Health extension program in ethiopia

A total of 8 respondents participated in the study. The first two were policymakers at the national level from the non-communicable disease directorate and PHC and HEP directorate. Two of them were decision-makers at the regional level and the other two were from service management bodies, district health offices. We finally took information from two health extension workers Table 1. Notes: Supplementary file I-Key informants guide. Supplementary file II -Codes. Mental health problems are not well studied in Ethiopia.

But recent findings indicate that there is a high burden of mental health problems in the country. According to an expert from the MOH, non-communicable diseases directorate, mental health problems are increasing fast in the country recently. Respondents from the Oromia regional state health bureau also mentioned some possible reasons for the increasing burden of mental health problems. The economic strain of the people in the country contributed to the burden of the problems. According to the respondents, the current high unemployment rate and extreme poverty are major reasons for the recent mental health problems.

Furthermore, they stressed that drugs in many areas of the country could be the primary reason. Especially the use of Khat is increasing fast. Regarding this, one respondent from MOH said,. The other major reason for the recent high prevalence of mental health problem magnitude is the recurrent internal displacements in the country.

The dispute ended with a significant number of deaths, property loss, and displacement of inhabitants from their original living area. They have been forced to live in temporary camps.

The displaced people have experienced terrible situations during the conflicts and the camps. For instance, a mental health focal person from ORHB reported that:. There is an increase in mental illness in recent times because of the displacement of a significant number population in the region [Oromia region].

The burden is high among those displaced people living in settlement camps. Many of them lost their families, and some saw their relatives killed in front of themselves. They were also under stressful conditions. Therefore, post-traumatic stress disorder, depression, anxiety, and psychotic feature are prevalent among this population. The mental health cases were more seen in camps around Sululta and Bishan Guracha [Two of the centers for displaced people].

The mental health focal person in the MOH has seen the burden dividing into the urban-rural residence. This difference could be factors like displacement, unemployment, psychoactive substance use are more common in urban areas of the country. In an interview with these HEWs, we recognized that they had observed some people with signs and symptoms of mental health problems during their house-to-house visit in their catchment population.

For instance, one 32 years old HEW said:. I also observed a boy who got into conflict and disagreement with his family. Another guy also was highly suspicious of his mother, and he kicked out all the family members from their house and started living alone. These can be examples of the mental health problem in my working area. The Ethiopian health service delivery system has three tiers.

At the tertiary level, highly specialized medical services being given on a referral basis. At the secondary level still, services are provided based on a referral basis. Still, the specialty and the number of catchment populations are lower than the tertiary level care. On the other hand, at the primary level, mostly preventive, promotive, and essential curative services are being given. This primary health care is currently administered at primary hospitals, health centers, and satellite health posts.

Regarding mental health services, the actual practice in Ethiopia tells us that the services are administered only in tertiary level hospitals. There is only one specialty hospital for mental health service situated in the capital of the country, Addis Ababa. There is a framework to deliver the services at general hospitals [secondary level] and primary level hospitals.

However, because of different reasons, the activity remains in some of the health facilities. The vast majority of the population living in a rural setting who need care were not benefited. The mental health focal person in the ministry of health mention the reasons for this limited health service access.

The first fundamental issue is the shortage of trained professionals. According to him:. However, all these professionals are not actively working in psychiatry clinics.

Some, especially those at masters level, remain in office work in one health administrative organ. The information we obtained from the Oromia regional health bureau mental health focal person supports this argument. There is a high turnover of mental health professionals because of transfer and promotion. The promotion policy in the region supports the transfer of health professionals from health facilities to administrative offices.

Therefore, the regional state has lost many mental health professionals from their actual clinic area. The expert from the HEP directorate of the ministry of health sees the reason from another angle. According to him, the source of the problem is the absence of clear policy documents at the national level. The strategy indicates mental health services have to be given up to the lower level of care. In most parts of Ethiopia, mental health problems are considered a punishment from God or some kind of evil spirit possession.

They, therefore, prefer traditional healers and religious organizations avoiding orthodox health services. The regional health bureau has implemented and achieved many health indicators is through community health service activity by health extension workers. The recently updated health extension program consists of eighteen health service packages.

Among these packages, mental health service is one. Based on these packages, the ministry of health has developed a training manual to give refresher training to existing HEWs and full package training to newly recruited candidate HEWs. Their primary role in mental health service is to provide behavior change education, identify suspected mental health cases with vital signs and symptoms, link to health service keeping their referral chain, and follow up treatment adherence. The integration of mental health services into health extension packages was first started in the urban health extension program.

