Over the past three years, Last Mile Health has partnered with research institutions in Bangladesh, Brazil, Ethiopia, and Liberia to identify trends on establishing and sustaining high-performing national community health worker programs. Together, these countries offer valuable lessons that are documented in the newly-launched Exemplars in Global Health.
The following blog is the final blog in a four-part series highlighting the Exemplars in Global Health Initiative. The case study can be found here and was written in collaboration with the International Institute of Primary Healthcare-Ethiopia.
Following almost two decades of political instability and war, Ethiopia found itself facing countless challenges, including some of the worst health indicators in the world. In 1991, 15,000 women died of childbirth each year; under-5 mortality was 182 per 1,000 live births; and neonatal mortality was 51 per 1,000 live births.
Reversing poor health indicators presented an immense challenge. In 2000, Ethiopia still had one of the worst doctor-patient ratios in the world at 1 to 48,000. Most of the country’s doctors worked in urban centers, while nearly 80 percent of the population lived in rural areas. In 2002, nearly half of all deaths in Ethiopia were due to preventable and treatable diseases like malaria and tuberculosis.
In 2004, Ethiopia introduced an aggressive, targeted plan to combat its dismal health indicators. First, the country launched an Accelerated Expansion of Primary Health Care Coverage to increase the number of physical clinics and health centers around the country. Then, it established a national Health Extension Program to deploy a robust army of community health workers (known locally as health extension workers) to provide preventive care to communities nationwide. Ethiopia quickly trained 30,000 community health workers to work in 15,000 health posts, which meant that every 3,000-5,000 Ethiopians could be served by a pair of community health workers closest to them. However, as preventive care was the priority, the community health workers didn’t just wait for patients at their health post; instead, they were mandated to spend at least 75 percent of their time going into the community to educate the public on good health practices (ranging from nutrition to hygiene), and also generate demand for services.
Ethiopia’s community health workers were formally integrated into the country’s health system, with every grouping of five health posts reporting to a health center, the Primary Healthcare Unit, and local or specialized hospitals. This allowed for effective supervision of community health workers by clinicians, but also gave communities easier access to the higher levels of care when needed.
In 2006, the program further expanded into the community level by recruiting model families. The concept of a “model family,” which had proved successful in the country’s agriculture sector, was introduced in the health sector as a mechanism of influencing others via example. Families were identified as volunteers and given training in topics ranging from breastfeeding to the importance of immunization, and then modeled healthy behaviors in their communities and served as a resource for neighbors.
The scale up and expansion of its community health worker program has helped Ethiopia, in a short amount of time, deliver health services that match the country’s disease burden.
Today, Ethiopia has 40,000 full-time, salaried community health workers. It also counts on three million “health development army” volunteers (one for every six families) to attend to the population at large, with 92 percent of Ethiopians having access to care.
Ethiopia’s community health workers program was selected as an Exemplar in Global Health due to its impressive results. Ethiopia’s community health workers have contributed to the reduction of under-five mortality by 67 percent and maternal mortality by 71 percent; the rate of HIV infections has declined by an astounding 90 percent; the rate of death from malaria and tuberculosis have both fallen by 50 percent or more; and immunization rates for rural children have tripled.
While challenges still exist around quality of care and ineffectiveness in some parts of the country, Ethiopia’s community health worker program is proof that a solid program can deliver lasting change, especially where gaps in healthcare coverage or access to care are so pervasive. It also demonstrates that investing in improving health outcomes, like Ethiopia has, can lead to remarkable progress. This progress, outlined in the Exemplars in Global Health platform, can be used by countries looking to inform their decision-making, set their goals, track their progress, and change health outcomes for the better.
About Exemplars in Global Health
Exemplars in Global Health is a program led by Gates Ventures and fueled by the research and insights of both in-country and global experts and partners, to identify the biggest global health success stories of our time. Exemplars in Global Health seeks to identify what public health interventions have delivered impact, how programs have been designed to circumvent challenges, and why specific interventions have led countries to become positive outliers of success. The program’s aim is to allow decision makers to explore proven strategies, policies and actionable recommendations that create similar pathways to scale their own success, in a faster, more effective manner.
To learn more about Ethiopia’s remarkable transformation, read the case study here.
Banner Photo Credit: Kat McDowell