Empowering communities to take charge of their health care in Ethiopia

More than 16,000 health posts have been constructed nationwide

Farmer Lomi Dechasa teaches other villagers about proper health care. (Credit: Xaume Olleros)

GERMAMA, Ethiopia — Lomi Dechasa remembers when women in her Ethiopian village were only allowed to urinate and defecate twice a day — before sunrise and after sunset. Going during the daytime was taboo for females.

“If a man saw you doing your business during the day, you would become a laughing stock. They would sing songs ridiculing you. It was painful,” said Lomi, standing in the muddy courtyard of her home on a farm growing wheat and teff a two-hour drive outside the capital, Addis Ababa.

It was easy to spot women relieving themselves because there were no private toilets. They had to squat in the farm fields.

But those days are over for Lomi because her household is a proud owner of a new pit latrine. It’s nothing fancy. Just a small outhouse made of rough-hewn planks of wood. Gaps between the boards are filled in with a mixture of mud, straw and cow dung. A stone slab with a hole makes up the floor. A thick sheet of plastic serves as the roof.

With a big smile, Lomi eagerly showed off the latrine. The highlight of her tour was when she pointed to a yellow plastic jug filled with water hanging near the door. She pulled a stopper out of the jug and a stream of water shot out. She took a chunk of pink soap wedged between the boards on the latrine’s wall, splashed water on her hands and washed them.

Soap can save lives. (Credit: Xaume Olleros)

A pit latrine seems like a simple thing. But it’s a game changer on farms where the lack of a proper toilet used to cause a variety of illnesses, many of them potentially fatal. The outhouse was made possible by Ethiopia’s successful Health Extension Program (HEP), which has trained 39,000 health workers across the country. They provide guidance about sanitation, vaccinations, family planning, disease prevention and several other issues.

Ethiopia’s remarkable progress battling malaria, tuberculosis and HIV/AIDS is largely due to the HEP. The program was started by the charismatic Dr. Tedros Adhanom, who served as Ethiopia’s health minister from 2007 to 2012 and is one of the most successful change leaders in Africa.

Improving the lives of women and girls along with providing better access to health care were among Dr. Tedros’ key goals. They continue to be his top priorities as he campaigns to be the next director-general of the World Health Organization.

Children in the Ethiopian village of Germama. (Credit: Xaume Olleros)

One of Dr. Tedros’ biggest devotees is Christian Tadele, an affable 29-year-old official who has been working for the Ministry of Health since he graduated with a sociology degree nine years ago. Tadele has fresh memories of what life was like before the HEP. He grew up in a rural area of the northwestern region of Amhara, where malaria was a big killer.

“We would all go to school cheerful and laughing, but then someone would have to carry us home because the illness would erupt while we were in class,” he said. “Even the farmers while working their fields, they would fall down to the ground because of malaria.”

Christian paused and got a bit choked up before adding, “Actually, I lost my little sister to malaria. She was 5 at the time. There were no health facilities nearby. There were no drugs. No one to reach us. If there had been someone, HEP workers, to provide us with the drugs, she would have been alive now. She would have been in college. The HEP has saved millions of lives. Truly. Millions of Ethiopian children are celebrating their birthdays.”

He added that the HEP is about much more than training a battalion of health workers.

“The basic philosophy is that the right knowledge and skills are transferred to households so that they can take responsibility for producing and maintaining their own health,” he said. “Long ago, we health workers thought we were producing the health in the community. But we now think the community can produce its own health.”

Christian Tadele visits a HEP health post. (Credit: Xaume Olleros)

Villagers work with the HEP staff to identify health challenges and they look for their own solutions and implement their own designs, Tadele said. It’s vital that the villagers take ownership of the problems and are completely invested in solving them.

“It’s a community-owned program led by the community,” he said.

On a recent HEP inspection visit, Tadele took a two-hour drive outside of the capital on bumpy dirt roads that make you feel like you’re sitting on a jackhammer. Along the way, he passed farmers tilling fields with wooden ploughs pulled by oxen. His minivan had to swerve around mule trains loaded with big bundles. A group of willowy distance runners — possibly training for the Olympics — glided by on a morning workout.

