A little girl in a shiny princess dress and matching glittering pumps stands at the gate leading to her home. Her princess attire looks out of place in the farm-like setting of her home in a rural village in the Oromia region of Ethiopia, about 40km outside Addis Ababa.
When she spots Fantaye Alemayehu and Sintayehu Worku walking towards her home, she turns around and runs towards the house at the end of the spacious yard. It had been raining that morning and the ground is still wet and muddy, making it even harder for the two-year-old to make her way.
Inside, the house is empty except for a bed at the one end, a bench and a small table. The walls are neatly decorated with blue-green at the bottom and white paint at the top.
The toddler’s mother, 20-year-old Brahini Mokonen, is sitting on the edge of the bed cradling an infant wrapped in a thick blanket on her lap. The room is dark and quiet except for the suckling noises coming from the 45-day-old baby Mokonen is breastfeeding.
Alemayehu pulls the bench from across the room and sits down in front of Mokonen.
"There is a wedding next door so they have borrowed all of our chairs," the young mother explains apologetically. She turns back to Alemayehu, who is asking her questions about her family’s health and making notes on the sheet on her lap.
Regular home visits Alemayehu and Worku are community-based healthcare workers – in Ethiopia, they’re referred to as health extension workers. According to a 2016 study in the journal PlosOne, more than 38 000 health extension workers operate across the country. Most are based in the rural parts of Ethiopia and they’re all recruited to serve in the communities where they live. Health extension workers undergo a year of training to treat infectious diseases such as malaria as well as provide family planning and maternal and newborn care.
Worku and Alemayehu are stationed at the Kusaye health post about 40km west of Addis Ababa. At the modest health facility they are able to administer vaccines or contraceptives and conduct check-ups on pregnant women. But they spend most of their time visiting their patients at home to show them how to prevent diseases such as diarrhoea.
"They taught me about cleaning my house, children and my environment. Now I wash my babies at least once or twice a week and I wash their clothes frequently. I also make sure their sleeping area is clean so that they don’t get sick," says Mokonen.
Alemayehu visits Mokonen often to make sure that she doesn’t miss vaccinations for her children.
"I like to teach the community about health. Because we are here people have better access to health and they don’t have to spend money to go to the hospital," says Alemayeh.
Some villages are so remote that it would take hours to walk to the nearest health facility.
Community health workers can help to address the severe shortages of nurses and doctors in developing countries. A 2010 World Health Organisation (WHO) review of community health worker programmes around the world found that community health workers provide an array of services ranging from helping with child birth, assisting with managing chronic illnesses and contributing to preventing infectious diseases such as malaria.
The review found that there was no uniformity in the way the different countries ran their community health programmes.
For example, a 2016 study published in the BMJ Global Health journal found that there is a general lack of consensus on the scope of practice for community health workers and that there is little policy support. Focusing on the role of community health workers in Ghana, the study calls for a national policy on community health workers, a professional body to regulate their standards and practice as well as a long-term plan to absorb community health workers into the formal health service in Ghana.
In Brazil, community health workers are community members who are paid to work in a healthcare team. The family health strategy teams are made up of a doctor, a nurse, a nursing assistant and between four and six community health agents, according to a 2015 article in the New England Journal of Medicine.
Numerous studies have shown that Brazil’s community health workers have been largely responsible for a two-thirds drop in mortality rates among children under five, from 58 per 1 000 live births in 1990 to 15.6 in 2011, according to United Nations Development Programme figures.
WHO recommends that the training of community health workers be formalised and that they be absorbed into existing health systems because research shows that "they can add significantly to the efforts of improving the health of the population".
Although community health workers cannot replace doctors or nurses, they do play an important role in linking villagers to medical care. In most countries, including Ethiopia, health extension workers are selected from the villages they serve.
"Their selection [is] managed by their district health office manager. The selection criteria includes speaking the local language, they must be 18 years or older and have at least a grade 10 level education," explains Abebech Araya from the Ethiopian ministry of health.
