H E A LT H
E XT E N S I O N
P R O G RA M
IN
ETHIOPIA
PROFILE
Health Extension and Education Center
Federal Ministry of Health
Addis Ababa, Ethiopia
June 2007
All Roads Lead to Health Extension Program!
The Health Extension and Education Center would like to extend its appreciation to Health
Communication Partnership (HCP) for the technical assistance including the graphics work
of this profile. We would also like to thank the United States Agency for International
Development (USAID) for its financial support.
Health Extension Program
In Ethiopia
PROFILE
Health Extension and Education Center
Federal Ministry of Health
Addis Ababa, Ethiopia
June 2007
Acronyms
AIDS Acquired Immunodeficiency Syndrome
ANC Antenatal Care
ARI Acute Respiratory Infection
CBRH Community Based Reproductive Health
CHA Community Health Agent
CHP Community Health Promoters
EPHA Ethiopian Public Health Association
FGD Focus Group Discussion
GDP Gross Domestic Product
HEW Health Extension Worker
HIV Human Immunodeficiency Virus
HEP Health Extension Program
HMIS Health Management and Information System
HSDP Health Sector Development Program
IEC/BCC Information, Education, Communication/Behavior Change Communication
IRT Integrated Refresher Training
ITN Insecticide Treated Net
MCH Maternal and Child Health
M&E Monitoring and Evaluation
MOE Ministry of Education
MOH Ministry of Health
NGO Non-Governmental Organization
ORS Oral Rehydration Salt
PASDEP Plan for Accelerated Sustainable Development to End Poverty
PHC Primary Health Care
PNC Post Natal Care
SNNPR Southern Nations, Nationalities and Peoples Region
STI Sexually Transmitted Infection
TB Tuberculosis
TBA Traditional Birth Attendants
TT Tetanus Toxoid
TVET Technical Vocational and Educational Training
UNFPA United Nations Population Fund
UNICEF United Nations Children Fund
VCHW Voluntary Community Health Workers
VCT Voluntary Counseling and Testing
VHC Village Health Committee
WHO World Health Organization
Contents
1. BACKGROUND 1
2. INTRODUCTION 3
3. GOAL 5
4. STRATEGIES 7
5. IMPLEMENTATION STRATEGY 9
5.1 Human Resources 9
5.2 Construction of Health Posts 10
5.3 Procurement of Contraceptives, Medicine and Supplies 10
5.4 Components of the Health Extension Package 11
Disease Prevention and Control 11
Family Health 11
Hygiene and Environmental Sanitation 11
Health Education and Communication 11
5.5 Health Extension Approaches 12
Model Families 12
Community Based Health Packages 12
Health Posts 12
5.6 Program Management 14
Planning Processes 14
Roles and Responsibilities 14
Monitoring and Evaluation 15
5.7 Indicators of HEP 18
6. STATUS OF HEALTH EXTENSION PROGRAM 19
6.1 Current Program Status 19
Training and deployment of Health Extension Workers 19
HEP Coverage 19
HEP for Pastoralist and Urban Areas 20
Integrated Refresher Training (IRT) 21
Success Story 22
6.2 Program Challenges 22
6.3 Way Forward 23
1 Background
It is clear that multifaceted steps have to be taken by the government and the people to
eradicate poverty in Ethiopia. Millions of Ethiopians, especially those who live in rural areas,
are exposed to a variety of preventable diseases, including malaria, tuberculosis (TB) and
childhood illnesses. Ethiopia's maternal, infant and under-five mortality rates are still among
the highest in the world.
The Ethiopian Government has formulated a series of Health Sector Development Programs
(HSDP I, II and III 1997-2010 ) in line with the Plan for Accelerated and Sustained
Development to End Poverty (PASDEP) and to achieve the health-related Millennium
Development Goals (MDGs).
Despite the gains that were made in the implementation of HSDP I, it became clear that basic
health services had not reached those in need, owing to lack of primary health care (PHC)
services at the community level.
