1. PRIMARY HEALTH CARE IN PRACTICE: PROVISION OF PREVENTIVE AND BASIC CURATIVE CARE AT THE COMMUNITY LEVEL THROUGH HEALTH EXTENSION WORKERS Neghist Tesfaye (MD, MSc. IH) National Program Coordinator for MNCAH Director of the Urban Health Promotion and Disease Prevention Directorate Federal Ministry of Health Addis Ababa, 24 April 2012 SPECIAL SESSION COUNTDOWN TO 2015 IN ETHIOPIA

2. Outline Health Extension Program/Health Extension Workers Successes Challenges Scale up strategy/Health Development Army Way forward

3. Health Extension Program Community-based health service delivery program approach is based on the innovation-diffusion model, which holds that community behavior is changed step by step: early adopters, laggards (16%)….. Health Extension Program assumes that health behavior can be enhanced in communities by creating model families

4. Health Extension Program Flagship program of Ethiopia with strong support from the political leaders as a sub-component of Health Sector Development Program II (2002– 2005), Health Sector Development Program III 2005/6 -2009/2010, Health Sector Development Program IV 2010/11 – 2014/15 One of the Bloodlines in Health Sector Development Program IV

5. Health Extension Workers Female 10 grade and above with one year training (rural and pastoralist) Speak local language Resident in the village Paid by government Rural, Urban, Pastoralist 2HEW 5000 people 34000 rural+ 4000 urban

6. Ethiopian Health Tier System 1. Primary level health care: Health post Health center Primary hospital Urban Health center for 40,000 people 2. Secondary level health care: General hospital 3. Tertiary level health care: Specialized hospital

7. Increasing access Upward trend in building infrastructure: construction of Health Post reaching 15,095 in 2010/11 construction of Health Centers reaching 2,800 in 2012

8. Trend of Health Extension Workers deployed Cumulative number of Health Extension Workers trained and deployed (target reached in 2010)

9. 16 Health Extension Packages Disease Prevention & control (3) Family Health (5)- Health Education and communicati on Hygiene & Environmental Sanitation (7) MCH FP Immunization Nutrition Adolescent Health HIV/TB Malaria First AID Personal Hygiene Water and sanitation Food hygiene Latrine Solid & liquid waste disposal Housing construction Insects & Rodents control

10. Health Extension Program Services provided: Promotion, Prevention and Basic curatives services Skill based Clean and safe delivery & provision of Misoprostol Integrated Community Case Management of common childhood illness (Malaria, Pneumonia and Diarrhea) Task shifting- Implanon insertion by Health Extension Workers Community Directly Observed Treatment (DOTS)

11. Health Extension Worker inserting single rod Implants

12. Career development Integrated Refresher Training: 1.CMNCH 2.EPI 3.TB/HIV 4.Integrated Community Case Management of common childhood illness (Malaria, Pneumonia and Diarrhea) 5.First Aid Upgrading of Health Extension Worker- from Level 3 (certificate) to Level 4, 1700, 1 year training in health science college (diploma)

13. Success

14. Trend in population-based indicators Health Extension Workers contributed to an increase in coverage of some MCH services

15. Total Fertility Rate (TFR)

16. Contraceptive Prevalence Rate

17. Trend in antenatal care, delivery assisted by skilled attendant and postnatal care coverage

18. Challenges

19. Referral linkage in the Primary Health Care Unit was not optimal and we did not tap the full potential of the Health Extension Program High MMR-3 delays: (1) deciding to seek appropriate medical help for an obstetric emergency; (2) reaching an appropriate obstetric facility; and (3) receiving adequate care when a facility is reached

20. Scale up strategy: addressing delay one Designed to scale up new technologies and health extension packages (HEPs) best practices in a short period of time with high coverage. Core issue to ensure scale up strategy is building capacity by establishing Health Development Army (HDA) thereby ensuring prompt and sustainable development. Determined for blanket coverage in a short period of time. Intends to develop capacity to solve the development bottlenecks in the area of leadership, attitude and skill. Creates strong network between the health centre and health posts

21. Health Development Army Health Development Army will be strengthened at all levels 1 to 5 networking is the main tool used in Health Development Army Implementation of all Health Extension Packages at the community to produce and sustain their own health Best mechanism to improve capacities of families at the household level in the area of skill and attitude and increase demand for services.

22. Health Development Army The leader of the 1-5 network will be chosen by the community based on performance of Health Extension Packages Leader will have 5 households as followers Approach builds strong support and monitoring mechanism in identifying bottlenecks and gaps and seeking solutions as early as possible High political commitment

23. 1 to 5 networking One kebele has 1000 households One development team has 5 networks One development team has 20-30 households One kebele has 30-33 development teams Kebele Development Team 1-5

24. Addressing delay two Ambulances- one for each woreda Tricycle Ambulances- being tested to be scaled in all kebeles Experience from some regions- Traditional ambulances using people, using other sector ministry cars

25. Way forward Health Extension Program and Health Development Army work toward increasing awareness and changing health seeking behavior Strengthening Primary Health Care Unit and improving referral linkage to better support Health Extension Workers Strengthening Health System and better finance to address delays 2 and 3 for better maternal and newborn health outcomes