St Comp Int Dev (2015) 50:455–478

DOI 10.1007/s12116-015-9197-z

A Women’s Development Army: Narratives

of Community Health Worker Investment
and Empowerment in Rural Ethiopia

Kenneth Maes 1 & Svea Closser 2 & Ethan Vorel 2 &

Yihenew Tesfaye 1

Published online: 24 September 2015

# Springer Science+Business Media New York 2015

Abstract Creating community health worker jobs in the public sector is a prominent goal
in the global health development industry. According to industry leaders, Ethiopia’s
government has created community health worker jobs at a scale and in a way that other
countries can look to as a model. Based on extensive document review and interviews with
district, national, and international health officials, we show that narratives about saving
lives, empowering women, and creating model citizens in a context of resource scarcity
allow Ethiopia’s ruling party to obtain international admiration for creating salaried
community health worker jobs and to simultaneously avoid criticisms of its concurrent
use of unpaid women’s community health labor. Public sector community health worker
investments in the twenty-first century reveal the layered narratives inherent in global
development practices that entangle states, international donors, NGOs, and citizens.

Keywords Ethiopia . Women’s empowerment . Community health workers . Citizenship

. Population health

Introduction

Reducing unemployment is a contested approach to alleviating poverty and improving

public health and wellbeing. In the public sector, the legacies of structural adjustment
and neoliberal notions of cost-effectiveness and budgetary sustainability lead many

This research was funded by a National Science Foundation Cultural Anthropology Program grant to PIs
Kenneth Maes and Svea Closser (#1155271/1153926).

* Kenneth Maes
[email protected]

1
Department of Anthropology, Oregon State University, Corvallis, OR, USA
2
Department of Sociology & Anthropology, Middlebury College, Middlebury, VT, USA
456 St Comp Int Dev (2015) 50:455–478

officials to treat job creation for poor people as a poor use of money (Ferguson 2010;
Swidler and Watkins 2009). But as the Millennium Development Goals (MDG)
deadline has crept closer over the past few years, creating community health worker
jobs in the public sector has become a prominent goal in the global health development
industry. Several global health leaders in public and private spheres have signed on, for
instance, to the 1 Million Community Health Worker Campaign, sending a message
that salaried community health worker jobs are unique, in that they offer not only
livelihoods to the workers but also much-needed primary health care to wider commu-
nities. Conceptualized as important health technicians who wield multiple technologies
(bikes, smartphones, forms, medicines, diagnostics) and who transmit information for
population health monitoring and evaluation, community health workers are supposed
to fill the gaps where doctors and other health professionals are absent or few. Even
where there are other health professionals, community health workers are seen as
useful, because they meet people “on their level.” That is, they ideally come from the
same socioeconomic backgrounds as the people they serve and provide them with
relatively intimate care (Earth Institute 2011: 6–10). Based on costing exercises, the 1
Million Community Health Worker (CHW) Campaign offers a simple equation:

6:86 USD per year per person served

þ1 bicycle; 1 smart phone; 1 backpack
þ political will
¼ 1 paid; supervised; integrated CHW

(McCord et al. 2013; Earth Institute 2011; Singh and Sachs 2013)
“Taken to scale” with sustained financing as well as best practices in recruitment,
training, and supervision, this equation is supposed to translate into a health system-
integrated, technology-equipped, and data-driven community health workforce at the
country level, which cost-effectively carries a country towards Millennium Development
Goals and universal primary health care (Earth Institute 2011; McCord et al. 2013: 250).
As the value of community health workers has been constructed and asserted in this
way, sustaining the funding needed for large investments in community health work-
forces has come to be treated as imperative by industry leaders like the World Health
Organization (2008). In contrast to those who see paying ground-level health staff as
unsustainable, then, some global health leaders have criticized the common practice of
relying on unpaid “volunteer” community health workers. Thus, creating community
health worker jobs has become an important terrain for debates over the role of public
sector job creation in improving health and wellbeing in poor countries (Maes et al.
2010; Glenton et al. 2010; WHO 2008; Drobac et al. 2013).
Backed by the Earth Institute’s 1 Million Community Health Worker Campaign, the
WHO’s Global Health Workforce Alliance, and other industry leaders, high profile
efforts at the country level have demonstrated the possibility of large-scale job creation
for public sector community health workers in settings of “resource scarcity” and high
unemployment (Earth Institute 2011; Singh and Sachs 2013; Drobac et al. 2013).
Ethiopia’s recent community health worker investments, namely its well-known Health
Extension Program, have been lauded by the 1 Million CHW Campaign and many other
international health development agencies, foundations, and NGOs (McCord et al. 2013;
GHWA 2010; Donnelly 2010). According to these funding agencies, Ethiopia’s
St Comp Int Dev (2015) 50:455–478 457

government has created community health worker jobs at a scale and in a way that other
countries can look to as a model. In this article, we look critically at the presentation of
Ethiopia as a model for community health worker investment, describing the complex
political and moral economy surrounding investments in CHWs.
In today’s global health development industry, the funds, energies, and affects of
multiple players, including states, foundations, NGOs, and “local people,” interact in
complex ways (Ferguson 2010; Cueto 2013). Simplifying narratives and expressions of
humanitarianism, however, often obscures these complex interactions of funds, ener-
gies, and affects (Fassin 2013). Following historian Lorraine Daston (1995) and anthro-
pologist Didier Fassin (2005), in this article, we make use of the concept of moral
economies, broadly conceived as involving the global and local “production, distribu-
tion, circulation, and utilization of moral sentiments, emotions and values, norms and
obligations, in regards to specific social issues in particular historical contexts” (Fassin
2013). The political and moral economies of community health workers include the
production, distribution, and circulation of community health workers themselves and
the ideas, emotions, and moral sentiments associated with them.
According to Fassin (2013), moral economies generally eclipse political economies:
expressions of and narratives about empathy and concern for certain categories of
people, often women and children, allow people to avoid “the necessary analysis of the
structural determinants of their exposure to health risks and social hazards” (p. 129).
When certain moral sentiments, emotions, and values become normative, Fassin asks,
“what truth remains untold or even unspeakable?” (p. 111). As we show in this article,
there are multiple narratives when it comes to community health worker job creation,
which circulate among government and international NGO officials and donors,
eclipsing underlying political-economic and historical complexities.
At the most simplifying and obscuring level are public statements by global health
institutions such as the WHO and the 1 Million CHW Campaign, as well as by leaders
of Ethiopia’s Ministry of Health, which assert that Ethiopia’s government has under-
taken a bold investment in CHWs. As we explain below, such assertions obscure the
complex political and budgetary processes that have accompanied this investment.
Ethiopia’s community health programs continue to rely on a massive amount of unpaid
women’s labor. Community health worker labor organization is nonexistent in
Ethiopia, and contracts between labor and management are highly uncertain if not
absent. In their place typically exist political dynamics in which government, donor,
and NGO officials negotiate budgetary decisions in order to create (or not create)
community health worker jobs and devise their job descriptions, while community
health workers themselves are excluded from the policy-making process, are expected
to do whatever it is that governments and NGOs would have them do, and, in return,
receive below poverty-level wages or perhaps a mix of nonfinancial incentives (Maes
et al. 2015).
Yet, Ethiopian government officials and donor and NGO “partners” circulate pow-
erful narratives that work to make unpaid community health worker labor and an
overriding emphasis on worker/citizen discipline seem not only acceptable but desir-
able. Narratives about saving the lives of babies and mothers, empowering women, and
creating model citizens in a context of resource scarcity are circulated by Ministry of
Health officials and donors, as well as by district health officials who actually imple-
ment community health worker policies.
458 St Comp Int Dev (2015) 50:455–478

