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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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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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.

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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Mobilising communities in the fight for safe motherhood

Momina sits on the bed in the hut where she will give birth to her third child. The bed is a traditional Afar “oloiyta” made of thatched sticks and slightly raised. She is ready to deliver any day now.

“The baby has been moving around a lot,” Momina says. She is nine months pregnant, and is visited twice a week by a Women’s Extension Worker (WEW) from the Afar Pastoralist Development Association (APDA) – the Ethiopian partner of Anglican Overseas Aid in The Road Less Travelled project.

Momina is nine months pregnant and waiting to give birth at home, with the support of a trained traditional birth attendant. Image: Kate Holt / Anglican Overseas Aid

Expectant mother, Momina, is waiting to give birth at home in the remote Afar region of Ethiopia.
Image: Kate Holt / Anglican Overseas Aid

The WEW has monitored Momina throughout her pregnancy, and provided antenatal care. However, this has not always been the case for women giving birth in the Afar region of Ethiopia. In one district surveyed by the project, 66 percent of women reported having received no antenatal care during their most recent pregnancy. (Read more in our Baseline Report).

As a country, Ethiopia has one of the highest ratios of maternal mortality in the world, in 2011 recording 676 maternal deaths for every 100,000 live births.1 For women in the Afar, the risks of injury or death during childbirth are even greater.

Due the remoteness of the Afar pastoralist communities and their nomadic lifestyle, communication, transport and access to health services has in the past been extremely limited or non-existent. There are also significant cultural or attitudinal factors that affect the care mothers receive during pregnancy, delivery and post-delivery.

APDA is improving the chance at life for Afar mothers and their children, by mobilising members of the community in the fight for safe motherhood. With a 20-year history working within the pastoralist setting, the organisation is uniquely positioned to facilitate relief and development activities that are relevant to the community, and implemented by the community.

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The Afar tradition of disability inclusiveness

Teacher Humaid Said shared his experiences of disability inclusiveness in the Afar community of Ethiopia with Tanya Caulfield of the Nossal Institute for Global Health – Anglican Overseas Aid’s partner in The Road Less Travelled project.

When he was 12, Humaid Said contracted polio and lost the use of his leg.

In many developing countries, Humaid would have been consigned to a life on the margins of his community. People with disabilities are among the poorest and most vulnerable and are often at greater risk of social exclusion.1 This, in turn, reduces their access to education and healthcare, along with opportunities to participate in decision-making and provide for themselves and their families.

But for Humaid, growing up in the rural Afar region of Ethiopia was an entirely different experience that challenges the notion that development work must always teach people about how to include people with disabilities.

The nomadic pastoralists of the Afar have a deeply embedded traditional social support network, and the concept of excluding an individual from family and community life based on their disability is perceived to be counter to Afar cultural laws.

Teacher Humaid says that in Afar culture, people with disabilities are active participants in the community.  Image: Tanya Caulfield / Nossal

Teacher Humaid says that in Afar culture, the community perception is that no one should be treated differently.
Image: Loretta Pilla

“When I was younger, I would see others participating in activities when I couldn’t, so I wished to be like them,” he explained. “But the community perception is that no one should be treated differently – there is a law in Afar tradition not to treat people differently in the family and the clan.”

Despite wishing at times that he had full use of both legs, Humaid said that in Afar culture people with disabilities are active participants in the community and are involved in different ways in socioeconomic activities.

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Educate a girl, educate a community

This post was written by Sarah Manyeki, Monitoring & Evaluation Officer for Mothers’ Union Kenya – Anglican Overseas Aid’s partner in The Road Less Travelled project.

In the pastoralist communities of Kenya, there are several factors that limit women’s participation in safe motherhood practices, with the substantive factor being illiteracy. In Laikipia County, where the project works, 40 per cent of men are literate in Swahili while barely 25 per cent of women are. In Samburu County, 30 percent of men are literate while only 15 percent of women are. Figures for English literacy are even lower. Illiteracy not only inhibits mothers from reading and understanding their children’s clinic cards, prescriptions, and nutritional advice, but it also lowers their confidence and increases difficulties in understanding – much less applying – legal rights.

Suzan is working hard to change this. She is one of four female Community Development Committee (CDC) members elected to represent the Chumvi Group Ranch in Laikipia County, Kenya. The CDC was formed in March 2012, with the support of The Road Less Travelled project. Suzan is one of the few Maasai women from this community who has been fortunate to have the opportunity to participate in education up to the secondary school level.

Suzan is one of the few women in her community who has been fortunate to have access to education; now she has started a literacy education class for other women in her community.  Image: James Senjura / MUACK

Suzan is one of the few women in her community who has been fortunate to have access to education; now she has started a literacy education class for other women in her community.
Image: James Senjura / MUACK

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Keeping pastoralist children in school during drought

In the past few months, relief has come in the form of much-needed rain to many drought-stricken districts in the Afar region of northern Ethiopia. Following an extreme dry season in 2012, and two previous years of minimal rainfall, the need for rain was critical in communities that are supported through The Road Less Travelled (TRLT) project.

Before the rains, 24 water distribution trucks were being used in an effort to avert thirst. Many Afar communities were weakened by severe malnutrition, animals were too weak to collect and carry water for households, and communities were unable to reach markets and sell stock as the animals were too emaciated. There was a strong fear that livestock would die en masse, leaving thousands of households destitute.

Between March and May, rainfall in some areas has replenished water storages, however, much of the water is unprotected and highly exposed to contamination. This leads to an increased risk of waterborne diseases among an already vulnerable community. Health extension workers have been working with project-trained health workers to establish community-level sanitation, which is a huge challenge in itself given the Afar nomadic lifestyle.

Rain has provided temporary relief for some communities in the drought-stricken Afar region of northern Ethiopia in recent months, while other areas remain dry.
Image: AVI / Fran Noonan

Other areas remain dry, having received minimal rainfall in recent months, and communities have been forced to move far from their homelands in search of grazing lands for their livestock. With the health of the herd at the heart of the pastoralists’ livelihood, TRLT partner the Afar Pastoralist Development Association (APDA) continually monitors these conditions and supports displaced communities through animal feeding and treatment, and water distribution.

A flow-on effect of the drought is that many pastoralist school children are forced to abandon their studies. Continue reading

Education as a catalyst for change in Samburu

Travelling through Samburu County, Kenya, you can’t help but gaze in wonder at the vast, dusty landscape and the huge numbers of livestock that are herded through the region. Beside them is often a child as young as five years.

For children growing up in nomadic or semi-nomadic pastoralist communities, mainstream education has, traditionally, not been an option. As cultural mores dictate ways of life, young girls and boys are often obligated to take up the role of shepherds for their family’s livestock, covering great distances with their animals in search of fresh pastures for grazing.

The vast landscape of Kenya’s nomadic pastoralists, on the road north to Samburu County.
Image: Anglican Overseas Aid / Matthew Willman

Education, in the past, may have been considered low on the list of needs within this setting. Now this view is gradually changing, but the question of accessibility remains. The herding responsibilities of children during day mean they have little opportunity to attend mainstream schools, even with the support of their families. To make any progress in improving education for marginalised communities, alternative education models are required.

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