1All dates in this document are based on the European Calendar.
1
In the past, public health financing gave priority to the curative sector. This led to a
considerable increase in the number of health facilities, but with limited rates of utilization,
partly because of lack of physical access. Evaluation of HSDP I also revealed constraints in
the availability of trained, high-level health professionals.
Therefore, inresponse to the country’s health problem the government introduces
“Accelerated Expansion of Primary Health Care Coverage” and the Health Extension Program
(HEP). The new health policy focuses mainly on providing quality promotive, preventive and
selected curative health care services in an accessible and equitable manner to reach all
segments of the population, with special attention to mothers and children. The policy has
a particular emphasis on establishing an effective and responsive health delivery system for
those who live in rural areas.
2
2 Introduction
The Extension Program (HEP) is a defined package of basic and essential promotive,
preventive and selected high impact curative health services targeting households. Based on
the concept and principles of PHC, it is designed to improve the health status of families,
with their full participation, using local technologies and the community's skill and wisdom.
HEP is similar to PHC in concept and principle, except HEP focuses on households at the
community level, and it involves fewer facility-based services.
The philosophy of HEP is that if the right knowledge and skill is transferred to households
they can take responsibility for producing and maintaining their own health.
The HEP is the main vehicle for bringing key maternal, neonatal and child health
interventions to the community. It is expected that almost all of the activities listed in the
National Child Survival Strategies are to be implemented through the HEP.
To provide coverage for the whole country, the government has decided to accelerate the
implementation of the HEP by training and deploying 30000 Health Extension Workers
(HEWs) by 2009.
3
A Kebele is the smallest governmental administrative unit, and on average has a population
of 5000 people. By 2009, each Kebele will have a Health Post which will be the operational
center for two HEWs, who will be responsible for providing outreach services. Construction
of Health Posts and training of HEWs are being accelerated to reach these targets.
In addition to creating 30000 jobs for women at grassroots level, the HEP requires the
creation of posts with responsibility for effective supervision and operation of the program.
The manpower of the health departments at Federal, Regional, and Woreda (district) level is
being increased to support the newly deployed HEWs.
At the community level, in addition to
HEWs, there are also groups of
Voluntary Community Health Workers
(VCHW). It is important that HEP links
VCHWs to HEWs and ensures each
group supports the work of the other.
HEWs are most effective when working
in collaboration with VCHW both to
extend contact with families and the
community, and to share different skills.
The HEP is a core component of the broader health system. While the strategies for the
interventions focus on the household and community, the success calls for coordinated
action at all levels. Health Centers in particular have a crucial role to play in providing referral
care, technical and practical support to the HEP. The Woreda Health Offices similarly have an
important role to play in support of the Health Centers and the Health Posts. The
government has shown high commitment in prioritizing the HEP program by ensuring it
receives the necessary financial and political support.
4
3 Goal
The overall goal of the HEP is to:
Create a healthy society and reduce rates of maternal and child morbidity and mortality.
5
Latrine Construction
6
4 Objectives
The objectives of the HEP include:
to improve access and equity to preventive essential health interventions at the village
and household levels in line with the decentralization process to ensure health care
coverage to the rural areas.
to ensure ownership and participation by increasing health awareness, knowledge, and
skills among community members.
to promote gender equality in accessing health services.
to improve the utilization of peripheral health services by bridging the gap between the
communities and health facilities through HEWs.
to reduce maternal and child mortality.
to promote health life style.
7
Training of HEWs
8
5 Implementation Strategy
As a major nationwide health program, HEP requires substantial investment in human
resources, health infrastructure, and provision of equipment, supplies and commodities, as
well as other operating costs.
5.1 Human Resources
Candidate HEWs must be women aged 18 years or older with at least 10th grade education.