It was then expanded to the rural health extension program. Currently, mental health services are integrated into both the urban and rural health extension packages. As it has been revealed in various health indicators in Ethiopia, the implementation of HEP has significantly changed the health status of the community.

Since the focus of HEP is on prevention and promotion, the burden in health facilities was minimized. The health system saved a substantial amount of resources that could have been used for curative services. Similar benefits are expected while implementing preventive and promotive mental health services with the HEP in Ethiopia. That is why the government has included mental health services in health extension packages and trained HEWs with the necessary modules.

However, as the information we obtained, the program packages were not implemented so far. The Ethiopian health care tier system is a well-designed primary health care structure. There is a service management system called the primary health care unit PHCU under the primary health care structure.

In this unit, there is an average of five health posts with a referral health center. The administrative organ of these units is the district health office. The health center oversees all the services and the activities of health posts.

Currently, in this system, there is also a primary referral hospital. Cases that could not be managed at the health center level will be referred to primary hospitals.

The district health office supervises the overall service at the PHCU. Our key informants from the ministry of health of Ethiopia and Oromia regional health bureau consider this established system and management an excellent opportunity to implement mental health services. There are also policy documents and strategies that help the implementation of the services.

The currently available health extension program guideline includes mental health as one of the main components. The study participant from non-communicable diseases prevention and control directorate:. We also develop plans together regarding the mental health services in the PHC system. Despite its delay in implementation, there is a mental health strategy document in the ministry of health. This document has given due emphasis to managing mental health problems at the primary health care level.

Government officials and the ministry of health are now giving concern to mental health and mental health services. Previously there was no even a focal person dealing with mental health in the ministry of Health. However, recently a case team dedicated to mental health was established under the non-communicable disease directorate. The ministry is fulfilling the case team with human resources.

The same is true in Oromia regional state health bureau. In Ethiopia, there are about HEWs actively working in health posts and community outreach. It has been two HEWs averagely per health post.

Meanwhile, currently, the ministry started increasing the number of HEWs to four per health post. The level of training given to HEWs was up to level three. However, currently, the training manual and packages were updated, and they get training up to level four. HEWs get training on preventive, promotive, and basic management of mental health problems at this level.

Contrary to this, a HEW interviewed in one of the Jimma zone districts responded that she and her colleague have not got trained on mental health and mental health services. We then confirmed this information from a respondent working in the district health office. He said that he has no information regarding mental health training given to HEWs so far.

The focus of the health systems managing body in Ethiopia is mostly on donor-focused communicable health problems and maternal and child health issues. The managing body has given priority to similar health issues in the policy and strategy documents. The mental health focal person in the ministry has a great concern about this. He said:. This concern does not remain a problem by itself. It then translated to the shortage in the availability of medical supplies, lower budget, and absence of incentive packages and staff retention strategies for mental health professionals.

From the responses of one of the respondents in the ministry, we could catch that mental health services are not integrated well with the PHC system starting from the ministry of health.

They perhaps support the planning and policy department during issues related to integrating mental health into HEP. The private health care delivery system is also the other center of focus. According to the key informants in the ministry of health, engagement of private institutions in the service [mental health service] is very much minimal.

There are only some two or three facilities giving specialty mental health services in Addis Ababa, the capital of Ethiopia. In other big towns, there are no such dedicated private health facilities for mental health. The major difficulty that all the respondents raised was the shortage of resources for mental health services. The referral system does not look functional for mental health services. Despite the availability of HEWs trained with mental health packages, there are no mental health professionals at the referral health center and primary hospital level.

Even though HEWs are trained in identifying and linking suspected people with mental health problems, the referral health centers and primary hospitals do not give services to the patients. There is a shortfall of human resources trained in mental health. According to informants from the ministry, the total number of psychiatrists in the country does not exceed Similarly, the health system is in short of psychiatry nurses and other mental health professionals.

Therefore, even if there is a demand for mental health services at each health system level, the ministry could not fill the gap. As has been described above, the respondents agreed that, despite the prevailing mental health problems in the country, the focus of health system administrators and policy documents is on other issues like infectious diseases and maternity care.

Therefore, most education programs and many students join education programs, directed to what the government outlined priority. These are the main problems occurring in most government health and medical schools. It is not only from the government administration side; students who join medical and health schools negatively perceive mental health courses.

For instance, if you see physicians, most of them do not prefer to specialize in psychiatry. The other primary concern is financial constraints. Ethiopia is among the countries that have the lowest per capita health expenditure in the world. In this country, the amount of budget and finance spent on mental health services is meager. Based on this, we have traced back to why mental health has a low policy and political concern.

