By. Dr. Mekdes Daba, Minister of Health Ethiopia
Community Health Workers contribute to the achievement of Universal Health Coverage (UHC) through the provision of a continuum of preventive, promotive, and curative services on Reproductive, Maternal Newborn, and Child Health as well as for communicable and non-communicable diseases (1).
Ethiopia has made remarkable progress in advancing Universal Health Coverage over the past two decades, with the UHC service coverage index increasing from 13 in 2000 to 35 in 2021. During this period, substantial progress was achieved in health outcomes. The maternal mortality ratio dropped from 871 per 100,000 live births in 2000 to 267 per 100,000 live births in 2020. Similarly, the under-five mortality rate decreased from 166 per 1,000 live births in 2000 to 59 per 1,000 in 2019. Modern contraceptive use rose from 6.3% in 2000 to 40.5% in 2019, while DPT3 vaccination coverage increased from 20.8% in 2000 to 53.9% in 2019. Additionally, the proportion of health facility deliveries climbed from 4.9% in 2000 to 53.9% in 2019 (2,3).
The Health Extension Program (HEP) has played a pivotal role in this achievement. Integrated into the primary healthcare system, the Health Extension Program is a community-based health initiative primarily implemented by Health Extension Workers (HEWs). Health Extension workers are proffessional community health workers who are certified, salaried and supplied with essential medicines and equipments. Typically, two HEWs are assigned to each health post, serving a population of 3,000 to 5,000 people. Their primary responsibilities include health promotion, disease prevention, and the treatment of uncomplicated and non-severe illnesses, such as malaria, pneumonia, diarrhea, and malnutrition. Deploying HEWs as full-time civil servants ensures they dedicated their days to serving their communities with limited competing interests (4).
The Health Extension Program plays a critical role in advancing the three dimensions of Universal Health Coverage. In terms of population coverage, HEP extends access to essential health services to remote and hard to reach communities. Regarding service coverage, Health Extension Workers provide a comprehensive package of promotive, preventive, and curative services while facilitating continuity of care through referrals to health centers. For financial risk protection, Health Extension Workers reduce out-of-pocket expenses by offering services closer to communities and free of charge. Early diagnosis and treatment of diseases such as common childhood illnesses and malaria by Health Extension Workers prevent the progression of health issues that could lead to expensive emergency care and hospitalizations. Moreover, the promotion of healthy behaviors by Health Extension Workers reduces disease incidence, lowering healthcare costs for individuals, families, and the broader health system. Evidence shows that the Health Extension Program has enabled Ethiopia to achieve significant improvements in maternal and child health, communicable diseases, hygiene and sanitation, knowledge, and health care seeking (5). It has proven to be highly cost-effective, resulting in a greater number of lives saved and offering a more cost-effective method for providing essential health services to rural and vulnerable communities with limited access to qualified staff (6).
Despite its achievements, a national assessment of the Health Extension Program conducted in 2019 identified several challenges. These included limited competency among Health Extension Workers, slow progress in digitizing the community health information system, shortages of drugs and supplies, and inadequate basic amenities such as water, electricity, and sanitation facilities at health posts. In response to these findings and the growing health service demands of the community, the government developed and launched a 15-year roadmap in 2020 to optimize the Health Extension Program and support the achievement of Universal Health Coverage. The roadmap focuses on ensuring equitable access to essential health services, improving the quality of care provided through the HEP, securing sustainable financing to eliminate financial hardship associated with HEP services, strengthening community engagement and empowerment, maintaining resilience by sustaining essential service delivery during health emergencies, and enhancing political leadership, multi-sectoral collaboration, coordination, and partnerships. Moreover, as part of the roadmap, the ministry is focusing on adapting the Health Extension Program and primary health care delivery approach to better suit pastoralist and urban contexts. This includes expanding mobile health services in pastoralist areas and the family health team approach in urban areas to better address the needs of vulnerable populations (7).
As we celebrate this Universal Health Coverage Day under the theme “Health: It’s on the Government” I would like to emphasize the pivotal role of the Ethiopian government’s political commitment in the design and implementation of this innovative Health Extension Program. This commitment is reflected in the allocation of domestic resources, the coordination of donor funding through the one plan, one budget, one report principle, and collaboration with other sectors such as the Ministries of Education, Finance, and Civil Service to train and deploy over 40,000 Health Extension Workers as civil servants. The role of the Ministry of Civil Service was crucial in integrating Health Extension Workers into the civil service system and advancing their careers within it. This included ensuring fair evaluation and grading of HEWs’ tasks during the comprehensive Job Evaluation and Grading process conducted for the entire civil service system.
Through South-South collaboration, Ethiopia has hosted delegations from multiple African countries, sharing valuable lessons from the Health Extension Program. It is inspiring to see some nations adopt and adapt this model to suit their unique contexts. Looking ahead, we aim to strengthen the South-South collaboration framework, working with organizations such as HeDPAC to further share our experiences and, equally, to learn from other countries in areas like digitization, quality of care, and community-level infrastructure development.
References
- Cometto G, Ford N, Pfaffman-Zambruni J, Akl EA, Lehmann U, McPake B, et al. Health policy and system support to optimise community health worker programmes: an abridged WHO guideline. Lancet Glob Health. 2018 Dec 1;6(12):e1397–404.
- Central Statistical Agency [Ethiopia]. Ethiopia Mini Demographic and Health Survey. Addis Ababa: Central Statistics Agency; 2019.
- Cresswell J. Trends in Maternal Mortality 2000 to 2020: Estimates by WHO, UNICEF, UNFPA, World Bank Group and UNDESA/Population Division. 1st ed. Geneva: World Health Organization; 2023. 1 p.
- Exemplars in Global Health. Community Health Workers. Available from: https://www.exemplars.health/topics/community-health-workers/cross-country-synthesis/recommendations
- Assefa Y, Gelaw YA, Hill PS, Taye BW, Van Damme W. Community health extension program of Ethiopia, 2003–2018: successes and challenges toward universal coverage for primary healthcare services. Glob Health. 2019 Mar 26;15(1):24.
- Assebe LF, Belete WN, Alemayehu S, Asfaw E, Godana KT, Alemayehu YK, et al. Economic evaluation of Health Extension Program packages in Ethiopia. PLOS ONE. 2021 Feb 2;16(2):e0246207.
- Ministry of Health of Ethiopia. A roadmap for optimizing the Health Extension Program of Ethiopia (2020-2035). 2020;