Community Health Roadmap

Bridging the SDG gap through accelerated primary health care at community level

Ethiopia 2021
Update

Neonatal SDG
Under-5 SDG
Maternal SDG
Mortality Rate Target Mortality Rate Target Mortality Rate Target
1,000 1,000 100,000
At a Glance: Country indicators 900 90,000
40 80 800

(per 100,000 live births)

(per 1,000 live births)

(per 1,000 live births)

Population (2019/2020): 33
70
67
700
100,666,096 30
29
60
50
59
600
500
597

Total number of community 20 40 400 401

30 300
health workers (CHWs) 2019/2020: 10 12 20 25 200
41,826 10 100
0 0 0
70
Gender disaggregation of CHWs: 2016 2019 2030 2016 2019 2030 2010 2016 2030
Years Years Years
Female: 96%
Male: 4%
Community Health Roadmap
2021 Update Ethiopia
Community Health Overview

Ethiopia’s Health Extension Programme (HEP) seeks to reach

communities with a set of essential health services, both preventive
and curative. HEP was introduced in 2003 based on primary health
care (PHC) guiding principles; it was designed to address challenges
inherent in earlier community health worker (CHW) initiatives.

VISION: Accelerate the realization of STATUS OF NATIONAL PLAN:

universal health care (UHC) through Ethiopia has developed its HEP
which all Ethiopians will have access to Optimization Roadmap 2020-2035 in
needed health services, including health alignment with the second Health Sector
promotion, disease prevention and Transformation Plan and national 10-year

© UNICEF/UN0157434/Ayene
treatment, rehabilitation and palliative development plan. The roadmap contains
care. These services will be of sufficient several transformative initiatives that will
quality to be effective while preventing be rolled out in phases towards the goal
financial hardship from the use of of achieving UHC.
these services.

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Community Health Roadmap
2021 Update Ethiopia
Urgent Investment Actions

1. Close the human resources gap. 2. Re-evaluate/update roles of CHWs. 3. Strengthen and ensure the quality
Increase the number of CHWs, and Re-stratify health posts into three of community health services. Offer the
improve the quality and diversity of CHWs; categories to reflect changing needs: basic health package through the BHP, i.e.,
deploy at least five staff by 2025 and seven (1) health post (existing category); promotive, preventive and selected curative
staff by 2035 at Comprehensive Health (2) Basic Health Post (BHP), within services provided by nurses and level 4
Posts, a new category of health post; 5 km of the health centre, and health extension workers; offer the
ensure diversity of gender and a (3) Comprehensive Health Post (CHP), comprehensive health package through the
professional mix in these deployments. more than 5 km from the health centre. CHP, i.e., promotive, preventive, curative
and rehabilitative services.

4. Strengthen the community health 5. Update/develop national guidelines. 6. Enhance community engagement.
data system. Update, digitize and scale up Revise protocols and standards in Implement approaches that will increase
electronic-based data registering within the accordance with the HEP Optimization community participation and ownership,
framework of the community health Roadmap and the continued development are sustainable and will revitalize existing
information system (CHIS). of manuals and guidelines to aid roadmap community mobilization platforms.
implementation by community health
professionals.

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Community Health Roadmap
2021 Update Ethiopia
Description of Community Health Structure

Cadres: Currently, there are 41,826 health Services offered: User fees:
extension workers (HEWs) across rural, • Disease prevention and control: HIV • Adults and adolescents treated
pastoral and urban parts of the country; and AIDS, TB, malaria, neglected tropical at the CHP would be charged for
and nearly 1 million Women’s diseases (NTDs), non-communicable these services.
Development Army (WDA) volunteers who diseases (NCDs).
are recruited by their communities and
trained in health promotion and disease • Family health services: Maternal and
prevention activities. newborn health, child health [integrated
management of newborn and childhood
illness (IMNCI), growth monitoring,
nutrition screening and treatment, etc.],
family planning, immunization, adolescent Supervision:
reproductive health, nutrition. • HEWs are supervised and mentored
• Hygiene and environmental sanitation. on a weekly basis by the Health Officer
Scale-up: Maintain the current number or other personnel at the Primary Health
of HEWs with focus on building their • Health education and communication
(cross cutting). Care Unit (PHCU).
competencies. Additional health
professionals (FHPs, Health Officer, • Treatment of common illnesses in • The supervisor is responsible for
midwives, nurses and environmental health adults and adolescents. approximately 10 HEWs and is expected
professionals) will be deployed by 2035 as to report weekly/monthly on supervision
part of the Family Health Team approach. and mentoring.

