Helping health workers save Ethiopia’s youngest children

By Demissew Bizuwerk

Kejelo, Tiro AFETA, Oromia, 14 June 2018: Inside the small room of Kejelo health post, health extension worker Amelework Getachew carefully monitors her stock of medicines stacked on a small wooden shelf. She checks to make sure that an Oral Rehydration Salt (ORS), a fluid replacement used to prevent and treat diarrhoea, Amoxicillin Dispersible Tablet and Gentamicin injection, antibiotics used to treat children with pneumonia and serious bacterial infections, are available in good quantity. She cross checks the numbers on each bin card and the actual quantities on the shelf. “I can’t afford to run out of these medicines,” says Amelework, pointing towards a stock of sachets of ORS and packs of amoxicillin tablets and gentamicin injections. “They are lifesaving.”

After Amelework is done taking inventory, she collects her essential job-aids for home visits and attends to five-month-old Aziza in her home as part of her routine house-to-house visit. This way, Amelework makes sure that pregnant women and newborn babies get health follow-ups.

When Aziza was only 45 days old, she suffered from pneumonia, the common killer of infants in Ethiopia. “I was so worried when my child was sick,” says Rawda, Aziza’s mother. “She was struggling to breathe and had it not been for ‘doctor’, my child would not have survived.”

“I was so worried when my child was sick. She was struggling to breathe

Amelework, whose name also means “a golden character,” is a committed health worker. Her nine-year journey as a health extension worker started in a remote village of Kereyu Dodo when she was given the daunting task of changing people’s attitudes on a range of health-related misconceptions.  It wasn’t easy for her to convince people to dig toilets or use bed nets to keep them safe from malaria. “They used to call us names like the ‘toilet controllers’ or ‘bed net checkers,” she remembers.

CNBC Jimma, Oromia
Amelework examines five months old Aziza. When Aziza was 45 days old, she suffered from Pneumonia. But now she is growing up healthy. ©UNICEF Ethiopia/2018/Demissew Bizuwerk

But Amelework is now dubbed ‘doctor’, a name bestowed to her out of love and respect by the village women.  She is key to the livelihoods of the community, saving mothers and newborns including little Aziza in the small village of Kejelo.

Although Ethiopia has managed to significantly reduce its under-five child mortality, newborn deaths have declined at a much slower pace.  Twenty-nine newborn babies die out of every 1,000 live births from preventable causes such as complications due to prematurity, birth asphyxia, and infections like sepsis, and pneumonia[1]. Newborn deaths also account for a greater and growing share of all deaths among children under 5; almost 44 per cent.

Supported by UNICEF, the Government of Ethiopia introduced the Community Based Newborn Care (CBNC) strategy in 2012. CBNC aims to empower health extension workers, such as Amelework, with skills to provide maternal and child health services during pregnancy, childbirth and postnatally. Heath extension workers are also trained to identify and treat newborns with severe bacterial infections or sepsis where referral is not possible. They provide treatment for sick children both at the health post and in houses during their regular visits.

“The treatment we are providing is free of charge,” says Amelework. “This is encouraging mothers to bring their children early when they are sick.  It is also helping us to save young children from serious illnesses like pneumonia.”

Amelework is trained to provide CBNC services by JSI Research & Training Institute, Inc/ The Last Ten Kilometers Project (JSI/L10K), which is implementing the programme with technical and financial support from UNICEF.  She also gets constant support and follow-up from the CBNC supervision team who regularly visit her health post to make sure that she is applying the standard operating procedures.

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Wosen Darge, the CBNC Regional Technical Officer from JSI/L10K supports Amelework with regular visits to her health post. ©UNICEF Ethiopia/2018/Demissew Bizuwerk

“We train and support Amelework to deliver her very important work by effectively identifying sick children in the village during her regular immunization outreach work and when she is providing house-to-house postnatal care,” says Wosen Darge, the CBNC Regional Technical Officer from JSI/L10K.  “We also monitor and evaluate her records to ensure key information is recorded and stored in the treatment book.”

Amelework is also provided with guidance and support on supply management. She keeps track of her medical supplies to avoid shortages of crical drugs that she needs for immediate use.

“Nothing is more fulfilling than seeing a mother’s happy face when her child is recovering from such illnesses”

UNICEF is supporting the scaling up of CBNC services with funds from the Margaret A. Cargill Foundation. Working in coordination with the Ministry of Health, it is expected that the positive experiences observed in villages like Kejelo will be expanded to pastoralist areas.

CNBC Jimma, Oromia
Amelework is the indispensable medical person for Kejelo village mothers and children. She is dubbed ‘doctor’ by the local women for saving their children. ©UNICEF Ethiopia/2018/Demissew Bizuwerk

A humble hard worker such as Amelework embodies Ethiopia’s hope to end preventable newborn and child deaths within this generation. “Nothing is more fulfilling than seeing a mother’s happy face when her child is recovering from such illnesses,” she says, “I am a mother myself and I know the feeling.”

