Ethiopia’s launch of its Health Extension Program in 2004 further fortified its longstanding engagement of CHWs. Two Health Extension Workers (HEWs) are assigned to each kebele, the lowest administrative unit with about 1,000 households. They operate at their posts and in the community to provide education, immunizations, and curative services. To further extend the reach of the HEWs, the Women’s Development Army (WDA) engages neighboring communities and selects a WDA Volunteer to promote healthy behaviors and use of primary health care centers.

Background
Community health workers (CHWs) have a long history in Ethiopia, dating back to the time of the 1978 Declaration of Alma-Ata on primary health care (PHC). During Ethiopia’s civil war in the 1970s and 1980s, one early program in Tigray trained 3,000 CHWs. In 1997, the Ethiopian Federal Ministry of Health (FMOH) launched its 20-year National Health Sector Development Program (HSDP), which shifted the health system away from a predominantly curative, urban, and facility focus to better meet the needs of its rural inhabitants. The government launched its renowned Health Extension Program in 2004.

Implementation
In Ethiopia, two Health Extension Workers (HEWs) are assigned per kebele, which is the lowest administrative unit of the government structure with an average of 1,000 households and approximately 5,000 people. HEWs provide services at their health post and in the community. To extend the reach and effectiveness of the HEWs, the Women’s Development Army (WDA) was organized in 2011. The WDA engages communities by organizing five or six neighboring households into teams, with each team selecting a WDA Volunteer from a model household (defined by adoption of healthy behaviors). At present, Ethiopia has approximately 40,000 HEWs and an estimated three million WDA Volunteers.

Roles/responsibilities
HEWs provide health education in households and in communities, prevent disease (such as by giving immunizations), and provide basic curative services (including provision of family planning). The WDA and WDA Leaders promote healthy behaviors and utilization of PHC services.

Training
HEWs are required to complete at least grade 10. They then receive one year of training on basic health promotion, disease prevention, selected curative services, and documentation of health information. HEWs provide informal training for the WDA Leaders.

Supervision
HEWs are primarily supervised by the health center staff, who conduct regular supportive supervision visits to improve the capacity of HEWs to provide health services to the community. The village health committee and community members are also very involved in supporting the HEWs and evaluating their performance. HEWs provide supervision and support to the WDA.

Incentives and remuneration
HEWs are formal, government-salaried employees and received in 2014 a base salary of approximately US$ 84 per month. The WDA Volunteers do not receive any monetary compensation, but they do receive important non-financial incentives.

Impact
Ethiopia has made notable strides in improvements of health outcomes. Declines in under-five and maternal mortality are among the most notable impacts of the country’s efforts. The Health Extension Program and expansion of PHC have made a strong contribution to these results.

Author Affiliations

• Zufan Abera Damtew is a Former Director, Health Extension and Primary Health Service Directorate, Federal Ministry of Health.
• Seblewengel Lemma is a Former Director of Research, International Institute for Primary Health Care—Ethiopia.
• Rose Zulliger is an Epidemiologist, PhD, MPH, President’s Malaria Initiative Resident Advisor, US Centers for Disease Control and Prevention.
• Amsalu Shiferaw Moges is an Immunization Specialist, UNICEF.
• Alula Teklu leads MERQ Consultancy.
• Henry B. Perry is a Senior Scientist at Johns Hopkins School of Public Health.

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