed that number! And three: Own the process. Determine what you want to do and rally your forces to help you do what you set out to do!”

Surveys conducted by L10K have confirmed that the Rural Health Extension Program has had tremendous impact on almost all key health indicators in the country except for institutional deliveries and postpartum care. The proportion of women using a family planning method in L10K and USAID’s IFHP implementation areas have jumped from 15 percent (as indicated by the 2005 Ethiopia Demographic Survey conducted) to 40 percent in L10K’s 2010 midline survey, which is a remarkable achievement. The conclusion, therefore, is that these extraordinary achievements have been possible because of the Government of Ethiopia’s commitment to a vision of having a healthier nation, all development and implementing partners who have worked hand in hand with the Government, and of course women like Chaltu and Aster who have labored to make this national vision a reality by taking primary health care closer to the people. And because of the evident success of the National Health Extension Program, all eyes are on Ethiopia—especially now. Why now? Because the preliminary results of the nationally representative 2010/2011 Ethiopia Demographic Health Survey are to be released in September 2011. We will know very soon exactly how successful the Health Extension Program has been.

See also: Integrated Family Health Program