Asmera Getachew had completed a teacher training course when she saw an advert inviting applications from those interested in joining the government Health Service Extension Programme (HSEP).

The advert, which was posted on a wall, changed her life. After a one-year training course, she was assigned to Tensyie, a rural village of 5,092 people in North Gonder Zone of Amhara Regional State, to work as a health extension worker.

One of 2,800 graduates from 14 HSEP training centres in Ethiopia, Asmera's new duty station was not far from her birthplace in Dabat, in the same zone, and she quickly settled in to implement a three month plan focusing on health education, environmental health, family health and disease prevention.

"The people asked us why we were not treating them and bringing medication," she told IRIN, referring to questions about disease prevention. "They did not believe in the prevention approach."

The HSEP, a component of a strategy to institutionalise village health service delivery, targets 15,000 'kebeles' throughout the country by assigning two health extension workers to each.

So far, 15,527 workers have been appointed in 10 regional states and 7,268 more are in training. Upon graduation, officials say, they will enable the Ethiopian government to cover 82 percent of the programme requirement.

Prevention better than cure
Disease prevention and control has been advocated in Ethiopia since the introduction of the first health policies in the 1950s. But the current health policy, enacted in 1993, lays emphasis on prevention rather than treatment, although rural people still give priority to treatment.

The Health Ministry estimates that 60-80 percent of the country's health problems are due to potentially preventable communicable diseases.
"What differentiates this programme from customary health services is that the former are [implemented] at family level," Shiferaw Teklemariam, the state minister for health said. "The main working place of health extension workers is within the family."

Data at the ministry show that the leading causes of mortality in the country are malaria, HIV/AIDS, tuberculosis, diarrhoea, acute respiratory infections and nutritional deficiencies. The spread of these diseases are attributed to the poor socio-economic conditions in Ethiopia, including widespread poverty, poor sanitary living conditions, nutritional deficiency, low levels of health awareness and inadequate health care delivery.

With 85 percent of the population living in rural areas, the Health Ministry hopes that the HSEP approach will bring health services closer to the population at family level.

Maternal mortality
One important aspect of the HSEP, Shiferaw said, was its links to family health service delivery where it focuses on the survival of mothers and children - especially given that Ethiopia has one of the highest maternal and children mortality rates in the world.

According to the 2005 Demographic and Health Survey 2005, maternal mortality rate stood at 673 deaths per 100,000 live births. Another Health Ministry statistic showed that 472,000 children died per year before celebrating their fifth birthday.
The link has, however, created misgivings, said Teshiwork Moges, a health extension worker in Fekreselam District, Wagena Hemra zone of Amhara region.

"Men thought that the programme was all about mothers and children," said Yeshiwork. "They asked us why the programme excludes them."

Asmera said dispelling such misconceptions was more challenging than walking kilometres and moving from one house to the other.

Success story
Asmera and 36 other extension workers have been recognized by the government as the best performers in the HSEP programme this year. Her success brought her to Awassa, about 1,000km from Dabat to receive a present on the first national Health Extension Day held on 25-26 May.

Officials used the occasion for awareness-raising on latrine use, family planning and breastfeeding

When Asmera first came to Tensyie, they said, there were no latrines. Two years later, she had managed to convince all 785 households to construct their own latrines.

She also improved family planning coverage from 3 to 25 percent. Her efforts to change the thinking of mothers to ensure breastfeeding in the first six months after birth, led to a 72 percent growth in such behaviour in two years.

Like Asmera, another success story was Tsige Gebreselassie, a health extension worker from Woreileke District in the central zone of Tigray region.
Her achievements in encouraging family planning were even more satisfying given that she was a mother of a two-month-old son. Following her work, the number of family planning users in Woreilke rose from 51 to 110 in two years.

"Such results contributed a lot to improvements registered in the last four years," Shiferaw said, adding that HSEP had helped increase national vaccination coverage from 51.5 to 75.6 percent between 2002and 2006.

It had also doubled latrine coverage from 25 percent in 2002. "Family planning users have increased from 14 to 35.8 percent in the last four years," he said.