tag:theconversation.com,2011:/us/topics/ethiopian-health-22884/articlesEthiopian health – The Conversation2017-05-24T19:35:30Ztag:theconversation.com,2011:article/782772017-05-24T19:35:30Z2017-05-24T19:35:30ZThe WHO’s new African leader could be a shot in the arm for poorer countries<figure><img src="https://images.theconversation.com/files/170793/original/file-20170524-31373-qq2v03.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Tedros Ghebreyesus, the newly elected Director-General of the World Health Organisation.</span> <span class="attribution"><span class="source">Reuters/Denis Balibouse</span></span></figcaption></figure><p><em>Dr Tedros Ghebreyesus is the first African to be elected as the <a href="http://www.who.int/mediacentre/news/releases/2017/director-general-elect/en/">Director-General</a> of the World Health Organisation (WHO) in its 70 year history. The WHO is the United Nations body that directs its member states on international health issues. David Sanders explains to The Conversation Africa some of the main challenges Ghebreyesus will face in his five-year term.</em> </p>
<p><strong>What is the significance of this appointment?</strong></p>
<p>This is the first time the entire 194-strong WHO assembly voted for the position. Votes were cast by secret ballot. Previously the organisation’s Executive Board selected the DG. The massive margin for Tedros – 133 votes vs 50 for the UK candidate David Nabarro – suggests that the entire Global South voted for him. The size of the landslide had not been expected. </p>
<p>The vote almost certainly represents a vote against <a href="http://www.ghwatch.org/sites/www.ghwatch.org/files/D1_0.pdf">big power domination and machinations</a> in the WHO which often appears to ignore the main challenges and aspirations of low and middle income countries.</p>
<p><strong>What does he bring to the table?</strong></p>
<p>As Ethiopia’s former Minister of Health Ghebreyesus spearheaded major reforms to their health system. This included a massive expansion of primary health care infrastructure and a dramatic increase in health human resources at all levels. He oversaw a rapid increase in the training of doctors, shifted the responsibility for key interventions such as caesarean sections to mid-level workers, and the introduction of community-level workers (Health Extension Agents). </p>
<p>All contributed to <a href="https://www.researchgate.net/publication/307509510_Reduction_in_child_mortality_in_Ethiopia_analysis_of_data_from_demographic_and_health_surveys">impressive improvements in health</a> outcomes – especially in child health. </p>
<p>This track record is certainly behind his election. But he’ll have his work cut out for him. The WHO is experiencing its greatest crisis since its founding in 1948. It’s biggest challenges are finance-related.</p>
<p>The organisation is facing a financial crisis with a <a href="http://apps.who.int/gb/ebwha/pdf_files/WHA70/A70_6-en.pdf">US$ 456 million deficit</a> this year. This is bound to mean that there will have to be a major cuts to some programmes. Some might even have to be closed. Retrenchments are also on the cards.</p>
<p>For the past few decades the organisation has increasingly relied on donor funds because member states – particularly richer ones – have been reducing their <a href="http://www.reuters.com/investigates/special-report/health-who-future/">contributions</a>. A full 80% of the organisation’s funding is now from sources other than member states. Donors such as the Bill and Melinda Gates Foundation are making <a href="http://www.reuters.com/investigates/special-report/health-who-future/">major contributions</a>. </p>
<p>This means that the priorities of donors tend to dominate, thus making it difficult for the WHO to carry out the policies identified by its member states. In addition, intergovernmental bodies such as the World Bank have <a href="http://ijme.in/wp-content/uploads/2016/11/1653-5.pdf">weakened the WHO’s role</a>.</p>
<p>And some key programmes have had their budgets significantly reduced. One example is the programme to control non-communicable diseases. They are now the top cause of <a href="http://www.who.int/gho/ncd/mortality_morbidity/en/">morbidity and mortality</a> globally, and in low and middle-income countries. </p>
<p>Some vital programmes central to the WHO’s mandate remain underfunded. Sometimes this is due to the fact that they conflict with the interests of rich countries and big donors, particularly those with links to industry. For example, governments have consistently opposed putting in place food regulations to <a href="http://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1001253">address the rise in consumption of unhealthy food</a>. This is presumably because they would affect big corporations that are <a href="http://www.thelancet.com/pdfs/journals/lancet/PIIS0140-6736(12)62089-3.pdf">prominent investors</a> in those countries. </p>
<p>The result has been that the WHO’s leadership role in global health has been undermined. </p>
<p>Another big challenge is strengthening health systems. The Ebola epidemic in West Africa in 2014 showed up <a href="https://theconversation.com/ebola-and-zika-epidemics-are-driven-by-pathologies-of-society-not-just-a-virus-54191">weaknesses in the WHO</a> as well as in the health systems of low and middle income countries. </p>
