Retaining Community Health Workers in Ethiopia
In a recent New York Times opinion, Tina Rosenberg asked “What makes community health care work?” Her commentary highlights the important elements for sustaining community health work in developing countries—careful financing, using teaching as part of the sustainability structure, supervision and training, working with the government, and scaling up according to the program and country context—and refers to the rich experiences of BRAC in Bangladesh.
Ethiopia’s health extension worker (HEW) initiative, established in 2004, is another example of a successful program in sub-Saharan Africa. Developed and implemented by the Federal Ministry of Health in collaboration with the Ministry of Education, the HEW program has evolved both in scope and scale to accommodate new health initiatives. To date it has deployed over 32,000 rural and urban HEWs and more than 10,000 HEW supervisors. These workers are deployed in 16,000 local units, reaching 5,000 people—this equates to almost 600 households assigned for every two HEWs.
Reasons for success
HEWs are employees of the Ministry of Health, whereas community health workers in other developing countries are often supported by development partners or the local community. Also, HEWs are recruited from and then assigned back to their own communities, which means they do not have to overcome language or cultural differences in providing services. Rural women feel confident going to HEWs for reproductive health services, as the HEWs are also female and possess a relatively high level of education. The majority of HEWs have completed grade 10 prior to joining the program— in contrast, only about 23% of women in the country enroll in secondary education.
HEWs receive ongoing training and mentoring, which helps them upgrade their knowledge and skill for service provision. Last but not least, HEWs are able to carry out their duties successfully, as they have access to equipment, supplies, and capacity-building for the health information system to help support their work.
Challenges for retention
Retaining community health workers is key to sustaining delivery of essential health services for populations residing in rural and remote areas of the country. The HEW program is in line with the World Health Organization’s 2010 retention policy recommendations.
However, through my own encounters with HEWs in different parts of Ethiopia, I learned that some HEWs left their post after serving their community for five years. They chose to join private colleges for nursing education or left the health sector for other occupations (e.g., agriculture, business). In addition, other HEWs have requested transfers to nearby urban sites. If they are not replaced in a timely manner, this creates a challenge for delivering primary health care. Considering the amount of resources invested in the program, replacing the departing HEWs with new workers may be another challenge for the country.
The Ministry of Health has designed career strategies for health workers that depict the career ladder for HEWs, and the Health Promotion and Disease Prevention Directorate is in the process of identifying approaches to respond to rural communities’ needs. Therefore, it is timely for all partners to work together with the Ministry of Health toward addressing retention per the World Health Organization’s recommendations.
Photo by Crystal Ng