We explain these policies and the narratives circulated to legitimate them, by relating
them to Ethiopia’s high maternal and neonatal mortality rates, to Ethiopia’s position in
regional and global political economies, and to the ruling party’s history of mobilizing
rural peasants and women in particular. These political dynamics shape attempts to
improve population health at the district and village levels. These dynamics, however,
are obscured by simplified narratives (of “saving lives” and “empowering women”)
inherent in global development practices that entangle states, international donors,
NGOs, and citizens.
In this paper, we focus on the discourses of government and international officials
and not on the perspectives and experiences of CHWs themselves (on the latter, see
Maes et al. 2015). Our goal is to show how Ethiopia’s national CHW program works
discursively in policy documents and official narratives within government, NGO, and
donor circles, but not on the ground. Our analysis thus draws on interviews with
national-level health officials and advisors in Addis Ababa (n=8), health officials in
three districts in the West Gojjam zone of Amhara state (n=7), and health extension
workers in the same districts (n=11), as well as on an extensive review of documents
produced by the Ethiopian government and donor partners, concerning primarily the
Health Extension Program and the Women’s Development Army. In our interviews, we
asked about the army—its structure and purpose. We asked about the economic
calculations that inform decisions about employee pay and job creation. We also asked
about their understandings of volunteer labor and livelihoods and of the motivations of
volunteers. We received IRB approval from Middlebury College and Addis Ababa
University’s Faculty of Medicine. We also pursued and received approval to carry out
our research from the Federal Ministry of Health.

Ethiopia’s Health Extension Program—a Pioneering Move “Away

from Volunteerism”

Ethiopia’s Health Extension Program, which centers on the creation of thousands of

paid community health workers, is commonly identified by national and international
health experts as the ministry’s “flagship” initiative and the “bedrock” of Ethiopia’s
attempts to expand primary health care. The Health Extension Program is frequently
heralded as a model of community health worker investment for other countries to
follow. Teklehaimanot and Teklehaimanot (2013), for instance, describe the Health
Extension Program as a “model” for the 1 Million CHW Campaign. “The Ethiopian
approach of revitalization of primary health care through innovative and locally
appropriate and acceptable strategies,” these authors explain, “can provide important
lessons to other countries” (Teklehaimanot and Teklehaimanot 2013: 10). In the
Bulletin of the World Health Organization, McCord and colleagues (2013: 244) refer
to Ethiopia, along with Rwanda and Malawi, as “pioneering countries” in community
health worker investment. The Global Health Workforce Alliance, part of the WHO,
calls the Health Extension Program an “innovative” program that reflects Ethiopia’s
“current momentum of international partnership, political commitment and leadership”
(GHWA 2010: 7). And in The Lancet, Donnelly (2010: 1907) claims that with the
Health Extension Program, “Ethiopia had created a model to improve primary health
care for others to follow.”
St Comp Int Dev (2015) 50:455–478 459

What exactly is this program described as so pioneering, innovative, and successful?

Starting in 2003, the Health Extension Program involved the construction of thousands
of new health posts throughout the countryside and the creation of full-time, salaried
health extension worker (HEW) jobs for roughly 34,000 young women who have
completed 10 years of schooling. HEWs receive 1 year of health education before
beginning work in a rural kebele, the lowest level unit of Ethiopia’s federal government
structure. There, they are responsible for a wide range of primary health care services,
including preventive, promotive, and curative health care, as well as data collection and
reporting for monitoring and evaluation. According to both qualitative evaluations and
government claims, health extension workers are closely supervised by district health
officials, local government officials, and health center staff. In return for their work,
health extension workers receive a monthly salary of about $100.
Accolades for the Health Extension Program like the ones described above illustrate
that a government that rules over one of the poorest countries in the world can obtain
significant international recognition for creating community health worker jobs.
Community health worker reforms and “innovation” have become a key indicator of
governmental commitment towards improved population health.1

An Activist State

How did Ethiopia manage to create a salaried cadre of approximately 35,000 commu-
nity health workers? The official narrative begins around the year 2000, when the
Ethiopian Ministry of Health took stock of its progress in meeting the primary health
care needs of the rural population and, disappointed, devised the Health Extension
Program as part of a strategy to accelerate expansion of primary health care and to meet
the Millennium Development Goals (FMOH 2007). According to the official narrative,
Ethiopia’s government announced that it would fund the Health Extension Program
with its own revenues, “demonstrating the commitment of the state” to meeting the
MDGs and improving population health (GHWA 2008: 4). After committing govern-
ment funding, Dr. Tedros Adhanom, the Minister of Health of Ethiopia at the time, as
well as Prime Minister Meles Zenawi, had an easier time lobbying international donors
to provide additional support to the program (GHWA 2008: 6).
Gaining donor support is complex. In the global health development industry, there
is a conventional conceptualization of “sustainability” that prefers funding projects that
will continue to exist after a few years of donor funding end (Swidler and Watkins
2009; Watkins and Swidler 2012). In this approach, creating jobs and paying local labor
with international donor funds is considered a bad idea, because these expenditures
cannot be sustained by cash-strapped local organizations and governments when
1
It is important to note, however, that experts do not really know just how successful the Health Extension
Program has been, in terms of reducing maternal and child mortality in particular. The Global Health
Workforce Alliance admits in a 2008 profile of the program that, “Some improvement has been observed in
health indicators over the last five years, for example, infant mortality in 2005 was 77 per 1000, down from 97
in 2000. However, this cannot be attributed to the HEWs because the first graduates of the programme were
only deployed in 2005. More time is needed before their impact can be fully evaluated” (GHWA 2008: 2).
Teklehaimanot and Teklehaimanot (2013: 9) also clarify that while observed changes in mortality and health
indicators are “likely” due to the Health Extension Program, mediated by increased health service coverage
and health-seeking behaviors, “formal systematic evaluation” is nonetheless required to know the real impact
of the program.
460 St Comp Int Dev (2015) 50:455–478