<p>Finally, health systems, particularly in Africa and Asia, face drastic resource shortages. Huge investments are required in human resources, the most expensive and important component. Africa in particular has an extreme shortage of health workers. Their numbers are further threatened by inadequate training programmes and external migration (<a href="http://www.bmj.com/content/343/bmj.d7031.full">‘brain drain’</a>) to rich countries. A WHO Voluntary Code of Practice on International Recruitment of Health Personnel has failed to impact positively on such losses. The clear challenge remains for health human resource shortages to be urgently and effectively addressed.</p>
<p><strong>What does he need to do to deal with these challenges?</strong></p>
<p>Ghebreyesus needs to use his strong mandate – notably from the Global South – to truly reform the WHO and its operations in favour of the world’s poor majority. </p>
<p>To do this, he needs to push strongly for member states to honour their commitments to the WHO and to rapidly and significantly increase their financial contributions.</p>
<p>He also needs to ensure that the influence of the food, beverage, alcohol and tobacco industries to control non communicable diseases is resisted. This will be difficult given that a framework has been passed that allows non-state actors to participate in WHO policy-making processes.</p>
<p>On top of this Ghebreyesus must ensure that the health systems of low and middle income countries are strengthened so that health emergencies such as infectious disease outbreaks can be contained.</p>
<p>The <a href="http://apps.who.int/gb/ebwha/pdf_files/WHA70/A70_16-en.pdf">current investments</a> in building surveillance capacity for infectious diseases are welcomed. But these efforts will remain inadequate without sustained investment in health systems. </p>
<p>This will ensure that agenda for health security isn’t focused on securing the health of rich country populations against contagion from the poor but on protecting all, particularly the most vulnerable. </p>
<p>What will be interesting to watch over the next five years is whether the evident solidarity between low and middle income counties in voting in Ghebreyesus as their candidate is maintained during the debates and decisions about world health. Until now, rich countries have been dominant in WHO meetings.</p><img src="https://counter.theconversation.com/content/78277/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>David Sanders is the co-chairperson of the People's Health Movement, which sponsored his trip to the World Health Assembly in Geneva. </span></em></p>There are a number of challenges that the World Health Organisation’s new leader, Ethiopian-born Tedros Ghebreyesus, will have to navigate during his tenure.David Sanders, Emeritus Professor, School of Public Health, University of the Western CapeLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/638352016-08-31T15:41:43Z2016-08-31T15:41:43ZWork is underway on a more efficient vaccine to beat deaths from diarrhoea<figure><img src="https://images.theconversation.com/files/135513/original/image-20160825-6622-jj87nn.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">The Rotavirus vaccine is expensive and takes a long time to manufacture.</span> <span class="attribution"><span class="source">Flickr</span></span></figcaption></figure><p>Globally every year <a href="http://www.who.int/immunization/monitoring_surveillance/burden/estimates/rotavirus/en/">nearly a quarter of a million children</a> under the age of five die from diarrhoea caused by the rotavirus. Nearly all of these deaths are in the developing world.</p>
<p>The rotavirus is a bug that results in acute gastroenteritis, diarrhoea and then severe dehydration. It can also cause fever and vomiting. Without proper medical attention it can be fatal.</p>
<p>Seven of the <a href="http://www.who.int/immunization/monitoring_surveillance/burden/estimates/rotavirus/en/">10 countries</a> that account for most rotavirus deaths are in Africa. Nigeria leads the pack, accounting for 14% of rotavirus deaths. The bug kills more than 31 000 children in Nigeria every year. Ethiopia, which has an under 5 population of 1.4 million, loses 7000 children every year to rotavirus. They account for <a href="http://www.who.int/immunization/monitoring_surveillance/burden/estimates/rotavirus/en/">3% of all rotavirus deaths globally</a>. </p>
<p>There are no drugs available to treat rotavirus. It can be prevented by using a live, attenuated vaccine. <a href="http://www.vaccines.gov/more_info/types/">These</a> are a living version of a microbe weakened in the lab so it can’t cause disease. But they are expensive and need cold storage, a challenge in developing countries.</p>
<p>Currently an international organisation, the <a href="http://www.gavi.org">Gavi vaccine alliance</a>, finances developing countries to procure rotavirus vaccines. But when this support eventually does fall away, the cost of marketed rotavirus vaccines will be too expensive for developing countries.</p>
<p>My colleagues and I are <a href="http://onlinelibrary.wiley.com/doi/10.1002/pro.2953/full">developing a vaccine</a> that is cheaper and that won’t require refrigeration. It could also be manufactured in a fraction of the time currently required. We are in the process of testing the vaccine on animal models.</p>
<h2>Traditional challenges</h2>
<p>By the end of 2015 the rotavirus vaccine had been introduced in <a href="http://www.who.int/mediacentre/factsheets/fs378/en/">81 countries</a>. The number of <a href="http://www.who.int/immunization/monitoring_surveillance/burden/estimates/rotavirus/en/">deaths</a> from the disease has been reduced by more than half. But the global coverage of the vaccine is still <a href="http://www.who.int/mediacentre/factsheets/fs378/en/">estimated at only 23%</a>. </p>
