Written August 12, 2008
Today I will write about a remarkable young woman I met in a remote area of Africa. However, I will first describe the context of our meeting.
I asked my friend Tewodrose Adhanom Ghebreyesus, Minister of Health for Ethiopia, to show me the system of Health Extension Workers (HEWs). Our government, through our HIV/AIDS, Malaria and USAID funds, has helped build the system. We need to ensure our money is building capacity for ultimate sustainability and not just creating an endless dependency.
To understand the design of this effort, one must first remember the starting place. This is a nation estimated to have 80 million people. Statistics don’t do the level of poverty justice, but the average annual income is $700, although the majority of people earn less than $100 a year. The entire gross domestic product of the nation is about 80% of the non-entitlement budget of HHS. Vast numbers of the people live in villages where the word remote is inadequate. The average life expectancy of a male is less than 46 years old.
The Prime Minister and Minister Twedorose properly concluded that improved health was a pre-requisite to improved economic vitality. They also concluded that with the resources they had available to them, improving health through normal methods was impossible. They had to build something unique, and they had to start basic. They concluded the first objective was to build a primary health system that was within the reach of every Ethiopian citizen. They created a construct that calls for training 30,000 public health workers known as health extension workers.
HEWs are almost all woman and typically young, generally 18 to 25 years old. The Ethiopian government sought to identify high school educated woman from every area of the country and set up a training course that lasted one year, during which the women were taught to provide a surprising and impressive array of services, and a limited number of medical treatments.
By design, HEWs live in their communities, work in pairs, and cover 1,000 households. Their job is to know the people in their community on a personal enough basis that they are able to teach, persuade and enable the adoption of improved personal health practices in a way that will attack the problem of poor health at the root.
The Ethiopian government has undertaken (again with help from HIV/AIDS money from the United States) to build a series of health centers; one for every 250,000 people. These health centers have the capacity to provide basic curative service and have around 15 beds capable of managing a patient for up to 48 hours. These are typically managed by the equivalent of what we know as physician assistants. When needs go beyond what the health center can manage, they aspire to get patients into a system of larger hospitals.
The Ethiopian government reports considerable progress on fulfilling this vision. They will have recruited and trained 24,000 of the needed 30,000 health workers, for example. They admit to being a little behind on opening new health centers, but the reality is all systems like this have weak spots and break downs, and the goals of starting with prevention and focusing on the basics seem logical and admirable.
The Minister accompanied my delegation, which included Dr. Julie Gerberding and Tim Ziemer, the Coordinator of the President’s Malaria Initiative, to Axum, Ethiopia, a small city on the northern border. Our purpose was to accompany a HEW into homes and watch her work.
In that setting, I met Abrehet Tarekegne, an attractive and smart 20-year-old woman, who has been working since she was 18 years old as a HEW. Together, we visited a family that lived in a dwelling that appeared to be typical to the area. It was made of a collection of materials including mud, stone and straw. The family had seven children ranging in age from late teens to three years old (my estimate). They cultivated the land around them with some corn and wheat. They had some chickens and three cows, which they yoke and use to plow and cultivate their fields. They told me proudly about bees they raise. It is the one crop they have that generates cash. They get the equivalent of $50 per hive. Last year they generated eight hives.
Abrehet told me privately about the conditions in which the family was living when she first visited them two years earlier. There was no separation between themselves and their animals. They had no latrine system, no malaria nets and little idea of personal hygiene. My visit revealed they had rearranged their living quarters to separate the animals, though not as completely as she hoped. The living quarters were small, maybe 14 feet by 14 feet. There were two beds, both with bed nets. They had a latrine system built so that the waste was kept away from the house. She insisted I go inside the latrine to show me the way it worked. It was slightly more information than I wanted, but it demonstrated to me how committed these health workers are. She had a list of over 250 homes she was working with.
I asked how many visits she is able to make. She told me her goal is to spend considerable time with 10 families a week. She said, “I like to spend enough time with each one so that I can make real progress. Sometimes I have to help them do things.”
Two important things to put into context here: First, she walks everywhere she goes and the families often live a long ways apart. Second, all this is on top of the routine other work she does as she moves about. I asked her if she keeps records on her work. She reached into a black bag she carries with her and produced a paper summarizing her work during the past year. During the past 12 months, working on her own, Abrehet has:
- Tested 1,100 people for HIV/AIDS
- Counseled the 9 people who tested positive
- She is currently tracking 105 pregnant woman
- She delivered 7 babies herself
- Trained 152 mothers on breast feeding
- She follows 152 woman with family planning
- Distributed 1,001 vitamin A capsules
- Vaccinated 219 children against tuberculosis
- Distributed more than 3,000 condoms
This was done by a 20-year-old woman walking from home-to-home with a canvas bag as her office.
I asked if the family had been resistant to change. She said, “Almost everybody is, but if you just keep coming back and explaining why it is important, they ultimately begin to change.”
I asked the husband about his reaction to this young woman asking him to change the way he and his family lived. He confessed to the resistance but said, “We knew her for a long time, and also believed it was the right thing.”
Minister Tewodrose told me that choosing the HEWs from the local village is a critical part of the formula. They have relationships they can build on. It was clear to me that Abrehet has begun to develop a fair amount of trust and stature by virtue of the personal service she provides. “What are your aspirations for the future?” I asked her.
“I want to get more education, maybe become a nurse or doctor,” she said. She told me she rarely takes a day off, because the needs are so abundant, but also made clear how satisfying she finds her work.
Abrehet Tarekegne, a Health Extension Worker, demonstrating how she uses one of her tools to listen to Secretary Leavitt’s heartbeat.
The Minister of Health told me they expect HEWs will provide an ongoing source of motivated medical students. He said, “We have told them, if they produce results, we will help them get an education.”
Perhaps one of the most interesting parts of our time together, was when I asked her to open her black bag and show me what was inside. It was a mini clinic. She had vaccines, malaria medication, vitamins, etc.
Abrehet Tarekegne showing Secretary Leavitt supplies she carries on her visits to families.
I have seen public health systems used like this in many other places around the developing world. El Salvador is one recent example (blog on Health Promoters). I find this system to be such a practical and efficient formula to make progress in this incredibly difficult situation.
The health system of the United States deals with a much different set of problems than a developing nation like Ethiopia, and nobody would trade our outcomes for theirs. However, there are things we can and should learn from these systems. One is that basic health care, provided by trained care extenders, in spartan facilities, is vastly superior to nothing and will produce substantial benefit to people.