Disparities in the implementation of the Health Extension Program in Ethiopia: doing more and better towards universal health coverage

IntroductionLarge-scale implementation of the Health Extension Program (HEP) has enabled Ethiopia to make significant progress in health services coverage and health outcomes. However, evidence on equity and disparities in implementation of the HEP and its outputs is limited. The aim of this study was to examine disparities in the implementation of the HEP in Ethiopia.MethodsWe used data from the 2019 National HEP assessment conducted between Oct 2018 and Sept 2019 in nine regions in the country. Data was collected from 62 districts, 343 Health posts, 179 Health centres, 584 Health Extension Workers (HEWs), 7,043 women from 7,122 Households. This study focused on selected input, service delivery, and service coverage indicators. We used rate differences, rate ratios and index of disparity to assess disparities in HEP implementation across regions.ResultsWe found wide interregional disparities in HEP implementation. Developing regional states (DRS) had significantly availability of qualified HEWs (Rate Ratio (RR) = 0.54), proportion of households visited by Health Extension workers (RR = 0.40, and proportion of mothers who received education on child nutrition (RR = 0.45) as compared national average. There are also significant disparities in HEP implementation among DRS in proportion of household visited by HEWs in the past 12 months (Index of disparity = 1.58) and proportion of adolescents who interacted with HEWs (Index of disparity = 1.43). Despite low overall coverage of health services in DRS, the contribution of the HEP for maternal health services is relatively high.ConclusionThere exist significant interregional disparities in HEP implementation in Ethiopia. The level of disparity among DRS is also remarkable. If the country is to achieve UHC, it is important that these disparities are addressed systematically and strategically. This calls for further attention in all regions, in general, and a tailored approach in DRS, in particular.

Association between a complex community intervention and quality of health extension workers’ performance to correctly classify common childhood illnesses in four regions of Ethiopia

Background Due to low care utilization, a complex intervention was done for two years to optimize the Ethiopian Health Extension Program. Improved quality of the integrated community case management services was an intermediate outcome of this intervention through community education and mobilization, capacity building of health workers, and strengthening of district ownership and accountability of sick child services. We evaluated the association between the intervention and the health extension workers’ ability to correctly classify common childhood illnesses in four regions of Ethiopia. Methods Baseline and endline assessments were done in 2016 and 2018 in intervention and comparison areas in four regions of Ethiopia. Ill children aged 2 to 59 months were mobilized to visit health posts for an assessment that was followed by re-examination. We analyzed sensitivity, specificity, and difference-in-difference of correct classification with multilevel mixed logistic regression in intervention and comparison areas at baseline and endline. Results Health extensions workers’ consultations with ill children were observed in intervention (n = 710) and comparison areas (n = 615). At baseline, re-examination of the children showed that in intervention areas, health extension workers’ sensitivity for fever or malaria was 54%, 68% for respiratory infections, 90% for diarrheal diseases, and 34% for malnutrition. At endline, it was 40% for fever or malaria, 49% for respiratory infections, 85% for diarrheal diseases, and 48% for malnutrition. Specificity was higher (89–100%) for all childhood illnesses. Difference-in-differences was 6% for correct classification of fever or malaria [aOR = 1.45 95% CI: 0.81–2.60], 4% for respiratory tract infection [aOR = 1.49 95% CI: 0.81–2.74], and 5% for diarrheal diseases [aOR = 1.74 95% CI: 0.77–3.92]. Conclusion This study revealed that the Optimization of Health Extension Program intervention, which included training, supportive supervision, and performance reviews of health extension workers, was not associated with an improved classification of childhood illnesses by these Ethiopian primary health care workers. Trial registration ISRCTN12040912, http://www.isrctn.com/ISRCTN12040912.

Economic evaluation of Health Extension Program packages in Ethiopia

Background Ethiopia launched the Health Extension Program (HEP) in 2004, aimed at ensuring equitable community-level healthcare services through Health Extension Workers. Despite the program’s being a flagship initiative, there is limited evidence on whether investment in the program represents good value for money. This study assessed the cost and cost-effectiveness of HEP interventions to inform policy decisions for resource allocation and priority setting in Ethiopia. Methods Twenty-one health care interventions were selected under the hygiene and sanitation, family health services, and disease prevention and control sub-domains. The ingredient bottom-up and top-down costing method was employed. Cost and cost-effectiveness were assessed from the provider perspective. Health outcomes were measured using life years gained (LYG). Incremental cost per LYG in relation to the gross domestic product (GDP) per capita of Ethiopia (US$852.80) was used to ascertain the cost-effectiveness. All costs were collected in Ethiopian birr and converted to United States dollars (US$) using the average exchange rate for 2018 (US$1 = 27.67 birr). Both costs and health outcomes were discounted by 3%. Result The average unit cost of providing selected hygiene and sanitation, family health, and disease prevention and control services with the HEP was US$0.70, US$4.90, and US$7.40, respectively. The major cost driver was drugs and supplies, accounting for 53% and 68%, respectively, of the total cost. The average annual cost of delivering all the selected interventions was US$9,897. All interventions fall within 1 times GDP per capita per LYG, indicating that they are very cost-effective (ranges: US$22–$295 per LYG). Overall, the HEP is cost-effective by investing US$77.40 for every LYG. Conclusion The unit cost estimates of HEP interventions are crucial for priority-setting, resource mobilization, and program planning. This study found that the program is very cost-effective in delivering community health services.