HEWs will be selected from the communities in which they reside in order to ensure
acceptance by community members. Selection committees are comprised of a member
nominated by the local community, representatives from the Woreda Health Office, Woreda
Capacity Building Office and Woreda Education Office. Following selection, the HEW
completes a one-year course of training which includes coursework as well as field work to
gain practical experience.
Courses for HEWs are held at Technical and Vocational Education Training Schools (TVETs)
of the Ministry of Education with the support from the Health Bureau and health service
management at different levels. Forty TVET schools provide training to HEWs, and 140
TVET tutors have been trained to deliver pre-service training.
9
5.2 Construction of Health Posts
The operational center of the HEP is the Health Post, which functions under the supervision
of the Woreda Health Office, Kebele administration, with technical support from the nearest
Health Center. Health Posts are located at Kebele level to serve a population of 5000 people.
Where possible, Health Posts are located near other public services and institutions (e.g.
Kebele Administration offices) to foster enhanced coordination among government service
providers. In localities where Health Posts are not yet built, the service are provided in
provisional posts.
Each Health Post is staffed by two HEWs. If there are VCHWs (e.g. trained birth attendants,
community based reproductive health agents) in the community, they work together with
HEWs.
5.3 Procurement of Contraceptives, Medicine and Supplies
Health Posts must be adequately provided with equipment materials and supplies required
to deliver the different packages of essential services to the community. Medicines and
supplies are procured and distributed to the health posts by the Federal Ministry of Health,
Regional Health Bureaus and Woreda Health Offices. Supplies are provided by Health
Centers or Woreda Health Offices to the Health Posts.
10
5.4 Components of the Health Extension Package
HEWs are responsible for explaining and promoting the following preventive actions at
community level.
Disease Prevention and Control
HIV/AIDS and other sexually transmitted infections (STIs) and TB prevention and control
Malaria prevention and control
First Aid emergency measures
Family Health
Maternal and child health
Family planning
Immunization
Nutrition
Adolescent reproductive health
Hygiene and Environmental Sanitation
Excreta disposal
Solid and liquid waste disposal
Water supply and safety measures
Food hygiene and safety measures
Healthy home environment
Control of insects and rodents
Personal hygiene
Health Education and Communication
11
5.5 Health Extension Approaches
HEWs are required to spend 75% of their time conducting outreach activities by going from
house to house. During these visits, HEWs are expected to teach by example (eg by helping
mothers care for newborns, cook nutritious meals, construction of latrines and disposal of
pits). HEWs utilize the following three approaches.
Model Families
HEWs identify and train model families that have been involved in other development work,
and /or that have acceptance and credibility by the community, as early adopters of desirable
health practices to become role models in line with heath extension packages. Model families
help diffuse health messages leading to the adoption of the desired practices and behaviors
by the community.
Community Based Health Packages
HEWs communicate health messages by involving the community from the planning stage
all the way through evaluation. HEWs utilize Women and Youth Associations, Schools and
Traditional Associations such as idir, mehaber, ekub, to coordinate and organize events
where the community participate by providing money, raw materials and labor.
Health Posts
At the Health Post HEWs provide antenatal care, delivery, immunization, growth monitoring,
nutritional advice, family planning and referral services to the general population of the
Kebele.
12
13
5.6 Program Management and Governance
Planning Processes
The HEWs, in collaboration with the members of the Kebele Council, begin work by first
conducting baseline surveys. Based on the survey findings, health problems are identified
and prioritized, and plans of action are prepared. The draft plans of action are submitted to
the Woreda Council through the Kebele Council for approval. Once approved, the plans are
disseminated to the Woreda Health Office, Regional Council and Regional Health Bureau.
Roles and Responsibilities
Clear identification of roles and responsibilities is imperative for effective planning,
implementation, monitoring and evaluation of the HEP. Duties and responsibilities of
different government stakeholders at each level are described below:
Federal Ministry of Health
Develop overall program concept, standards and implementation guides
Determine career structure for HEWs
Mobilize national and international resources
Provide communication tools and materials
Procure medical equipment and supplies
Set up Health Management Information System.