international funding pulls out. An unwillingness of some organizations to pay for local
labor is also a result of the legacies of structural adjustment, which involved slashing
government payrolls in order to balance government budgets (Pfeiffer and Chapman
2010; Cometto et al. 2013; Goldsbrough 2007). When the International Monetary Fund
discourages governments from raising public sector payroll expenditures, paying for
essential labor becomes widely imagined as financially unsustainable (Dräger et al.
2006; Ooms et al. 2007).2
However, in creating the Health Extension Program, the Ethiopian government appar-
ently used the rhetoric of sustainability in the service of creating paid jobs. Dr. Tedros
Adhanom claimed that the success of the Program hinged upon “engaging health exten-
sion workers as full-time salaried civil servants” and thereby “moving away from volun-
teerism” (WHO 2009). In Ethiopia’s 4th National Health Accounts (FMOH 2010), too,
paid job creation is identified as the key to both the “HEP’s early success and long-term
sustainability.” These statements echo the World Health Organization’s 2008 recommen-
dation that “essential health services cannot be provided by people working on a voluntary
basis if they are to be sustainable” (WHO 2008). These statements and recommendations
are significant in that they mobilize a specific, progressive conceptualization of sustain-
ability that counters the more conventional conceptualization in the field of global health.3
Ethiopia was the first country to sign an International Health Partnership “compact”
with its “development partners,” which helped Ethiopia’s leaders to pool donations that
are not “ear-marked” for donor-driven projects and that thus can be more easily used
for long-term expenditures like health worker salaries (FMOH 2008). This approach is
part of what makes the Health Extension Program “pioneering,” “innovative,” and
“successful.” According to this narrative, Ethiopia’s head bureaucrats became partici-
pants, leaders even, in an activist movement away from volunteerism in primary health
care delivery, through difficult negotiations with donors.

Aiding an Ally

The narrative outlined above provides useful insight into competing notions of sus-
tainability in global health. Yet, with regard to Ethiopia, this narrative is
decontextualized and ahistorical, conjuring a blank slate in which the world begins
around the year 2000, with the announcement of the MDGs and Ethiopia’s leadership
realizing that it needed to greatly invest in primary health care (Easterly 2014). Behind
this narrative, there is a more complex set of processes involved in funding the Health
Extension Program, including Ethiopia’s role in the US/UK-led war on terror, its
contentious human rights abuses, and the impacts these have on Ethiopia’s relationship
to international donors.
2
In contrast, global donors have in recent history been more motivated to raise and spend the money to pay for
high-level “expert” labor (i.e., NGO officers, consultants, and auditors) and medical technologies (i.e., the
products sold by for-profit pharmaceutical and medical technology corporations). The sustainability doctrine
has thus generated a salient inequality between the local, underpaid laborers, and the salaried, transnational
professionals involved in health programs in Africa.
3
The WHO policy recommendation and the designers of Ethiopia’s Health Extension Program implicitly
argue that the widespread reliance on unpaid labor ironically creates programs that are unsustainable, in part
because unpaid “volunteers” are usually poor and hopeful of receiving better opportunities and that truly
sustainable programs must create jobs backed up with a long-term commitment to funding by governments
and global donors (Ooms et al. 2007).
St Comp Int Dev (2015) 50:455–478 461

Ethiopia’s previous regime, a military Marxist force known as the Derg, deposed
Emperor Haile Selassie in 1974 and ruled Ethiopia until 1991. In 1991, the Derg fell to
a coalition headed by the Tigrayan Peoples Liberation Front (TPLF). The TPLF-led
coalition, now known as the Ethiopian Peoples Revolutionary Democratic Front
(EPRDF), still holds power. 4 The Derg signed on to the Declaration of Alma Ata in
1978 and created a community health worker program shortly thereafter (Kloos 1998).
Community Health Agents, as they were called, were supposed to be supported with
donations or tributes of food and money from the community members they served.
Partly because the Derg was stretched too thin by warfare, the regime did not invest
much in the program. A few years before the Derg fell, the World Bank evaluated the
program and concluded it required major investments (Kloos 1998). When the EPRDF
took power in 1991, however, it did not invest in the Community Health Agent
program. More than a decade lapsed before the new regime began to reinvest in the
newly designed Health Extension Worker program.
This decision to invest in primary health care, furthermore, occurred in the wake of
not only the solidification of the MDGs but also Al-Qaeda’s attack on the World Trade
Center in New York City, which led the USA and UK to ramp up its global war on
terror. As Feyissa (2011) explains, the war on terror had already included substantial
investments in the Horn of Africa, targeting the rise of political Islam in Sudan. The
US’ policy of “encircling” Sudan involved establishing a category of what it called
Frontline States, which included Ethiopia in the 1990s. In the 2000s, Ethiopia was
categorized as an “anchor state” in the war on terror and has remained a strategic ally to
the USA (Feyissa 2011: 793–4). As such, Ethiopia receives substantial US military aid
(Feyissa 2011).
It is rumored that the EPRDF made its initial investments in the Health Extension
Program by dipping into its burgeoning military budget (personal communication,
anonymous, 2014). If true, then the Health Extension Program is not a “totally
government funded program.” Instead, the program was financed through US financial
support for the EPRDF’s military and the EPRDF’s subsequent reallocation of funds
from its military to its decrepit rural health system. The reallocation of funds from
Ethiopia’s military budget to its health budget may sound progressive; however, this is
in a context of increasing—not decreasing—militarization in Ethiopia and the Horn.
Even if the rumor is not true, its existence reflects contentious political and economic
processes surrounding Ethiopia’s overall development agenda, including its Health
Extension Program.
In the first years of the new millennium, Ethiopia’s ruling party likely perceived a
double opportunity: to be a US/UK ally and receive military aid that could shore up the
EPRDF against its internal and external enemies and to seriously pursue the MDGs and
thereby keep the international development aid money flowing (Feyissa 2011). The
year 2005, however, presented serious difficulties to the EPRDF. In May 2005, Prime
Minister Meles Zenawi and the EPRDF were faced with apparently unexpected
electoral defeats and election-related protests in Addis Ababa. The party responded

