By Camille Coyle
As community health worker (CHW) programmes expand throughout the world, it is crucial that we learn from the experiences of CHWs themselves. By giving voice to these frontline health workers, CHW programme design can be informed by and responsive to their unique needs. In 2014, I conducted a qualitative study that explored the perceptions and experiences of health extension workers in Ethiopia.
With a workforce of over 38,000 female health extension workers (HEWs), Ethiopia is at the vanguard of global efforts to expand community health worker programmes. Just as Ethiopia’s health extension programme was inspired by Pakistan’s lady health worker programme, many countries are striving to replicate Ethiopia’s success. As this takes place, the voices of HEWs must be heard.
As part of my study, in-depth interviews took place with ten HEWs in southern Ethiopia, and the research uncovered a powerful sense of agency among them. These HEWs reported feeling proud of their work and of their role in the community. Moreover, they felt motivated by engaging with and serving their communities, and they described this as the most satisfying aspect of their job:
We are happy with our service by looking at the changes in the community and the fruits of our performance. I am so satisfied because of my good performance for my community.
Participants gave particularly rich descriptions of the satisfaction they experienced when working with mothers and children, and they highlighted the fact that knowing these women and children personally heightened their sense of gratification:
I am proud to support and serve the mothers in my community, who taught me when I was young. I felt so much pleasure one time when I supported a mother I know. She gave birth to a healthy child after being assisted by me. When she looked at her baby for the first time and said “my child,” I felt joy.
HEWs also conveyed a deep sense of commitment to their communities, which they described as having strongly influenced their commitment to the job:
I was offered a different position in another district regarding women’s affairs politically. I refused that position because I love to serve the mothers in my community. I do this job with great pleasure. I always remember my mother, she gave birth to 11 children. If there had been such privileges previously like there are now with the health extension programme, our mothers would not have suffered.
However, alongside their commitment to the community, many HEWs expressed deep frustration with work overload, lack of career development opportunities, and low levels of financial reward relative to their hard work:
The tasks we are performing are too many and do not match the salary we are being paid. There is such a big difference. We are neither satisfied by our salary, nor are we getting the opportunity to advance ourselves in our jobs. But still I am performing this job with great pleasure because I have fallen in love with this HEW job.
This study has important implications for the global expansion of CHW programmes. The findings suggest that HEWs in southern Ethiopia feel a strong sense of agency, marked by commitment and motivation, based on satisfaction derived from supporting their own communities. However, it is unclear if this is sustainable without addressing their underlying frustrations. Furthermore, addressing these issues could potentially increase their sense of agency.
Policy makers could operationalise these findings and address HEWs’ frustrations in a variety of ways. Salary scales for HEWs could include incremental annual increases – even small annual increases might allow HEWs to feel that their hard work is valued, not only by the community, but by the health system as a whole. Regarding career development opportunities, policy makers ought to design career pathways for HEWs that facilitate merit-based upward mobility. These career pathways, along with specific promotion criteria, should be shared with HEWs during initial training and during annual career performance evaluations.
Health extension workers have become the bedrock of Ethiopia’s health system. These women are the human foundation upon whom expanded access to health services is almost entirely dependent. Their satisfaction, motivation, and commitment to their work is paramount. Serving them and addressing their unique needs, indeed the needs of all community health workers, is key to unlocking our potential to achieve health for all.
Peer-reviewed articles resulting from this study are forthcoming. For further information, please contact Camille Coyle at firstname.lastname@example.org
The photo is of Fantu and her daughter in Ethiopia by Rosie Steege
This project is funded by the European Union.