Socio-demographic characteristics of the study participants
The total number of 62 individuals participated in the study. The majority of participants were married females with age ranging from 31-40 years. Also, the majority of them have working experience of four years and above. The socio-demographic characteristics of the participants were described as follows in table 1.
Table 1: Socio-demographic characteristic of participants who take part in the study, Addis Ababa, 2017
R. No
|
Participants characteristics
|
Number
|
1
|
Sex
|
Male
|
|
Female
|
|
2
|
Age
|
18-30
|
11
|
31-40
|
42
|
41 and above
|
8
|
3
|
Marital status
|
Single
|
20
|
Married
|
38
|
Divorced
|
2
|
Widowed
|
1
|
4
|
Educational status
|
Primary
|
9
|
Secondary School
|
16
|
Senior Secondary School
|
13
|
College Certificate/Diploma
|
10
|
University Student
|
13
|
5
|
Work Experience
|
6 months – 2 years
|
4
|
2 – 3 years
|
3
|
3 – 4 years
|
3
|
4 years and above
|
11
|
The findings of this study were organized under three major themes: The Urban Health Extension Packages being on implementation and program fidelity, Strategies used to facilitate the implementation of the Urban Health Extension Program, and the challenges for the successful implementation of UHEP. All these themes were described as follows.
The Urban Health Extension Packages on implementation and program fidelity
Across the interviews and group discussions, participants mentioned that Urban Health Extension Program was launched by the Federal Ministry of Health in Addis Ababa around July 2008 and its implementation was started practically in September 2009. They indicated a total of 15 essential health care packages under four major program areas provided for the community members under this Program.
Table 2: Health Service Packages provided through Urban Health Extension Program in Addis Ababa, 2018
Major program areas
|
Essential services provided under each major areas
|
Hygiene and environmental sanitation
|
(1) Solid and liquid waste disposal
(2) Personal hygiene and healthy home environment
(3) Food and water safety
(4) Latrine construction and utilization
|
Disease prevention and control
|
(1) Malaria
(2) TB and leprosy
(3) HIV and AIDS
(4) Non-communicable disease
(5) Mental illness
|
Family health services
|
(1) Maternal and child health,
(2) family planning,
(3) immunization,
(4) Youth and adolescent health, and
(5) Nutrition.
|
Injury prevention and control, first aid, and referral services
|
“We provide all the fifteen packages of the health extension program focusing on our household need. For example, if household needs focused training in family health services, we provide intense training on that.” (HEPs, INI)
Health Extension Professionals also indicated that the community member’s knowledge and behavior towards the prevention of both communicable and non-communicable diseases are improved. Participants from the community members also, in turn, mentioned that they have obtained important information on disease prevention.
“The health extension professionals teach us how to keep our hygiene and our children’s health”. (WIC, INI)
Regarding family health, in all of the Districts, it was mentioned that Urban Health Extension Professionals provide regular family planning services and promote maternal and child health care services utilization.
“All pregnant women in our community have a follow-up at health centers. After delivery, our children get vaccination on time. The health extension professional teaches us regularly about family planning and the importance of vaccination.” (WIC, INI)
It was also mentioned that the program helps households to have handwashing facility in nearby the latrines, to prepare separate liquid waste disposal pits, to have clean cooking practices, to keep drinking water free from contamination, and to keep environmental cleanness. On the other hand, they mentioned that at some districts there was no first aid and emergency package training provided to community members due to lack of equipment, knowledge or skill.
“We didn’t provide first aid and emergency training regularly due to lack of materials and equipment.” (HEPs, INI)]
Strategies used to facilitate the implementation of Urban Health Extension Program
Training
Study participants mentioned that the Urban Health Extension Professionals are nurses, additionally, who took three-month training on health extension packages. But, there were health extension professionals who did not take this basic training instead conduct their activities referring to the manuals, and integrating with and consulting of those trained Health Extension professionals. Apart from these basic three-month basic training, they also mentioned that short term training was provided for them from different stakeholders.
Home Visitation
Home visitation is also mentioned by Health extension professionals as one strategy to implement the UHEP. It was mentioned one UHE professional is assigned to 500 or more households and each HEP expected to reach at least 15 – 20 households every day to visit all households weekly. But, they indicated that this plan would be affected by other competing programs and expectations from the District Health Office.
“We may plan to accomplish certain activities, but, from the district health office, we would be told to do other things.” (HEPs, INI)
Creating model households
A model household in the context of this study refers to the family that implemented all the health extension packages after taking training from HEPs with their support and close supervision. Therefore, the study participants mentioned that transferring health knowledge and skill is being done to household members to create ‘model households’ and build their capacity to use them as a strategy to improve the accessibility and quality of the health extension program utilization.
“Most of our district community members are graduated as a model family and we use them as a strategy for delivering health extension packages to the community members.” (SUP, KII)
Strengthening the Health Development Army
Study participants mentioned strengthening the Health Developmental Armies is used as a strategy for improving the implementation of the UHEP. This is because if they are strong enough and become functional, they play a great role in facilitating the service utilization, developing health care service utilization behavior, mobilizing the communities for health activities to influence their communities, monitoring the implementation, being role models for others; identify problems, gather and analyze the data, propose solutions, and share best experiences among the network members as well as with others.