4
For years, Dr. Tedros Adhanom, the previous Minister of Health who presided over the rollout of the Health
Extension Program, has sat on the executive committee of the TPLF, the central core of political power in
Ethiopia. Until his death in 2012, Prime Minister Meles Zenawi was the undisputed leader of the central
committee of the TPLF. After his death, Dr. Tedros was reassigned as Minister of Foreign Affairs.
462 St Comp Int Dev (2015) 50:455–478

with state violence and repression, including the killing of protestors and jailing of
many opposition leaders. In 2007 and 2008, Human Rights Watch released two reports
documenting crimes against humanity perpetrated by the EPRDF military during its
efforts to combat rebels in the Ogaden and Gambella regions. There was an interna-
tional backlash to the violence and repression. Members of the US Congress and other
international donors threatened to defund the central government and to direct money
instead to NGOs and to Ethiopia’s district bureaucracies.
The EPRDF in fact avoided a reduction in international aid channeled through the
central government (Feyissa 2011). As noted above, in 2007, the Ethiopian govern-
ment’s International Health Partnership “compact” with donors advanced Ethiopian
leaders’ efforts to direct development assistance for health into central government
accounts. In 2009, the EPRDF-controlled legislature passed a law that greatly restricts
the freedoms of NGOs and “civil society” (Feyissa 2011). While the international and
domestic NGO community expressed considerable dissent in regard to the 2009 law,
ultimately, they have had to follow suit.5
One way to explain Ethiopian leaders’ apparent ability to pursue this agenda is to
point to Ethiopia’s role as a crucial ally in the war on terror. In 2006, the Union of
Islamic Courts gained power in Somalia and appeared poised to take control of the
country away from the internationally backed Transitional Federal Government of
Somalia. Amid international criticism over Ethiopia’s human rights abuses in the
domestic sphere, the Ethiopian army, backed by the USA, invaded Somalia to defeat
the UIC (Barnes and Hassan 2007). In this context, Prime Minister Meles Zenawi and
Minister of Health Dr. Tedros Adhanom were able to not only avoid losing their grip on
international aid but also move towards a reform of development assistance for health
that would channel more money through the central government.

Moving Away from Volunteerism?

So far, we have shown that the narrative that presents Ethiopia’s leaders as pioneers in
CHW investment obscures important political-economic processes that accompanied
the financing of the Health Extension Program. Also softpedaled or absent in most
international descriptions of the Health Extension Program is the fact that from the
beginning, health extension workers relied heavily on a larger number of unpaid
“volunteer community health workers” (CNHDE 2011). These unpaid community
health workers were given a number of tasks including helping during immunization
campaigns and relaying messages between households and HEWs (CNHDE 2011;
FMOH 2007, 2010). The number of unpaid community health workers was never
publicly tracked, but a conservative estimate is that there were five to ten volunteers for
every health extension worker.
In 2011, the Ethiopian government announced that it would replace the existing
volunteer community health workforce with a “Women’s Development Army,”6 which

5
There is a great need for ethnographic work investigating exactly how domestic and international NGOs as
well as bilateral, multilateral, and private donors have responded and adapted to this law.
6
The Amharic translation is yesetoch lemat serawit. Sometimes the Army is called, in English, the “Health
Development Army,” and sometimes the “Health Transformation Army.”
St Comp Int Dev (2015) 50:455–478 463

would include a huge proportion of the adult women living in Ethiopia’s countryside.
One woman out of every five households would become a Women’s Development
Army “leader,” responsible for promoting the health of five neighboring households,
under the supervision of the health extension workers. These women are usually called
“1-to-5 leaders.” In addition, women called “1-to-30 leaders” are selected to liaise
between a health extension worker and six of the 1-to-5 leaders. All of these leaders are
unpaid volunteers, and tasked with activities similar to those performed by the previous
volunteer CHWs. Thus, much of the health care labor needed by the Ethiopian
government’s flagship program falls to unpaid women.
Given the bold leadership offered by Ethiopia’s government in “moving away from
volunteerism,” why did health officials continue to rely on so much unpaid labor? Part
of the answer is that Ethiopia’s population (at approximately 90 million) is one of the
largest in Africa, and 85 % of the population resides in rural areas. To reach the number
of paid community health workers per capita that the 1 Million CHW Campaign
recommends, there would need to be about four times as many health extension
workers (Earth Institute 2011; McCord et al. 2013). Also, while the Health Extension
Program was initiated during a time of burgeoning global health funding (Ravishankar
et al. 2009), the global recession of 2008 constrained that funding (Benatar et al. 2011).
In 2010, the Global Health Workforce Alliance thus reported that although the gov-
ernment had received a significant amount of pledges to its MDG Fund and pooled
Multi-Donor Trust Fund, “it [was] still far from [the level of funding] needed based on
the joint MDG costing” (2010: 26). Making a clean break from volunteerism may have
seemed unaffordable.
Yet, while the reliance on unpaid labor may have had a basis in budgetary con-
straints, it was supported through yet another layer of narratives, of saving lives,
empowering women, and creating model citizens. We describe each in turn below.
Ultimately, these narratives help solidify a reliance on unpaid women’s labor in the
development industry, even in the face of an emerging global consensus on the
importance of paying community health workers.

Saving Lives

Compared to other nations in Africa and around the world, maternal and child mortality
rates in Ethiopia are high. As shown in Fig. 1, a drop in the maternal mortality ratio

Fig. 1 Maternal mortality ratio

(MMR) in Ethiopia, 2000–2010 MMR,
(from Teklehaimanot and
2000,
Teklehaimanot 2013, based on MMR, MMR,
871
data from the demographic and 2005, 2010,
health surveys of 2000, 2005, 673 676
and 2011)

Year
464 St Comp Int Dev (2015) 50:455–478

(MMR) seen between 2000 and 2005 appears to have stalled in 2010 (Teklehaimanot
and Teklehaimanot 2013). According to Ethiopia’s Demographic and Health Surveys
(DHS), early neonatal death rates were also stagnant between 2005 and 2011 (Central
Statistical Agency and ICF International 2012).
The need to reach Millennium Development Goal targets by lowering these
maternal and child mortality rates is routinely cited as the basis for major invest-
ments in Ethiopia’s rural health care system, by both the government (FMOH 2007,
2010, 2011) and major donors like the Gates Foundation. Health extension workers
and volunteer community health workers, Ethiopia’s Ministry of Health and its
partners say, will hopefully do better in the coming years, particularly in promoting
health facility births (i.e., not home births), as well as antenatal and post-natal care
(FMOH 2011; Teklehaimanot and Teklehaimanot 2013). A post to the Gates
Foundation web blog “Impatient Optimists” provides a typical example of the
saving lives narrative:

Ethiopia…is working diligently to save the lives of women and children; and
it’s doing it with the help of an army of thousands of women. The country is
specifically aiming to reduce child mortality by two thirds and reduce by three
quarters the maternal mortality ratio, all by 2015. Unfortunately some of these
numbers are stubborn in their refusal to decline rapidly enough—or decline at
all… It's why thousands of women are being trained as ‘frontline health
workers’ to spot diseases and get women and children treated as quickly as
possible (James 2012).