The mental health focal person in the ministry disclosed improvements in the allocated amount of budget for the service in recent years.

The other primary source of finance in Ethiopian health care is an international organization and bilateral aids. In this regard also, mental health services do not benefit. Most external aids are mainly spent on services like maternity care and infectious diseases control purposes. As far as I know, mental health has no support, except little amount of monitory and technical support from WHO. Therefore, it would be challenging to address the mental health need in the country with the sum of the available amount of finance.

Both Respondents from the Oromia regional health bureau and non-communicable diseases focal person in the Jimma zone agreed with this issue. They frequently looked for additional funds from external organizations, but they left with nothing. There are no external collaborators at the regional and district levels. For long HEWs have been serving in the Ethiopian health care system as community health workers.

There is an average of about two HEWs working in a health post. A single health post is supposed to give service averagely to population. That means two HEWs provide the services to more than households living in a kebele. They serve the people both based in a health post and house-to-house visit.

According to respondents in the ministry, they have a significant impact on improving the health status of the community in the country.

However, their pay scale is the lowest in the public health system career structure. Therefore, there is a fear that HEWs may lose their commitment when a new service package is integrated and became add up to the existing one. We are forced to cover a long-distance foot walk to address all the households in a kebele. We are loaded with the existing health service packages.

All the assigned HEWs do not always available onboard for assignments. Some of them may be on maternity leave, and some may absent from their work. On top of this, I have not got any mental health training so far. Therefore, how can I supposed to do additional activities? It could be challenging to administer mental health services in the existing HEP arrangement and career level. There are also some more challenges from the community side to use the available health services.

In most parts of the country, people, especially those living in rural areas, consider mental health problems as some evil spirits and look for some traditional healers or religious organizations. Some community members are not willing to accept advice from a health professional and HEWs.

According to their thought, there is an adverse perception of the causes of mental health problems and a negative attitude regarding mental health services.

This would be a challenge when implementing mental health services with HEP. The Ethiopian health system monitoring and evaluation generally guided by a system called the health management information system HMIS. The system has pre-defined health-related indicators. Therefore, the reporting of health events directly adheres to these pre-defined indicators.

According to the information we have received from the Ministry of health and Oromia regional health bureau, there is no indicator of mental health in the system. The mental health focal person has given stress to this point. The newly designed system, the district health information system DHIS2 , consists of mental health indicators. Since then, community health service has been practiced in many countries of the world and found useful.

Ethiopia has started implementing a structured community health workers approach since to support primary health care in the preventive and promotive aspects. The service used to have sixteen health service packages before being updated recently. Many countries achieved health-related goals with this approach.

Low and middle-income countries like Zambia, Uganda, and Bangladesh integrated their mental health services with a community health approach and shown massive improvement in mental health and service use.

The findings in this study indicate, there is a high burden of mental health problems in Ethiopia. Quantitative figures also show that mental illnesses, especially depression and anxiety, are most common in various countries. Substance use is increasing in many parts of the country, particularly among young and adolescent age groups at secondary schools and colleges vulnerable to this situation.

Currently, in Ethiopia, there are more than three million internally displaced people because of political disputes. Some documents indicated Ethiopia recorded the third-largest internal displacement in the world. The people, in most cases, use traditional and religious ways of treatment to treat mental health problems.

Mostly they associate the disease with an evil spirit possession or a punishment from God against their sins. More severely, some families keep a member with mental illness in their house without any treatment.

It is the case in many African countries too. For instance, a study conducted in South Africa indicated that mentally ill people live in dangerous situations. This is the reason that triggers the health system to avail health service as nearest as possible to the population.

Although integrating mental health issues in the primary health care delivery system is the right approach, its practicality is difficult in a resource-limited country. For instance, when we see the Ethiopian situation, a well-structured primary health care system and strategic documents support the integration of mental health service into the system.

Health systems and programs people in the Ethiopian healthcare system list lots of reasons for this occurrence. Even though mental illness is a big problem in the country, leaders in the health care system and most policy documents have not made this issue a priority problem. Failures of various health service approaches give a lesson that 54 , 55 if there is no political commitment in the health care system, it would be merely the result of low effort.

The resource is at the heart of the health care system. In resource-limited countries, it is a headache to allocate the existing few resources into various health services. The impacts of foreign aid were not clear to some participants, causing them to think that mental health care is neglected and therefore not necessary. On the other hand, some attitudinal and behavioral issues in the community and health care providers affect the implementation of mental health services in the community health service.

