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.

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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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Keeping track of The Road Less Travelled

We are pleased to announce the publication of The Road Less Travelled Annual Report for 2013-14.

Cover of Annual Report

The report provides detailed feedback about the impact of the project in Ethiopia and Kenya, as well as narrative stories of transformation and life-change. Of paramount importance is the engagement with, and benefit for, the most marginalised people within the project communities, especially women.

This is done through a strengths-based approach to community development, in which communities are at the centre of their own development vision and recognise and draw on their existing assets to achieve their development aims.

“People want to live a good life, so they see the value of our work in the community.
The level of knowledge in the community is slowly increasing.
People are beginning to change.”

Cecilia, a Community Health Worker in Longewan, Samburu County, Kenya

Significant progress has been made, with:

  • 2584 additional people having access to sustainable, safe water.
  • 3283 additional people having access to appropriate sanitation.
  • 506 additional people accessing a modern family planning method.
  • 1278 additional children receiving vaccines within the first 12 months of life.
  • 379 child deliveries occurred with a skilled birth attendant present.
  • 317,150 people received vital health education messages around measles, malaria, diarrhea, pneumonia and nutrition.

“Mille hospital has changed the lives of mothers. There is less threat of abnormal presentations and good food is supplied to expectant mothers.”
(Response from a men’s Focus Group Discussion)

You can read the report here: The Road Less Travelled Annual Report 2013-14

The Road Less Travelled: Update

As you are likely aware, this blog has been somewhat dormant over the past few months as we have transitioned its management from Australian Volunteers International (AVI) to the lead project partner, Anglican Overseas Aid.

Changes in Federal Government funding meant that AVI could no longer undertake the communications component of the project. We offer our deep gratitude to AVI, and particularly to Hannah Ford, for the amazing work they have done to run this blog. We highly recommend reading Hannah’s powerful final blog post ‘If these hands could talk’.

We regret that the transition has taken longer than expected, but we are looking forward to sharing a range of new stories over the coming weeks and months.

Of particular note, we recently completed our Annual Report for 2013-14, which outlines the progress made through the project. We will make it available here soon.

Over the coming weeks and months we will be sharing:

  • interviews with voluntary and professional health workers in Kenya
  • an article about cultural shifts among the pastoralists of Ethiopia and Kenya
  • video news stories about our work from National TV in Kenya
  • an article about small steps creating big changes through women’s empowerment
We hope you will continue the journey with us along The Road Less Travelled.

If these hands could talk

I remember gazing at the hands of a traditional birth attendant in pastoralist Laikipia, Kenya, and wondering about the stories they might hold. How many newborns had these hands supported into the world? What challenges had been faced by the women they helped through childbirth, in their remote rural homes far from any health clinic? Beneath the rough and wrinkled surface, how much loss had they absorbed through these experiences?

The hands of a traditional birth attendant in Laikipia County, Kenya.  Image: Hannah Ford / AVI

The hands of a traditional birth attendant in Laikipia County, Kenya. Image: Hannah Ford / AVI

Sub-Saharan Africa has the highest maternal mortality rate, bearing the burden of more than 50 per cent of the world’s maternal deaths. One in 39 women in this region faces the risk of dying in childbirth in their lifetime.

Yet less than half of all mothers in sub-Saharan Africa have the support of a trained midwife, nurse or doctor during childbirth. Even fewer mothers from the marginalised nomadic pastoralist communities of Kenya and Ethiopia have access to skilled birth attendants. While evidence has shown that access to skilled care during pregnancy, birth and post-delivery, is key to saving lives, many women don’t have an option.

For the past two years, I’ve had the privilege of working on The Road Less Travelled project and coordinating this blog. I have learnt so much during this time. As I reflect on my experiences, what stands out to me most is the strength and resilience of the pastoralist communities at the heart of the project – and especially that of the mothers. They want what all women want for their children: the chance to survive and thrive.

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Let our sisters learn

For pastoralist children in the isolated Afar region of Ethiopia, access to education has always been extremely limited. For girls, there is even less opportunity. The Afar Pastoralist Development Association (APDA), which began its first literacy program in 1996, is responding to the situation.

Since APDA started the literacy program, it has evolved to improve the coverage and quality of education in the Afar region, with an emphasis on education options that are appropriate for pastoralist children. While primary level education was being achieved in many areas through a combination of mobile and static education, the next challenge was to come up with a solution for how the children would continue their learning.

As an extension of the literacy program, APDA has been piloting a strategy that will ensure more girls gain access to education on an ongoing basis.

In the first year it was difficult to get girls into the student hostel, but over time pastoralist families have come to realise the benefits of giving their daughters the opportunity to learn. Image: Kate Holt / Anglican Overseas Aid

The Road Less Travelled project partner APDA is working with remote pastoralist communities in the Afar Region of Ethiopia to increase girls participation in education.
Image: Kate Holt / Anglican Overseas Aid

Through The Road Less Travelled, a partnership project led by Anglican Overseas Aid, APDA has established a student hostel in the town of Asayita. Pastoralist children from remote rural areas move to the town to live in the student hostel accommodation during the school term, so they have the opportunity to continue learning. The project supports the students to live while they attend the local government school from grade five onwards.

