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, time.com, 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.

By 2020 there will be over 50,000 HEWs in Ethiopia – they are the largest single group in the health workforce (47%), most HEWs are women (98%), and most are under 30 years of age (Africa Health Workforce Observatory, 2010; Feysia et al., 2012; Center for National Health Development in Ethiopia and Columbia University, 2011).

Each of the HEWs who was part of my project was trained to interview women about their experiences of pregnancy and childbirth. I interviewed most of the HEWs about their experience participating in the research and during the final workshop we discussed what they had learnt from the women and each other.

One HEW in Kafa Zone in the southwest described how there have been measurable changes in attitudes and practices in her kebele in the past two years: “At the beginning, nobody wanted to see us or to use family planning, vaccinate their children or attend ANC. Now women even come knocking on our door on holidays.”

A HEW from rural Tigray was called to help a woman who had post-partum haemhorrhage after home delivery about four years ago – before the ambulance service was introduced. Even though most of the family believed there was no point taking the woman to hospital because she “had already died” and asked why they should “carry a dead woman,” the HEW persuaded the family to carry the woman on a stretcher to the road. Coincidentally at the time this was happening, officials from the Regional Health Bureau were visiting to conduct supervision so there was a car to take the woman to the hospital. If they’d waited another five minutes, the woman would have died – but she survived. After this incident, the community changed their views and “accepted her as their HEW.” Now the woman is raising her children and visits the HEW regularly and praises her for saving her life and her baby’s life.

One of the most encouraging things to come out of the research was that women told HEWs how much they respect them and described them as being like sisters or family members. Some HEWs reported they had never been told how much they are valued by their communities before.

A health extension worker visits a pregnant woman in her home in the Afar region of Ethiopia. Image: Kate Holt / AOA

A health extension worker visits a pregnant woman in her home in the Afar region of Ethiopia.
Image: Kate Holt / AOA

All the HEWs I met want more training and more opportunities for promotion after many years of service. They have limited opportunities to do so unlike male agricultural extension workers who are also based in rural kebeles. Young girls don’t aspire to become HEWs for these reasons. Many HEWs want to leave their positions; “now we cannot work with joy, with happiness, because there is no chance for follow up positions, no chance for promotion” (HEW, Sidama Zone).

Another HEW from Afar Region said she is respected by the government and the community and has even received an award as a model HEW. But respect is not enough, “I need more, I need more education to get a promotion to a higher level.”

There is a high attrition rate of HEWs in some areas. One reason is that although HEWs were selected from their kebele because they know their community and culture, they are unable to transfer to other kebeles—even within the same district (woreda). This means HEWs who have worked for many years in the one place, have married, and had children may be unable to live with their husband and children: “Most HEWs who leave do so because they can’t move. Husbands and wives are separated. I love my job. I love my husband and my child. How can I choose between them?” (HEW, Kafa Zone).

HEWs have gained respect in their kebeles and often speak to husbands, religious and kebele leaders about health matters. It’s taken for granted that HEWs talk to rural women about the need to vaccinate their children, to attend ANC, or to go to a health facility for the birth of their child.

Does education empower female HEWs in rural Ethiopia? In part, yes, because they have had the opportunity to work in rural kebeles where they would otherwise not have found any paid employment.

While there’s nothing new about HEWs needing more training and education, it’s important to see how they are starting to question the strong leadership role they are providing to uneducated women in rural kebeles across Ethiopia – and whether they feel they can continue to do this without a stronger sense of agency for themselves.

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