Human resource development for a community-based health extension program: a case study from Ethiopia

Abstract

IntroductionEthiopia is one of the sub-Saharan countries most affected by high disease burden, aggravated by a shortage and imbalance of human resources, geographical distance, and socioeconomic factors. In 2004, the government introduced the Health Extension Program (HEP), a primary care delivery strategy, to address the challenges and achieve the World Health Organization Millennium Development Goals (MDGs) within a context of limited resources.Case descriptionThe health system was reformed to create a platform for integration and institutionalization of the HEP with appropriate human capacity, infrastructure, and management structures. Human resources were developed through training of female health workers recruited from their prospective villages, designed to limit the high staff turnover and address gender, social and cultural factors in order to provide services acceptable to each community. The service delivery modalities include household, community and health facility care. Thus, the most basic health post infrastructure, designed to rapidly and cost-effectively scale up HEP, was built in each village. In line with the country’s decentralized management system, the HEP service delivery is under the jurisdiction of the district authorities.Discussion and evaluationThe nationwide implementation of HEP progressed in line with its target goals. In all, 40 training institutions were established, and over 30,000 Health Extension Workers have been trained and deployed to approximately 15,000 villages. The potential health service coverage reached 92.1% in 2011, up from 64% in 2004. While most health indicators have improved, performance in skilled delivery and postnatal care has not been satisfactory. While HEP is considered the most important institutional framework for achieving the health MDGs in Ethiopia, quality of service, utilization rate, access and referral linkage to emergency obstetric care, management, and evaluation of the program are the key challenges that need immediate attention.ConclusionsThis article describes the strategies, human resource developments, service delivery modalities, progress in service coverage, and the challenges in the implementation of the HEP. The Ethiopian approach of revitalization of primary care through innovative, locally appropriate and acceptable strategies will provide important lessons to other poorly resourced countries. It is hoped that the approaches and strategies described in this paper will aid in that process.

Maximizing the Impact of Training Initiatives for Health Professionals in Low-Income Countries: Frameworks, Challenges, and Best Practices

“…The competencies and skills that allow different cadres of health professionals to work together as a team and address both biomedical and psychosocial determinants of health are especially important and have begun to be prioritized only recently, such as in programs recently launched in Ethiopia and South Africa [4,9,31–33]. …”

Assessing political priority for reproductive health in Ethiopia

“…Even though HEWs work on general maternal and child health issues, provision of family planning is central to their work. 29,30 Actor power then began to play a strong role with the expansion of reproductive health services throughout the country. The strength of actors was also more visible in the 2000s with many civil society organizations, including professional associations, actively participating in the debate and this could have contributed to family planning being at the forefront of reproductive health discussions in the country in the early-mid 2000s.…”

“…At the village level, services are primarily provided by Health Extension Workers, a public sector cadre developed to increase access to services. 29,30 HEWs' family planning work is supported by community-based reproductive health agents and private sector-supported social marketing of contraceptives. 31 Nearly all respondents mentioned the need for better measurement strategies, more timely data collection, and better indicators.…”

Use of Balanced Scorecard Methodology for Performance Measurement of the Health Extension Program in Ethiopia

“…55 Pastoralists have many special health needs that could not be completely met by the largely static health post-based HEP strategy, thereby resulting in poor performance of the program in such settings. 3,56 In recognition of HEP's inadequacy in pastoral areas, FMOH took steps to redesign the program. FMOH and pastoral regions in collaboration with research institutions are undertaking research projects to understand the pastoral context and generate information to inform the design of the most appropriate health services and effective service delivery models.…”

“…2 The national health system was reformed to create a platform for integration and institutionalization of HEP. 3 A total of 38,819 female Health Extension Workers (HEWs) with a high school education who received 1-year training on HEP were deployed in over 15,000 newly constructed health posts in rural villages. 4 The candidates were recruited from their prospective villages to limit staff turnover and address gender, social, and cultural factors in service provision.…”