Skilled and respected workers have revolutionized neighborhood healthcare in Ethiopia – using a model other countries could follow.

Health extension workers (HEWs) are the backbone of Ethiopia's health system. According to the World Health Organisation, Ethiopia has a health workforce crisis. With only 0.7 health workers per thousand people, scaling up primary healthcare is a matter of urgency. The need is greatest in poor, rural areas, where 85% of the country's population live and where accessing even basic services can be a challenge. Problems such as poor sanitation, communicable diseases and unplanned pregnancies are common. To compound the situation, less than 2% of rural Ethiopians own any form of transport and most have little or no formal education.

Ethiopia has 34,000 workers at the frontline of the government's health extension programme (HEP), which began in 2003. The are ideal ambassadors for the HEP's philosophy that good health begins at home, as they are recruited locally, and return to work in their communities following training. As well as providing information and treatment, HEWs mobilise communities for emergency funds, and initiate self-organised, sustainable strategies for environmental improvement, such as malaria prevention committees.

While the dedication of individual HEWs is vital, the wider transformation of healthcare provision in Ethiopia rests on visionary policymaking, backed up with support from donors, and strong partnerships with NGOs and the private sector.

In most African countries, the selection, training and employment of community health workers (CHWs) is relatively informal, and the system often relies on volunteers whose capacity is overstretched as separate NGOs attempt to train them in one programme after another. In Zambia, CHWs even found themselves completing anti-poaching training for the wildlife authorities.

In Ethiopia, by contrast, the ministry of health has implemented a formalised recruitment and training structure with a single curriculum, as well as joint review mechanisms enabling all the different partners to identify areas for improvement and reaffirm priorities. Zambia is now adopting the Ethiopian model by looking at what Ethiopia had done. Ethiopia had recruited people, trained them, given them a salary, and 10 years later, they're still doing the job that they had been trained and paid to do.

It has not all been plain sailing, however. The HEW system has arguably become a victim of its own success, as it struggles to meet the growing demands of communities that have become accustomed to improved services. And for some HEWs, the limited opportunities for career development can lead them to seek employment in the private sector, putting further pressure on their remaining colleagues.

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