“We have a coffee ceremony every two weeks and discuss our community issues, propose solutions and revise selected packages together with the health extension professional. We also have a saving account that will help us to solve our neighborhood problem.” (HDA-L, INI)
It was also mentioned that HDA support HEPs in the identification and referral of pregnant women, conducting postnatal care follow-up, mobilization of communities for immunization campaigns and health education in the community. Despite positive contributions by the HDA, the structure was inactive in some districts.
“We teach the women in our community. We, the leaders of the Health Developmental Army, give our advice to convince pregnant mothers to have a follow-up, organizing sanitation campaign, arranging the coffee ceremony and discuss of the leaflets the HEPs provide” (HDA-L, INI)
Monitoring and supervision
Health workers who participated in this study mentioned that HEP sits at either the HC or at the District Health Office; up to 16 HEPs placed in each HC catchment. One supervisor is assigned to conduct regular supervision for 8–12 HEPs. There are around 200 supervisors found in the city. HEPs compile daily work and report weekly to the supervisors. The supervisors report monthly HEPs work to disease prevention and control core processor focal person. However, HEPs mentioned no clear cut is there on who directly monitors or follows them due to the overloading of tasks from different sectors.
“Sometimes it is not clear who is our immediate supervisor. Different sectors give us extra work without considering our main responsibility. For example, the District Health office, the health center, Women and child affairs, District small enterprises and the sub-city health officials involved in assigning an additional task for us. Even though, working with different sectors is useful; there is no clear framework on how to work.” (SUP, KII)
Besides, HEPs indicated that supervision meetings were not conducted regularly even if it was mentioned as they are satisfied with the supervision obtained from supervisors or the district health office. They also mentioned that there supervisors having a fault-finding attitude who lacks supportive and problem-solving approaches.
Referral & Feedback
Health extension professionals mentioned that cases are referred to the health center after filling the referral form when the condition needs further medical attention.
“We refer community members who need further check-up and treatment to the health center. We have a referral form to do that.” (HEPs, INI)
They also mentioned that even though the referral is done, the feedback given to the HEPs varies from facility to facility and there is improper handling of referral forms in the health centers.
“Most of the time, we receive feedback from the health center. But, sometimes the referral forms and/or feedback papers might be lost either in the health center or by the referred patient.” (SUP, KII)
In some cases, the HEPs collect feedback from the boxes at the health center; in other cases, the client returns the slip, and yet in other sites, the supervisor is charged with managing the collection of the referral feedback.
Community mobilization
Across the interviews, all HEP and supervisors mentioned that they agreed upon the necessity of community participation, and they conduct community mobilization in their day to day activity to empower the community for facilitating service utilization.
“There is a coffee ceremony program and sanitation campaigns. Also, the women’s development army leaders conduct community mobilization to facilitate utilization of vaccination, family planning methods, and the like.” (WIC, INI)
Challenges for successful implementation of UHEP
Health Extension Professionals and supervisors related challenges
Health extension professionals and supervisors were mentioned that HEP is the focal point of health programming, and so increasingly, different partners are executing their programs through HEP; creating heavier workloads for HEPs that affect the implementation of HEPs.
“The workload is too difficult, and no one understands that…When you ask your right, you are not granted, even if you fulfill your duties. For instance, we work in emergencies, be it immunization or epidemics like Acute Watery Diarrhea, but the right of the health extension is not respected like other health professionals.” (HEPs, INI)
It was mentioned that there is observed HEPs burn out due to an unclear career path, including lack of continuing education, and both financial and non-financial incentive mechanisms that posed a major challenge for the Program. The selection process of official training provided for upgrading was not clear, or the promotion after attending the training or upgrading is not guaranteed which resulted in disappointment among HEPs.
“Our salary and benefits are far from attractive in addition to the problem of education/training opportunities. For example, a diploma holder should have the opportunity to advance their qualification to degree level.” (HEPs, INI)
“The HEPs who are also nurses by profession is getting the same salary as those who are working in the health center, and compared to HEPs workload, HEPs need to be paid more.” (SUP, KII)
In addition to the dissatisfaction in their salary, it was mentioned that there is a lack of basic needs for work like; umbrella, gown, towel, scissors, office and the likes make their job very difficult together with lack of practicable career structure and training scheme.
Nevertheless, HEPs has experienced additional challenges. They mentioned that model households did not graduate as per the plan. Also, the use of voluntary HDA leaders appears hard to sustain without some material compensation for extra services rendered to communities.
