OPTION 1 Policy Brief; Problem Purpose Statement
Title: Exploring the use of mobile health clinics in rural Ethiopia to supplement the
national Health Extension Worker program
Organization: Ethiopian MOH
I. Problem and Purpose Statement
Problems recruiting providers to rural areas and resource allocation favoring urban
centers have resulted in historical inequalities in terms of access and quality of care
(Weinhold & Gurtner, 2014). In countries with a high percentage of the population
living in rural areas, these inequities can result in unmet demand for primary care
and screening services (Stillman & Strong, 2008) and higher levels of morbidity and
mortality (Negusse, McAuliffe, & MacLachlan, 2007).
With 82% of the population living in rural areas, Ethiopia faces challenges in rural
health care access and quality. In recent years, the country has made sustained
efforts to improve the coverage and quality of primary care in rural areas, including
implementing the Health Extension Plan (HEP) in 2003. The HEP is designed to
provide universal primary care coverage and address maternal and child health,
family planning, immunization, nutrition, reproductive health, WASH (water,
sanitation and hygiene) and health education (Karim et al., 2010).
The HEP is staffed by 38,000 community health workers called Health
Extension Workers (HEW) who are primarily female and have completed a 10th
grade education. HEWs participate in a year of training before being placed in
service in rural communities (Medhanyie et al., 2012; USAID, 2014). The structure of
the HEP includes a health center staffed by nurses, midwives, and health officers
which then oversees five health outposts at the kebele or community level, each of
which is staffed by two HEWs (Karim & Betemariam, 2012). The health center and
health outposts serve a catchment area of 25,000 people and 5,000 people
respectively (USAID, 2014). HEWs split their time between making home visits and
staffing the health outpost (Karim & Betemariam, 2012).
The HEP has resulted in improvements in the contraceptive prevalence rate,
immunization rate, and antenatal care coverage since its inception, and the number
of households located more than one hours distance from a health facility has
decreased from 22% in 2008 to 9% in 2010 (Karim & Betemariam, 2012). However,
the HEP program still faces challenges in terms of community utilization of health
outposts; women do not regularly visit the health outposts staffed by HEW for
maternal care and instead travel to health centers, staffed with clinicians, which are
farther away (Medhanyie et al., 2012). As previously mentioned, 9% of communities
are still over an hour from a facility. Additional research has shown that HEW do not
visit homes as often as recommended (Negusse et al., 2007), and only 41% of
households located over an hour from a facility were visited by a HEW in the last 6
months (Karim & Betemariam, 2012).
Mobile health clinics may be an effective method of addressing the remaining
barriers to access in rural areas of Ethiopia. Mobile clinics have the potential to
bring clinicians and HEWs to the most isolated communities, and provide high
quality supplies and clinical care at the health outposts. This policy brief will explore
the potential of mobile health clinics as a method of supporting the HEP and
increasing access and utilization in rural areas. As Ethiopia continues to work
towards its goal of universal primary care, it may need to explore several methods
of health care delivery to ensure that demand is met in rural areas.
Sources
Karim, A. M., & Betemariam, W. (2012). Equity of Maternal, Newborn, and Child
health Services in Rural Ethiopia (pp. 1–30). Addis Ababa, Ethiopia. Retrieved
from
http://l10k.jsi.com/Resources/Docs/Equity_of_MNCH_Services_in_Rural_Ethio
pia.pdf
Karim, A. M., Betemariam, W., Yalew, S., Alemu, H., Carnell, M., & Mekonnen, Y.
(2010). Programmatic correlates of maternal healthcare seeking behaviors in
Ethiopia, 24(Special Issue 1), 8.
Medhanyie, A., Spigt, M., Kifle, Y., Schaay, N., Sanders, D., Blanco, R., … Berhane, Y.
(2012). The role of health extension workers in improving utilization of
maternal health services in rural areas in Ethiopia: a cross sectional study. BMC
Health Services Research, 12(1), 352. doi:10.1186/1472-6963-12-352
Negusse, H., McAuliffe, E., & MacLachlan, M. (2007). Initial community perspectives
on the Health Service Extension Programme in Welkait, Ethiopia. Human
Resources for Health, 5, 21. doi:10.1186/1478-4491-5-21
Stillman, P. C., & Strong, P. C. (2008). Pre-triage procedures in mobile rural health
clinics in Ethiopia. Rural and Remote Health, 8(3), 955. Retrieved from
http://www.ncbi.nlm.nih.gov/pubmed/18707198
USAID. (2014). All Eyes on Ethiopia’s National Health Extension Program. Retrieved
September 07, 2014, from http://www.usaid.gov/results-data/successstories/all-eyes-ethiopia%E2%80%99s-national-health-extension-program-0
Weinhold, I., & Gurtner, S. (2014). Understanding Shortages of Sufficient Health Care
in Rural Areas. Health Policy. doi:10.1016/j.healthpol.2014.07.018
II. Working Outline:
Introduction
- Discussion of rural health disparities; both health outcomes and services
provided
- Discussion of value of primary care and need for equitable access for all
people
Current Situation
Ethiopian healthcare system
- Structure of HEP and physical structures
- Addition of HEW and corresponding effects on primary care usage and
quality indicators
o Ratio of healthcare providers to population
o Attended delivery and facility delivery rates
o Number of ANC visits attended
o Source of care for last childhood illness
- Review of HEW health outcome successes and gaps
o The gaps will identify the most logical additional method of health
care delivery
Potential solutions
Telemedicine
- Not an option because Ethiopia’s current infrastructure cannot support
telemedicine (only 5% of rural households have electricity – DHS)
Building high quality physical facilities
- Is in process; will take time; currently is low utilization and a preference for
higher quality primary care clinics.
Mobile health units
- Could supplement the HEP by increasing access to the most rural populations
while the HEW program expands and strengthens its physical facilities
- Can be converted from primary care to screening and specialized treatment
when HEW health posts are finished
- Will allow for equitable access to healthcare (a main goal of the GOE) while
the HEP scales
- Discussion of cost effectiveness of mobile health units compared with
physical facilities
- Discussion of the types of services that are best provided from a mobile
health unit (periodic, limited ability to perform complex diagnostics and
treatment)
(NOTE: If most of the gaps in the current HEW program center around maternal
health disparities, I may add mother shelters as another structure that could
supplement the HEW system)
Discussion and recommendations
- Focus on the feasibility of implementation, upkeep, and staffing of mobile
health units
- (Possibly address implementation challenges of maternal shelters)
-
Discuss how the current HEP structure allows for community identification
of health needs, and how the choice of mobile unit or mother shelter could be
brought to the target communities
Conclusion
- General praise for the progress made thus far
- Reassert the need to fully develop the health care delivery system to
equitably serve the rural population
III. Work Plan for Submitting Drafts:
In order to complete the GH Culminating Experience in fall 2014, I will submit drafts
on or before the following dates:
PPS & CE Contract: Sept. 12
Draft 1: October 10
Draft 2: November 7
Draft 3: December 5
Final Draft: December 19
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