Regional Health Bureau/Zonal Health Department
Provide technical and administrative support to Woreda Health Offices
Adapt implementation guidelines to local conditions
Adapt communication tools and materials into local languages and distribute to Woreda
Health Offices
Obtain reports from Woreda Health Offices and provide information to the MOH
Mobilize regional resources
Establish referral systems between Health Posts and Health Centers
Strengthen Health Management Information System.
14
Woreda Administration
Allocate budget and other resources
Co-ordinate activities implemented by Governmental and Non-Governmental bodies
Monitoring and Evaluation.
Woreda Health Office
Provide technical, administrative and financial support to HEP
Allocate budgets and supplies to Health Centers and Health Post
Adapt communication materials
Provide supportive supervision of HEWs and the overall management of Health Centers
and Health Posts
Plan and provide in service training to HEWs and Woreda Health Office staff
Obtain reports from Health Posts and Health Centers and provide information to Regional
Health Bureau/Zonal Health Department.
Health Extension Workers
Manage operations of Health Posts
Conduct home visits and outreach services to promote preventive actions
Provide referral services to Health Centers and follow up on referrals
Identify, train and collaborate with VCHWs
Provide reports to Woreda Health Offices.
Monitoring and Evaluation
Monitoring and evaluation are integral and important components of the HEP and contain
both technical and managerial purposes. Monitoring is the process of regularly reviewing
achievements and progress towards the goal. In this context, monitoring is the process of
measuring, analyzing, and communicating information on the implementation of the HEP for
effective decision making at all levels.
15
Evaluation is carried out to assess whether objectives are met and to determine the
effectiveness and efficiency of the program. This helps to correct and improve the future
planning process.
Monitoring and evaluation have to be built into the program from the outset as an integral
part of the planning process. Monitoring and evaluation requires a health management
information system to measure progress against objectives indicators and targets. Both
qualitative and quantitative methods can be used to evaluate HEP. Tools or techniques to be
used in collecting qualitative data are observations, in-depth interviews, and focus group
discussions. In quantitative evaluations, tools used should include surveys. Quantitative
and qualitative data are used together to give a clearer picture of the situation about the
performance of the program.
The HEWs collect information with standardized reporting formats. The HEWs must keep
accurate and timely records of their activities. The information captured is passed on to the
Kebele Council and Woreda Health Office for review and action. At the Kebele level, the
Kebele Committee, HEP and VCHW meet weekly and provide a report to the Kebele cabinet
on program implementation. During town hall meetings the community identify weaknesses
and strengths and provide ideas for improvement.
16
Supportive Supervision
Supportive supervision enhances capacity and helps to correct any constraints encountered in
the implementation of the HEP. Effective supervision requires a team of experts with an
appropriate mix of skills, strong management abilities and continuity among team members.
A supervisory team drawing its members from different disciplines is established at the
Federal, Regional and Woreda levels to direct and support HEWs so that they effectively
perform their duties. The teams will be involved in all aspects of program management
including planning, implementation, monitoring and evaluation. Through these planned and
coordinated supervisory activities at various levels, it will be possible to ensure that the
quality and quantity of work is to the standard and in line with the general government policy.
Members of the team are trained in skills needed for supportive supervision (facilitation,
interpersonal communication, problem solving and analytical skills), oriented on various tools
and methods (such as peer review, performance assessment tools), and provided with
opportunities to frequently upgrade their technical skills. The supervisors are trained on a
specially designed curriculum.
At each level the supervisory team prepares its own annual plan, checklists and detailed
schedule for each supervisory visit.
Organizational Composition of Supportive Supervisory Team
Federal supervisory team
Disease prevention and control expert
Maternal and child health expert
Administration and finance expert
Environmental / hygiene expert
Regional supervisory team
Health education expert
Disease prevention and control expert
Maternal and child health expert
Administration and finance expert
Environmental / hygiene expert
Health education expert Woreda supervisory team
Health officer
Public health nurse
Environmental / hygine expert
Health education expert
17
5.7 Indicators of HEP
Immunization, breastfeeding, use of Oral Rehydration Salt (ORS), adolescent
parenthood, antenatal care, assisted delivery, contraceptive use, and tetanus toxoid
immunization.