Reliance on unpaid community health workers in rural Ethiopia is thus partly driven
by a construction of maternal and child mortality as urgent humanitarian problems by
Ethiopian and Western health officials (see also USAID 2012). When the focus is on
immediately saving lives, questions of wages are eclipsed.
This process can be seen at work in the case of two multi-million-dollar Gates
Foundation-funded projects, L10K and MaNHEP, aimed at reducing maternal and
child mortality in Ethiopia. Both of these projects were implemented through a
partnership between John Snow International, the Ethiopian government, and other
international NGO actors, and via the labor of government-salaried health extension
workers and unpaid community health workers. In their published newsletters and
websites, L10K and MaNHEP construct Ethiopia’s maternal and newborn mortality
rates as major problems.
No efforts have been made to more fully move away from volunteerism in
districts in which L10K or MaNHEP worked. We spoke with high-level staff at
JSI and MaNHEP in Ethiopia, and they were well aware of the ethical and
“sustainability” concerns involved in relying on unpaid labor and questioned the
Ethiopian government’s policy of doing so. MaNHEP even produced a formative
research report that provided evidence that volunteer community health workers
were over-worked and often could not manage all of their farm work, housework,
and community health work (see http://www.nursing.emory.edu/_includes/docs/
sections/manhep/Formative_Research_Report.pdf [accessed May 7, 2015]). But
high-level staff also felt strongly about reducing the number of maternal and
newborn deaths in Ethiopia. If they wanted to carry out their respective projects
St Comp Int Dev (2015) 50:455–478 465

successfully in “partnership” with the Ethiopian government, they had no choice

but to rely on volunteer labor. It was a decision already made by Ethiopian
government policymakers.
Thus, L10K commissioned a consultant to study volunteers’ motivations and
responses to various “nonfinancial incentives.” Based on the study, L10K officials
came up with recommendations for more and better festivals, trainings, visits by health
officials, refreshments, prizes, credit schemes, and “community anchors,” influential
local people who can potentially motivate volunteers to work without a salary (L10K
2010, 2012). Given the perceived urgency of reducing high mortality rates, these
methods of encouraging or pushing unpaid community health workers to reduce these
rates seemed acceptable.

Creating Model Citizens

The creation of the Women’s Development Army in 2011 was supported by another set
of narratives supporting a reliance on unpaid community health labor (Fig. 2). One
pervasive narrative is about creating model citizens. The Health Extension Program
was originally conceived as a way not only to deliver primary health care but to also
create more and more “model households,” households that adopt a full package of
healthy beliefs, desires, and behaviors, and that assume “responsibility” or “ownership”
for their own health, particularly with maintaining sanitation and hygiene, seeking
antenatal checkups, and giving birth within health posts or health centers. As the name
implies, model households are expected to get other households on board and thus
diffuse desirable beliefs and behaviors throughout the population (FMOH 2007;
CNHDE 2011).

Fig. 2 A USAID web publication

that profiled the new Barmy^
reform (Ramundo 2012)
466 St Comp Int Dev (2015) 50:455–478

A Dose of Healthy Discipline

Government documents state that the diffusion of model beliefs and practices was
happening too slowly during the first several years of the Health Extension Program.
Ethiopia’s 2011 Ministry of Health Annual Performance Report (FMOH 2011) notes
that there were many communities and families “lagging behind” in terms of adopting a
“healthy lifestyle,” a major impetus for organizing the Women’s Development Army
(CNHDE 2011; FMOH 2010, 2011; James 2012; Teklehaimanot and Teklehaimanot
2013). The Annual Performance Report portrays the new army as a means of strength-
ening and improving the Health Extension Program and extending it “deeper into
communities and families” (FMOH 2011). In the army, one woman who comes from
a “model household”—an army leader—is to lead the women of five other nearby
households towards a healthier lifestyle.
Connected to the goal of creating model households is an emphasis on discipline. In a
January 2014 article in the UK newspaper The Guardian, Ethiopia’s current Minister of
Health, Dr. Kesetebirhan Admassu, made clear that military-like discipline was an ideal
underlying the Women’s Development Army: “Such a movement would not be suc-
cessful without the discipline of the army… We said this is the way we really want to
mobilise the community…they work with the discipline of an army” (Provost 2014; cf.
Admassu 2013). This rhetoric has resonances to the TPLF's guerrilla struggle against the
Derg in the 1980s, when rural women were mobilized as fighters and lieutenants.7

“The Principal Thing Is Unity in Understanding”

The emphasis on discipline and the intention to create more and more model households
through a pervasive 1-to-5 network point to a core belief of the Ethiopian government:
that unified thinking and behavior across its population is key to achieving economic
growth and the reduction of poverty. This philosophy is further elaborated within a
nonpublic Amharic language document apparently created by a high level government
official, a long series of PowerPoint slides titled “Developing a Change Army”8:

Like a regular army that is arranged for war, all the bodies—from the lower
soldier to the higher leading powers—unite and form the army.

[The Development Army] starts from the top leading power of the country all the
way to the lower army fighter, for example to the rural farm owner…. The
principal thing is unity in understanding and implementation…. It is not possible
to say that a Change Army is established if there is variation in ideas….
7
During the guerilla struggle, the TPLF (the precursor of the EPRDF) also organized women’s associations in
Tigray and denounced women’s oppression under feudal and capitalist regimes (Hammond 1999). However,
as recounted by Yewubmar Asfaw, one woman who fought in the struggle and served as a TPLF cadre
member for several years, the TPLF ultimately sought to subordinate women to the cause of gaining political
control over the country. Some TPLF women sought to pursue a feminist agenda only to face intimidation and
disempowerment from men within the TPLF leadership (http://www.ipsnews.net/2008/11/politics-ethiopia-
disappointed-but-not-defeated/ [accessed May 29, 2015]). More recently, Azeb Mesfin, the wife of former PM
Meles Zenawi and a former woman fighter during the guerrilla struggle, has been the sole woman on the TPLF
central committee (International Crisis Group 2012).
8
The document was apparently written circa 2011 by someone near the top of Ethiopia’s ruling party.
St Comp Int Dev (2015) 50:455–478 467

During formation of this Change Army, there will be struggle between develop-
ment and rent-seeking. We must make the developmental front prevail… By
[organizing the Army], we can have an unbreakable impact on rent-seeking and
shift the power to the side of development once and for all, in an undisputable
way.