Once the health extension workers have been trained and they qualify, they become government employees who earn between $80 and $120 a month, depending on their education level, says Araya.
Since the health extension programme started in 2003, Araya says there has been a "significant reduction of maternal and child death" and a dramatic uptake of "hygiene and environmental health-related activities".
Help was a phone call awayNearly three years ago Daru Damosa woke up at the crack of dawn. She was nine months pregnant – and after giving birth three times previously she immediately recognised the labour pains.
She woke her husband up and he helped her walk the 500m to the health post at the top of the dirt road. The modest clinic was closed, but luckily Damosa and her husband were able to phone a health extension worker who lived nearby for help.
"When I received the phone call I immediately went to the health post and realised that she was in labour. I called an ambulance," says Worku.
The crude structure that makes up the health post has no running water so health extension workers are unable to deliver babies in this facility. Women from this village have to travel 8km to the Holeta health centre where they are able to give birth in a clinical setting.
But resources remain a problem. Although the health centre is only a 30-minute drive from Kusaye the ambulance only arrived at the health post at seven o’clock – three hours after Worku had made the call.
"By the time I arrived at the Holeta health centre it was too late. I was expecting twins but the other one died," says Damosa.
Sitting on one of the matching couches in the single room that doubles as a dining room and a bedroom, Damosa takes her two-and-a-half- year-old daughter’s hands.
"If Sintayehu [Worku] was not here I would have died with both my babies," she says quietly.
Making progressAlthough Ethiopia has one of the highest rates of maternal and child mortality in the world with 68 per 1000 children dying before their fifth birthday and 420 in 100 000 women dying during pregnancy, childbirth or shortly thereafter, research shows the situation is improving. According to a 2013 article in the journal PlosOne, the rate of children dying before their fifth birthday decreased from 166 per thousand live births in 2000 to 88 per 1000 live in 2011. The WHO estimates that, between 2005 and 2015, the number of maternal deaths dropped by half from 22 000 deaths to 11 000.
A 2012 BMC Health Services Research study found that health extension workers may have "brought essential maternal health care closer to the rural population in Ethiopia", but their success is limited. The introduction of the health extension programme has improved antenatal care, but a shortage of resources and cultural beliefs that support home births prevent health extension workers from assisting in the birthing process. According to the study, only 5% of women gave birth in a health facility.
With more than 90% of women giving birth at home, the health extension programme has adopted low-cost strategies to make home deliveries safer. These include cleaning one’s hands and the place of delivery as well as the umbilical cord, according to the 2013 PlosOne study.
Women who do go to a health facility to give birth face a gruelling journey. In some instances villagers have to carry pregnant women on a stretcher and walk the distance to the nearest health centre, says Worku.
Comprehensive careBut health extension workers’ duties go beyond maternal and child care. Worku spends a great deal of time teaching people about building pit latrines and general hygiene to prevent illness.
About 10 years ago Damosa, her husband and their children shared this one room with all their livestock.
"The children can get diarrhoea because the animals defecate in the house. People can also get tuberculosis from living in close proximity with animals," says Worku.
A rooster walks into the room and starts pecking at the ground under the dining room table.
"Everything used to be in this room. The kitchen, the cows, the goats, we were living together. But now that the health extension workers came and spoke to us things have changed. The kitchen is one side and we live here," says Damosa.
Have something to say? Tweet or Facebook us on @Bhekisisa_MG
The ups and downs of community healthcare
Community health workers "soldier on" for better health services
Health workers brace for an increased need for palliative care as waiting lists grow.
Have something to say? We can help you say it – but only if you promise to read this first.
In this township, alcohol makes violent men close to three times more likely to rape a woman.
Bhekisisa means "to scrutinise" in Zulu
In South Africa, Zulu patients who would like to be thoroughly assessed by a doctor, would ask the physician to "bhekisisa" them.