Our last blog covered Ethiopia's health extension workers-- a massive scale-up on non-clinicians who have helped the child mortality rate to plummet over the last decade. Dr. Tedros Adhanom, the former Minister of Health, stated in an address at Georgetown University, "Our community-based Health Extension Program actually exceeded its target by training and deploying over 38, 000 health extension workers countrywide." How exactly did they do it in just three years?

USAID describes the tiered organization of the network of the Health Extension Program (HEP) as working “like a countrywide referral network, rippling up from its foundation at rural health posts...to the larger, better-equipped health centers, each servicing around 25,000 people. At the top of the pyramid are the country’s 122 hospitals, each staffed with at least one doctor.” In this way, it is capable of providing sophisticated care to a much higher percentage of the largely rural nation.

USAID/Ethiopia Mission Director’s Tom Staal stresses that health extension workers do not provide direct medical care themselves, but rather perform much more of a teaching function:

“The really basic things are what’s most important for the rural people; in other words, vaccinations, antenatal care, sanitation, nutrition; helping people understand the importance of hand-washing; simple malaria prevention like bed nets and spraying; and the need for pit latrines. [...] These basic interventions can help prevent 90 percent of health-care issues for most families”

This behavioral change component, coupled with the focus on prevention and the ability to pass emergencies further up the medical chain of resources, have been the driving forces behind Ethiopia’s immense strides in maternal and child health in the last decade. By diffusing the message along each branch of the medical care hierarchy, Ethiopia has developed an effective means of stemming the flow of newborn and child deaths, even in rural communities.

A little bit of a puzzle remains; [a 2011 study conducted in Ethiopia showed](http://www.biomedcentral.com/1472-6963/12/352) that while the influence of these Health Extension Workers greatly improved usage of family planning, HIV testing, and antenatal care by women in a given village, it did little to change access to postnatal checkup, use of iodized salt, and general improvement in health facility delivery.

by Lizi Jones
UN photo Eskinder Dedebe Ethiopia.

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