Does education empower Health Extension Workers in Ethiopia?

This guest post is written by Dr Ruth Jackson of the Alfred Deakin Research Institute. Dr Jackson is working on a project focused on improving the use of maternal, neonatal and child health services in rural and pastoralist Ethiopia. The project is funded by the Australian Development Research Awards Scheme. Dr Jackson has been learning from the experiences of Women’s Extension Workers who work with the Afar Pastoralist Development Association, a partner in The Road Less Travelled project.

“…Across the world, as we talk about women in developing countries, there’s been increasing recognition that empowering women and girls is a key change agent for development.”

– Julia Gillard,, 24 September 2014

Last year Hillary Clinton and former Australian Prime Minister Julia Gillard announced US$600 million in private and public funding for girls’ education. The project aims to reach 14 million girls around the world in the next five years.

Clearly, girls’ education is a good thing – but I’d suggest that education doesn’t automatically give girls or women agency – or the ability to make choices about what they want to do and to act on those choices (World Bank, 2012).

Ethiopia, ranked 173 out of 187 on the gender-related development index (GDI), has significant disparities between women and men. According to the Ethiopia Mini Demographic and Health Survey (Central Statistical Authority, 2014), 66% of rural women cannot read and write – more than three-quarters of these women are over 30 years of age.

During my current project funded through Australian Development Research Awards Scheme (ADRAS), I’ve met many Health Extension Workers (HEWs) in Ethiopia who’ve had some, but who all want more, education and training.

The criteria for HEW recruitment is that they are over 18 years of age, have grade 10 education and speak the local language. HEWs attend vocational training for one year before going back to their communities to become one of two HEWs for each rural village or kebele. Each kebele has a health post that serves around 5,000 people and functions as the operational centre for the HEWs. HEWs provide services in 16 packages in hygiene and environmental health; family health; disease prevention and control; and, health education and communication.

A rural health post in Ethiopia. Image credit: Ruth Jackson

A rural health post in Ethiopia.
Image: Dr Ruth Jackson

After training, HEWs were also expected to provide focused antenatal care (ANC), clean and safe delivery, and essential newborn care services. Recent policy changes mean that HEWs should now refer pregnant and birthing women to health centres staffed with skilled birth attendants capable of managing normal birth and Basic Emergency Obstetric and Neonatal Care (EmONC). Health centres refer women to hospitals that are equipped and staffed to provide comprehensive EmONC services if required.

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Saving the lives of women and children through access to health services

Abdella Issa, Monitoring & Evaluation Officer with the Afar Pastoralist Development Association (APDA), was interviewed by Ernest Etti from the AACES Resource Facility, about the changes he has noticed in the pastoralist communities of Ethiopia since he became involved in the AACES program, through The Road Less Travelled project.

Can you tell me about when and how you became involved in the AACES program?

I joined the AACES program in August 2011 and this was during the orientation of staff and government in the seven target districts in Ethiopia. I was recruited as a Monitoring and Evaluation Officer, and was briefed about my roles at that time.

What do you think are some of the changes you have experienced since you have been involved in the AACES program, thinking in particular about AACES partnerships and about civil society?

There are indeed changes in maternal and child health in the seven districts. There are changes on the ground like improvement of mothers delivering at hospitals. Malnutrition among children has also decreased and there are changes at a district level as well, like the establishment of stakeholder committees, which meet every six months to review progress of the project and discuss improvements of services on the ground.

There are also annual reflection meetings at a district level, to review progress of work for the past twelve months and then agree on plans for the next twelve months. These meetings have also improved relations among stakeholders; district local government, community leaders and other NGOs working in the same districts.

The project also conducted research at a regional level to investigate the role of women extension workers at community level. The key finding was that women extension workers are central to reaching out to pregnant women in pastoralist communities. Previously, there were more male extension workers, a situation that hindered access to health services on the part of pregnant women in pastoralist communities. Research results were shared with district and regional officials and it is expected that government will in future start recruiting more women extension workers in the field of maternal and child health.

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Gender transformative approaches

This post was written by Pamela Onyo, Research Officer in Kenya.

Gender transformative approaches are programs and interventions that create opportunities for individuals to actively challenge gender norms, promote positions of social and political influence for women in communities, and address power inequities between persons of different genders. It creates an enabling environment for gender transformation by going beyond just including women as participants in a project. The approaches are part of a continuum of gender integration into all aspects of program and policy conceptualisation, development, implementation and evaluation.

