Abstract
Background
Ethiopia has been implementing a community health extension program (HEP) since 2003. We aimed to assess the successes and challenges of the HEP over time, and develop a framework that may assist the implementation of the program toward universal primary healthcare services.
Methods
We conducted a systematic review and synthesis of the literature on the HEP in Ethiopia between 2003 and 2018. Literature search was accomplished in PubMed, Embase and Google scholar databases. Literature search strategies were developed using medical subject headings (MeSH) and text words related to the aim of the review. We used a three-stage screening process to select the publications. Data extraction was conducted by three reviewers using pre-prepared data extraction form. We conducted an interpretive (not aggregative) synthesis of studies.
Findings
The HEP enabled Ethiopia to achieve significant improvements in maternal and child health, communicable diseases, hygiene and sanitation, knowledge and health care seeking. The HEP has been a learning organization that adapts itself to community demands. The program is also dynamic enough to shift tasks between health centers and community. The community has been a key player in the successful implementation of the HEP. In spite of these successes, the program is currently facing challenges that remain to be addressed. These challenges are related to productivity and efficiency of health extension workers (HEWs); working and living conditions of HEWs; capacity of health posts; and, social determinants of health. These require a systemic approach that involves the wider health system, community, and sectors responsible for social determinants of health. We developed a framework that may assist in the implementation of the HEP.
Conclusion
The HEP has enabled Ethiopia to achieve significant improvements. However, several challenges remain to be addressed. The framework can be utilized to improve community health programs toward universal coverage for primary healthcare services.
Background
The Alma-Ata Declaration of 1978 identified primary health care (PHC) as the key approach to the attainment of the goal of “Health for All”. The PHC approach tackles the main health problems in the community through the provision of essential health services. The implementation of the PHC approach relies on health workers, including community health workers (CHWs). Community health worker embraces a variety of community health aides. They are members of a community who are chosen by community members or organizations to provide basic health and medical care to their community. As such, CHWs represent an important health resource with a potential to provide a reasonable level of health care [1].
Several countries have been implementing community health programs (CHPs), which provide basic health and medical care close to community, to increase access to and coverage of essential health services [2]. Ethiopia has been implementing a nation-wide CHP called health extension program (HEP) since 2003 [3]. Implementation of these CHPs, although they may have their own peculiarities, faces similar enablers and barriers for their effective implementation [4]. It is relevant that lessons from large-scale programs are synthesised to provide evidence of what works, what does not work and how can we improve performance. Currently, there is lack of evidence on the successes and challenges of the implementation of large-scale CHW programs which are included and implemented as an integral part of the national health system. It is therefore imperative to fill this knowledge gap toward improved and sustained implementation of large-scale and long-term CHWs program [4].
In a previous study in Ethiopia, we found that there were significant improvements in health outcomes during the era of the Millennium Development Goals (MDGs). There was a 67% reduction in under-five mortality; a 71% decline in maternal mortality ratio; a 90% decline in new HIV infections; a decrease in malaria-related deaths by 73%; and a more than 50% decline in mortality due to TB between 1990 and 2015 [5]. These successes in health outcomes were due to implementation of a mix of comprehensive strategies including improvements in health systems and overall socio-economic status in the country. The same study indicated that the HEP contributed to Ethiopia’s success in achieving the health MDGs [5]. However, the contribution of the HEP was not evaluated systematically. Hence, a number of questions remained to be answered by a systematic review and analysis of the existing evidence. The main questions that the program needs answer for include: What are the successes and challenges of the HEP between 2003 and 2018? What initiatives have been implemented to address the challenges and improve access to primary healthcare services?
The objective of this study is to identify successes and challenges in the implementation of the HEP in Ethiopia, find out initiatives undertaken to improve program challenges, and develop a framework, based on the review and synthesis, which may assist the country in strengthening its community HEP toward universal coverage for primary healthcare services.
Methods
Community health extension program of Ethiopia
Ethiopia’s health service delivery is structured into a three-tier system: primary, secondary and tertiary levels of care. The HEP is positioned, implemented and managed under the umbrella of the primary health care unit (PHCU) (Fig. 1) [3, 6]. Two HEWs are assigned to one health post to serve a population ranging from 3000 to 5000 in a village (kebele). Five health posts and a health center work in collaboration and form the PHCU that serves 25,000 people. The health center serves as a referral center. The health post is under the supervision of the district health office and the kebele administration and receives technical support from the nearby health center.