He pulled up to a small yellow building with a sign near its entrance that said, “No mother should die while giving birth.” It’s the health post of the HEP workers in Germama, which serves 586 households in the area.

HEP worker Hana Alemu at the health post in Germama. (Credit: Xaume Olleros)

More than 16,000 health posts have been built across the country under the initiative started by Dr. Tedros. Ethiopia’s HEP model has been replicated in more than a dozen countries.

Two HEP workers staff the health post in Germama, and they take turns going out into the villages to work with the people. Christian met with the one on duty, Hana Alemu, a young woman who has been on the job for seven years. Like all HEP workers, she had to have at least a 10th grade education and a year of health training.

The walls of the office are covered with posters about TB screening, guidelines to spot malnourishment and danger signs for maternal health and newborns. Each family has a file documenting a variety of information, including whether their kids were vaccinated and what kind of latrines, water sources and handwashing facilities they use.

A short walk away across a farm field is the home of Lomi Dechasa, the woman who showed off her new latrine. Her family lives in a traditional walled-in compound that includes a thatch-roofed building for a kitchen and a separate structure that serves as a family room and sleeping area. Goat skins lined a ledge around the rooms. Both buildings have hard-packed dirt floors and no electricity or running water.

Christian gave the tidy home high marks for having windows that allow for ventilation. Villagers used to be reluctant to add windows because of security concerns. But the health official noted the cow-dung fire smoldering in the cooking area lacked some type of smoke stack to clear the fumes from the room. More work needed to be done.

Village life in Germama. (Credit: Xaume Olleros)

Lomi is a feisty woman who lobbied Christian whenever she could. She had precious face time with an official from the capital and used the opportunity to constantly remind him that her village needed electricity and a better water supply.

Rather than be annoyed, Christian was encouraged. It showed him that the villagers were shedding their complacency and becoming less willing to just shrug their shoulders and accept their lot in life.

“This is the sign of development here,” he said. “Now the people have the mindset. They understand.”

Another thing that was reassuring was that the 38-year-old Lomi only had three children. Her mother gave birth to 13 children and 11 survived.

Family planning is one of the topics Lomi champions in the special role she plays in the HEP. She’s a leader of the “Women’s Development Army,” a group of grassroots health volunteers. Her community elected her to lead women from five households.

Once a week, they meet to sip coffee and discuss health issues. An illustrated booklet with 63 health messages guides the discussion. Pictures show a man accompanying his wife to a prenatal visit and feeding her nutritional food. Diagrams tout the benefits of breastfeeding.

Christian started flipping through the book and pointing out special points before Lomi jumped in and enthusiastically took over.

“Lately, we’ve been talking about the danger signs of pregnancy,” she said.

Lomi added that less than an hour’s drive away, there was a new health center where women can give birth with the assistance of medical professionals. The facility has a Toyota Land Cruiser that has been converted to an ambulance that can be called for emergencies.

The farm woman marveled at how much her life has changed in just a few years.

“It was truly ugly before,” she said. “There was no health service. When someone was sick, there was no treatment. Now, we can receive health services at our doorsteps.”

Lomi shows off her new latrine. (Credit: Xaume Olleros)

Back in the capital, the new minister of health is building on Dr. Tedros’ legacy and improving the HEP. The continuing challenge will be making sure that there is no complacency in addressing communicable diseases.

“Although we have controlled malaria today, it can always come back — sometimes with a vengeance. The same is true with HIV and TB,” said Dr. Kesetebirhan Admasu, who took over the ministry in 2012.

Meanwhile, chronic diseases are on the rise. As people live better and longer, they’re more prone to developing diabetes, hypertension, cancer, asthma and cardiovascular problems, Dr. Kesetebirhan said.

“We are upgrading the HEP workers to be able to deliver the package for the second generation of the HEP,” he said. “The vision we have is in probably 10 to 15 years from now, some of the HEP workers will be family physicians.”