1. A Case Study from Ethiopia The Health Extension Program (HEP) By Habtamu Argaw (MD,MPH) NHSDE, WHO/Ethiopia Innovative Education and scale up for rural health workers

2. The HEP and Reasons Behind its Introduction PHC adopted since 1970‘s, Aimed to universal coverage, Used CHWs and CHS, but failed due to; – Remuneration/incentives and support, – Sructure of MOH (limited to central/regional level, none at district level) – Maintained vertical programs Renewed efforts (1993) and yet during HSDP I (1997-2000/1), EHSP didn’t reach the people at grass roots level.

3. HEP Target of universal PHC coverage by 2009/10 HEP introduced in 2003 (HSDP II) – Aim – Creating healthy environment and healthful living (esp. Preventive, promotive, and health awareness) – Make available EHSP at grass root (Kebele & HH) as a package targeting HH (mothers and women) through HH visit, health education and demonstration.

4. HEP Implemented by two salaried staff at each Kebele,Health Extension Workers (HEW) HEWs are Female (exceptions) HEWs are recruited from the same kebele HEWs are trained for a year at Technical and Vocational Education and Training Centers. (TVET).

5. HEP Covers 16 health extension packages in 3 areas; 1. Disease Prevention and Control. – HIV/AIDS/STI and TB prevention/control – Malaria prevention/control - First Aid and emergency 2. Family Health Service. – Maternal and child health - Family planning - Immunization – Adolescent reproductive health - Nutrition 3. Hygiene and Environmental Sanitation. – Excreta disposal - Solid and liquid waste disposal – Water supply and safety - Food hygiene and safety measures – Healthy home environment -Control of insects and rodents – Personal hygiene IEC as cross cutting approach.

6. HEP Approaches to HEP delivery HEW uses the following approaches Model family Community based health packages HP based services HEW required to spend 75% of their time in the outreach activity by going from home to home

7. Progress 17,653 (59%) HEW trained and deployed 7,000 to be trained each year until end 2009 9914 (66%) of HP constructed by June 2007 Strong political commitment is key Partners joining hands TWG established to support Health represented in local administration (Cabinet)

8. Many Challenges Recruitment – Lack of adherence to rural recruitemnt Training and skills development, – Limited skills (esp. skilled delivery) Supplies and equipment – Not yet fullfiled – New needs emerging (transport, bags etc) Supervision. – DHMT not capable of giving effective support – Roles for HC limited Other problems – Career development – Transfer – Recognition and support from other HRH

9. Points for discussion and action System wide linkage and Integration to national health system including referral system Linkage with national HRH system Focus of basic training (priority) Large number of trainees vs. skills training Free HEP in contrast to private sector linkage