A key priority of the hostel is to increase girls’ participation in education – a challenge that has been met with some resistance from pastoralist communities. One factor that has helped to pave the way for Afar girls is the presence of the hostel house mother, Lako.

Lako is a mother from the same remote community as the students, and responded to APDA’s search for a volunteer house mother.

“They needed someone, so I said I’d go,” she says. “The best thing I can do is look after children. If our children learn, we can have a great future.”

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Improving the use of maternal, neonatal and child health services in rural and pastoralist 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.

“You won’t believe us – we start walking in the morning up til night time to collect water. Then we grind the wheat, collect sticks for firewood and take water to the animals. Sometimes if we have to sleep where we collect water, we take our baby with us, otherwise we leave the baby in the house.”

– Women’s Extension Worker, Logya, Afar Region, Ethiopia, 25 March 2014

We are sitting in the shade at the Afar Pastoralist Development Association (APDA) training facility with 19 Women’s Extension Workers. The women, many with young children and babies, are attending their annual refresher training. It’s too hot to sit inside the training centre but relatively cool in the shade of the building.

Along the fence line are the rooms in which the women stay for the month. Although they are square and joined together they are built of the same materials as the Afar huts or aris. Aris are normally hemispherical and made of palm ribs covered with matting. They are light and portable and easily dismantled – a job usually done by women.

While the Women’s Extension Workers are away from home attending training their husband or mother has to collect water. Men don’t like collecting water as it’s “women’s work”. But one Women’s Extension Worker explained that they had to help their husbands understand that “helping each other is good. Some men joke about doing it while others don’t like doing it … in the past, some men even refused to allow their wives to come to training.”

Fatuma is a Women’s Extension Worker Coordinator for the Afar Pastoralist Development Association, with a total of 12 WEWs in her team. Image: Kate Holt / Anglican Overseas Aid

Fatuma is a Women’s Extension Worker (WEW) for the Afar Pastoralist Development Association, and coordinates a team of 12 WEWs in her area.
Image: Kate Holt / Anglican Overseas Aid

Afar Region in north-eastern Ethiopia is dominated by the Danakil depression in the north, which is largely desert scrubland with shallow salty lakes and long chains of volcanoes. In the south, the Awash River flows into the northern lakes rather than to the sea. Much of Afar is below sea level and it is one of the hottest places on earth, with temperatures higher than 50°C in the summer. About 90 per cent of the regional population base their livelihood on livestock rearing – cattle, camels, goats, sheep and donkeys – with limited agriculture along the river basins and low-lying riverine areas.

The Ethiopian Ministry of Health acknowledged in Health Sector Development Program IV (2010/11-2014/15) that there was a lack of appropriate health service delivery packages to address nomadic and semi-nomadic communities in Afar Region.

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Hospital deliveries in Afambo: a success story

Abdella Isse, Monitoring & Evaluation Coordinator for the Afar Pastoralist Development Association, sat down with mother of six, Kulsuma Ahmed, to talk about her experiences of giving birth in Afambo in the Afar region of Ethiopia.

Kulsuma Ahmed is a mother of six from Afambo in the Afar region of Ethiopia. Image: Abdella Isse / APDA

Kulsuma Ahmed is a mother of six from Afambo in the Afar region of Ethiopia. Image: Abdella Isse / APDA

Many pastoralist women such as Kulsuma Ahmed, pictured above, from Afambo in the Afar region of Ethiopia, give birth at home. It is the cultural norm within the nomadic Afar community, despite not being the safest delivery setting for mothers and their newborns.

In the portable dome-shaped huts in which nomadic families live and women give birth, sanitation and hygiene are constant issues, water is not always readily available, and mothers are a long way from skilled medical support if they run into complications. Communities often live 30-40 kilometres from the nearest road.

Traditional birth attendants (TBAs) usually assist women during pregnancy and childbirth due to challenges of distance and lack of health facilities. The percentage of deliveries assisted by qualified health personnel in the Afar region is just 6.2 percent – compared to the national average of 18.4 percent.1

The Afar Pastoralist Development Association (APDA), Anglican Overseas Aid’s partner in The Road Less Travelled project, has been working with pastoralist women to educate the community about the benefits of attending a health facility at the time of birth. This education is delivered to the pastoralist women through the organisation’s Women’s Extension Workers and Health Extension Workers.

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Celebrate Mother’s Day with us!

Motherhood Matters exhibition poster

In Melbourne and wondering what to do with mum on Mother’s Day?

Join us at Fed Square this Sunday 11 May for a high-energy African drum and dance performance with Asanti Dance Theatre at 12pm and 2pm!

Then head inside to The Atrium to explore Motherhood Matters – a free photo exhibition that gives insight into the experience of mothers in sub-Saharan Africa. It runs until 13 May and is open day and night.

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