<p>There are two main problems with the vaccine: cost and logistics.</p>
<p>Some vaccines are more expensive than others. A dose of the <a href="http://www.unicef.org/supply/files/Rotavaccine.pdf">rotavirus vaccine costs US$5</a>. This compares to the measles vaccine, which costs less than <a href="https://en.wikipedia.org/wiki/Measles_vaccine">US$0.7 per dose</a>. </p>
<p>In developing nations, the cost of rotavirus vaccines is borne by not-for-profit organisations and philanthropists who regularly step into the funding breach.</p>
<p>The logistics challenge is also huge. Live, attenuated vaccines need to be refrigerated to stay potent. Rotavirus vaccines therefore need a lot of refrigerated space. This requires electricity which is in short supply in many developing countries and is often not available in rural areas.</p>
<h2>A new approach</h2>
<p>Traditionally vaccines are produced through a technique in which cells are cultured. This is a complicated, slow and costly process.</p>
<p>But in the past decade the <a href="http://www.aibn.uq.edu.au/">Australian Institute for Bioengineering and Nanotechnology</a> has developed a groundbreaking microbial technology. The process involves virus-like particles assembling on their own outside the host cells. This means that they can be controlled easily, radically simplifying the manufacturing process. </p>
<p>This technology has been used to <a href="https://www.researchgate.net/publication/51200512_A_microbial_platform_for_rapid_and_low-cost_virus-like_particle_and_capsomere_vaccines">manufacture</a> vaccines for influenza and group A streptococcus, a bacterium that causes a wide variety of infections including malaria. In both cases the cost of vaccines has dropped dramatically.</p>
<p>We are applying the same approach to develop a rotavirus vaccine that is made up of virus-like particles that display rotavirus antigens. The particles are not infectious but mimic a virus and stimulate the immune system which then learns to fight the real virus by practising on the virus-like particles.</p>
<p><a href="http://onlinelibrary.wiley.com/doi/10.1002/bit.26068/full">Injected subcutaneously into mice</a>, the particles induced high levels of antibodies. </p>
<p>Our latest findings open up the possibility of combining a vaccine against the virus that targets all circulating strains and reduces the economic burden of making it as well as storing it. </p>
<h2>The next frontier</h2>
<p>These are positive and encouraging results. But before any clinical trials can be done a series of safety and efficacy tests will need to be completed using appropriate animal models. </p>
<p>Once those are established we will move to clinical trials to generate sufficient efficacy and safety data.</p>
<p>Developing an effective rotavirus vaccine that is easier to manufacture and costs less will allow health authorities in developing countries to divert precious funds to other vital causes.</p><img src="https://counter.theconversation.com/content/63835/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Alemu Tekewe does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Rotavirus vaccines are expensive and take time to produce. For developing countries, the fact that the vaccines need cold storage also presents a challenge.Alemu Tekewe, PhD student at the Australian Institute for Bioengineering and Nanotechnology, Addis Ababa UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/521582016-01-25T03:30:31Z2016-01-25T03:30:31ZHaving a baby is hard in Ethiopia: women walk a lot, and wait a lot<figure><img src="https://images.theconversation.com/files/109081/original/image-20160124-403-y2dsah.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Long, often arduous walks are common for women in Ethiopia seeking health care.</span> <span class="attribution"><span class="source">Supplied</span></span></figcaption></figure><p>Maternal health has made great advances in Ethiopia. In my 10 years conducting research on maternal health, I’ve seen a big push to build more health facilities and to provide ambulances to transport pregnant women to these facilities. </p>
<p>But one of the big challenges for women is referring them for help from one facility to the next level. Aside from the facilities being very far apart, in some places there are no roads and limited transportation. The women have to walk from facility to facility. Or be carried. This makes it impossible to calculate how much time it will take them. </p>
<p>As more and more health facilities have been built in the past few years, more and more women walk to attend antenatal care clinics and to have a skilled birth attendant deliver their baby.</p>
<p>In Ethiopia just over 80% of the population lives in <a href="http://www.aho.afro.who.int/profiles_information/index.php/Ethiopia:Introduction_to_Country_Context">rural areas</a>. My doctoral research took place in the rural neighbourhoods (kebeles) in Kafa Zone in southwest Ethiopia. It looked at maternal health and how the goal of reducing maternal mortality fits into Ethiopia’s development agenda. </p>
<p>But it’s impossible to think about maternal health without thinking about the time and distance between where women live in rural kebeles and where the government constructs health facilities: health posts, health centres and hospitals. The three make up a primary health care unit.</p>
