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.

Continue reading

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.

Continue reading

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.

Continue reading

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.

Small steps generate bigger changes

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. The project is led by Anglican Overseas Aid in 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. TRLT’s holistic approach focuses on improving core maternal and child health (MCH) outcomes, and applies methods to 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 on it’s exciting to see people’s lives changing for the better in Longewan Ranch in Samburu County, especially for women.

Longewan Dispensary, Samburu county.  Image: Loretta Pilla/AOA, 2014

Longewan Dispensary, Samburu county.
Image: Loretta Pilla/AOA, 2014

Understanding women’s empowerment

Transforming women’s lives in a patriarchal environment is a difficult but essential challenge for TRLT. Empowerment is not a simple task; it is a multi-faceted process. Adequate support needs to be in place before starting the process. A sense of belonging and increased self-esteem are factors that contribute to a woman’s status in community. Her respect subsequently grows within families, communities and the broader society. TRLT, through its partnerships, provides the necessary support, information, resources, and creativity to allow women to find solutions to their own problems.

Challenges for women’s health

Initiating the process to improve women’s authority, one cannot ignore the cultural, social and environmental milieu which can inhibit progress. In Samburu, women traditionally birth at home away from qualified nurses. There are many constraints to attending clinics, including lack of nurses, distance, refusal by husbands, and women’s own beliefs that delivering at a clinic is a sign of cowardice.

Antonella Leakono has been the only nursing officer in charge of Longewan Dispensary for five years. As a Samburu woman, she recognises the need to invest in community health programs to achieve better health over the long haul for the people of her community.

“The biggest child health issues in this area are malnutrition, pneumonia, and diarrhea,” Antonella explains. “For women of reproductive age, it is anemia and infections related to giving birth at home.”

Causes of infections can include the use of unsterilised instruments during the delivery such as a knife for cutting the umbilical cord. Raising awareness on MCH remains a challenge, an almost impossible task for one Ministry of Health staff member, like Antonella, to tackle on her own.

Providing support: Instigating change

Longwean Link Person, Carolin, proudly displays her medical supply bag that she carries to every household visit. Image: Loretta Pilla/AOA, 2014

Longwean Link Person, Carolin, proudly displays her medical supply bag that she carries to every household visit. Image: Loretta Pilla/AOA, 2014

At the frontline of change are community health workers (CHWs) who have been trained collaboratively by TRLT and the Ministry of Health to provide frontline health services. Although the 18 Longewan CHWs do not have the same qualifications of a community health nurse, these volunteers spend approximately six hours per day, three days per week, visiting and caring for families, whilst also looking after their own. In one month, the 18 CHWs visit up to 248 households, and provided community members with pain killers, vitamins such as zinc, and oral rehydration solutions.

Carolin, the TRLT link person who has been trained as a CHW, explains that: “We educate women on importance of visiting clinics and on immunisations. Through trainings in the area of maternal neonatal child health, nutrition and first aid, we have the skills to identify danger signs such as bleeding during pregnancies, if a child is malnourished or if a child is not breastfeeding properly”. The work of the CHWs make significant contributions across many of TRLT’s goals in improving women’s health through women’s empowerment in the region. Yet their impact is far greater than just basic health services. They have an effect on community socio-economic standards generally, along with influencing the esteem with which women are regarded.

Empowerment through education and training

In Samburu, only 15% of women can read and write in Maa and/or Swahili.  Hosea and Cecilia are two CHWs in Longewan who have started to facilitate free adult literacy and numeracy classes for men and women. Currently, 24 women and three men attend the classes. Literacy plays an important role in determining women’s health, and their ability to seek healthcare. Improved literacy levels expand women’s access to knowledge, economic resources, and political power.

Painting on the Longewan Dispensary wall encourages pregnant women to visit the clinic.  Image: Loretta Pilla/AOA, 2014

Painting on the Longewan Dispensary wall encourages pregnant women to visit the clinic.
Image: Loretta Pilla/AOA, 2014

TRLT, in partnership with Equity Bank, have organised business training and financial management classes to improve men and women’s ability to save and better manage their assets. Poverty is intrinsically linked with poor health as it forces people to live in inadequate environments. By empowering women with the skills to manage their finances, it makes them less dependent on their husbands, and more likely to financially invest in their family’s health.

Identifying child malnutrition and anemia in pregnant women as a need, CHWs have also been involved in broadening the diet of community members through kitchen garden awareness training conducted in partnership with the Department of Agriculture. TRLT’s seed bank initiative encourages community members to produce their own food, whilst supporting others in their community. TRLT provides start up seeds from which community members grow their own crops. Once the crop has gone to seed, they are expected to keep a proportion for their next harvest, whilst distributing the remaining to others who can then start their own garden.

Saving Lives, Healthy Children, Improved Economy

In combination the CHW activities have an impact far greater than each individual task. Encouraging women to go to clinics for checks and to birth reduces risk of infection and even mortality. Improving diet, and working with the Ministry of Health on vaccination campaigns, leads to healthier children more resistant to debilitating diseases. Literacy education increases confidence and the ability to make and apply decisions that affect mothers’ lives. Starting-up small-scale economic activities generates disposable income to be spent on improving family well being. Along with reducing demand, and associated costs, on curative health services, the total effect contributes to the social health and well being, improves productivity adding to societal wealth, and accordingly strengthen the entire community.

The road ahead: Working together with the community health workers

The cohesion and commitment of these CHWs is palpable. They are being seen as community leaders, and regarded by their peers, both male and female, as equals because of the competencies and authority they provide. Moreover, the carry on effects of their work – empowering women and their communities through an integrated maternal and child health approach – is invaluable.

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

 

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

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.

Continue reading

The changing role of Maasai men in maternal health

James Senjura works closely with the Maasai pastoralist community of Laikipia, Kenya, to improve maternal and child health. He is a Project Officer for Mothers’ Union, Anglican Overseas Aid’s partner in The Road Less Travelled project, and also a father and positive role model for other men in his community. The project works with the community to identify key development challenges, and helps to develop locally-appropriate solutions to deliver basic health care and education where access to formal services is limited. James answers some questions about traditions and gender norms relating to maternal and child health within his culture.

In the Maasai community of Laikipia, how would you describe the traditional role of men in maternal and child health?

Traditionally, men’s role in maternal and child care has been passive. Maternal and child health care was in the hands of traditional birth attendants and old women.

Mostly men provide financial support and organise for transportation, and sometimes in consultation with the traditional birth attendant they decide for further action in case of complications or disease occurring. The father would advise on the estimated date of delivery, so that the woman would be prepared.

Image: Matthew Willman / Anglican Overseas Aid

Traditionally, the role of Maasai men in maternal health and child care has been a passive one. Image: Matthew Willman / Anglican Overseas Aid

It was also the role of man to source food (slaughter animals, draw blood) for the mother during and after pregnancy. When a woman was in the last trimester, the man would ready some rams for slaughter after delivery.

Continue reading

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.

Continue reading

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.

Continue reading