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Community Health Roadmap
2021 Update Ethiopia
Description of Community Health Structure

Training: Renumeration: Data collection:

• HEWs must have graduated from high • HEWs are government civil servants. • CHIS is the primary information system
school; initially they receive the level 3 Monthly salary ranges from US$90 for the collection, aggregation and
training (one-year course). Health to US$120. reporting of health data about individuals,
Extension Professionals receive level 4 • HEWs may also receive formal social households and communities targeted by
upgrading/training and an additional recognition, opportunities for career the HEP. HEWs use family folders /
one-year course. Both groups receive a advancement, benefits such as annual registers for collecting, organizing and
certificate of competency upon completion leave, and in some areas, housing. reporting community health data.
of training. • CHIS is in the process of being digitized.
• WDA and other community volunteers
• Family Health Professionals (FHP) are are usually unsalaried.
recruited from level 4 Health Extension
Professionals. They receive an upgrading
/ training at the college degree level, i.e.,
two years towards the Bachelor of
Science degree in Family Health before
deployment by the health post.
• Volunteers in the Women’s
Development Army (WDA) are offered
an informal, competency-based training
(52 hours), mainly on health promotion
activities.

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Community Health Roadmap
2021 Update Ethiopia
Description of Community Health Structure

Health system linkages: Community engagement:

Health posts are linked to: Community engagement activities are
• District and town health offices for organized by WDAs. A functional WDA
support on leadership and management requires the establishment of health
(i.e., human resources management). development teams of up to 30
households in the neighbourhood. Teams
• Health centre for making referrals, are further divided into smaller groups of
participatory planning, reporting, six members, commonly referred to as
supervision and mentorship support, M&E ‘one-to-five’ networks.
backing, and health logistics/supplies.
• Kebele (town) administrations for support
on leadership and for political support
from local governors. As a member of the

© UNICEF/UN0378659/Tamiru
kebele council, the health post has access
to decision-making processes.

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Community Health Roadmap
2021 Update Ethiopia
Primary Health Care Structure at Community Level:
Supports service delivery, engagement and accountability
Ministry department
responsible for community LEVEL STRUCTURE STRUCTURE
health: HEP and Primary Health FOR HEALTH FOR HEP
Care Directorate, Federal
Ministry of Health (FMOH). Federal Ministry PHC and the
Government of Health HEP Directorate
HEWs receive logistical,
managerial and technical support
from focal points at the woreda
health office, health centres and HEP Team under
Regional Regional Health Health Promotion and
regional health bureau. Government Bureau Disease Prevention

Zone /Woreda Zone /Woreda HEP

Administration Health Office Coordinator

HEP Supervisor /
Woreda Council Health Centre PHCU Vice Director

Kebele Health Post HEWs / WDA

Administration

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Community Health Roadmap
2021 Update Ethiopia
Primary Health Care Priorities and Progress at Community Level
Service Service delivery structure, package and quality of care
Delivery Priorities (2021-2022) Progress (September 2021)
• Ensure the delivery of comprehensive health • HEP service delivery scope and modalities
services to people in hard-to-reach areas restructured
through CHPs
• Health extension service packages expanded
• Reach all age groups, genders and ethnic groups (adult and adolescent treatment services added)
with the package of essential health services, per
• Quality improvement system embedded in health
national service standards
extension services
• Ensure the delivery of essential health services
through different outlets (static services at the health
posts, household visits, outreach to communities
and schools, mobile services)
• Assure the safety of services provided at facility
and community levels
• Raise awareness among individuals, households and
communities about the essential services available at
BHP and CHP levels
• Ensure that individuals and households are satisfied
with the services provided at BHPs and CHPs

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Community Health Roadmap
2021 Update Ethiopia
Health Recruitment and accreditation
Workforce Priorities (2021-2022) Progress (September 2021)
• Accredit about 400,000 WDAs • Additional WDAs recruited; 382,171 WDAs accredited
• Provide certificate of competency (COC) to
15,000 level 4 HEWs
• Provide COC to 200 FHPs

Training
Priorities (2021-2022) Progress (September 2021)
• Provide competency-based training (CBT) to • Adequate number of HEWs trained and deployed
233,452 WDA at all health posts (nearly 18,000 health posts)
• Increase the number of level 4 HEWs through • About 50% of rural HEWs received level 4
upgrading/training upgrading/training
• 10% of HEWs received in-service training
(RMNCH and SBCC modules)
• About 666,548 WDAs received CBT
• About 260 health extension professionals trained
as FHPs

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Community Health Roadmap
2021 Update Ethiopia
Health Supervision
Workforce Priorities (2021-2022) Progress (September 2021)
(continued) • Strengthen HEP supervision system at all levels • HEWs are supervised twice a year by the woreda
health office and weekly/monthly by the PHCU team
• Strengthen a system of mentorship and coaching of
health extension professionals by establishing strong
linkages between the PHCU and health extension
professionals Please remove

Remuneration/reward and advancement

Priorities (2021-2022) Progress (September 2021)
• Develop/review and standardize a motivational • Job evaluation and grading system developed to
package for HEWs, which may include performance- determine HEW monthly salaries
based payments and opportunities for promotion,
training/education, transfers, etc.

