| 4. In which ways is the initiative creative and innovative?
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As a major nationwide health program, HEP required substantial investment in human resources, health infrastructure, and provision of equipment, supplies and commodities, as well as other operations described as follows.
Step I: Human Resources:
Candidate HEWs are women aged 18 years or older with at least 10th grade education.
HEWs were selected from the communities in which they reside in order to ensure acceptance by community members. Committee comprised of member from the local community, representatives from the Woreda Health Office, Woreda Capacity Building Office and Woreda Education Office led the selection process. Following selection, the HEW completed a one-year course of training which includes coursework as well as field work to gain practical experience.
Step II: Construction of Health Posts:
The operational center of the HEP is the Health Post, which functions under the supervision of the nearby catchment health centers and Kebele administration. Health Posts are located at Kebele level to serve a population of 5,000 people. Where possible, Health Posts are located near other public services and institutions (Kebele Administration offices, schools, agriculture) to foster coordination among government service providers. Each Health Post is staffed by two HEWs.
Step III: Procurement of Supplies:
Health Posts are equipped with materials and supplies required to deliver the 16 health packages of essential services to the community. 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.
Step IV: Deployment of HEWs and Provision of Services:
Two HEWs are deployed in every Kebele with an average of 5,000 populations, one HEW for an average of 2,500 populations. As soon as they are deployed they contact the community and kebele leaders, visit every household and collect baseline information and understand community’s health situation, identify priority problems by consulting the community and kebele administrators and other government service prviders in the kebele, proposes and implement key activities to address identified gaps with the engagement of the community and monitor progress.
Health Extension Workers are required to spend half of their time conducting outreach activities by going from house to house and the other half by providing services at health posts. During home visits, HEWs are expected to teach by example like helping mothers care for newborns, cook nutritious meals, construction of latrines and disposal of pits. They utilize the following three approaches to implement the health extension packages.
1) Model Families
The main aim of the health extension program is to get families graduate as model families by implementing all the necessary packages of the HEP within their own family. To facilitate their work HEWs identify positive deviant community members called “innovators”. Health extension workers will closely work with the identified innovators to recruit early adopters who can be used to influence other community members. An average of 40 – 60 early adopters/innovators will be trained by HEWs for a total of 96 hours, which might take about four months. The training will be participatory, practical, and action oriented. Soon after the training the trainees are expected to implement it in their own life. Through this process when the trainees get the key health actions implemented in their own life they will graduate in a big community festival and they will receive certificates. The graduated model families will be supported to remain models and they will be encouraged to work with the HEWs as volunteers.
In summary model families have been involved in other development work; they are accepted by the community as early adopters, and they enjoy the credibility which comes from having adopted health practices and become role models. As role models, model families help in diffusing health messages. This leads to the adoption of improved health practices and behaviors by the community.
2) Community Based Health Packages
In addition to the model family activity HEWs implement community package which aims at communicating health related messages by involving the community at different stages, from planning to evaluation. To strengthen the community structure below the health extension worker the Ethiopian government launched “Health Development Army”. This is an initiative designed to scale-up best practices of the HEP for wider coverage with particular attention to family health services. Women are organized in smaller groups of six families in their neighborhood one serving as leader namely health development army and the other five will be followers. The leaders are those who are early adopters and graduated model families who will take initiative to move other families to follow their practice. In addition to using the health development army HEWs use different community networks, schools, women and youth associations to communicate messages.
3) Health Posts
The other mechanism used by HEWs to improve accessibility of services is through delivering services at Health Post level. At the Health Post, HEWs provide antenatal care, conduct normal and safe deliveries, administer vaccines, assess and manage sick children, provide treatment for Malaria, conduct growth monitoring, provide nutrition counseling, offer family planning services, and organize referrals for services to the general population of the kebele.
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| 5. Who implemented the initiative and what is the size of the population affected by this initiative?
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The HEP was designed under the leadership of the government with technical support from stakeholders. The community participated actively in; building residence for HEWs, construction of health posts, mobilization of clients for services, and volunteering to serve as health message promoters and role models.
The government’s Technical and Vocational Education and Training center provided the one year pre-service training with field experience for the HEWs while Ministry of Health and Regional Health Bureaus provided intensive technical support during the training process. Providing on the job technical assistance, supportive supervisions, distribution supplies and commodities and other operation are primarily led by the government through the Ministry of Health, Regional Health Bureaus, woreda health offices and health centers with support from donors and nongovernmental organizations.
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| 6. How was the strategy implemented and what resources were mobilized?
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The development of training curriculum and training manuals, facilitating the recruitment of candidates, providing the actual pre-service training, deploying the HEWs and paying their salary, constructing and equipping health posts, providing on the job technical assistance, providing continuous refresher trainings, providing supplies, and other related activities were the associated costs.
Government, the community, donors, and nongovernmental organizations jointly covered the expenses. Government covered expenses related to establishing and running the program using domestic resources, loan, and donations. Nongovernmental organizations contributed in filling gaps during the training, deployment, and start-up of the program and in providing continuous support to enhance the functionality of the program. The community contributed in the construction of health posts and HEWs residence.
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| 7. Who were the stakeholders involved in the design of the initiative and in its implementation?
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Some of the most successful outputs of the program are:
1)Access to basic primary health care services increased: by deploying two HEWs at every village access has been significantly improved. Previously communities needed to travel long distances to health centers to get these services.
2)Relationship between communities and health services strengthened: as HEWs work closely with communities strong linkage and interaction has been established.
3)Health seeking behavior improved: health seeking behavior has been increased through consistent health education, community conversations, model family trainings, and other related work.
4)Utilization of key preventive and promotive health care services increased: since the launch of the health extension program utilization of services has increased. Malaria has been under control through the implementation of key preventive care including use of Insecticide Treated Nets and early diagnosis and treatment services by HEWs.
5)Hygiene and sanitation practices improved: use of latrine and clean home management practices has been adopted by majority of the community.
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| 8. What were the most successful outputs and why was the initiative effective?
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Health Extension workers report their monthly accomplishment to supervising health center, woreda health office and kebele administration based on standardized reporting template. The health center and woreda health office review the report, identify areas needing improvement and provide support to improve their performance. On top of this, experts from health centers and woreda health offices make visits to health posts every week to help HEWs accomplish their task, identify gaps and provide support to address them.
With regard to evaluation, the overall performance of the program is evaluated every year by external body through “Joint Review Mission”. Different large-scale national surveys including series of Demographic Health Surveys are carried to evaluate the impact of the program.
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| 9. What were the main obstacles encountered and how were they overcome?
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Some of the challenges facing the program are:
•Lack of means of communication and transportation impeding supervision and reporting,
•Woreda Health Offices lack sufficient capacity to provide supportive supervision/monitoring and evaluation, and
•Weak referral system.
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