<p>There is a health post in each of the kebeles or neighbourhoods, which serves around 5 000 people.</p>
<h2>A series of complications</h2>
<p>One day in 2007, after hours of walking to interview women in their homes, we met an extended family who invited us into their home. </p>
<p>As squawking chickens ran about and a baby cried, a woman called Birke told me how she had been in labour for three or four days in Sherada in a rural part of Kafa Zone. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/109082/original/image-20160124-444-enqafx.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/109082/original/image-20160124-444-enqafx.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=448&fit=crop&dpr=1 600w, https://images.theconversation.com/files/109082/original/image-20160124-444-enqafx.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=448&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/109082/original/image-20160124-444-enqafx.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=448&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/109082/original/image-20160124-444-enqafx.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=563&fit=crop&dpr=1 754w, https://images.theconversation.com/files/109082/original/image-20160124-444-enqafx.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=563&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/109082/original/image-20160124-444-enqafx.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=563&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Men prepare a stretcher to carry a woman.</span>
<span class="attribution"><span class="source">Supplied</span></span>
</figcaption>
</figure>
<p>Her husband’s family kept hoping the baby would be born but the labour continued. There was no nurse and no road so she was carried by stretcher for five hours to the road at Gojeb. There she was taken by bus to Bonga. </p>
<p>In Bonga Hospital she was in labour for another two days. The baby died but they didn’t remove it as she needed a blood transfusion which could not be done at the hospital. Her husband went home, sold their ox and borrowed extra money for her treatment and the cost of transportation and walked back to the hospital. </p>
<p>Finally, Birke was taken to Jimma Hospital (three to five hours drive away) where the dead baby was removed by caesarean section. Birke left her husband because of ongoing ill health and now lives with her elderly mother and other relatives in Sheyka.</p>
<p>It is not only Birke’s area that is like this. In Muti, the women have to balance in the mud when they walk after it rains. And in Deckia the knee-deep mud is on a 50-degree angle and even the mules struggle to find their way. </p>
<h2>Changes afoot</h2>
<p>Eight years later and on a different research project, I was able to hire a car to visit health facilities and health extension workers in three different regions in Ethiopia. </p>
<p>Health extension workers are community health workers selected from the rural areas they come from. They are trained and return to their communities to provide health care services. </p>
<p>Two health extension workers are based in health posts in a rural kebeles. They provide a range of services including family planning, antenatal care, and other services that aim to halt and reverse the spread of major communicable diseases. But most importantly, they try to encourage women to give birth in health centres rather than at home. Health extension workers can now refer women in labour or prior to labour to health centres by ambulance. </p>
<p>Time is dependent on so many external factors: weather; the availability of men to make a stretcher and carry a woman; the availability of transport; and the availability of trained medical staff to treat the woman at the referral centre. </p>
<p>Throughout my research, as I’ve waited for the rain to stop or for the bus to leave, while I waited for hours in the queue at the hospital with friends, or outside an office for an interview, I’ve often felt that waiting was so normalised that it seemed opaque.</p>
<p>Like waiting for the baby to come and hoping everything will be alright.</p>
<hr>
<p><em>* If you are a woman who has conducted research in Africa and you’d like to contribute a chapter to an edited book about your experiences, please send <a href="r.jackson@deakin.edu.au">Ruth Jackson</a> an abstract of 300 to 350 words along with your name, institutional affiliation and email address by the end of February 2016. We’re looking for autobiographical, ethnographic, reflective accounts grounded in theory or a combination of approaches.</em></p><img src="https://counter.theconversation.com/content/52158/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Ruth Jackson received funding from the Australian government's, Australian Development Research Award Scheme (ADRAS), under an award titled, Improving the use of maternal, neonatal and child health services in rural and pastoralist Ethiopia, AusAID Agreement 66420. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. </span></em></p>It’s impossible to think about maternal health in Ethiopia without thinking about the time and distance between where rural women live and where the government constructs health facilities.Ruth Jackson, Research Fellow of International Development, Deakin UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/509872015-11-25T04:37:57Z2015-11-25T04:37:57ZEthiopia has cracked the problem of rural health, but its workers feel stuck<figure><img src="https://images.theconversation.com/files/102982/original/image-20151124-18255-1u20knc.