Ambassadors for health

Skilled and respected workers have revolutionized neighborhood healthcare in Ethiopia – using a model other countries could follow. Evelyn Owen discovers how the programme works and the problems it has confronted

Health extension workers at the Sululta health centre are helping increase the number of babies
who receive vaccination against deadly diseases. Photograph: Petterik Wiggers/Panos

In the hubbub of the vaccination clinic, young mother Damanech Alemu waits patiently with a tiny blue bundle nestled in her arms. Six-week-old Ermias is about to receive the injections that will safeguard him against an array of common diseases, including diphtheria, whooping cough and polio.

"I'm glad to be here, because it means healthy development and a safe life for my son," Alemu says afterwards, comforting her baby. "I made an appointment, I came here, and I received the service, so I'm happy about that."

Alemu's trip to Sululta health centre might sound perfectly ordinary, but less than a quarter of Ethiopian children under the age of two are fully vaccinated. The service offered here, 20 miles north of Addis Ababa, is only possible thanks to the expertise and enthusiasm of the women in white coats bustling about the clinic, preparing needles, checking charts and filling in forms. They are health extension workers (HEWs) – the backbone of Ethiopia's health system.


According to the World Health Organisation, Ethiopia has a health workforce crisis. With only 0.7 health workers per thousand people, scaling up primary healthcare is a matter of urgency. The need is greatest in poor, rural areas, where 85% of the country's population live and where accessing even basic services can be a challenge. Problems such as poor sanitation, communicable diseases and unplanned pregnancies are common. To compound the situation, less than 2% of rural Ethiopians own any form of transport and most have little or no formal education.

This is where Zaid Birhane comes in. She is one of 34,000 workers at the frontline of the Ethiopian government's health extension programme (HEP), which began in 2003. At 23, she has already been a HEW for seven years, providing essential preventive and curative healthcare to the 640 households in her kebele [village].

Poised and outspoken, she outlines her typical working week, which includes house-to-house visits, question-and-answer sessions and appointments at the local health post, where she does everything from prescribing drugs to delivering babies. "My planning is based on the needs of the community," she explains. "We arrange conversations on issues like health education, immunisation and family planning on different days, based on time schedules agreed by everyone."

HEWs are ideal ambassadors for the HEP's philosophy that good health begins at home, as they are recruited locally, and return to work in their communities following training.

Community presence

For Birhane, it's very simple: "If someone dies, I take part in the funeral; if there's a newborn, I share the family's joy. I eat what they eat, so they feel that I'm part of them. When they recognise the changes that are happening, they respect me and value my presence in the community."

As well as providing information and treatment, HEWs mobilise communities for emergency funds, and initiate self-organised, sustainable strategies for environmental improvement, such as malaria prevention committees.

According to community leader Muluken Lule, the changes have been remarkable. "Our children used to be malnourished, and suffer from infestations and infections," he says. "But now they are neat, clean and healthy, and this is one big thing that we can be proud of." His experiences are borne out by a recent report from the Ethiopian ministry of health, which shows that in the five years after the first cohort of HEWs graduated, the infant mortality rate decreased by 23%.

While the dedication of individual HEWs is vital, the wider transformation of healthcare provision in Ethiopia rests on visionary policymaking, backed up with support from donors, and strong partnerships with NGOs and the private sector.

In most African countries, the selection, training and employment of community health workers (CHWs) is relatively informal, and the system often relies on volunteers whose capacity is overstretched as separate NGOs attempt to train them in one programme after another. In Zambia, CHWs even found themselves completing anti-poaching training for the wildlife authorities.

In Ethiopia, by contrast, the ministry of health has implemented a formalised recruitment and training structure with a single curriculum, as well as joint review mechanisms enabling all the different partners to identify areas for improvement and reaffirm priorities.

Angela Spilsbury, senior health adviser for the UK Department for International Development in Ethiopia, explains that as a result, Zambia is now adopting the Ethiopian model. "In the end, the Zambian government looked at what Ethiopia had done. They had recruited people, trained them, given them a salary, and 10 years later, they're still doing the job that they had been trained and paid to do."

It has not all been plain sailing, however. The HEW system has arguably become a victim of its own success, as it struggles to meet the growing demands of communities that have become accustomed to improved services. And for some HEWs, the limited opportunities for career development can lead them to seek employment in the private sector, putting further pressure on their remaining colleagues.

The latest phase of the HEP promises to combat these problems, with a programme enabling some of the best-performing HEWs to strengthen their knowledge, gain skills and increase their salaries. "The upgrading programme provides a career path and gives longer-term promises, not only for the communities, but also for the HEWs themselves," says Dr Florence Temu, Ethiopia country director of Amref, an African NGO that has been working with the Open University to develop training materials and monitor the upgrade programme.

Feedback from the trainee HEWs so far is positive. "Previously, we knew a little about everything, but now we're learning deeply, about the science as well as the practice," says Birhane. As she explains, an increase in highly-skilled, confident, motivated community workers could help the whole health system: "I'll be able to do things that I used to refer to the health centre, so the burden on health centres and hospitals would be decreased."

For ambitious HEWs, upgrading their qualifications can lead to tricky decisions. Wudset Andarge says returning to her kebele will not be easy. "It's human nature to want to work in urban areas, where things are better," she says. "It's a dilemma." Whatever she decides, there is little doubt that on her way through the HEW programme she will have saved many lives. For now, she heads back to class with a smile: "When I see the changes that are being made as a result of my work, I feel very proud."

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