Transforming Health Care in Ethiopia

Dr. Tedros Adhanom Ghebreyesus served as the Minister of Health for the Federal Democratic Republic of Ethiopia from 2005 through 2012. During that time, the prominent infectious disease researcher led the implementation of the country’s Health Extension Program (HEP), an innovative effort to bring life-saving preventive-health services to Ethiopia’s largely rural population. HEP, which included the training of more than 38,000 health workers to provide health education and services, has yielded remarkable improvements in health in Ethiopia. From 2005 through 2010, life expectancy at birth increased by 3.5 years in the nation, and mortality rates for children under the age of five fell 23 percent.

Ghebreyesus, now Ethiopia’s Minister of Foreign Affairs, shared his thoughts with The Boston Consulting Group about how HEP was designed and why it succeeded where previous efforts had fallen short. Edited excerpts from the interview follow.

Where did the original idea of the Health Extension Program come from?

The first experience of our government in extension programs was actually in the agriculture sector. Under that original program, the agricultural extension workers taught farmers best practices in agronomy, and it really helped many farmers develop the skills and knowledge needed to improve productivity. The idea of the Health Extension Program was adopted from that program.

Of course we designed the program to meet the needs of the population. So while the agricultural development agents were primarily men, HEP workers were women. This reflected the fact that women and children often do not fully utilize health services.

What were some of the major hurdles in making this program work?

One issue was the program’s focus on the prevention of disease. This created a very serious challenge because most people simply did not really believe that preventive health care worked and they tended not to focus on curative services. So it was a challenge to convince the health workers that this approach would work. This was especially true at the start, when we had to focus on helping our health professionals understand the benefits of preventive health. Initially, it was an uphill battle. We had to have a dialog with all the stakeholders to help them understand the model and support it.

Obviously, limited resources pose an obstacle to progress in many places. How did you solve the funding challenge?

By design, HEP is a low-cost program. Many of the prevention programs don’t cost a lot. So preventing malaria, for example, can start with proper water management within the family compound or at nearby water sources. Of course, there are areas that need funding—like vaccines, bed nets, and other commodities needed to prevent the spread of infectious diseases that prevail in our country.

Initially, the financing portion of the program advanced slowly because the idea was new for many stakeholders—partners, donors, health professionals, and communities—and they didn’t commit immediately. But in order to show its commitment, our government started financing the program from its own coffers, and the cost of training the extension program workers was covered by the government. The idea was to go ahead and do it and achieve some results. We thought the results would convince our stakeholders to commit to [ongoing] financing of the program.

Where do you think some of the original skepticism came from?

There was some reluctance on the stakeholder side. It was lack of confidence in the approach to primary health care. Some of our stakeholders were openly telling us, “Ok this thing is not new. There was this Declaration of Alma-Ata [which was adopted at the International Conference on Primary Health Care] more than 30 years ago. That effort [which called on the international community to focus on primary health care] had similar concepts but it didn’t go very far.” So there was this concern that this program would just be another slogan.

But we told them that the problem with the Alma-Ata declaration had not been with the principles; the problem had been that the recommendations weren’t implemented properly. Although the Health Extension Program was based on the same policy, it was going to be accompanied by aggressive implementation. We set a target that every village needed to have a health post staffed with a minimum of two health extension workers. That meant that we needed more than 38,000 health extension workers across the nation.

How did you overcome that resistance?

The government was very serious about the benefits of HEP and the way it could revolutionize our health system. In particular, our late Prime Minister Meles Zenawi was very committed to the effort. He really believed in the idea of HEP and in primary health care in general as the centerpiece of our health system. So despite the concerns from partners and stakeholders, we really kept pushing. And finally, after we started the implementation of the program, many of the stakeholders who had concerns saw the results and said, “OK, this thing is working.” With time, they started to provide major funding support, meeting virtually all of the financing requirements for our program and even exceeding some. The commitment really increased.

Even well-designed programs fail if execution is weak. How was this project managed and implemented?

As you know, our country follows a system that decentralizes not only health services but many government programs. This approach helped accelerate the implementation of HEP and was one of the factors that enabled its success. But while there was decentralization, there was also cooperation and collaboration between the regions and the federal government. So from the start, we indentified areas of responsibility for the federal ministry of health and responsibilities for the regions. We conducted a joint planning exercise upfront. And we also had joint supervision programs that began after we started implementation so that we could evaluate the progress not only of HEP but also of our other joint primary-health programs.

That kind of management really helped. The decentralization also gave the regional governments ownership and autonomy to implement the program in their respective regions. Cooperation, but at the same time devolution of power, helped us achieve very good results.

Were there any goals of HEP that were not achieved?

We had better results in some areas, and progress has lagged in others. When you look at efforts to prevent the spread of malaria, HIV, and tuberculosis, the results are impressive. And programs to reduce mortality among children under the age of five have also achieved good results.

But we have not made as much progress in the effort to reduce maternal mortality. There has been some improvement, but we are not on track to meet the Millennium Development Goals [set by the United Nations] on maternal mortality.

We recognized that HEP alone wouldn’t be able to do that. To reduce maternal mortality, we not only need to implement the preventive measures under HEP, but we also need to build better facilities such as health centers and hospitals. Those facilities, with the capability to perform cesarean sections and to manage hypertension and excessive bleeding during delivery, are critical to reducing the risk of mothers dying during delivery. Cutting that mortality rate requires more extensive intervention.

Although we only have two-and-a-half years to meet the Millennium Development Goals, this objective is still achievable, especially if we encourage women’s groups to take responsibility for implementing many of the recommendations outlined in HEP—and if our government continues to have the political commitment, which I expect it will.

As you know, many projects in Africa are launched with great ambitions yet do not succeed. What can other governments learn from Ethiopia’s experience?

Even within Ethiopia, many similar projects had been initiated some years before. The reason for their lack of success, I think, was the lack of political commitment or political will.

And it is important to note that political commitment is about the government taking ownership and trying to influence other players in addition to providing financial support. The ownership and influence are more important than the provision of financial resources. In our experience, one of the most important forms of commitment was how our leaders owned the program, assisted with the mobilization of resources, and influenced other health-care players and stakeholders to secure buy-in into the program. The government truly believed that primary health care, including a Health Extension Program focused on preventive care, should be the centerpiece of the health system. That is why it succeeded.