Implementation, experience, and challenges of urban health extension program in Addis Ababa: a case study from Ethiopia

Background Even though the urban health extension program (HEP) has been implemented since 2009, little was known about its implementation, experience and challenges. Therefore, this study was aimed at exploring the implementation, experience, and challenges of the urban HEP. Methods A qualitative case study was conducted in Addis Ababa from November 15 to December 29, 2017. The study participants were recruited purposefully. The parent populations were health extension professionals (HEPs). However, health post supervisors, health development army leaders (HDAs), Addis Ababa city HEP administrators, and other community members were also involved in the study. Four focus group discussions and 31 in-depth and key informant interviews were conducted. Data were transcribed verbatim, translated into the English, and analyzed by an inductive thematic analysis approach using Atlas ti7.1 software. Result The study found that there were 15 health service packages of the urban HEP delivered to the community based on the need of the households. The strategies for the program implementation were provision of trainings, home visitation, creation of model households, strengthening of HDAs, supervision and reporting, referral and feedback, and social and community mobilization. However, program implementation was challenged by the health system related challenges (health service package and delivery, workload of HEPs, shortage of trained HEPs, lack of regular supervision or monitoring, lack of logistical or motivational support, poor supply chain management, dissatisfaction of HEPs, assigning of more than expected households for HEPs, etc.), multisectoral related and community related challenges (HDAs need of incentives, and lack of graduating model households as per the plan, etc.). Conclusions Although the program had a significant contribution to the health of community, it was affected by different challenges that underscore the need to develop different strategies and taking of actions. Therefore, the district health office, health centers and stakeholders from different sectors should have to support and motivate the HEPs and HDAs, and work together with them for successful implementation of the program.

Implementation of the ‘Optimising the Health Extension Program’ Intervention in Ethiopia: A Process Evaluation Using Mixed Methods

An intervention called ‘Optimising the Health Extension Program’, aiming to increase care-seeking for childhood illnesses in four regions of Ethiopia, was implemented between 2016 and 2018, and it included community engagement, capacity building, and district ownership and accountability. A pragmatic trial comparing 26 districts that received the intervention with 26 districts that did not found no evidence to suggest that the intervention increased utilisation of services. Here we used mixed methods to explore how the intervention was implemented. A fidelity analysis of each 31 intervention activities was performed, separately for the first phase and for the entire implementation period, to assess the extent to which what was planned was carried out. Qualitative interviews were undertaken with 39 implementers, to explore the successes and challenges of the implementation, and were analysed by using thematic analysis. Our findings show that the implementation was delayed, with only 19% (n = 6/31) activities having high fidelity in the first phase. Key challenges that presented barriers to timely implementation included the following: complexity both of the intervention itself and of administrative systems; inconsistent support from district health offices, partly due to competing priorities, such as the management of disease outbreaks; and infrequent supervision of health extension workers at the grassroots level. We conclude that, for sustainability, evidence-based interventions must be aligned with national health priorities and delivered within an existing health system. Strategies to overcome the resulting complexity include a realistic time frame and investment in district health teams, to support implementation at grassroots level.

Barriers and Facilitators to Implementing Mental Health Services into the Ethiopian Health Extension Program: A Qualitative Study

Background: Mental health problem is the major health problem globally and nationally in Ethiopia. To address this problem the Ministry of health of Ethiopia integrated mental health services in to the community health service. However, the preliminary reports showed the service has not been implemented yet. Therefore, the aim of this study was to explore the barriers and facilitators of mental health service implementation in to the Ethiopian health extension program.Methods: A qualitative case study was conducted in the Ethiopian primary health care system from 12 August to 25 September 2019. We have conducted about ten purposively selected key informant interviews from the Ministry of Health and community level workers (i.e. health extension workers). All interviews were recorded using voice recorder and transcribed verbatim and translated for analysis. The data then analyzed manually in relevant themes. Results: Mental health problem currently is a major health issue in Ethiopia. However, the service is not ready to respond for the existing health service need. The recently designed integration of mental health services in to health extension program was not implemented so far. The basic identified barriers were, low political commitment, shortage of resources, non-functional referral system, lack of interest from private health service organizations, attitudinal problems from both the society and service providers, the lack of reporting system for mental health problems. On the contrary, there are also facilitators for the service like well-designed primary health care system, trained health extension workers, changing political commitment and attitude of the community.Conclusion: Although mental health problems are widely spread and increasing in alarming rate, in Ethiopia, the existing health system is not capable enough to respond. This problem is complex and intertwined. A series of activities to solve the major barriers are expected especially from the health system leaders to implement follow up and evaluate mental health services at the health extension programs.