Health Extension program in Ethiopia

1. Health Extension program in Ethiopia Federal democratic republic of Ethiopia Ministry of health

2. Outline of the presentation • Country Background • Health Policy • Why HEP? • HEP Implementation Processes & Approaches • Current Status & Impacts • Achievements and Challenges • Lessons Learnt

3. 9 regional states and 2 City Administrations Primary health service coverage = 92% Hospitals =125 Existing + 185 under construction health centers= 3,245 health posts= 16,048 Country Background Geographical location Horn of Africa Population: 84 million Economy : 85% depend on Agriculture Resides in rural area 85% of the population

4. Continued…. • The Current Ethiopian Health Policy was formulated during the transitional government in 1993. • The policy recognized the then existing situation of the country • effects of prolonged civil war • significant socioeconomic crisis • huge inequalities in all health and social indicators • poor health status • Millions of Ethiopians, especially those who live in rural areas, are exposed to a variety of preventable diseases. • Maternal, infant and under-five mortality rates are were among the highest in the world.

5. Continued…….. • The new health policy focuses • Decentralized and democratized health system • quality promotive, preventive and selected curative health care services • accessible and equitable manner to reach all segments of the population, • with special attention to mothers and children.

6. Translating the Policy • The Ethiopian Government has formulated a series of Health Sector Development Programs(HSDP I, II ,III and IV 1997-2015 ) • Introduced health system reforms and restructuring • Introduced HMIS and CHIS • Worked on Logistics and Supply Chain Management

7. Policy linkages

8. Health system organization FMOH (Agencies= HAPCO, FMHACA, EHNRI,PFSA,EHIA)/ Fed Hospital RHB ( 3 Urban region & City Administrations) RHB ( 4 Agrarian Regions) RHB (4 Pastoralist Regions) Zonal Health Dept Zonal Health Dept Sub city/ Woreda Health Offices Woreda Health Offices Woreda Health Offices Woreda Health Offices Woreda Health Offices = 817 Woredas/ WoHOs 9 Regions 2 City Administrations

9. N: B: - Primary level health care includes Health post , Health center and primary hospital Urban Health center served for 40,000 people Secondary level health care =General hospital Tertiary level health care = Specialized hospital

10. Why HEP? • HSDP I review showed that • Basic health services had not reached the needy at the grass root level • Limited expansion of facilities • Fundamental gap in applying the core principles and practices • The uneven distribution of facility based health services This led to the development of new ideas and strategies

11. Continued…….. • An acute and chronic shortage of human resources coupled with poor community and private sector participation • Distribution of human resources for health was skewed toward urban centers, following the distribution of health facilities • Voluntary community health workers functionality and sustainability proved to be unsatisfactory due to their voluntary nature and the poor ownership of the lower levels of the government structures

12. Continued…….. • Country health problems were dominated by preventable and communicable diseases • Rapidly growing population and poor infrastructure, which had been crippled by the decades of war and neglect • Fundamental gap in applying the core principle and practice of PHC • The health institutions were few and inequitably distributed.

14. What should be our pace? ?

15. Health Extension Program The HEP in Ethiopia was embarked in 2002 as Flag ship program HEP is “a package of basic and essential promotive, preventive and curative health services targetingHOUSHOLDS in a community, based on the principles of primary health care (PHC) to improve the families’ health status with their full participation” Family and community centered program

16. Philosophy of HEP Produce their own health the way they produce their agricultural products Transfer knowledge & Responsibility of Producing Health Individual Households The underlined convection is that

17. PRINCIPLES: • Communities can best identify and prioritize their own heart felt health needs and problems, • There is untapped indigenous knowledge and skills in the community, • The supremacy of the people's priorities, interest, needs and wishes must be respected and accommodated in all aspects, • Women involvement in all decision-making process is the central

18. Continued….. • Preventive and promotive interventions are more cost effective • HEP can be seen as a part of the wider commitment and reform from the more traditional forms of top-down development practice to the participatory development direction in the Health sector,

19. Objective The overall goal of the HEP is to: Create a healthy society and reduce rates of maternal and child morbidity and mortality. Specific objective • To improve access and equity to preventive essential health interventions at the village and household levels

20. Continued……… • To ensure ownership and participation by increasing health awareness, knowledge, and skills among community members. • To promote gender equality in accessing health services. • To improve the utilization of peripheral health services by bridging the gap between the communities and health facilities through HEWs. • To promote health life style.