In the context of health and social and behaviour change communication (SBCC), the approaches address multi-level power hierarchies in communities that impede an individual’s ability to make decisions about his or her health. For women, this can include (but is not limited to) health decisions such as access to health services and birth spacing. These approaches strive to shift gendered community perspectives and social relationships towards perspectives of equality that allow both women and men to achieve their full potential within a society. Accordingly, the approaches go beyond improving health access for women alone, but include benefits for men that also affect women’s health and empowerment.

Image: Matthew Willman / AOA

AOA’s project has aimed to create an enabling environment for gender transformation, by going beyond just including women as participants in a project. Image: Matthew Willman / AOA

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Interview: Antonella Leakono, Nurse at Longewan Dispensary

Antonella Leakono is a nurse at Longewan Dispensary. Sarah Manyeki (M&E Officer for the project in Kenya) spoke to her about the changes she has noticed since the Community Health Workers (CHWs) were trained, and some of the challenges she faces in her work at the dispensary.

When was the community health unit formed?

The unit was launched on 7 December 2013 although the CHWs had started being functional in August 2013.

In your opinion, how many CHWs are active?

Out of the 25 CHWs, only eight of them are active. They are active in terms of referrals, identifying and referring immunisation defaulters, bringing expectant mothers to the clinic and following up on the referrals. Other services that they offer include escorting women to the facility to seek family planning services and growth monitoring for children.

What changes have you noted since the CHWs started doing their work?

Antonella said that hospital delivery before the CHWs started doing their work was at zero but currently, an average of seven women are delivering at the facility per month. The number of women seeking antenatal care services has also increased from 15 to 45 per month, children going to the clinic for growth monitoring has also increased from 0 to 100 and those seeking family planning services have increased from 10 to 40.

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Cultural shifts: women speak now

This post was written by Loretta Pilla, Anglican Overseas Aid.

The Road Less Travelled (TRLT) is an integrated maternal and child health and community development project working with nomadic pastoralist communities in Kenya and Ethiopia, led by Anglican Overseas Aid, Kenya, partnering with the Mother’s Union of the Anglican Church of Kenya and the Maasai and Samburu nomadic pastoralist communities in Laikipia and Samburu counties.

Focused on improving core maternal and child health outcomes, TRLT’s holistic approach involves methods that address education and literacy as well as improve access to water, food security, and sustainable livelihoods. The desire to achieve health equity through the empowerment of women underpins all activity. Three years since the project’s inception, the results are redefining lives and wellbeing, especially for women.

Where we used to stand

Planting seeds. Image: Matthew Wilman/AOA, 2012

Planting seeds. Image: Matthew Willman/AOA, 2012

The Maasai ranch of Tiamamut in North Laikipia, Kenya, is accessible only by an indistinguishable dirt road. Here, in this highly patriarchal society, men’s voices have traditionally drowned out those of women. Land and livestock, which are of paramount importance to the Maasai, are owned by the men, whilst women are afforded ownership of only a few products and resources, such as kitchenware, food, milk, chickens, and hides. The only possessions a woman can inherit are her mother’s ritual beads. Customarily, the viewpoint of many traditional elders has been that women have no rights and thus no role in decision-making within the traditional nomadic pastoralist social structures.

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Interview: Evalyne Ngise, Nurse at Arjijo Dispensary

Evalyne Ngise works at the Arjijo Dispensary, she was deployed there in 2010. Sarah Manyeki (M&E Officer for the project in Kenya) had a short interview with her on the 26 June 2014

How many CHWs were trained and of those how many are active?

“The only person who can answer that question precisely is the CHEW, but I think 25 CHWs were trained. Out of this number, I have only noted 1 CHW who is outstandingly active and her name is Mama Faith (Rosemary)”

Asked why she said that the CHW is outstandingly active, she based it on the number of referrals by the CHW and the follow up calls that she makes.

What changes have you noted since the CHWs were trained?

“Since the CHWs were trained, there has been a big improvement. The number of outpatients seeking services has increased from 40 people per month to a minimum of 98 people and an average of over 100. Number of women seeking antenatal services has increased from 1-2 per month to 9-10 per month. The CHWs have also been trained on assessing malnutrition (using the MUAC provided by the MoH) and are therefore referring the children to the facility. They are also following up on immunization and once they identify that a child does not have a scar, then they refer them to the clinic, so far we have received 2 from Katunga village this month and another one who is scheduled to come next week from Sepeyo village (they can not immunize all the time, have scheduled immunization days to avoid wastage)”

“It is now more common to see men coming to the clinic to request for a HIV test. In the last month, we witnessed an upsurge in the number of women seeking Family Planning services. Very many women had a Norplant implanted on them. In the past, there were misconceptions on Family Planning. Many women however prefer depo because it has privacy and not many husbands will allow their wives to practice Family Planning in this community although some men have embraced the change.”