The construction of “rent-seekers” as enemies who must be indoctrinated is a

particularly important one. The government aims for a citizenry that will not seek to
support themselves through patronage from the state but instead will be productive
farmers and entrepreneurs, creating wealth and “development” not only for themselves
but also for the entire country (Little 2013; Segers et al. 2008; Brown and Teshome
2007; de Waal 2012).
Accordingly, the Women’s Development Army is expected to work without seeking
“rent,” that is, without expecting any sort of payment. In fact, the government has
stipulated that army leaders not be given any incentives by international NGOs or
bilaterals. One national-level NGO staff told us that the government had recently
prohibited providing nonfinancial incentives for volunteer community health workers
and that NGOs were now prohibited from giving army leaders so much as a T-shirt or
an umbrella. One NGO official said he had been told regarding army leaders, “don’t
touch them.”9
Through a focus on discipline and “development mindedness” as opposed to “rent-
seeking,” high-level government officials foreclose discussion of payment and instead
focus on the special kind of goal that army leaders will pursue: turning people into
model families, systematically and quickly. Creating compliant patients is of course a
goal of many health systems and global health interventions (Nguyen 2010). But the
EPRDF’s conception of model households goes beyond the domain of behaviors like
using bednets and getting prenatal checkups. Creating model households may also
mean encouraging the population to support the EPRDF’s medium-term hold on power
and to be satisfied with contributing unpaid labor to state-led programs (Bach 2011;
Emmenegger 2011; Little 2013).
The EPRDF maintains a philosophy and style of government that encourages
strong state power over the economy, promoted by the party as abyotawi
(revolutionary) democracy (Bach 2011; Data Dea Barata 2012; de Waal 2012;
Feyissa 2011). Mega-dam construction, large agrarian land leases to foreign inves-
tors, and achieving Millennium Development Goals are crucial elements in the
ruling party’s development dream of becoming a middle-income nation and a
regional power in East Africa in the next couple decades (Feyissa 2011; Teferi
Abate Adem 2012; Little 2013; Abbink 2012; Verhoeven 2013; 2015; Jones et al.
2013; de Waal 2012). Yet, they are still highly dependent on international donors
and beset with governing a massive rural population they see as having “backward”
beliefs and behaviors. With its ideology of abyotawi democracy, the ruling party has

9
He added, “the government doesn’t want us to go below the Health Extension Workers.” His NGO had also
been clearly directed to do “no training whatever” of army leaders and members. When asked why this
restriction on training was in place, the official responded that the government wants to show its people that
health-development “is a government effort, without any external input.” Other NGO officials also speculated
that restrictions on training and remuneration were to ensure that the government had control over motivations
and incentives, thus increasing their influence vis-à-vis NGOs.
468 St Comp Int Dev (2015) 50:455–478

thus aimed to maintain state power not only over the macro economy but also over
social organization and peoples’ basic beliefs and desires.
Many farmers in agrarian Ethiopia say they feel the government treats them as
people in need of indoctrination and micro-management from the top-down (Little
2013; cf. Abbink 2012 regarding southern agro-pastoralists). Recent ethnographers of
agrarian Ethiopia describe a reality in which peasants do not simply volunteer their
labor to agricultural and other development projects led by the state. Rather, peasants
participate and donate labor in order to demonstrate their support for (or their lack of
open opposition to) the ruling party. If peasants choose not to participate, they risk
fines, confiscation of farmland, lack of access to key resources doled out by the
government, and imprisonment (Harrison 2002; Lefort 2007; Little 2013; Teferi
Abate Adem 2012; Abbink 2012). A Women’s Development Army with “unity in
understanding” fits this pattern of government mobilization against rural people’s
putative backwardness, tendency towards rent-seeking, and thus lack of development
(Little 2013).

“They Work for Themselves”

When asked why Women’s Development Army leaders should not be paid,
district level officials—in contrast to national-level documents—did not engage
in ideological talk about rent-seeking. Instead, they said that leaders in the
Women’s Development Army are not working for the government but are
working for themselves.
Some district health officials claimed that the women’s army leaders are
simply expected to tend to their routine “housework” with more hygiene in
mind, to take care of their own health, and socialize with other women like
they usually do, but now with a goal to spread and reinforce healthy household
behaviors. Other officials asserted that army leaders were fulfilling their own
personal interests through their work and thus did not deserve pay from the
government. One said, “They work for their own children, for their own
families… So, the idea is, for the development of their own community, they
should work by being committed without any payment.” Another explained,
“They are not working for somebody else but for themselves. Once they are
made clear and aware of this, they work with the understanding that their work
is totally for themselves.”
But army leaders are expected to do more than their own housework and
neighborhood socializing. A mid-level Ministry of Health official noted that the
ministry intended that army leaders would “take over” the promotive and preventive
health care aspects of the Health Extension Program. Army leaders are also sup-
posed to help compile health data and report it to the government.10 Several district
level health officials said that the introduction of the Women’s Development Army

10
One district level official hoped that the “hard” work—physical labor and extensive recordkeeping—would
soon become the responsibility of the Women’s Development Army once the army was “strengthened.”
Noting their responsibilities, one high-level NGO official commented, “Of course [what the army does is]
work.”
St Comp Int Dev (2015) 50:455–478 469

had already successfully eased the workload of health extension workers. One
explained:

In previous times, before the development army was established, the HEW had to
go to each house for her work, but now the HEW supports the development army
leader… So, the person that the HEW now directly interacts with, which was
previously with each household, has become closer: it is the development army
leader.

Thus, the claim that army leaders are working “totally for themselves” sidesteps the
fact that their jobs are supposed to take over some of the workload of health extension
workers—that creating model citizens and monitoring this process is in fact work.
Taken as a whole, the Creating Model Citizens narrative is a powerful example of a
health initiative involving an attempt to increase state power: both through the creation
of a “disciplined” population, one that follows government mandates rather than rent-
seeking, and also perhaps by putting greater pressure on rural populations to support the
ruling party (Foucault 1977, 2008; Ferguson 1990). The program is, of course, unlikely
to work so neatly in practice; this narrative reveals only the state’s intentions, not what
is actually happening in rural districts. On one level, in good neoliberal fashion,
improvements in health in this conception will come not from additional state services,
but from changes in the behavior of the poor (Goldstein 2001). This narrative promotes
claims that by engaging in healthy behaviors exemplified by “model families”—and by
engaging in behavior change work for free, without engaging in rent-seeking—health
will improve independent of state provision of higher quality health services.
This is not to say that the Ethiopian government, through the Health Extension
Program, has not made significant efforts to improve health care in rural areas.
Government legitimacy in the eyes of both peasants and of international partners
appears to depend in part on genuine attempts to deliver better health care. Still, the
Creating Model Citizens narrative may function to relieve some of the pressure state
leaders feel to both provide more services for citizens and pay citizens for their labor.
Providing health care infrastructure and strengthening control over the behaviors/
lifestyles of citizens are attempts both to improve population health and expand state
power.

Empowering Women

One of the most pervasive claims made by Ethiopia’s Ministry of Health is that
women are being empowered by the Health Extension Program and Women’s
Development Army (e.g., FMOH 2007). “These development [army] teams,” says
Ethiopia’s Health Sector Development Plan, “are being empowered to monitor
health and well-being” (FMOH 2010). These claims reflect the fact that “gender
mainstreaming” is an official “focus area” within the government’s development
plans (FMOH 2010).
These narratives do not, of course, exist in a vacuum. The narrative that women’s
empowerment will lead to development is currently a powerful one globally. “Promote
gender equality and empower women” is a Millennium Development Goal. Nicholas
470 St Comp Int Dev (2015) 50:455–478

Kristof and Sheryl WuDunn (2009) write that the goal of their bestselling book Half the
Sky (which uses a photo of a starving Ethiopian girl to draw readers into the
Introduction) is to “recruit you to join an incipient movement to emancipate women
and fight global poverty by unlocking women’s power as economic catalysts” (p. xxii).
Melinda Gates (2014) was recently given space in the journal Science to argue that
“there are strong associations between women’s empowerment and specific health and
development outcomes” (p. 1274).