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">A woman extension worker employed by the Afar Pastoralist Development Association. Some health extension workers are separated from their families and some are unable to move.</span> <span class="attribution"><span class="source">Kate Holt/Anglican Overseas Aid</span></span></figcaption></figure><p>Health extension <a href="http://www.moh.gov.et/documents/26765/0/Annual+Performance+Report+2015/dddac759-77cd-43e8-a753-34f3222b1a0d">workers</a> have been vital in Ethiopia’s rural communities. They have introduced new mothers to the importance of child immunisation, taught households about sanitation and, with the recent introduction of ambulances, they refer women to health centres for antenatal care and skilled birth assistance. </p>
<p>These community health workers are selected from the rural areas they come from. After being trained they return to their communities to provide healthcare services. The programme has been very successful. As a result, international institutions including the World Bank, USAID and the World Health Organisation have commended its programme. And several other African countries have been eagerly <a href="https://www.usaid.gov/results-data/success-stories/all-eyes-ethiopia%E2%80%99s-national-health-extension-program-0">following</a> it to see how a community based health programme can be taken to scale. </p>
<p>Despite this, Ethiopia has placed little focus on the workers who make up this health workforce. Many want to leave their positions because there is little chance for promotion or transfer. </p>
<p>Unless Ethiopia provides these health workers with better opportunities for education, training and promotion, it stands to lose many of them. </p>
<h2>The need for health workers</h2>
<p>Critical shortages in Ethiopia’s health workforce, along with an uneven distribution of staff, a poor skill mix and high attrition of trained health professionals are among the major <a href="http://www.aho.afro.who.int/profiles_information/index.php/Ethiopia:Analytical_summary_-_Health_system_outcomes">obstacles</a> in delivering healthcare. </p>
<p>A total of <a href="http://www.aho.afro.who.int/profiles_information/index.php/Ethiopia:Introduction_to_Country_Context">83.6%</a> of the population lives in rural areas, making it one of the least urbanised countries in the world. The country’s economy is heavily dependent on agriculture, which employs over 70% of the country’s <a href="http://www-wds.worldbank.org/external/default/WDSContentServer/WDSP/IB/2015/11/19/090224b0831e8f19/1_0/Rendered/PDF/Ethiopia0s0gre0n0and0how0to0pace0it.pdf">workforce</a>.</p>
<p>The country’s major health system response is focused on primary healthcare. This is made up of primary hospitals, health centres and health posts, which together form a primary health care unit. The three are connected through a referral system. Primary hospitals refer to general hospitals which, in turn, refer to specialised hospitals. </p>
<p>The health extension programme was introduced in Ethiopia in 2003 to improve access to basic health services, with a specific focus on women and children.</p>
<h2>A local service</h2>
<p>By 2020 there will be over 50 000 health extension <a href="http://www.who.int/workforcealliance/knowledge/publications/Ethiopia_report.pdf">workers</a> in Ethiopia. They form 47% of the health workforce in the country, making up the largest single group. Most (99.5%) are women under the age of 30. They are among the highest educated women in Ethiopia, where only 29% of women are <a href="https://cdn2.sph.harvard.edu/wp-content/uploads/sites/32/2014/09/HSPH-Ethiopia4.pdf">literate</a>. </p>
<figure class="align-right ">
<img alt="" src="https://images.theconversation.com/files/102678/original/image-20151121-389-96c6hv.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/102678/original/image-20151121-389-96c6hv.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=450&fit=crop&dpr=1 600w, https://images.theconversation.com/files/102678/original/image-20151121-389-96c6hv.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=450&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/102678/original/image-20151121-389-96c6hv.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=450&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/102678/original/image-20151121-389-96c6hv.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=565&fit=crop&dpr=1 754w, https://images.theconversation.com/files/102678/original/image-20151121-389-96c6hv.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=565&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/102678/original/image-20151121-389-96c6hv.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=565&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">A rural health post in Ethiopia.</span>
<span class="attribution"><span class="source">supplied</span></span>
</figcaption>
</figure>
<p>Health extension workers typically have grade 10 education and speak one of the 90 local languages in Ethiopia. They attend vocational training for one year before going back to their communities to become one of two health extension workers for each rural community, or kebele. Each kebele has a health post that serves around 5 000 people and functions as the operational centre for these workers.</p>