On skilled birth deliveries she said “from 2010 when I was deployed here to late last year, only 2 deliveries had been conducted at the dispensary. Currently, I conduct between 2-3 deliveries per month” She however said that she does not encourage women to give birth at the dispensary. “I prefer visiting the women at the comfort of their homes to assist them from there because the facility’s maternity is not well equipped, there is no delivery bed, beddings and the beds there are not in good shape” She was however quick to note that the County Government of Laikipia has pledged to assist the dispensary with Kshs. 240,000 from their development kitty and this money will be used to equip maternity. “I have ordered for a delivery bed, 4 beds, blankets and pipes for installing piped water system inside the dispensary”. This will be a great relieve for her and for the women. I came to learn later that she had been called to assist 4 more women during the month but could not attend them due to distance and lack of transportation.

According to Evalyne, the community is now more aware of the health issues, “it is now a common occurrence for community members to walk in to the clinic and request for water treatment tablets” she noted. This she attributed to the sessions being offered by CHWs.

What are the challenges experienced?

Despite all these there are a few challenges and the major one is staffing. “As you must have noted, I work alone at this dispensary. Sometimes I am invited for workshops or I have to go out for training which can be as long as fourteen days and there is none to relieve me. This is very disappointed for those community members seeking services during my absence, some walk as far as from Lariokorok Village only to find there is no one and then walk back. I am forced to work through out without having off days and this is very tedious.” She said. Lariokorok after enquiry, I learnt that its 24 kilometers to and fro.

“Another challenge is that the CHWs have no kits. This means that even for the simple cases like headaches, they (CHWs) have to refer” Evalyne added. She felt that if the CHWs are provided with kits, then her workload could be reduced. She also said that the facility is not well equipped. “we have no laboratory and this means that even the simplest cases like the ANC test profiles have to be referred to Doldol Hospital, most of the clients end up not going (to Doldol for tests) because they do not find it as an emergency”, she said.

Referrals are another headache because of the transportation issues. Asked about the sub county ambulance, “Most of the time the ambulance is not available. Most of the time we are forced to transport the referral cases using motorbikes which is very uncomfortable for me and for the patients,” she said.

Recommendations and closing remarks

Asked on what she would recommend, she was fast to point out that there is need for more staff, equip the maternity which is on the pipeline and provide the CHWs with kits. She also highlighted the issue of a gas cylinder used to refrigerates the immunization drugs. “We only have one cylinder in this facility. We are therefore forced to skip immunizations sometimes when the gas is finished and have to wait for an extra cylinder from the Doldol sub county Hospital” She said that a second cylinder would be of great help.

On her closing remarks, she said that “the CHWs are doing a commendable job in referring cases and making up follow up calls, enquiring whether the nurse is available before referring and consulting on what to do for the simple cases as well as finding out the clinic and immunization days on behalf of the community” She however said that the CHWs need to do the household visits more often especially to the women with small children to identify cases of malnutrition.

Understanding links between Traditional and Skilled Birth Attendants


By Pamela Onyo, Anglican Overseas Aid


The Road Less Travelled (TRLT) is a project supported within the Australia Africa Community Engagement Strategy (AACES). AACES is a partnership comprising the Australia government with ten Australian NGOs and their partners working across eleven African countries. Each year AACES releases an annual report and this year the Kenya partners decided that the theme should be the outcomes of research conducted under the auspices of TRLT.

The research sought to enable better understanding of the current care seeking behaviour of childbearing women in pastoralist communities of Laikipia and Samburu Counties. The two-year study has been conducted by TRLT partners Nossal Institute for Global Health at the University of Melbourne and the Mother’s Union of the Anglican Church Mt Kenya Diocese, in collaboration with Amref Health Africa. It has been funded through the Australian Development Research Awards.

What is the issue?
Kenya has an unacceptably high numbers of mothers and babies dying at the time of birth. This is particularly and especially true for the semi-nomadic pastoralist communities who are living in remote parts of the country where many women deliver their babies at home attended by a traditional birth attendant (TBA). These TBAs are generally highly respected and trusted members of their communities who have a personal relationship with the women they are caring for. However, they are not trained nor equipped to manage complications of pregnancy and childbirth, which occur in about 15% of cases, and contribute to the preventable deaths of mothers and babies.

The government of Kenya wants all women to deliver their babies attended by skilled birth attendants (SBAs) in health facilities such as dispensaries and hospitals and has put a target of 90% skilled birth deliveries by 2015. SBAs are doctors and nurses who are trained and equipped to respond in the event of complications. However, for a range of reasons, women from pastoralist communities are often reluctant or unable to attend these services.