“They Are All Happy”

This narrative had powerful reach within the Ethiopian government system; its
rhetoric was pervasive among district health officials.11 To “empower” women to
participate more fully in Ethiopia’s development, district health officials said they
needed to convince men, and husbands in particular, to support the greater
participation and autonomy of women. Men, they said, typically influenced every
aspect of women’s lives, “taking every power for themselves,” and expected
women to stay in the house and refrain from “meeting and discussing things
together out of the house,” except perhaps at church. Through the Women’s
Development Army, a district official claimed proudly, women “now have the
freedom to communicate with their husbands,” and to converse with women and
even other men outside of the home. “Being able to talk freely like men is a big
change,” he said.
Empowering women and increasing their autonomy vis-à-vis husbands through the
army reform, district officials further claimed, improved women’s lives. District offi-
cials said that by helping women to increase their knowledge, expand their social
networks, and “develop their leading ability” through new social interactions, the
development army was “making their lives better.” District officials also argued that
such empowerment provided emotional benefits to women—happiness—“even with-
out payment”:

Starting from the leaders, they are all happy. I am not exaggerating when I say
that women, in the past, used to be in the forest and knew nothing about leaving
the village. Even leaving the home for health services was difficult due to the
men’s customs. Now, women are happy, even without payment, because being a
WDA member means being able to talk freely and move outside the home like
men.

Talk of empowerment primarily arose when officials were discussing unpaid com-
munity health workers and women among the peasantry more generally. District
officials did not explicitly connect the job responsibilities of paid health extension
workers to the idea of empowering them.12

11
The extent to which they believed it is not knowable given our methods, but they incorporated the narrative
fully into their rhetoric.
12
This is not to say that the empowerment narrative does not exist within discourse about HEWs. Dr.
Tedros Adhanom, other ministry leaders, and their development partners make much of providing health
extension workers with not only a salary but also opportunities for some to continue their education and
careers (USAID 2012).
St Comp Int Dev (2015) 50:455–478 471

Alma Ata, Participation, and Empowerment

When talking about female community health workers, the empowerment narrative
draws not only on global narratives of women’s empowerment but also on global
narratives of CHW work as community empowerment. Historically, community health
workers have been closely connected to the idea of local community participation in
health systems. Early models of local participation included China’s barefoot doctors as
well as village health teams organized by Christian missionaries in Africa and else-
where (Cueto 2004; Lehmann and Sanders 2007; Basilico et al. 2013). In 1978, the
well-known Declaration of Alma Ata affirmed community participation as central to its
goal of “health for all.” It advocated the “full participation” of communities in health
provision and emphasized that primary health care “requires and promotes maximum
community and individual self-reliance and participation in the planning, organization,
operation and control of primary health care.” The language in the Alma Ata
Declaration clearly connects local participation in primary health care to a pursuit of
social justice (Muller 1983; Cueto 2004), the ability of socially and politically margin-
alized people to control their health care system and hold states, donors, and health
development foundations accountable.
Following Alma Ata, community health worker programs were frequently concep-
tualized as being central to such community participation. However, many CHW
programs were actually statist and top-down, rather than autonomous movements
seeking health equity and social justice (Basilico et al. 2013; Maupin 2011). Such
outcomes illustrate the durability and resistance to change of health care bureaucracies
controlled by elites including doctors, government officials, and international donors
(Nichter 1999).
When it comes to the recent resurgence of interest in community health workers
in poorer countries, it is important to investigate whether a social justice orientation
remains at the margins (Arvey and Ferndanez 2012). In language, today’s CHW
programs are much less likely to refer to goals of social justice than in previous
decades (Lehmann and Sanders 2007). Based on his work with community health
workers in Mozambique, anthropologist Ippolytos Kalofonos (2014) explains that
the role of CHWs “has shifted from ‘change agent’ to ‘extension worker,’ oriented
towards technical and community management functions” rather than towards
social justice.
Global narratives construct female community health workers as improving health
and empowering themselves simultaneously as a result of their participation in health
work (Ramirez-Valles 1998). Because community health workers ideally meet people
on their level and provide them with intimate, quality care, their roles are often said to
provide them with experiences of emotional and spiritual satisfaction (Maes et al. 2010;
Maes 2012). These narratives of intrinsic satisfaction and empowerment form a
powerful moral economy around community health workers.

Critiques of the Women’s Empowerment Narrative

Jesus Ramirez-Valles explains that the women’s empowerment narrative typically

represents “third world and non-white” women as children who are “transformed,
enlightened, and admired for their efforts despite adversity” (Ramirez-Valles 1998).
472 St Comp Int Dev (2015) 50:455–478

Laila Kabeer (1999) argues compellingly that descriptions of the “average

disempowered third world woman” flatten significant social differences between wom-
en and create an analytical frame of an oppressed woman that lacks any social context
and fails to acknowledge the power that many women do wield (see also Malhotra and
Mather 1997).
When women’s participation in development programs is based squarely on women
as central to domestic life and the domain of health, gendered power structures may
actually be reinforced (Molyneux 2006). While poor women are frequently conceptu-
alized as having time to give (Budlender 2004), women are often “an over-utilized not
an under-utilized resource” (Elson 1999). The inherent contrast between using women
to make health development interventions more cost-effective and simultaneously
describing them as “empowering,” lead Katherine Brickell and Sylvia Chant to de-
scribe the idea that women are naturally accustomed to and happy to engage in unpaid
“altruistic” work as “one of the deepest bastions of gender inequality” (Brickell and
Chant 2010; Chant 2008).
Detailed ethnographic research on other CHW programs show that women’s
relationship with their work is complicated—that it empowers them in certain ways
and deeply limits them in others. In some contexts, the ability to travel outside the
home is important, and women find the health work that they do interesting and
meaningful. Yet, their position at the bottom of the health system hierarchy is one in
which they have very little power and is a position that many find oppressive
(Closser and Jooma 2013; Khan 2008; Maes and Kalofonos 2013; Mumtaz et al.
2003; Scott and Shanker 2010).