21. Implementation strategy Create a Healthy Society & Reduce Rate of Maternal and Child Morbidity and Mortality Establishing an Effective & Responsive Health Delivery System for those who live in Rural Areas Train & Deploy HEWs Medicine & Supplies Construction of Health post Full Community Participation Leadership, Monitoring & Evaluation

22. ImplementationStrategy(1 ) requires substantial Human Resource Training criteria • Sex Female • Age > 17 years • Education 10 grade & above • HEWs will be selected from the communities they reside • who has Ability to speak local language 2 HEWs 5000 people

23. Why HEWs are Female? Females are preferred for the provision of HEP because: • At the beginning it was part of an Affirmative action, • They are more appropriate to look after the health issues of mothers and children, • On grounds of our culture female are more accepted in the society to discuss with women at house hold level, • They yield less attrition rate,

24. HEP Training • Existing Technical and vocational educational training schools (TVETs) of the MOE were used for training of HEWs • TVET schools provide training to HEWs and TVET tutors have been trained to deliver pre-service training • Tutors are public health nurses, sanitarians HOs , Home economists were locally recruited and received 1 month training • The HEWs receives a 1 year course of training which includes field work to gain practical experience

25. HEP Training Package (16) curriculum HIV/TB/Malaria 1st AID Personal Hygiene& water sanitation , Food hygiene t Latrine Execrate wastage disposal Housing construction insecticide and MCH FP Immunization Nutrition Adolescent Health Disease Prevention & Control (3) 16 Health Extension Package Family Health (5) Hygiene & Environmental Health (7) Health Education (1)

26. What is new with HEWs? • Health Extension workers are generalists • Lead the Health program • Health educator, • Planner , Coordinator , trainer • supervisor , M&E expert • With all this there is no departmental function in HEP at grass root level

27. Implementation Strategy (2) HP construction • The operational center of the HEP is the Health Post, • Functions under the supervision of the Woreda Health Office, Kebele administration, with technical support from the nearest Health Center. • Health Posts are located at Kebele level to serve a population of 5000 people. • To ensure ownership of the health program by the community, the construction of health posts is undertaken both by the community and the government.

28. Implementation Strategy (3) • Procurement of Contraceptives, Medicine and Supplies • Health posts should be adequately provided with equipment, materials and supplies to deliver the different packages of essential services to the community • Medicines and supplies are procured and distributed to the regions by FMOH • Supplies will be provided by Health Centers or woreda health offices to health posts

29. HEP Implementation Approach • HEWs divide their time between providing services at the health post and undertaking community promotion program at the household level • HEWs are required to spend 75% of their time conducting outreach activities by going from house to house • The HEWs and vCHPs provide support to households for behavioral change and motivate to utilize primary health care services • Each HEW will select 40-60 households for frequent visiting of about 96 hours of training in 4 months(Hygiene and EH 30 hrs, Family Health 42 hrs and Prevention and control 24 hrs

30. Continued… • Household adopting and applying all of the 16 packages of the HEP get certificate of completion and this go on until all households graduate • Community participation, which is critical for the success of program implementation, is recognized as the backbone in the implementation of HEP • Understanding the community in terms of perception on HEP, degree of participation and utilization of services is an important step to improve implementation strategies and approaches in community-based programs

31. Continued… • Model families • Community Based Health Packages • Health posts

32. The theory behind Model families(Diffusion Model presents the normal pop. distribution) HEP is an innovative strategy • To implement model families diffusion theory is adopted • Diffusion is the process by which an innovation is communicated through certain channels over time among the members of a social system • In principle not all individuals in a social system adopt an innovation at the same time rather they adopt in a time sequences 1st model families HH will be selected 2.5% 13.5% 34% 34% 16% Adopter Categorization on the Basis of Innovativeness

33. Model Familiesimplementation cycle  They are the head of their own health

34. 1st batch (40-60 HH) 2nd batch (>40-60 HH) 3rd batch (>40-60 HH) Model Families Creation per year based on diffusion theory

35. Implementation cycle

36. Community Based Health Packages • HEWs communicate health messages by involving the community from the planning stage all the way through evaluation. • HEWs utilize Women and Youth Associations, Schools and Traditional Associations to coordinate and organize events where the community participate by providing money, raw materials and labor.