Use of Insecticide Treated Nets (ITNs), anti-malarial drugs, HIV and sexually
transmitted infections, TB follow-up and First Aid and self care.
Facilities for liquid/solid waste disposal, safe drinking water, healty home environment,
sanitation and hygiene.
Access to and utilization of preventive and promotive health services, referrals,
adequately-staffed and well-maintained health posts, participation in basic
health/demographic data collection, provision of financial support for Health Posts.
18
6 Status of Health Extension Program
6.1 Current Program Status
Training and deployment of health extension workers
The total number of HEWs required for the country is 30000. To date, three batches of HEWs
have already completed their one-year training course and have been deployed to the
Kebeles. The total number of health extension workers deployed as of June 2007 is 17653,
which is 59% of the total required.
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In addition, 7000 HEWs will be trained and deployed each year until 2009. Recruited HEWs
receive training in the forty Technical and Vocational Education Training Schools (TVETs) that
are found nationwide. The training is provided jointly by the Ministry of Education (MOE)
and the Ministry of Health (MOH).
HEP Coverage
There is wide Regional variation in the proportion of rural Kebeles deploying HEWs. For
example, Amhara, Tigray, Harrari, Dire Dawa, and SNNPR will have reached 100% coverage
of HEWs by the end of 2007, while BeniShangul Gumuz and Oromia have attained coverage
of 79% and 65% respectively.
19
According to HSDP II and III, the total number of Health Posts required for the country by
the year 2008/9 is 15000. A total of 9914 (66%) Health Posts had been constructed by June
2007. Health Posts are also being furnished with the proper equipment and supplies to
ensure their functionality. In 2006 the Federal Government had procured medical
equipments and supplies for 2300 Health Posts. The procurement will continue to equip
additional 4263 health posts in 2007.
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HEP for Pastoralist and Urban Areas
The MOH has initiated the training of HEWs for the pastoralist areas in Afar, Somali and
Gambella Regions, purchased Health Post equipment, supported translation and preparation
of training materials, and provided technical support in preparing integrated development
plans. The Afar, Gambella, and Somali Regional Health Bureaus has deployed 64, 50 and 135
HEWs respectively.
After consultation with Regional Health Bureaus and other stakeholders, a document
elaborating the content and direction of Urban Health Extension Services has been prepared.
This document will be the basis for the formulation of a HEP for urban areas and a
curriculum for the training of urban HEWs.
20
Integrated Refresher Training (IRT)
Preliminary assessments have shown that there is a gap in some of the practical skills of HEWs,
since HEWs were trained on a limited set of topics from the broader HEP curriculum including
immunization, family planning, HIV/AIDS, monitoring and evaluation. The MOH has therefore
decided to provide Integrated Refresher Training (IRT).
Woreda Health Offices and Health Center staff will be trained as trainers for IRT in order to
ensure adequate pool of trainers for future refresher training of HEWs, and to strengthen the
monitoring and evaluation provided by Woreda level personnel of HEWs. The trainers
undertake an eighteen-day course incorporating new and
existing information.
The Woreda health team is responsible for conducting similar trainings for HEWs, the Regional
Health Bureau and Zonal Health Offices, who will be responsible for the coordination of IRTs
in the future. Up to June 2007, a total of 856 trainers were trained and 4772 HEWs have
already received IRTs after their deployment. The trained HEWs in turn give the training to
VCHWs.
21
Success Stories
Bezunesh Zewde, Health Extension Worker
"My name is Bezunesh Zewde and I came from Jewe Kebele in Limu Woreda of the SNNPR
Region. I am 32 years old and grew up in the same Kebele. I have been working in this
Kebele for a long time.