<p>Health extension workers provide services in 16 packages. These include:</p>
<ul>
<li><p>hygiene and environmental health, </p></li>
<li><p>family health, </p></li>
<li><p>disease prevention and control, and, </p></li>
<li><p>health education and communication. </p></li>
</ul>
<p>After training they also provide focused antenatal care, clean and safe delivery and essential newborn care services. </p>
<p>Most of the workers joined the programme because there were few other job opportunities and because they wanted to help mothers and children in their kebeles. </p>
<p>Their presence has made a difference. Before the programme was introduced many of the women didn’t know where to go or who to call during birth. One health extension worker explains how she helped a woman in labour:</p>
<blockquote>
<p>I was called to help a woman who had post-partum haemhorrhage after home delivery. The family believed there was no point taking the woman to hospital because she ‘had already died’. They were not keen on carrying the woman - but I persuaded them to carry her on a stretcher to the road. Coincidentally at the time, officials from the Regional Health Bureau were visiting to conduct supervision so there was a car to take the woman to the hospital. If they’d waited another five minutes, the woman would have died — but she survived. After this incident, the community changed their views and accepted me as their health extension worker. Now the woman is raising her children and visits me regularly and praises me for saving her life and her baby’s life.</p>
</blockquote>
<h2>Limited opportunities</h2>
<p>Despite health extension workers’ contribution, these women have two main problems which lead to them leaving their jobs. Firstly, some want more education and training and secondly, some want to be able to transfer to live with their families while providing healthcare. In some areas, these two problems have led to a high attrition rate of health extension workers. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/102983/original/image-20151124-18261-1ufiz8n.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/102983/original/image-20151124-18261-1ufiz8n.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=450&fit=crop&dpr=1 600w, https://images.theconversation.com/files/102983/original/image-20151124-18261-1ufiz8n.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=450&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/102983/original/image-20151124-18261-1ufiz8n.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=450&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/102983/original/image-20151124-18261-1ufiz8n.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=565&fit=crop&dpr=1 754w, https://images.theconversation.com/files/102983/original/image-20151124-18261-1ufiz8n.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=565&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/102983/original/image-20151124-18261-1ufiz8n.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=565&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Women extension workers pose. Health extension workers have little opportunity to progress.</span>
<span class="attribution"><span class="source">APDA</span></span>
</figcaption>
</figure>
<p>The workers are selected because they know their community and culture. But once they return to their kebeles, some are unable to transfer to other kebeles — even within the same area, or woreda. This means most women who have worked for many years in one place and then marry someone from another area are unable to move to live with their husbands.</p>
<p>All the health extension workers I met want more training and opportunities to be promoted after many years of service. Many have limited opportunities to do. Comparisons are drawn with male agricultural extension workers who are also based in rural kebeles but are given opportunities in other areas. Even those women who were receiving advanced training were still considering leaving as they were unable to transfer.</p>
<p>There is no denying that the health extension workers have been empowered through education. And the programme has given them an opportunity to work in an area where they would otherwise not have found any paid employment. </p>
<p>But they have started to question the limitations imposed by the current system. In addition, they have come to realise that they provide a strong leadership role to uneducated women in rural kebeles. Whether they feel they can continue to do this without a stronger sense of agency for themselves, is a different story.</p>
<p><em>* This article is based on research into the health extension workers experience and the lessons they have learnt, due to be published shortly.</em></p><img src="https://counter.theconversation.com/content/50987/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Ruth Jackson received funding from the Australian government through the Department of Foreign Affairs and Trade Australian Development Awards Scheme under an award titled, Improving the use of maternal, neonatal and child health services in rural and pastoralist Ethiopia, AusAID Agreement 66420. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.</span></em></p>In Ethiopia health extension workers in rural areas fulfill an essential service - but they feel they have no career path.Ruth Jackson, Research Fellow of International Development, Deakin UniversityLicensed as Creative Commons – attribution, no derivatives.