Ethiopia's Health Extension Programme: Impact on Universal Primary Care Coverage
Abrha Asefa, Yibeltal Assefa, Dessalegn Melaku
BMJ Global Health · 2019 · DOI: 10.1136/bmjgh-2019-001936
Countries: Ethiopia
What Was Studied
A mixed-methods evaluation of Ethiopia's Health Extension Programme, which deploys trained, salaried female Health Extension Workers (HEWs) to provide 16 packages of primary care services at community health posts across the country. The study examined coverage, quality, and equity outcomes over 15 years of implementation.
What They Found
The HEP achieved near-universal primary care coverage: contraceptive prevalence increased from 15% to 36%, immunisation coverage reached 85%, and skilled birth attendance improved significantly in rural areas. Key success factors: (1) standardised one-year training programme; (2) deployment of HEWs in pairs to their home communities; (3) clear service packages with referral protocols; (4) regular salary and career progression pathway. Challenges included high attrition (15% annually), supervision gaps, and limited curative care capacity.
What This Means for Nepal
Ethiopia's HEP offers a roadmap for professionalising Nepal's community health workforce. Key takeaways: (1) Salaried positions with career progression dramatically improve retention over volunteer models; (2) Standardised training with clear service packages enables quality at scale; (3) Deploying workers to their home communities builds trust. Nepal's 52,000+ FCHVs could transition to a similar salaried model, but this requires significant fiscal investment that local governments may struggle to fund alone — federal support would be essential.
Contextualisation
Ethiopia's Health Extension Programme (HEP) deployed over 38,000 salaried Health Extension Workers to rural communities — a model Nepal could learn from as it considers professionalising its FCHV cadre and strengthening primary care under federalism.