The Trekking ‘Doctors’

Clutching her medicine box, Tibre Desu rounded a bend and sauntered down a rough road towards the distant hills on the horizon. She had just replenished her stock of medical supplies at Work Amba Health Center. Now her mind was on Dembela Health Post, her work station at the heart of her village in the Tigray region of northern Ethiopia.

Though she is based 90 kilometers out of Mekelle, the capital of the Tigray region, Tibre is a key player in the Ethiopia’s health system. As one of the 38,000 front-line health extension workers spread across the country, Tibre’s job is to trek those dirt paths, knocking on doors and calling on people in the fields with the single-minded mission of stopping diseases from occurring and spreading.

She and her fellow health extension workers are bringing access to health care to the homes of underserved rural communities out of reach of bricks and mortar health clinics. Through the National Health Extension Program, these workers are changing the shape of health care delivery in Ethiopia. Kesetebirhan Admasu, the country’s minister of health, says the program has been transformative to the country’s health by making communities true agents of their own health and captains of their ship.

Saving Lives, Transforming Gender Roles in Ethiopia

The government of Ethiopia, with support from the Global Fund, has trained more than 38,000 female health extension workers to bring basic health care closer to people’s homes.

The Achilles’ heel of provision of health services in many remote villages in Africa is it often leave people out of reach and off the health-care grid. A woman who gets obstructed labor hours away from a navigable road, and from a health facility has slim chances of having a safe delivery. Often, the lives of mothers and their babies are lost.

The health extension workers in Ethiopia encourage women to deliver in health facilities and teach them how to recognize early signs of labor. These community health workers are also trained and equipped to assist women to safely deliver their babies in case the health center is out of reach. As a result of their work, the rate of delivery assisted by skilled health personnel has tripled, increasing from 20 percent in 2000 to more than 60 percent in 2015.

The program has led to improved gender equity in access to health services and resulted in significant reductions in deaths of mothers and their children, says Dr. Kesetebirhan. The health extension workers have also improved parity in access to disease preventive services by bridging the gap between the community and health facilities. Through the program, communities feel a genuine ownership of the health-care infrastructure at the local level, Dr Kesetebirhan says.

That gulf between the hard-to-reach populations and medical attention is one that Ethiopia hoped to bridge by connecting communities to health-care systems. Established in 2004, the National Health Extension Program recruited women as salaried community health workers to take health care to their villages. At the time, Ethiopia had a critical shortage of health care services with one health worker – including doctors, nurses and health extension workers – serving more than 40, 000 people.

The health extension workers, almost all of them women, are high school graduates who are trained for one year in basic health delivery. They are recruited from the local communities where they work, and use their experience and bonds with the population to transform community health.

Twelve years and 38,000 health extension workers since the establishment of the program, there has been a dramatic increase in access to health for rural populations. Today, thanks to these women, more than 95 percent of Ethiopia’s population has access to primary health care within a distance of 10 kilometers. The ratio of health workers has improved to one health worker for less than 3,000 people. Relying on health extension workers, who are easier and quicker to train and deploy, has helped the country to rapidly increase the linkages between health care and the people.

A sizeable share of the country’s health challenges are due to preventable communicable diseases such as malaria, pneumonia, tuberculosis and HIV. The health extension workers march through the country’s 15,000 villages, taking disease prevention issues head on. They also offer basic tests and offer treatments for common diseases like malaria. Additionally, they encourage immunization, contraceptive use, and personal and environmental hygiene, while keeping health records for every family in the village.

Tibre arrived at the home of Medhin Haileselasie – a 37-year-old woman with six children. They talked about child nutrition, sanitation, and the family’s use of mosquito nets. The health extension worker also discussed experiences about health issues in her home and in the neighborhood. Family planning services provided by the health post helped Medhin to space her children, having each one after a gap of about two years.

In Ethiopia’s national strategy, the primary health units are the health centers, each linked to five health posts. A health post serves a population of about 5,000 and is staffed by two health extension workers, who are supported by a health development army – volunteers who serve as the eyes and ears of health extension workers in the valleys and hills. Lem Lem Alemayo, a member of the army, said she works with Tibre because she has to fight hard against the ills that continue to kill people in her community.

Ayalew Asgedon, the head of Work Amba Health Center says the network of frontline workers “stops diseases before they get here.” Earlier in the day at the health center, which supports four health posts like hers, Tibre had talked with Ayalew and other health officials – reporting concerns at the village, delivering data from the field and refilling her supplies. The petite health worker also met members of the health development army. In a soft sing-song voice that was filled with passion, Tibre talked to her troops about the importance of women using contraceptives, families sleeping under mosquito nets and the community adopting stronger disease prevention measures.

Great systems for health are pivotal in improving the health outcomes in any country. The health extension workers are a critical of Ethiopia’s health infrastructure. The country is a leader in building resilient and sustainable systems for health in countries with fewer resources. The investments are bearing fruit. Since the program was launched in 2004, life expectancy has jumped by 10 years, from 54 years at birth to 64.

Additionally, the program has also allowed thousands of women to enter the workforce, providing them with improved income opportunities and transforming gender roles in their communities. In a country where unemployment is still high, finding fulfilling work can be life changing. The health extension worker program has transformed the lives of thousands of workers who have become breadwinners for their families, says Dr. Kesetebirhan. A better livelihood for her family is an added reason why Tibre and other health extension workers of Tigray take the less-travelled roads to save lives of people in their communities.

Ethiopia seems like a country in a hurry to achieve as much as it can for its people as soon as it can. With the support from partners such as the Global Fund to Fight AIDS, Tuberculosis and Malaria, the country is expanding the numbers of health extension workers and the quality of their work by training and retraining the health workers to keep them up to date and growing. The program is becoming a symbol of pathways that other low- and middle income countries can follow to bring health care closer to the people. Many countries in Africa have been visiting Ethiopia to see the health extension worker program and learn from it, Dr. Kesetebirhan says.

At the College of Health Sciences in Mekelle, Dagnew Araya, the Dean of the school, said he has more than 300 students studying to become health extension workers or to upgrade their skills. “With this training, we are doing our part in contributing to creating healthy communities,” Dagnew says.

As the students file out of their classes, they seem to exude a special sense of purpose.

Birhan Atsebha, 26, left her village health post 70 kilometers away, where she was already serving as a health extension worker and came to advance her knowledge and skills. She will return home with expertise to tackle bigger health challenges and in a better way. Birhan says she became a health extension worker because she wanted to live and serve her community. When the opportunity to become a health extension worker happened it was godsend, allowing her to live in her village and do gratifying work while earning her livelihood.

The training will keep her away from her husband and her five-year-old daughter for much of the year. She cannot wait to be back to her family, she says. She also cannot wait to be back to the health post to attend to her community, which calls her ‘Doctor Birhan.’

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Published 06 July 2016