Health Extension Programme (HEP)
Federal Ministry of Health, Ethiopia

A. Problem Analysis

 1. What was the problem before the implementation of the initiative?
The Ethiopian health sector development program review carried out in 2002 came-up with important gaps limiting access to primary health care services to the needy population. Some of the identified gaps were; •Basic health services had not reached the needy at the grass root level, •The expansion of health facilities delivering primary health care has been limited, •There has been gaps in applying the core principles and practices outlined in the health policy, and •There was uneven distribution of health facilities meant to deliver primary health care services. Primary health care (PHC) services were not reaching the poor, illiterate, women and children. Hygiene and sanitation practices were not universally adopted with low coverage of latrine use and poor home management and living condition. Nutrition practices; poor infant and child feeding, inappropriate maternal nutrition, and micronutrient deficieny were highly prevalent. Malaria, diarrhea, pnuemonia, malnutriton, and vaccine preventable disease were claiming the lives of many children. Communicable disease like malaria were highly prevalent with recurrent and widespread epidemics and Tuberculosis was also affecting significant proportion of the population. HIV/AIDS has been highly prevalent particularly in urban areas due to risky sexual practices among the adult population particularly among youth within the age group of 15 to 24 years. In summary although Ethiopia has been progressing toward ensuring accessibility of PHC services it was beyond the actual need of the community. These alerted the government to develop new ideas and strategies to accelerate change towards healthy lifestyle and improved living condition with particular attention to the rural population.

B. Strategic Approach

 2. What was the solution?
Cognizant of the problem the Ethiopian government with the support of stakeholders designed and implemented the Health Extension Program (HEP). The basic philosophy of the HEP is to transfer ownership and the responsibility of maintaining health to individual households so that communities will be empowered to produce their own health as a product with focus on disease prevention and health promotion. It is healthcare delivery by the people, of the people and for the people. It involves the community in the whole process of healthcare delivery and encourages them to maintain their own health. The overall goal of HEP is to create a healthy society and reduce preventable morbidity and mortality with particular attention towards improving maternal and child health. The objectives of the HEP are: •to improve access and equity to preventive essential health interventions at the village and household levels, •to ensure ownership and participation among communities by increasing health awareness, knowledge, and skills among community members, •to promote gender equality in accessing health services, •to improve the utilization of primary health care services by bridging the gap between the communities and health facilities through HEWs, •to reduce maternal and child mortality, and •to promote health life style. The core principle of HEP is to live with the community, learn from them, love them and everything with them and let them feel that they have done it themselves. The main principles of the program are; •Communities need to identify and prioritize their own health needs, •Use the untapped skill and knowledge in the community, •Respect community’s priorities, interest, wishes, •Involve women in all decision making process, and •Promote community ownership, empowerment, autonomy and self-reliance. Implementation strategy Health Extension Workers (HEWs) are the center piece of the HEP. They are females age 17 years and above with 10 grade complete or above who received one year pre-service training. They are selected from the community that they serve. Due to this they speak the local language, live with their community, and serve their own community. On average one HEW will serve a total of 2,500 populations. Two HEWs are deployed per village locally called kebelle which is the smallest administrative unit with an average of 5000 population. At a kebelle level HEWs are tasked to lead health related activities from planning to execution and monitoring. Primarily they are responsible to get 16 health packages implemented properly in their village. These packages were identified based on the health needs of the Ethiopian community. The 16 health packages are categorized into four major components. The first categories are related to hygiene and sanitation. The seven packages under hygiene and sanitation are personal hygiene, water and sanitation, food hygiene, latrine, solid/liquid waste disposal, housing condition, and insects and rodents control. The 2nd category is Family Health and the five packages under this category are Maternal and Child Health, Family Planning, Nutrition, and Adolescent Health. The 3rd category is related to Disease Prevention and Control. The three packages under this category are HIV prevention and control, Tuberculosis prevention and control, and Malaria prevention and control. The fourth category is health education which is a crosscutting intervention. Health extension workers were tasked to work closely with communities in the delivering preventive, promotive and limited curative care under the 16 health packages in every village in Ethiopia to address identified gaps with respect to reaching the needy population.

 3. How did the initiative solve the problem and improve people’s lives?
This initiative is creative and innovative in many ways. One, the fact that almost all HEWs are females helped to enhance use of maternal and child care services and hygiene and sanitation practices. HEWs were able to establish trusted link with women in the community who have key role in changing the health of their families. The second innovative approach was the recruitment of HEWs from their local areas that contributed to easy and fast adjustment to their work place. The other innovative approach was the “Model Family” training process by which early adopters are selected to receive training on key health extension packages for about 96 hours in four months and graduate when they practice what they have been trained on. After their graduation they are expected to maintain their behavior and influence other community members to adopt similar practices. Others in their neighbor are expected to adopt similar practices by learning from them. The networking of communities into “one to five network” so that they will support each other, identify their health problems, develop action plan to address them and implement concrete activities to address identified gaps helped to organize the community for stronger link with the health extension workers

C. Execution and Implementation

 4. In which ways is the initiative creative and innovative?
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.

 5. Who implemented the initiative and what is the size of the population affected by this initiative?
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.
 6. How was the strategy implemented and what resources were mobilized?
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.