“It is expected for a model family to be graduated within four months. But, this is not happening currently because the training depends on their schedule, not on our action plan.” (HEPs, INI)
“There is no support we receive from the District or the health center. I am doing this voluntarily because I would like to see my community changed. It will be great if we receive recognition either from the District or the Health center but this is not happening right now.” (HDAL, INI)
Mobility, a feature of an urban lifestyle, has been challenged HEPs to identify and to provide health services to certain target population on a consistent and continual manner. This is because they mentioned that the target populations’ move from place to place across towns or in the same town. The mobility affects the continuity of services being provided to the clients and this will continue to be a major challenge.
“The working behavior of our community members makes the home visitation and training very hard. Therefore our work depends upon their working schedule” (HEPs, INI)
Supply chain management related challenges
The health extension professionals mentioned that no logistics system is there that supports requesting, tracking, and refilling of supplies and consumables. Due to this problem, there were challenges they have faced for predicting the supply and to refill the orders of medical and non-medical supplies and equipment due to the shortage of budget.
“We have requested several times even the basic ones like an umbrella, Gown, tissue paper, soap but they respond shortage of budget as a problem to refill these issues. For example, for Vitamin-A supplementation, we need a towel and a scissor, but we bought for ourselves from our pocket” (HEPs, INI)
Multisectoral collaboration related challenges
Study participants mentioned that there is a need to collaborate with different sectors to accomplish their activities. Even if this is in need, there is a poor multi-sectorial collaboration resulting in diminished work results of health extension professionals.
“There are needs from the community that we alone couldn’t solve. For example, some households do not have latrines, some of them had a solid waste collection or a sewerage line problem. Therefore unless we work with other governmental and non-governmental sectors it is difficult for us to solve these problems.” (HEPs, INI)
Community-related challenges
It was also mentioned that the community members have an economic problem to be practical as per the support they obtained from health extension professionals. They raised that most of the community problems need action that involves different private and public stakeholders since these problems are not only solved with local community members' economies.
“The HEPs educate us to have latrines, constructing sewerage lines and environmental hygiene. But, there is no space and money for latrine construction. We barely fulfill our daily basic needs. We need support from the government and private companies.” (WIC, INI)
Deployment: Recruitment and Training related challenges
The HEPs have an identity as clinical nurses because of their initial three-year training. They are drawn from the ranks of clinical nurse graduates of private colleges who did not have employment after graduation, unlike nurses trained in public colleges. The pre-service training of three months was to foster their public health skills and prepare them to work at the household level on health prevention and promotion. Therefore, these professionals do not believe the training neither makes them public health practitioners nor fully competent to be UHE-Ps. Also, they mentioned that there is a shortage of trained or qualified personnel with the appropriate skills to manage, support, and coach the HEPs and continued turnover of staff at various levels also presented as the challenges of UHEP implementation.
Household allocation related challenges
The health extension professionals and supervisors mentioned that the Federal Government assigned one UHEP per 500 households, and used this as a recruiting target. But, they are a problem with these issues because some Districts assigned one UHEP for more than 600 households. Due to this problem, it was mentioned that HEPs can not complete their supervision provided for households timely challenging the successful implementation of UHEP.
“Generally one HEPs is assigned to 500 households but this is not true in our District; each HEP is assigned for more than 600 households. That means we expect each HEPs to visit 15-20 households per day. It takes around two months for each HEP to home to home visit for all 600 households” (SUP, KII)
Logistical Support and Motivation related challenges
The health extension professional mentioned that reaching 500 households, or more in sub-cities seems to be considered small enough to facilitate easy access. However, it was indicated that the catchment areas are too big to manage productively which, in turn, resulted in a negative impact on the implementation of UHEP. During interviews, many HEPs said they spend an average of 10 Ethiopian Birr, which are not reimbursed, for traveling to and from the furthest points within their catchment area. Otherwise, they walk for more than 40 minutes between clients, on average to complete a daily action plan. Many women said they had worn out their shoes in trying to keep up with all their households. Not including the weather condition.
“We travel long distances to complete our catchment area. During day time, the sun is unbearable and don’t even mention about the rainy season. As you know the transportation problem in Addis Ababa is increasing from day to day. I pay more than 10 birrs per day while visiting clients from my pocket. They provide us monthly 343 birrs for transportation and phone bills as a benefit which is not enough” (HEPs, INI)
Service Delivery: Practices and Packages related challenges
Emphasis to date has been on health education and referrals but demand by clients has influenced the HEPs and they mentioned that, currently, they provide simple curative and “biomedical” preventive interventions, such as implants. HEPs also mentioned that they provide immunizations, and counseling and testing services through outreach in the community, schools, and youth centers. Although the program mandated that all three venues were of equal importance, to date, the HEPs has directed the majority of their services just to the household.
One consistent issue that was raised is that either through their interest or perhaps because of client demand, the HEPs are not implementing the full set of 15 packages as originally envisioned. It appears that there is no clear guidance provided to UHE-Ps on which package of services they should provide at the household and outreach levels; this contributes to an inconsistency of services and lack of uniformity in the type of services HEPs provide.
“We are not providing all the 15 packages of the program to each household because most of them do not need all the packages. Therefore, we provide them based on their need and problem” (HEPs, INI)