According to our findings, uneducated people, even educated and health care workers, have a negative attitude toward mentally ill people and the service itself. As part of the community, some HEWs have a poor attitude regarding mental illness and mentally ill people.

We have also identified other barriers like; inadequate knowledge of community members, lack of indicators in the reporting system, lack of need from students to join mental health professions, etc.

A systematic review has also revealed that the same barriers happen in other low-income settings. On the other hand, our study has identified some major facilitators that help to implement mental health services at the community level. Implementing mental health services in the PHC system does not need a considerable establishment cost in Ethiopia. More than HEWs working in various parts of the country are mostly trained with basic mental health services.

A study done in Uganda revealed respondents reported they had not received in-service training in the mental health area.

The health care providers felt that mental health was not as crucial as other diseases where a lot of attention and resources were directed. Some health centers had donor-funded project s with a set plan and necessary resources to achieve the aims. This was not clear to some of the participants thus causing them to think that mental health care is neglected and, therefore, considered unnecessary.

There were no regulatory measures at the health facilities to encourage them to screen for mental health problems. Overall, we have found that mental health problems are increasing at an alarming rate and should be a major concern in Ethiopia.

Yet, the currently functioning mental health services is not capable enough to respond to the current need. We have identified a low level of concern among health system leaders and policy documents, low-level of public-private partnership, inadequate and donor-dependent budget, low acceptability of the services from both the community and HEWs, low commitment of HEWs, absence of mental health indicators in the Ethiopian health information system were identified as barriers to inadequate mental health services.

On the other hand, some factors could facilitate mental health services within the health extension program. Integrating the mental health service in the health extension program as one of the primary health components, availability of the policy documents, and the availability of well-trained HEW at the grass-root level could be considered facilitating factors.

In general, implementing mental health promotive and preventive health services at the grass-roots level through HEWs would have paramount importance for mitigating and controlling the devastating effect of mental health. We are also grateful to all the data collectors, supervisors, and respondents for this study.

Similarly, the provision of zinc and ORS for diarrheal case management, malaria case management, pneumococcal vaccination, TB treatment follow-up i. Figs 4 and 5 present the results of the sensitivity analysis, which was conducted by varying the various parameters, such as unit cost, discounting LYG, life-years of capital items, pre-service and in-service training, and salary scale.

Although changes in the rate used for age discounting do affect the ICER for the lower This study has estimated the cost and cost-effectiveness of providing selected HEP packages. The incremental cost per LYG was The unit costs and cost-effectiveness of the HEP based on health need and supply constraints provide contextual evidence for decision-makers to prioritize healthcare interventions and allocate resources efficiently in order to improve population health.

The cost of DPC interventions has a higher variability in their unit cost than family health services costs. Although the total costs depend on the interventions included in the community health program, the estimates for family health and DPC services are similar to the average cost estimated in Ghana [ 30 ].

A study conducted in Ethiopia estimated that district-based IRS would cost more than community-based IRS, both in terms of cost per district and in terms of cost per person protected [ 33 ]. Drugs and supplies were the key cost drivers of the program, unlike in the previous study in Ghana, where staff costs accounted for the largest proportion of unit costs.

This may be attributed to the difference in the average number of workers per health facility, the difference in the estimation of staff time, or the variation in the wage scale between the two studies [ 30 ].

Thus, the HEP leads to a higher proportion of lives saved and a more cost-effective approach to delivering essential health services to rural and vulnerable communities, where access to qualified staff is limited. Similarly, previous studies and systematic reviews of the cost-effectiveness of community health workers have indicated that providing essential healthcare services through community health workers is a cost-effective or very cost-effective strategy [ 35 , 36 ].

Our study, however, found that the HEP is a very cost-effective program. In this study, the difference in ICER i. Moreover, the implementation period of the HEP that we used is longer than the previous study i.

The study indicated that community health programs represent an attractive and low-cost investment that increases the coverage of key child interventions and decreases child mortality. A previous study conducted in Bangladesh compared community healthcare with home-based care for maternal and neonatal interventions. Although it is difficult to make a realistic comparison of ICER data due to the variability of time horizons, settings, perspectives of the studies, the disease burden and range of interventions, aggregate evidence from other studies provide insights and the genuine lesson that community health programs are a cost-effective or a very cost-effective strategy.

The provision of health care services through the HEP, however, is not a standalone strategy, but a complementary approach to other mechanisms of delivering healthcare services in the country.

The following limitations apply to this study. First, although this study considered a wide range of HEP interventions, it excluded interventions with an absence of clear cost and outcome measures; this could affect the findings of this study.