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Community Health Roadmap
2021 Update Ethiopia
Health Data reporting and information systems
Information Priorities (2021-2022) Progress (September 2021)
Systems • Ethiopia plans to scale up its electronic data • CHIS improvements are ongoing; system shortfalls
systems, including through the use of electronic continue to be addressed
registers to link community health data directly
to DHIS2
• Update the rural CHIS; implement urban CHIS;
digitalize both rural and urban CHIS

Supply Chain Supply chain management (including commodities)

Management Priorities (2021-2022)
• Establish strong health post/supply chain management
system including digitalization

Health products
Priorities (2021-2022)
• Improve the supply of drugs and medical equipment for
both BHP and CHP

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Community Health Roadmap
2021 Update Ethiopia
Finance Finance
Priorities (2021-2022)
• Allocate budget for health post construction and health
supplies, HEW/WDA training and supervision, community
health system evaluations
• Allocate earmarked recurrent budget for health posts
• Maximize external and domestic resource mobilization
for HEP
• Initiate innovative mechanisms of revenue generation
at community level
• Strengthen community-based health insurance to finance
the HEP
• Recover costs from user fees introduced to CHPs

Leadership System design and policies

and Priorities (2021-2022) Progress (September 2021)
Governance • Develop HEP standards for CHPs and revise • HEP Optimization Roadmap finalized and launched
existing standards for BHPs
• HEP implementation manual and additional
• Develop additional HEP service implementation guidelines finalized
protocols and guidelines
• Community health quality improvement manual developed
• Develop HEP delivery strategy for pastoralist
communities

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Community Health Roadmap
2021 Update Ethiopia
Leadership System management and leadership
and Priorities (2021-2022)
Governance • Develop health post reform guideline
(continued) • Revisit health post management arrangements and
governance at all levels
• Provide support for sound leadership
• Effectively manage HEP optimization activities (planning,
implementation and evaluation) according to the HEP
optimization roadmap
• Strengthen supportive supervision at all levels

Political priorities
Priorities (2021-2022) Progress (September 2021)
• Make HEP issues a priority on national and subnational • There has been proven political commitment at all
political agendas levels to reform HEP towards achieving UHC
• Organize continuous advocacy platforms at national
and subnational levels to maintain political commitment

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Community Health Roadmap
2021 Update Ethiopia
Community Community engagement
Engagement Priorities (2021-2022) Progress (2021-2022)
• Finalize pilot testing of a new community • A new community engagement strategy designed
engagement strategy and piloted in selected woredas of the country
• Assess and revitalize existing community • Implementation of the WDA approach increased
mobilization platforms demand for and utilization of health care services by
mobilizing of individuals, families and communities

© UNICEF/UN0378636/Tamiru

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Community Health Roadmap
2021 Update Ethiopia
Roadmap Implementation: Costs to implement
primary health care at community level
Estimated costs of HEP Optimization Roadmap, 2020-2035: US$12.6 billion
Estimated resource gap, 2020-2035: US$3.3 billion
The total cost of implementation over the 15-year period is estimated to be US$12.6 billion (Figure 1). Infrastructure, medicines and supplies
are the major drivers of implementation costs (Figure 2). The HEP is financed by the government and donors; government contribution
accounted for 40.3% of total HEP spending in 2017.

Figure 1. Figure 2. 3.
Figure Figure 1.
Implementing the HEP optimization roadmap: Total cost of implementing
Implementing the HEP optimization
the HEP optimization, 2020-2035 Implementing
Planned expenditure, 2020-2035 US$ roadmap,
Resource2020-2035, by millions,
gap in US$ categoryaverage
(%) scenario Planned expen
US$6 billion US$6,000 Other health system-related costs: US$6 billion
US$5.387 billion Resources needed
US$516 million $5,387
Resources available
US$5 billion 5,000resources:
Human (4%) $646 US$5 billion
US$4.226 billion US$1.636 billion $4,226 $4,741

Millions of US dollars
US$4 billion 4,000 (13%) $1,437 US$4 billion
US$3.031 billion $3,031 Infrastructure:
US$3 billion 3,000 US$5.245 billion US$3 billion
$1,212Total cost: (42%)
Medicines $2,789
US$2 billion 2,000
and supplies: US$12.643 US$2 billion
US$5.244 billion $1,819 billion
US$1 billion 1,000(41%) US$1 billion