37. Health Posts • At the Health Post HEWs provide antenatal care, delivery, immunization, growth monitoring, nutritional advice, family planning and referral services to the general population of the Kebele.

38. Strategic issues in the health extension programmes • Maintaining sustainable financing to HEP • Strengthening health infrastructures at all levels • Strengthening decentralization and democratization of the health services • Promoting intersectoral and multisectoral collaboration • Reorganization of the various health offices from centeral to the woreda level

39. Continued…. • Reorientation and strengthening the health service delivery system that can facilitate the health service extension implementation • Defining roles and functions of stakeholders for the implementation of HEP • Enhancing community involvement for united community action for health • Enhancing political will, commitment and support for HEP

40. Continued….. • Reorientation of staff( outlook, commitment, accountability, approach, integrated skills training) at various level • Strengthening referral system at all levels • Strengthening supervision system at all levels • Strengthening health information system at all levels • Strengthening monitoring and evaluation system at all levels

41. Program Management and Governance Management and support is critical in the implementation of HEP to ensure • Interventions are well coordinated; Technical support is provided; • Inputs are provided in a timely and cost-efficient manner; Resources are appropriately managed; • Effective monitoring and progress reporting is carried; and Challenges are identified and addressed in a timely manner • HEP is fully owned by the community and the government, and, thus, managed in accordance with the decentralized structures of the country.

42. Continued…. • The communities (and model families) are expected to cooperate and disseminate health knowledge and practices • The local village administration supports HEP by providing political leadership, mobilizing the communities, and monitoring the performance of HEWs based on an agreed plan. • The nearest health center provides technical support to the HEWs, and serves as referred clients and patients • District health office is primarily responsible for supervision and management of HEP. The district government collaborates with villagers to construct a health post

43. Continued….. • The regional health bureaus and zonal health departments provide strategic leadership as well as technical support to the districts in implementing HEP. They also cover the stipend and salaries of HEWs during training and deployment, respectively • The Federal Ministry of Health (FMoH) provides the curriculum and guidance on the recruitment of HEWs and mobilizes resources from development partners for procurement and distribution of medical equipment and supplies for the health posts.

44. Major activities performed • Health Extension Package training curriculum was developed by the Ministry of Health in close collaboration with the Ministry of Education • The curricula produced were distributed to 14 TVTS selected to train HEWs • Sixteen different Health Extension Packages were developed in English and Amharic. • The first teachers for HEWs (Eighty four public health nurses, sanitarians and health officers) were nominated and received training for one month in training methodology in Addis Ababa.

45. Continued…… • Two thousand eight hundred female students who completed grade ten, from six regional states were enrolled into 14 TVTS in January 2004 for one year training • The RHBs facilitated the teaching and learning process by providing logistics and appropriate teaching aids • HEP implementation guideline has been prepared by the FMOH and distributed to RHBs

46. Continued…. • Pilot implementation was launched in 5 regions in 2002/03 and encouraging results were seen construction and utilization of latrines, utilization rate of contraceptives and vaccination services • Technical guideline for HEP Supportive supervision technical, reference books for rural HEP and manuals for school health program were prepared • In order to expand Urban HEP in seven regions of the country, 15 HEP packages along with implementation manual have been developed and distributed for implementation.

47. Continued…. • Implementation Manual for Pastoralist and semi-pastoralist areas was finalized and has been distributed to respective regions • Integrated Refresher Training (IRT) • career development of HEWs has been started in order to update and improve the skills and knowledge of the Level III HEWs • HAD • PHCU linkage

48. Major achievement • Rural 32,168 and urban 4,124 female Health Extension Workers have been trained and deployed • A total of 13,924,988 Model Households have been trained and graduated • Reduction of under5 mortality • Reduction in Morbidity and Mortality related to major communicable diseases has been achieved