 7. Who were the stakeholders involved in the design of the initiative and in its implementation?
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.

 8. What were the most successful outputs and why was the initiative effective?
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.

 9. What were the main obstacles encountered and how were they overcome?
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.

D. Impact and Sustainability

 10. What were the key benefits resulting from this initiative?
Since its rollout in 2004, the health extension program (HEP) has shown substantial outcomes in areas related to disease prevention, family health, hygiene, and environmental sanitation. The program has improved the skewed distribution of health facilities and human resources. In five years, Ethiopia’s human resources for health doubled as a result of the deployment of more than 34,000 HEWs. A 2010 study indicates that about 92% of households were within an hour’s (5 km) distance from a health facility. HEP has enabled Ethiopia to increase primary health care coverage to 76.9% in 2005 and 90% in 2010. A 2010 nationwide study found that over half (52%) of the health posts were open for at least five days a week, and about 62% were open on Saturdays and/or Sundays. It also found that most health posts provide immunization (89.7%), family planning (87.7%), and antenatal care (86%) services. However, less than 50% offered delivery services (45.1%), outpatient treatment program (33.2%), and management of childhood illnesses (31.7%) (FMOH 2010). In addition, a community satisfaction survey covering more than 10,000 people indicated that 60% of the respondents rated all components of the HEP services as very satisfactory or satisfactory, with family planning receiving the highest score (76.5%). (FMOH 2010). Data from the 2011 Demographic and Health Survey (CSA and ICF International 2012) indicate the following improvements in health indicators between 2005 and 2011: under-five mortality declined from 123 per 1,000 live births to 88 per 1,000 live births; the contraceptive prevalence rate increased from 15% to 29%; the total fertility rate decreased from 5.4 to 4.8; skilled birth delivery increased from 5% to 10%; and the use of insecticide-treated nets increased from 1.3% to 42%. Even though, it is difficult to directly link the aforementioned results to the HEP, there is no question about its significant contribution to the achievements. Since the introduction and deployment of HEWs, there has been an increase in the proportion of women who have utilized family planning, antenatal care, and HIV testing. As per the 2011 EDHS 27% of family planning users obtained their contraceptives from health post or Health Extension Worker (HEW). This proportion increased from 16% in 2005 and it was nonexistent in 2000. In addition, a home visit during pregnancy has generally improved utilization of maternal health services. A strong evidence of a dose-response relationship has been demonstrated between the HEP and better maternal and child care practices, which indicate that the program is an effective platform for improving family health practices at scale (Karim, 2013). According to study done in West Gojjam zone, Amhara region, “model families” were 3.97 times more likely to use contraceptives compared to those who are not model families. Model family status contributed to 29.3% of the increase in current contraceptive utilization (Mezgebu, 2014).

 11. Did the initiative improve integrity and/or accountability in public service? (If applicable)
Government is leading the design and implementation of the initiative, which is key to sustainability. From the recruitment, training, deployment of HEWs to continuous ongoing follow-up and support the program is fully owned and led by the existing government system. The other key factor to suitability is community ownership. The community provides continuous support for HEWs, facilitate their work, and mobilize resources for different activities as needed. The establishment of the community health development army with “one to five” network will serve as an important platform to sustain the HEP.

 12. Were special measures put in place to ensure that the initiative benefits women and girls and improves the situation of the poorest and most vulnerable? (If applicable)
Developing such cost effective and easily scalable initiative helps to get primary health care services near to households addressing distance, cost and other related factors as barriers to use of primary care services. Organizing the community in networks and linking them with the nearby health facility helps to establish strong relationship with the community. Strengthening planning, continuous support and supervision, ongoing capacity building, strengthening logistic management system, strengthening referral system and monitoring and evaluation including health management information system and use of data to improve performance will help to get the maximum output from its implementation

Contact Information

Institution Name:   Federal Ministry of Health, Ethiopia
Institution Type:   Government Agency  
Contact Person:   Dr Keseteberhan Admasu
Title:   Minister  
Telephone/ Fax:   +251115516378
Institution's / Project's Website:  
E-mail:   noaheliast@gmail.com  
Address:   Lideta Sub-City
Postal Code:   1234
City:   Addis Ababa
State/Province:  
Country:  

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