2016年-世界发展银行全球_Ethiopia_Health_Extension_Program___An_Institutionalized_Community_Approach_for_Universal_Health_Coverage_121页_3mb

Ethiopia Health Extension Program: A Summary

Core Content

The Ethiopia Health Extension Program (HEP) is a key initiative under Ethiopia's Health Sector Development Program IV (HSDP IV), aimed at achieving Universal Health Coverage (UHC) through a community-based approach. The program was conceived as a response to Ethiopia's limited resources and poor health outcomes, and it has been instrumental in improving access to health services, particularly in rural areas.

Main Objectives

• To improve health outcomes by expanding access to primary health care services.
• To reduce maternal and child morbidity and mortality rates.
• To promote community participation and responsibility for health.
• To scale up best practices across different regions of Ethiopia.

Key Components of HEP

The HEP is structured around four major program areas, offering 16 essential health packages:

1. Hygiene and Environmental Sanitation:

   • Proper excreta disposal
   • Solid and liquid waste management
   • Water supply safety
   • Food hygiene and safety
   • Healthy home environment
   • Arthropods and rodent control
   • Personal hygiene

2. Disease Prevention and Control:

   • HIV/AIDS prevention and control
   • TB prevention and control
   • Malaria prevention and control
   • First aid

3. Family Health Services:

   • Maternal and child health
   • Family planning
   • Immunization
   • Adolescent reproductive health
   • Nutrition

4. Health Education and Communication:

   • Cross-cutting activities promoting health awareness and behavior change.

Implementation Mechanism

Key Actors

• Health Extension Workers (HEWs): Deployed to kebeles (villages), they are responsible for training model families, mobilizing the Health Development Army (HDA), and delivering basic health services.
• Model Families: Trained and mobilized to implement health packages and influence their neighbors.
• Health Development Army (HDA): A community-based movement that engages residents in identifying local health challenges and promoting health practices. It is organized into one-to-five networks (groups of 6 households) and health development teams (up to 30 households).

Recruitment and Training

• HEWs are selected based on local residency, language proficiency, and willingness to serve in their communities.
• Training is conducted by technical vocational education training (TVET) institutions, which also develop occupational standards for HEWs.
• The HEP is closely aligned with the National TVET Qualification Framework (NTQF).

Financing

• HEP is primarily funded by the government and communities.
• Government covers HEW salaries, which account for 21% of recurrent expenditures and 32% of woreda-level recurrent expenditures.
• Communities contribute in non-monetary forms such as labor, food, and accommodation.
• The cost to train a model family is estimated at Br 871 per household, totaling Br 10.8 billion for 12 million model families.

Progress Toward UHC

• Over 34,382 HEWs were deployed by 2009/10.
• By 2010/11, 70.5% of households had graduated as model families.
• Over 442,755 HDA groups were mobilized.
• The program has significantly improved sanitation facilities, knowledge on child stool disposal, use of ORS, family planning awareness, and antenatal care coverage.

Impact and Equity

• The HEP has led to pro-rural, pro-less-educated, and pro-poor improvements in health indicators.
• Concentration curves have shown a trend toward greater equity in health outcomes, with positive changes in rural/low-education/lowest wealth quintile groups.
• The program has enhanced service coverage, particularly in areas such as vaccination, modern contraceptive use, and skilled birth attendance.

Conceptual Model

The HEP-UHC model is based on a general framework of social determinants of health, which includes:

• Intermediary determinants: Circumstance factors, socioeconomic and psychological factors, and behavioral and biological factors.
• Service coverage: Improving access to services that minimize the impact of life events and diseases.
• Health outcomes: Reducing inequality and improving overall health status.

Lessons for Other Countries

• The HEP provides a community-based, decentralized model that can be adapted in other low-income countries.
• It emphasizes community participation, local capacity building, and equity in service delivery.
• The integration of TVET and health education is a notable feature that supports sustainable health workforce development.
• The program's success is attributed to strong governance, community mobilization, and targeted interventions.

Challenges

• Limited data on program costs and community contributions.
• Variability in implementation across different woredas and regions.
• Need for sustained funding and capacity building to maintain program effectiveness.
• Coordination between different levels of government and community actors.

Conclusion

The Ethiopia Health Extension Program represents a successful institutionalized community approach to achieving Universal Health Coverage. It has significantly improved health outcomes, particularly among the poor and rural populations, and serves as a model for other countries seeking to enhance health access and equity through community engagement and local capacity building.