Aziza is growing up healthy, her mother’s wish is to see her daughter becoming a ‘doctor’, like Amelework. “She [Amelework] saved my child’s life and I want my daughter to also do the same when she grows up,” says Rawda, with eyes full of hope to see a bright future for her baby daughter.

[1] EDHS 2016

Leadership matters: The case of community led total sanitation and hygiene

By Araya Mengistu


Ethiopia is a country showing strong progress in achieving global and national goals for WASH services. It has achieved the MDG target 7c for water supply. Although still behind for sanitation targets, considerable progress is made. As of 2012, 37 per cent of communities practiced open defecation, as compared to 92 per cent in 1990[1]

The progress on sanitation is mainly achieved through the national Health Extension Programme (HEP) and the community led total sanitation and hygiene (CLTSH) approach. CLTSH is an approach that helps to mainly rural communities to understand undesirable effects of poor sanitation, and through a process of “triggering” – igniting a change in behaviour – achieve sustained behaviour change leading to spontaneous and long term abandonment of Open Defecation (OD) practices. Since its introduction in 2006/7, CLTSH has remained the only instrument in Ethiopia to induce behaviour change of communities to consider construction of latrines and use them – discouraging the practice of open defecation. Although the achievements in the past decade are significant, the success of the approach varied significantly from place to place.

For example, the Oromia regional state, the largest in the country, consists 265 rural and 39 urban districts or woredas. Out of 6,531 kebeles (sub-districts each with an average population of 5,000) in rural areas, about 16 per cent are open-defecation free (ODF) – meaning no-one, including visitors and passing pedestrians, are openly defecating and all have access to basic latrines with handwashing facilities.

UNICEF supports 24 woredas in Oromia state between 2011 and 2015. Of the supported woredas, 24 per cent (116 of 477 kebeles) have achieved ODF status. Compared to regional average of 16 per cent, this is a huge achievement. Sire, one of the supported woredas, has recently been graduated in 2015 with 100 per cent performance, declaring all 18 rural kebeles ODF. Other woredas are at various stages. 11 woredas are between 20-50 per cent progresses, while the rest 12 woredas are of 0-10 per cent progress. Compared to these, Sire Woreda shows an outstanding performance.

Such exceptional achievement requires successfully overcoming a number of challenges. A key challenge is lack of thorough understanding of the steps involved in CLTSH and their importance. Usually CLTSH is about training facilitators and triggering communities. However, many practitioners agree that this is the easiest part. Rendering adequate supervision after the triggering stage and providing support that is necessary to sustain the momentum is the difficult part. Other challenges include diffusion of information to neighbouring communities that make the approach ineffective, lack of trainers with actual field experience, high staff turnover, poor coordination among stakeholders, weak commitment of staff and trained people and application of CLTSH without adequate or proper organisation and preparation.

Growing over all these challenges and as a result of four years of effort, Sire Woreda celebrated 100 per cent ODF achievement in April 2015, with all rural villages and kebeles free from open defecation.

Even though, some of these kebeles were declared ODF two or more years ago, , they continued to sustain their status despite the usual trend of falling-back to OD practice noticed as time elapses. This demonstrates an effective post-triggering activity by the Woreda that effectively complimented the planning and triggering activity.

How was this achieved? The Woreda administration leveraged existing structures to sensitize the leadership ladder down to village level on CLTSH and built it in to the regular reporting and evaluation process. This has helped to mobilize the largest possible support to the effort of Health Extension Workers (HEWs) and CLTSH facilitators, including teachers and students under the guidance and support of the Woreda Health Office. It has also avoided diversions of focus (including manpower, logistics, and resources) as CLTSH has become an official woreda priority.

Two notable practices can be praised in the woreda for this success.  (a) the technique of triggering one full kebele at a time in contrast to the usual practice of village by village, and (b) use of different post-triggering follow-up technique suited to context. The advantage of the first technique was twofold. It helped to avoid diffusion of information in to neighbouring communities. Since, focusing in one kebele at a time required more trained people, the coordinators called upon trained and experienced facilitators from adjacent woredas to support, which worked really well. On the other hand, the woreda experts consciously applied different post-triggering follow-up methods. In highland areas, they applied the ‘flag system’, where by communities themselves awarded white flags to households who have constructed basic latrines, and red flags to those who did not. In low land areas, students were organized to alert the community when they see any one defecating in the open, who will then ensure the person buries the excreta.

Currently, the Woreda continues to strengthen the community platforms for monitoring progress and pro-actively works with local leaders to provide the necessary guidance and technical support to sustain the achievement. As a result of this, they are expecting at least two kebeles to achieve secondary ODF, which includes upgrading of basic latrines to improved latrines (with washable slab, vent pipe, hole-cover) with hand washing facility by the whole community. The commitment of leaders, and subsequent effective coordination in the Woreda has benefited the wider community to keep children, women and the society at large healthy.

[1] Joint Monitoring Programme 2014.