Launching the AACES Annual Report
With the research now complete the findings were disseminated to local stakeholders from Laikipia and Samburu County’s, and also at the national launch of the Australian Africa Community Engagement Scheme (AACES) annual report. Over 200 people attended the national annual report launch including government representatives, community members, and NGO CEO’s.

The report was launched by the Australian High Commissioner, HE John Feakes, while the Archbishop of the Anglican Church of Kenya, HE Eliud Wabukala, was invited to deliver an address on the research report where he said: “If we are to reduce the incidence of maternal and neonatal mortality then we need to understand what the factors are that attracts or inhibits a woman from seeking professional support when giving birth … The report provides illuminating information on the situation for pregnant women in Laikipia and Samburu. This information gives a detailed picture about what it is like for a pregnant woman, the difficulties and challenges that she faces in bringing new life into the world.”

The Research Findings
The main findings from the study are that:

  • The pastoralist women knew about the free delivery care provided by the government, but for many, the distance to the health facility was too far to walk, and transport costs were a problem.
  • Both women and men acknowledged that delivery with an SBA in a health facility is more hygienic and safer because they can manage complications if they occur.
  • The women said that they were frightened of some medical procedures in hospitals, were concerned that their modesty would not be protected, found hospitals to be very cold places, and did not want to be separated from their families during the delivery period. Additionally, SBAs have a reputation for being unfriendly to pastoralist women. Some women thought that having a baby in a health facility was a sign of weakness.
  • According to pastoralist women, TBAs provide comfort and care in a warm and familiar place, and are locally available and affordable.
  • TBAs remain with the women for days to weeks after delivery to care for them and to take responsibility for household duties so they can rest.
  • The role of TBAs includes helping to mediate between the husband and wife, giving dietary advice (sometimes not very good advice), receiving the baby, massaging the woman, promoting breastfeeding, and if necessary, referring and accompanying the woman to the health facility.
  • TBAs are able to recognise the important complications of delivery, but refer rather late in the event of an obstructed labour. They do not really know how to manage a baby that is having difficulty breathing.
  • Actively including TBAs in programmes designed to improve better utilisation of SBAs in pastoralist communities will help to increase the number of SBA deliveries, and reduce the number of TBA deliveries, some of which are unhygienic and unsafe.

Conclusion and Way Forward

  • There is potential complementarity in the perceived strengths of SBAs and TBAs. TBAs are highly acceptable and accessible to women, and are valued for their supportive role and emotional and socio-cultural sensitivity, but are not trained or able to diagnose or manage most obstetric and neonatal risks and complications. SBAs are skilled in diagnosis and management of these risks and complications, but are not seen as very accessible, or acceptable, in their service delivery. This complementarily, and the strong support from all stakeholders for greater integration of the work of TBAs and SBAs, will lead to further consideration of potential models for collaboration and cross-learning.
  • When combined with results from the quantitative arm of the study, they informed options for collaborative models of care involving both TBAs and SBAs for more effective, efficient and contextually appropriate care, which will be developed in partnership with participants and other stakeholders. These models will consider the potential for collaboration across all stages of pregnancy, labour and delivery, and the neonatal period.

As a result of the research the TRLT project and research partners, in conjunction with the Ministry of Health, are investigating the possibility of piloting a ‘pastoralist friendly health facility’.

A pastoralist health facility would support shared care by traditional birth attendants (who are preferred by women to be their service providers) with skilled birth attendants (who are the providers with the skills to save maternal and newborn lives). Such a facility would be structured specifically to suit the requirements of pastoralist women and ameliorate the issues that inhibit them for attending. For example, it may have a traditional house with fireplace on clinic grounds where a woman may weight prior to going into labour, and her close friends and family can be in attendance. A TBA may accompany the expect mother and comfort her during the birthing process, while clinic staff are especially trained to respect the woman’s modesty and accommodate her cultural requirements. The clinic would build close links to the community so that they feel ownership and responsibility for it. The objective is to significantly increase the number of women who attend ante- and post- natal care, and deliver in a safe environment, therefore reducing maternal and neo-natal mortality.

You can watch a video on the AACES 2013-14 Annual Report at:

You can access the AACES 2013-14 Annual Report at:

You can download a booklet where TBAs and SBAs who took part in the research tell their stories:Walking together book viewing version

Below is a video about TBAs and SBAs, and how they are working together to benefit communities.

Credits for the photo are: From Left – Mary, AACES program beneficiary, John Feakes, Australia’s High Commissioner designate to Kenya (left), Anna Dorney from DFAT, Eliud Wabukala, Kenyan Anglican Archbishop, and Patrick Amoth, Ministry of Health. Photo by Douglas Waudo, ACBF.