The Value of Women

The decision to create the Women’s Development Army represents an explicit shift in
the gender makeup of unpaid community health workers—from men to women
(CNHDE 2011). In the past, both men and women have been compelled by the ruling
party’s district and local level arms to participate in building roads, digging rainwater
harvesting pans, terracing farmland, and promoting the Health Extension Program,
among other tasks. The Women’s Development Army is another installment in a series
of “mass mobilization campaigns,” this one focused intently on women’s beliefs and
behaviors.
Why has the Ethiopian state decided to focus on women in this way? District
officials told us that women are “naturally” suited to housework, family health,
and hygiene, and thus to meeting the health-related Millennium Development
Goals. District officials also said it was easier for women, as opposed to men,
“to accomplish the work of health at home.” In addition, district officials felt
women were ideally suited to convincing other women to adopt preferred
behaviors:

We are now observing big changes since the transition [from male to female
community health workers]. In previous times, approximately 30 women per year
in each district would deliver in health facilities. In this past year since the
transition, approximately 2000 women delivered in health facilities, assisted by
trained health professionals.
St Comp Int Dev (2015) 50:455–478 473

Another district level official said, “If we have women with us, it means that we
have the family with us, the community with us, and hence the whole country with
us… So, everything will be tied together by them, the women.” As community health
workers, then, women are framed as being more effective and thus more valuable than
men.
District officials also valued women because they perceived them as less likely to
expect pay. A health extension worker agreed that the Women’s Development Army
reform represented an opportunity to engage a naïve workforce not “habituated” to
payment:

It will not be good if they habituate to money. Men got used to money because
they got paid for training and vaccination campaign work. It was a problem that
they got habituated to money.

One district health official also compared male volunteer community health workers
to the Women’s Army leaders:

In previous times, it was the men who were attaching this work to incentives and
needing incentives… But the women do not know such kind of incentives from
the very beginning… The women do not expect money.

Thus, even as officials say they are empowering rural Ethiopian women to be more
equal to men, officials at the district level value their female workers specifically for the
ways in which, unlike men, they are associated with housework and less likely to
demand payment.
There are still other perspectives on why women are particularly valuable to
Ethiopia’s government. An expert on Ethiopia’s agricultural development sector told
us that the ruling party has identified women as an important constituency that had not
yet been sufficiently organized and pushed to adopt its philosophy and goals. Many of
our interlocutors in Ethiopia—but not district level health officials—told us that they
perceive that the ruling party created the Women’s Development Army partly to
solidify a countrywide, grassroots network of women who will conduct surveillance
over their neighbors.
In Ethiopia, health extension workers are supposed to sit on local government
(kebele) councils or cabinets, which officially gives them a way to advocate for
themselves and for the people they serve (FMOH 2010). The Global Health
Workforce Alliance argues that in Ethiopia, this arrangement leads to HEWs
having “good relationships with decision-makers at [the] grass-roots level”
(GHWA 2010: 16). But being a member of a local governing council in the
EPRDF’s Ethiopia does not necessarily empower health extension workers or
Women’s Development Army leaders to, for example, negotiate over their remu-
neration and job conditions or to hold the government accountable for the injus-
tices that they and their fellow villagers see and live every day. Instead, these
councils may primarily serve as a venue to take orders and report back on their
activities (cf. Abbink 2012). The actual consequences of the Women’s
Development Army and Health Extension Program on peoples’ lives, and the
ways that people are making their own attempts to reinforce, shape, and/or resist
474 St Comp Int Dev (2015) 50:455–478

these programmatic reforms and their associated discourses, demand in-depth and
sustained ethnographic investigation.13

Conclusion: Unpacking the Rationales for Unpaid Work

The creation of the Women’s Development Army is tied up in complex political

and moral economies and serves a constellation of interests beyond simply the
provision of health services. The political economy of aid and government
revenue generation largely dictates how much international funding is available
to pay community health workers, particularly over the long term. Further, the
political economy within Ethiopia reflects governmental desires for model,
compliant citizens that support the EPRDF, and carry out specific behaviors
like limiting their fertility and giving birth in government facilities. Ethiopian
officials can take advantage of the reemerging interest in community health
workers and the push to create CHW jobs to advance their goals of legitimizing
the government and strengthening its rural presence (cf. Ferguson 1990; Abbink
2012). In tandem with these political economies are powerful moral economies
that tout the importance of saving lives—especially the lives of mothers and
children (Fassin 2013)—and the importance of “empowering” women vis-à-vis
their husbands.
The political objectives of the Women’s Development Army are fairly clear to
NGO and donor officials in the capital. Interviewees repeatedly speculated, for
instance, that the Women’s Development Army could be used as a surveillance arm
of the EPRDF. However, their awareness of these factors had little effect on their
public support of the program.
Discourses promoting women's empowerment and saving lives can foreclose
discussions about giving CHWs rights to organize and take a seat at the policy
table. The emergent moral economy of community health work thus prevents the
potential needs and desires of the workers themselves from being seriously
examined and is likely to create new inequities and reshape existing ones.
These political and moral economies overshadow goals to “move away from
volunteerism” and to champion a new approach to CHW payroll “sustainability”
in global health, goals that both the Ethiopian government and international
donors have espoused. Narratives about empowerment, resource scarcity, and
saving the lives of children and mothers are empirically questionable but extremely
powerful.

13
From our preliminary observations in three districts of rural Amhara, the intended empowerment of
Women’s Development Army leaders appears to reference only potential empowerment within the family,
and not empowerment within the health bureaucracy. Neither health extension workers nor army leaders
appear to be more “empowered” by these programs in the sense of holding higher level officials accountable,
openly questioning policy and practice, and advocating for social and political changes (Maes et al. 2015).
Recent qualitative work conducted in another part of Amhara regional state by Banteyerga (2014) suggests
that through these same programs, Ethiopia’s government is in some cases genuinely encouraging more
women to make open requests and demands of government, pertaining to their desires for more easily
accessible health centers (not just the smaller and less comprehensive health posts), better selection and stock
of medicines at government pharmacies, and warmer, better quality health care within health centers and
hospitals. Future work in various parts of Ethiopia is needed to understand this variation.
St Comp Int Dev (2015) 50:455–478 475

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Kenneth Maes is assistant professor of Anthropology at Oregon State University. He has studied community
health worker programs in Ethiopia since 2006, and recently edited a volume on Community Health Workers
and Social Change: Local and Global Perspectives (Annals of Anthropological Practice, 2015).

Svea Closser is associate professor of Anthropology and director of the Global Health program at Middlebury
College. She is author of Chasing Polio in Pakistan (Vanderbilt University Press, 2010) and coeditor of the
third edition of Understanding and Applying Medical Anthropology (Left Coast Press, 2015).

Ethan Vorel recently graduated from Middlebury College, where he received his B.A. in English and
American Literatures. He is currently a first-year graduate student at the Warren Alpert Medical School at
Brown University.

Yihenew Tesfaye is a doctoral student in the Applied Anthropology program at Oregon State University, and
holds a M.Sc. in Biomedical Sciences from Addis Ababa University. His research interests include the
experience of household water insecurity, governance over water resources, and the roles of community
health workers in global health interventions.