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In 2004 Ethiopia launched its internationally acclaimed Health Extension Program, a national health policy which included community-based health interventions. The aim of this strategy was to achieve universal coverage in primary health care for the rural population. Female health extension workers were trained and paid by the government. They work in the community at ‘health posts’ covering populations of 5000 on average and delivering primary health services under sixteen separate health packages under the Health Extension Program. The health extension workers are supported by volunteer community health promoters, the ‘health development army’, who train ‘model families’ to implement health initiatives and to serve as role models or graduated households, showing the benefits to their village. The health development army links one model family to five other households. In Ethiopia, the community in general has benefited from political commitment to deliver primary health services to the community, but more is to be done to ensure universal coverage.
Maternal and neonatal health is a national priority in Ethiopia. Only 34% of mothers receive antenatal care, and only 10% have a skilled attendant at delivery. Performance has remained low despite efforts to improve antenatal care and delivery outcomes. Knowledge gaps can be categorised as institutional (inadequate training and supervision, and no monitoring and evaluation mechanisms) and systematic (limited quality assurance, and weak referral systems). Inadequate monitoring and evaluation and data collection tools compromise the quality of documentation and leads under-use of existing data. It is likely that the large number of health-related packages during routine house-to-house visits and health post work could be a factor in the poor maternal health outcomes however there is no firm evidence on this yet.
The providers work to deliver services under many constraints including limits on capacity, difficulties with logistics and supplies, and limited technical support. Although the health system is staffed with trained health workers there is need for further quality improvement. Practitioners do not generally evaluate their performance or use local data to generate evidence to improve service delivery. They lack the research capacity and knowledge to conduct operational studies that could enhance their effectiveness. The main problem for maternal health provision in the community is a lack of capacity and inadequate technical skills among health extension workers and volunteer community health promoters. At the institutional level there are opportunities to improve human resource management and monitoring and evaluation mechanisms; and at the systems level there are opportunities to improve quality assurance and referral systems.
The health system of Ethiopia is organised in such a way that policy and decision makers are situated in the administrative part of the health sector, remote from the practitioners who provide health services to communities in need. Policy makers are generally public health practitioners with management training. They implement national policy but do not always have the knowledge or resources to tailor policy for different contexts to improve health service delivery.
REACHOUT in Ethiopia will concentrate on known shortfalls in monitoring and evaluation, quality assurance, and human resource management that affect the delivery of maternal health services. We will develop the capacity of local researchers to work in partnership with providers and policy makers to develop a culture of operational research. REACHOUT aims to a) improve health care delivery by developing an evidence based framework, and b) improve access to a high quality service for pregnant women by using existing community health workers and volunteers. REACHOUT will develop easy-to-administer strategies for human resource management tailored to the limited resources in Ethiopia. REACHOUT will also help to develop the evidence base to improve TB services in Ethiopia and national policy.
This project is funded by the European Union.