Second, the health outcome measure takes into account only the mortality aspect of the intervention, and the ICER reported in this study may be overestimated because it ignores morbidity effects. Fourth, by their very nature, community-based programs function outside the formal systems, and the provider perspective does not capture all of the social costs associated with the HEP; incorporating other perspectives may yield better outcomes.

Notwithstanding a number of methodological and data-availability limitations, the study provided cost and cost-effectiveness estimates for national HEP programs and illustrated the potential effect of the program in Ethiopia. Overall, the findings of this study represent an additional contribution to the wider but still limited literature that suggests that HEP strategies tend to be cost-effective and improve the coverage of essential services.

Potential research focusing on implementation modalities, how the HEP can affect the wider health system, and what broader social costs and benefits they can offer is important. The costing of HEP interventions is important for setting priorities, mobilizing resources, and advocacy, as well as for various program-planning and budgeting activities.

All of the selected interventions were found to be very cost-effective. The cost-effectiveness analysis will enhance the case for stronger HEP investment and can be used during priority setting to identify the most cost-effective packages of interventions. Chan School of Public Health, and Dr. We thank Dr. Girmay Medhin and Dr. Girma Azene for useful discussions. Browse Subject Areas?

Click through the PLOS taxonomy to find articles in your field. Methods Twenty-one health care interventions were selected under the hygiene and sanitation, family health services, and disease prevention and control sub-domains.

Conclusion The unit cost estimates of HEP interventions are crucial for priority-setting, resource mobilization, and program planning. Introduction Ethiopia has a three-tier healthcare delivery system, with primary, secondary, and tertiary level units. Interventions The following 21 interventions were selected based on the availability of cost data, effectiveness measures, and interventions, mostly implemented by HEWs Table 1.

Download: PPT. Table 1. Selected HEP interventions from the family health services, disease prevention and control, hygiene and environmental sanitation subdomains. Costing approaches Costing was conducted from a provider perspective, where the costs incurred by the government were included [ 10 ].

Cost inputs and analysis The cost components include personnel, medicine, supplies, infrastructure, capacity building, and equipment Table 2. Cost-effectiveness analysis Since the founding of the HEP in , the health system has incurred additional costs of health services.

Sensitivity analysis One-way sensitivity analysis was performed by varying the unit costs, the discount rate, the lifetime duration of equipment, buildings, pre-service and in-service training, and the salary of HEWs and others to check for the robustness of the findings when those parameters are changed.

Table 4. Unit cost of selected HEP interventions by service delivery modalities in Ethiopia, Fig 1. Percentage distribution of family health services unit costs by ingredients. Fig 2. Percentage distribution of DPC unit costs by ingredient. Cost-effectiveness analysis The cost-effectiveness results, ranked from the most cost-effective intervention to the least are presented in Fig 3.

Fig 3. Incremental cost-effectiveness ratio of selected HEP interventions in Ethiopia, Sensitivity analysis Figs 4 and 5 present the results of the sensitivity analysis, which was conducted by varying the various parameters, such as unit cost, discounting LYG, life-years of capital items, pre-service and in-service training, and salary scale.

Fig 4. One-way sensitivity analysis showing cost-effectiveness ratio of TT injections over a range of key parameters. Fig 5. One-way sensitivity analysis showing cost-effectiveness ratio of pneumonia treatment over a range of key parameters. Discussion This study has estimated the cost and cost-effectiveness of providing selected HEP packages.

Conclusion The costing of HEP interventions is important for setting priorities, mobilizing resources, and advocacy, as well as for various program-planning and budgeting activities. Supporting information. S1 Dataset. References 1. Community health extension program of Ethiopia, — successes and challenges toward universal coverage for primary healthcare services.

Globalization and Health. Addis Ababa. Revised National Health Extension program implementation guideline. Addis Ababa, Ethiopia. Essential health Service Package for Ethiopia. Addis Ababa: Artistic printing Enterprise; Journal of Development Effectiveness. View Article Google Scholar 7. Amare SA. Cost-effectiveness of community-based practitioner programmes in Ethiopia, Indonesia and Kenya. Bull World Health Organ.

National assessment of the Ethiopian Health Extension Program. Health economics. Human Resource department, national health work force update. World Health Organization. Microsoft corporation. Microsoft Excel. Ethiopia Demographic and Health Survey, Addis Ababa, Ethiopia; Calverton, Md. Avenir Health. A World Health Organization resource. View Article Google Scholar Robberstad B. Ethiopia demographic and health survey, Effect of ethiopia's health extension program on maternal and newborn health care practices in rural districts: a dose-response study.

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