In my Kebele, there are 116 households with a population of 6790. I used to work in the
community for 8 years. Then, I became a volunteer Community Health Promoter and
worked for 2 years. While I am working as ahealth promoter, I have been selected to work
as a Health Extension Worker and have been given a one year training, When I finished
the training last year, I started working as a Health Extension Worker and usually visit up
to 200 homes per month.
The nearest Health Post is 4 hours on foot. The community appreciates our work very
much because of the services HEWs provide. The Health Post is open one fixed day a
week for antenatal care and counseling. Currently I am the only HEW working in our
Kebele therefore I can't be at the Health Post the whole day and wait for people to come
because I go from house to house and visit mothers with newborns to teach them about
breastfeeding, immunization and family planning.
Women are given priority to become HEW and empower other women to bring change in
their family because in our community women are the primary care givers.
The community's acceptance of me
as well as the healthful living has
grown gradually.
Of all the things in my Kebele that
I feel extremely proud of is
hygiene. Almost everyone has
constructed a latrine and as a
community we have had a campaign
to clean the water source and fence
it to prevent animals from
entering."
Source: Interview
22
Teguada’s Story
Teguada Terefe is a 25 years old and a mother of two children. She is a Health Extension
Worker in Libo Kemkem Woreda of Amhara Region. Having completed 10th grade, she was
selected to be trained as a HEW in her district’s Technical and Vocational Education
Training School. She successfully completed the one-year training course and has been
working at the Health Post in her kebele for almost two years now. Teguada and her HEW
colleague provide health services to the 6670 people in their kebele.
Teguada goes from house to house on Monday, Tuesday and
Wednesday each week to teach community members about
family planning, distrubute bed nets for malaria
prevention, create awareness of the importance of hygiene
and sanitation, and give training on first aid. She visits
mothers with newborn babies to teach them about
breastfeeding, immunization and preparing nutritious
meals. She also guides households to construct latrines and
improve hygiene, and shows them how they can combat the
flies, mosquitoes and parasites that carry disease by
keeping their environment clean.
On Thursdays and Fridays Teguada stays at the Health Post to provide services on family
planning, immunization, treatment of malaria and diarrhoea, advice on prevention of
HIV/AIDS, other sexually transmitted infections, and routine care during pregnancy.
Teguada needs to travel up to two hours on foot every day. She says, “Tough I feel tired
I don’t mind walking such distances because the community is very appreciative of our
work. There is nothing that makes me happier than seeing my community’s healthful living
improving. The community’s acceptance of the program has gradually increased from a low
base.”
Recalling the thousands who died of malaria in her woreda a few years ago, Teguada says,
“Thanks to the the Health Extension Program, my community members have better access
to anti-malaria drugs and bed nets and they live in a healthy home environment.” Although
she takes great pride in having helped to bring about a big increase in use of malaria bed
nets, she continues to strive for even greter improvement. “Eighty percent of households
in my kebele now use bed nets. The remaining twenty percent are not using them because
of lack of awareness. I will work hard to ensure the bed net coverage in my kebele reaches
100% next year” says Teguada.
Source: DFID Web site: [Link]
23
6.2 Program Challenges
Based on various reports and assessments of HEP the following program challenges have
been identified:
Some of the Health Posts are not fully furnished with the necessary equipment and
supplies
Inadequate means of communication and transportation impede supervision and
reporting
Woreda Health Offices lack sufficient capacity to provide supportive supervision/
monitoring and evaluation
The referral system is weak.
6.3 Way Forward
Allocate adequate budget to Health Posts
Construct and complete Health Posts to reach all Kebeles
Strengthen planning, resource allocation and supervision at the Federal, Regional and
Woreda level
Conduct continuous capacity building activities for HEWs and Woreda level staff
Strengthen logistic management system and provide regular and uninterrupted supply
of essential commodities
Strengthen referral system
Strengthen monitoring and evaluation including Health Management Information
System.
24
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