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Health extension workers: the backbone of Ethiopia’s immunisation programme

By Miraf Solomon, Health and Nutrition Specialist, Save the Children International, Ethiopia

Ethiopia’s flagship Health Extension Program (HEP) delivers cost-effective basic services to all Ethiopians, with a special focus on women and children. The main drivers of the HEP are health extension workers, delivering health promotion, disease prevention, including immunisation, and selected curative health services at the community level.

Dayo Mohamed, a 38-year-old health extension worker in Moyale Woreda in Ethiopia’s Somali Region, has served his community for almost 12 years. From early childhood, Dayo has been painfully aware of the devastating consequences for his community of the lack of accessible health facilities. With no health post or health centre close by, the community frequently suffered from vaccine preventable diseases like measles, pneumonia and diarrhoea. This was compounded by diseases due to poor hygiene and sanitation. Dayo always dreamed of being a health worker and has wanted to improve the health status of his community. The HEP was a great opportunity to pursue his dreams.

Dayo is grateful to Save the Children for supporting and strengthening the immunisation service and building his capacity through training, on-the-job supportive supervisions and mentoring to provide good-quality services. He has put his training to active use by supporting his health post for over seven years now, strengthening its immunisation and nutrition services. He has been selected as the best health extension worker in the zone and was rewarded at the regional level in 2017. As a result of his performance, he was promoted to a level IV health extension worker, the equivalent of a nurse.

Dayo appreciates the improvement in the health condition of his community over the years and says that his community is particularly appreciative of the immunisation service, which is regularly provided by him at the health post. In February this year, immunisation coverage in his catchment area was more than 80% for the third dose of pentavalent vaccine, with a drop-out rate of zero. In recent years, the incidence of vaccine-preventable diseases has dropped significantly.

Save the Children has been building the capacity of health workers and health extension workers like Dayo to make sure that good-quality immunisation services are available to all children, especially to those children in hard to reach areas of the pastoralist regions of Ethiopia.

The situation of children in Ethiopia

Ethiopia has scaled up key life-saving interventions, which has contributed to under-five mortality dropping from 166 deaths of children under five per 1,000 live births in 2000 to 55 in 2019. Vaccination has directly contributed to about one-third of this reduction and helped Ethiopia achieve the MDG target for under-five mortality. Currently 12 antigens are being provided in the national routine immunisation program. There has been significant progress in vaccination coverage over the years – from 17% for the third dose of pentavalent coverage in 2000 to 61% in 2019. The percentage of children with no vaccination has also declined from 24% in 2005 to 19% in 2019.

Despite the progress, one in five children in Ethiopia has still not been vaccinated. There is significant variation in the coverage rate between regions, ranging from 93% coverage for all basic vaccines in Addis Ababa City Administration to just 26% in the pastoralist region of Somali Region in 2019, illustrating stark inequities in immunisation coverage. While the HEP has made the biggest contribution to immunisation coverage, it is often with suboptimal vaccination coverage, regional coverage variations and high dropout rates.

To improve the delivery of primary health care and immunisation services, the government has adapted the HEP to suit the demands of the pastoralist regions. The Pastoralist Health Extension Programme (PHEP) considers the local context and has organised primary health care units differently to enhance delivery of good-quality primary health care services. Save the Children has been instrumental in advocating for the PHEP and continues to play a critical role in ensuring its implementation and the building of accountability mechanisms in the pastoralist regions. Continued prioritisation, investment and political commitment is required to strengthen the PHEP to improve primary health care and immunisation services and to prevent children dying from preventable diseases.

The global COVID-19 pandemic has also made its presence known in Ethiopia with the first reported case on the 13 March. As of 21 April, Ethiopia has reported 114 cases of COVID-19 with 3 deaths. In a health system that is already weak, the COVID-19 response will further increase the burden on the health system to provide basic services. The required social distancing protocol might contribute to parents becoming reluctant to bring their children to health facilities for vaccination and increases the chances of outbreaks of vaccine-preventable diseases.

What we’re doing

Save the Children will continue to support and work with health extension workers like Dayo and will ramp up our advocacy to:

  • maintain and scale up routine immunisation services while also delivering the COVID-19 response
  • ensure equity in the allocation of COVID-19 and other existing and new health financing so that pastoralist regions can strengthen their immunisation and primary health care services
  • use the COVID-19 response to increase investment in vaccines, cold chain and health workers required to deliver immunisation services
  • reiterate that routine immunisation is a core component of a strong, resilient health system, and deliver on Ethiopia’s commitments to achieve universal health coverage and to the principles of the African Declaration on Immunization
  • prioritise and strengthen the HEP/PHEP, so that health education and vaccination services can be delivered in a timely and effective manner.


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