Health Extension Model Struggles to Survive Due to Rising Pressures, Waning Support

Jul 5 , 2025
By Halima Abate (MD)

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The federal government’s signature program for public health extension services is at a crossroads. Launched in 2003 to bring essential care to the 85pc of Ethiopians who live in rural areas, the initiative once drew applause from global health experts who saw it as proof that a poor country could move toward universal coverage.

By assigning more than 38,000 one-year-trained female health workers to neighbourhood health posts serving roughly 5,000 people each, Addis Abeba cut maternal deaths almost in half from 728 for every 100,000 births between 2003 and 2016. The city lifted antenatal-care use from 34pc to 62pc between 2011 and 2016. The “magic bullet,” as some officials called it, offered measles shots and other services at costs well below the country's per-capita GDP of 852.80 dollars in 2018.

Sadly, the early wins have faltered. The same tightly scripted model that once delivered vaccines and promoted hygiene now struggles against non-communicable diseases such as diabetes and high blood pressure, which rise as Ethiopians live longer and urbanise. Health posts in sprawling towns often sit underused because their maternal and child care services no longer match local demand. Inside rural clinics, extension workers face empty drug cabinets and unreliable electricity that compromises vaccine storage.

According to one such worker, their job keeps expanding, but not the support they receive. This is an echo of the frustration that drives a 21.1pc attrition rate recorded over 15 years.

Burnout is only part of the squeeze. Monthly pay is low, promotions are rare and male recruits, now needed to treat gender-sensitive ailments, are still few. District officers, who are supposed to supervise, are often preoccupied with fighting disease outbreaks or completing donor paperwork. When supplies do arrive, poor roads delay delivery; when equipment breaks, replacements can take months. A 2019 economic review found that cutting the assumed life span of certain tools from five years to three pushed the cost-effectiveness ratio for tetanus shots up 30pc, a warning that the program’s celebrated thrift is eroding.

Politics, once a tailwind, has become a drag with successive governments showcasing the program as evidence of progress. They turned it into a catch-all gatekeeper for every new campaign. The result is a jumble of projects — HIV counselling one month, Covid tracing the next — that land on the same overstretched staff. Many physicians and nurses in nearby facilities still “do not fully understand the scope of the HEP,” a Health Ministry memo noted. Extension workers rarely receive backup from higher-level professionals, while community volunteers in the "Health Development Army," mobilised in 2011 to rally households, have likewise lost steam.

Design lock-in —the reluctance to alter the original 16 health packages —lies at the heart of the problem. The standardised checklist leaves little space for local priorities such as mental health counselling or screening for chronic disease. Rapid urbanisation magnifies the gap. Cities swell, yet the urban version of the program remains an afterthought, with services tailored to villages rather than crowded neighbourhoods. Even digital fixes lag. The electronic Community Health Information System, meant to replace paper logs, reached only 39.3pc of pilot districts because many posts lack power or internet connections, and staff training is uneven.

Officials are aware. A 15-year roadmap for health extension program optimisation, launched in 2020, and the second Health Sector Transformation Plan call for broader training, stronger supply chains and digital upgrades. The blueprints envision adding male health workers, diversifying tasks to include the diagnosis of high blood pressure and diabetes, and setting up clear career ladders. Yet, the documents read more like wish lists unless the resources and management follow. The World Bank and World Health Organisation (WHO) pledge technical aid, but domestic political will is the decisive currency.

Reformers argue that flexibility should replace rigid scripts. They propose letting districts add or drop services according to local data, a shift that would let clinics in truck-clogged Addis Abeba test drivers for hypertension while remote highland posts still focus on clean water. Salaries should rise, and training should connect health workers to referral hospitals, advocates add, so that junior workers can envision a future beyond their first assignment.

Supply chains need predictable budgets and digital tracking to cut stockouts. Electricity and running water, absent in many posts, are prerequisites, not luxuries, for refrigerating vaccines and washing hands.

Cutting the political strings that tie every health initiative to the program may be harder. One remedy is stronger inter-sector work, encouraging ministries of Finance, Education and Agriculture to support clinics instead of funnelling every new activity through them. Empowering local councils to set budgets and measure results would ground priorities in community demand instead of top-down directives. For donors, channelling money toward shared infrastructure rather than headline-grabbing pilots could reduce the fragmentation that now overloads the system.

None of these steps will succeed without addressing morale. Career ladders that allow frontline workers to specialise, becoming skilled midwives, lab technicians, or health information officers, could curb exits and enrich the talent pool.

Ethiopia still has the opportunity to regain its reputation as an innovator in low-cost primary care. The building blocks — a vast network of health posts, a mostly trusted cadre of community workers and decades of lessons — remain in place. Modernising the curriculum, improving pay, wiring clinics to power and data, and trimming political interference would restore momentum. If the government and its partners move beyond praise and address these practical fixes, the health extension program can again serve as a model for countries seeking to reach the hardest-to-reach with basic, life-saving care.

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PUBLISHED ON Jul 05,2025 [ VOL 26 , NO 1314]

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