US$0 0 US$0
2020-2025 2025-2030 2030-2035 2020-2025 2025-2030 2030-2035
(estimated) (indicative) (indicative) (estimated) (indicative) (indicative)

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 Community Health Roadmap
2021 Update Ethiopia
Milestones in Integrating Community Health 2020
within Primary Health Care, 2002-2020 2018 HEP Optimization
Roadmap
Family Health Team Development of the
introduced under urban roadmap, which was
2011 2016 HEP as part of the paused to allow for more
urban PHC reform time to collect evidence,
2004 Introduction of Second The FHT is composed of was reinitiated to
2002 2003 2008 2009 Health/Women generation HEP two physicians, health reflect data and
Deployment Development Army HEP packages officers, nurse, 2 diploma recommendations of the
HEP Inception Selection and of HEWS Introduction of HEP expanded to (HDA/WDA) increased from 16 to 18; nurses, and 4-5 urban 2019 HEP assessment.
16 high-impact training of HEWs 2,737 HEWs family folders, CHIS urban areas More than 990,000 changes in standards HEWs. By 2019, 123 health
interventions Graduation of the deployed to Stalled due to absence Training and deployment WDA groups organized and service delivery centres had implemented
identified first HEWs health posts of implementation guide of HEWs in urban areas by 2018-2019 modalities initiated the reform.

2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020

2003 2006 2010 2018 2019

HEP formally launched as Early performance assessment Introduction of treatment of Rapid HEP assessment and National assessment of
part of the second Health and gap identification pneumonia in to HEP HEP optimization the HEP completed
Sector Development Gaps identified: HEWs’ knowledge and skill gap, Integrated community case Rapid assessment followed by initiatives An independent assessment of the
Programme (HSDP-II) inadequate resources, and inadequate supportive management fully implemented to address identified challenges programme revealed successes and
Government employs HEWs supervision; Integrated refresher training initiated. challenges of the HEP and proposed
as salaried government staff Health post kits distributed. HEP supervisors trained. National evaluation of the rural HEP Competency-based training several recommendations.
and construct rural health posts Changes were introduced, including program for WDA leaders initiated
Introduction of Model Family training initiative the initiation of the level 4 HEW 422,524 WDA leaders completed the training; Degree program in
Initially used as community engagement and training programme 51,243 were assessed; 47,641 were family health launched
empowerment strategy found to be competent Curriculum for a post-basic degree
CHIS reinitiated and scaled-up program in the field of family health
HEP expanded to pastoralist areas Upgrading of HEWs was adapted. Eight universities from
Adaptation of HEP to pastoralist settings; More than 25% of HEWs upgraded six regions started the programme
mobile health team initiated. to Level 4 by enrolling 240 students in the
first year.

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Community Health Roadmap
2021 Update Ethiopia
Development Partners
Funders: Implementing Partners:
Bill and Melinda Gates Foundation AMREF-Ethiopia
European Union Clinton Foundation
Department for International Development (DFID) Digital Health Activity (DHA)
GAVI Ethiopia Data User Partnership (DUP)
The Global Fund John Snow, Inc. (JSI): The Last Ten Kilometers (L10K))
UNICEF John Snow, Inc. (JSI): Transform PHC
USAID Johns Hopkins Center for Communications Programs
The World Bank MERQ Consultency PLc
World Health Organization Pathfinder International
Project Hope

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Community Health Roadmap
2021 Update Ethiopia
Acronyms and Sources Used
Acronyms: Sources:
BHP Basic Health Post Original country roadmap at www.communityhealthroadmap.org and
CHIS community health information system subsequent versions.
CHP Comprehensive Health Post Federal Ministry of Health Ethiopia, Realizing Universal Health Coverage
CHW community health worker Through Primary Health Care: A roadmap for optimizing the Ethiopian Health
COC Certificate of Competency Extension Program 2020-2035, first edition, July 2020.
FHP Family Health Professional
Mortality: Federal Ministry of Health and Ethiopian Public Health Institute,
FMOH Federal Ministry of Health Mini Demographic and Health Survey 2019.
HDA Health Development Army
HEP Health Extension Programme Population: Federal Ministry of Health Ethiopia, Health Sector
Transformation Plan I: Health and Health Related Indicators 2019/2020.
HEW health extension worker
HRH human resources for health
IMNCI integrated management of neonatal
and childhood illness
M&E monitoring and evaluation
NCD non-communicable diseases
NTD neglected tropical disease
PHC primary health care
PHCU Primary Health Care Unit
RMNCH reproductive, maternal, neonatal and child health
SBCC social and behaviour change communication
TB tuberculosis
THE total health expenditure
UHC universal health care
WDA Women’s Development Army

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