Faced with the rapid spread of the coronavirus pandemic, Ethiopia’s government decided it could not afford to follow the lead of Western countries by implementing huge economic stimulus and rescue plans.

Limited by diminishing revenues, with a per capita income of only $770, and, when the pandemic began, just 54 ventilators for coronavirus, the East African nation opted to focus on prevention through its system of community-based health workers.

Spearheading the fight to stop the highly infectious respiratory disease, Ethiopia’s 40,000 health extension workers, mostly women who receive one year of training and are formally part of the healthcare system, are a model for primary care that is sustainable in low-resource settings.

“For us, the health extension workers are key”

“The health extension programme is one of the backbones of the healthcare system in the country,” said Azeb Tesema, assistant professor of public health at Mekelle University in Ethiopia.

“You can find them everywhere – in every village. They are part of, and from, the community. They know the culture, they know the language, and these things have a great advantage. The community has a strong level of trust already.”

Launched in 2003, the programme has already proved hugely successful in reducing maternal mortality, as well as improving care for HIV infections, tuberculosis and malaria, and now provides a vital network into Ethiopia’s sprawling rural regions in the midst of coronavirus.

Officials claim to have already screened a remarkable 40 million people across 11 million households since the pandemic began, verifying travel history and conducting routine temperature checks in a rigorous regime.

But these community workers also play an important role by working with religious leaders to debunk harmful disinformation about coronavirus which can gain traction in a country where traditional beliefs govern many aspects of daily life.

It has had a startling impact. According to official data, the country of 110 million people, the second-most populous in Africa, has recorded just 2,506 cases of Covid-19 and 35 Covid-related deaths to date.

The fact that Ethiopia has largely avoided the brunt of the pandemic may also be due to the country’s relative isolation or its young population, with a median age of just 17.9 and more than 60% under the age of 25.

The prevention-based primary public healthcare infrastructure has proven to be effective and cost-efficient and it could provide a blueprint for others to follow

Other factors such as the government’s rapid initial response have also played a role. In January, it introduced strict screening protocols at Addis Ababa’s international airport, East Africa’s largest aviation hub. Diagnostic testing was scaled up from zero in early March to 5,000 per day by May and authorities quickly converted public universities into quarantine places for 50,000 people and 15,000 beds in isolation centres.

Public awareness campaigns, including daily briefings by the health minister and the use of mobile-phone ring tones to remind people of the importance of hygiene measures, have also been implemented.

Yet the role of community healthcare is seen as crucial. “For us, the health extension workers are key,” said Misrak Makonnen, country director of public health NGO, Amref Health Africa, which provides support and training to health extension workers. “Particularly in a country like Ethiopia, which has large populations in rural areas.”

In order to prepare these frontline workers, Amref has been working in conjunction with the Ministry of Health of Ethiopia to roll out a mobile phone-based learning course known as Leap, which combines interactive SMS and audio training with quizzes on how to support their communities in preventing and containing the virus.

Thousands of women have been trained to spread awareness about the disease, identify people with symptoms and to trace those who they may have had contact with. More than 2,700 extension workers have been enrolled in the weeks since Leap was launched in the Addis Ababa and Amhara regions, according to Makonnen.

The prevention-based primary public healthcare infrastructure has proven to be effective and cost-efficient and it could provide a blueprint for others to follow.

“It’s a great success, it’s an exemplary programme,” added Professor Tesema. “Each country has its own context and own approach, but I think health extension workers could be effective for other countries. This established system gives an opportunity and hope for countries across Africa and the rest of the world.”

Unlike the community health workers present in many other sub-Saharan Africa countries – which deal with a quarter of the world’s disease burden yet are home to only 3% of health workers, Ethiopia’s health extension workers are part of the formal health system – and paid. The efficacy of the system is said to rely on that funding.

“We believe that all community health workers should be paid, integrated into the civil service and have monthly salaries,” said Makonnen. “The expenditure has been worth it, as we have seen with the protection against Covid-19.” — Peter Yeung