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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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.

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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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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