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December 20, 2010

Lessons from the Field: Ethiopia’s health extension workers

Piling onto the bus, it almost felt like a grade school field trip - except that instead of classmates, I was surrounded by high-level delegates from 5 different ministries of health. It was day two of MLI’s four-day Leadership Collaborative Forum in Addis Ababa, Ethiopia, and we were headed on a field visit to a rural Health Extension Worker Clinic.

The group included representatives from Senegal, Mali, Sierra Leone, Nepal, and Ethiopia – all five MLI countries – plus several senior staff from the Washington, DC offices, and me, MLI’s communications and website coordinator. As the bus wove its way down Bole Road, away from the hotel and out of Addis, I weighed the pros and cons of admitting I didn’t know what a health extension worker was.

The road was well-paved and complete with white paint designating lanes and lampposts overhead, but it was brimming with traffic and dotted with pedestrians and the occasional donkey. Looking at my fellow bus riders, I wondered about the streets of their home towns, and what the Addis streets looked like to each of them compared to each of their vastly differing home countries. When we finally arrived at the clinic, an hour and a half outside Ethiopia’s capital city, I shyly hung back.

An introduction to their work

The clinic was set far back from the road, on a field of dry yellow hay but surrounded by spiky green bushes and leafy trees, and it looked like a one-room schoolhouse: a pointy roof topped the small building and hung out over a platform porch. The two health extension workers stood in the doorway, their soft teenage faces contrasting with their starchy doctor’s coats, and everyone gathered around to hear Dereje Mamo of the Ethiopian Federal Ministry of Health give an overview of the health post and introduce the workers.

These women, he explained, were two of Ethiopia’s 35,000 health extension workers, who after completing grade school plus one year of training were stationed in rural communities around the country to increase access to health services, from assisting births and supporting other family care needs to conducting outreach around issues like family planning, sanitation and nutrition. Though the workers were on the payroll of the Ministry of Health, their services were provided free of charge. When cases were too complicated for the workers, they referred their patients to a clinic five miles away.

As 85 percent of Ethiopians live in areas like this one, he explained, rural community health practitioners were desperately needed in order to combat maternal and child mortality in particular. UNICEF estimates that about 60 women die every day in Ethiopia from complications related to childbirth – mostly because they live in rural areas and can’t get to a clinic – and Federal Health Minister Tedros Adhanom Ghebreyesus is renowned for his leadership in this area, among others. “We managed to deploy two health extension workers per village,” he has explained in a story. “These are salaried, full-time civil service staff working with communities to prevent malaria and other communicable diseases.”

Senior officials turn into students

After Dereje relayed each piece of information in English, he paused to allow the translator to repeat it to the Malians and Senegalese in French while Gaby Mallapaty, MLI Country Lead for Nepal, translated it to Nepali. Hon. Khadka Bahadur Basyal Sarki, the Nepalese Minister of State, listened thoughtfully beneath his traditional Topi cap; Senegalese Reproductive Health director Dr. Bocar Daff, in a navy track suit, stroked his chin; energetic Issa Berthe of Mali’s Ministry of Health Planning and Statistics Unit nodded with enthusiasm. I watched the delegates transform into avid students, taking in the information and analyzing it.

Meanwhile, the health workers watched the group; speaking only Amharic, they couldn’t know how Dereje was introducing them in English, much less follow the French or Nepali. Amid the cacophony of languages and the huddle of men and women wearing suiting material and shiny shoes, the workers stood silently, but on their faces read shyness, curiosity, and pride.

One woman looked much younger than the other. She peered through the crowd at me, perhaps wondering how another young woman fit into the ensemble of government representatives. I tried to calculate her age – maybe 16? Then Dereje asked her to describe life in the clinic and she spoke of knowing all the families’ names in her area, and how she and her partner co-ordinate community coffee rituals in order to create the space for a women-only discussion and health education opportunity.

Questions from their visitors

When it came time for questions, they came rapid-fire. Dr. Samuel Kargbo, Director of Reproductive and Child Health in Sierra Leone’s Ministry of Health and Sanitation, stepped forward. “I see your charts on the wall,” he said, gesturing to the graphs and tables covering the exterior of the clinic with statistics about the community as well as data tracking the health workers’ outreach efforts. “Why is your rate of neo-natal care lower than your birth rate? How can that be?”

The health workers explained that while the community members went to the bigger, central clinic for their neo-natal care, it was the health extension workers who attended to the births – whatever time of day or night they might occur. “So if I go into the clinic,” Dr. Kargbo said, “I would be seeing a graph with a very high rate of neo-natal care delivery and a very low rate of deliveries?”

The health workers smiled: yes. They fielded technical questions from Mali, Senegal, and Nepal, with the delegates revealing their passion and expertise on their subjects as well as their admiration for Ethiopia’s program. Each delegation thanked the women for their service to their community and called them inspiring and impressive. The women smiled and continued to paint a picture of a perfect system until Peggy Clark, the executive director of the Aspen Global Health and Development, raised her hand and asked what the women would change if they could.

Wanting a chance at advancement

The senior of the two women stepped forward and spoke passionately. “At first, my  colleague and I saw the one-year training program as simply an opportunity for a career,” she said through the translator. “Now, we know we are serving our people, and we are proud and motivated by this. However, I have been here for six years, with no promotion or salary increase. I would like to see more opportunities for advancement.”

The delegations absorbed the energy of the young girl and her dreams and ambitions and turned to each other with significant looks. I imagined they were thinking of rural health workers back home and the ongoing challenge of how to keep those most-needed positions filled: beyond a living wage and the possibility of raises and cash bonuses, employing efforts to support rural workers holistically, recognizing them for their services and ensuring they will be rotated out.

Secretary General of Senegal’s Ministry of Health and Prevention Moussa Mbaye stepped forward to thank the workers for their service; as the others had said, the women’s hard work and inspiring attitudes would stay with him as he returned to his country and worked to similarly reach out to his country’s rural populations. He seemed to finish, and then his eyes twinkled and he added something quickly in French. Chief of Information Issa Berthe of Mali immediately repeated the words, clapping Moussa on the back. It was translated to Amharic, and the girls laughed: “If you are dissatisfied working here in Ethiopia, you always have a job waiting in Senegal and in Mali!”


Evan (not verified)
January 2, 2011 - 1:39pm

It's great to get a new perspective on such a misunderstood subject. Just thinking of all those health ministers venturing out into the field, getting educated, and collaborating on solutions is inspiring. Keep it up!