The potential role of Ethiopian community health extension workers in COVID-19 prevention and control

Date of Publication: March 28, 2020

As of March 27, 2020, the WHO Africa region has reported 2,234 confirmed cases and 39 deaths due to COVID-19, with a steep increase in numbers seen in the last week. Though the numbers are still small compared to other countries, the WHO General Director, Dr. Tedros Adhanom Gebreyesus has cautioned his continent to prepare for the worst. Considering most countries in sub-Saharan Africa have fragile and resource constrained health systems, measures should be context specific and focus on the prevention, and containment of the spread of the virus.  

Ethiopia had its first confirmed case of COVID-19 on March 13, 2020. By the 27th of March, the count had risen to sixteen. In light of this, the government is aggressively taking measures in containment, travel restrictions, shutting down all education institutions, limiting mass gatherings and contact tracing. This early response is not entirely comprehensive and not equally in effect in all geographic areas (eg. Tigray region imposes State of emergency for COVID-19 but not in other). Furthermore, the health system is not prepared and resilient to contain the threat and its effect. Unless appropriate measures to prevent widespread community transmission are in place, the health system will be overwhelmed due to the shortage of resources especially shortage in health care workers. In this regard, preparing the Ethiopia Health Extension workers (HEWs) in prevention and early containment of the COVID-19 will be crucial.  

Experiences from previous outbreak (eg. Ebola) responses in various African countries show that community health workers (CHWs) played a vital role in increasing access to health services; provided health education; conducted community surveillance and contact tracing; infection prevention and control; detecting and referring suspected individuals. A recent publication by S. Olasford Wiah detailed the early plan and measures taken by Liberia for COVID-19 which included CHWs leading prevention and control measures in the community such as health education, organizing hand hygiene stations and referring patients with suspected COVID-19 to the next level.    

Having a strong and well-established community health extension program (HEP), the Ethiopian health system can train and deploy the health extension workers (HEWs) and play an important role in curbing this pandemic. Besides, the HEWs ( >42,000 government-salaried female workers) made remarkable achievements in prevention and management of common diseases such as malaria, TB and HIV.  Furthermore, studies indicated that the HEP enhanced reporting of disease outbreaks and contributed to control of epidemics before.  HEWs have also been trained and engaged in response to various epidemics and outbreaks and provided health education, house-to-house case identification and reporting of cases including for scabies outbreak and recurring outbreaks of acute watery diarrhoea/cholera in different parts of the country.  

Likewise, with the COVID-19 pandemic, the role of HEWs in prevention and control of the virus will be critical. Considering the challenges (such as: social system including strong communal lifestyle; cultural and religious orientation; health literacy status; access to information and geographic disparity); the HEWs will have a paramount contribution to sensitise community and create awareness for COVID-19, educate on the prevention measures and contact tracing. Furthermore, experience shows that epidemics interrupt the routine primary health care service delivery as all health care workers focus on the epidemic response. The HEWs will fill this workforce gap and provide basic health services to maintain the health of the community for other conditions.  

Role of HEWs during COVID-19

  • Educate the population about COVID-19
  • Promote preventive measures
    • social distancing
    • hand hygiene
    • respiratory hygiene
  • Case finding
  • Contact tracing
  • Report and refer patients to the health system
  • Provide the single source of truth to communities
  • Reach out to the vulnerable and remote communities
  • Provide continuity of care

Role of the Health System in supporting HEWs

  • Train HEWs
  • Provide protocols/ guidelines
    • mHealth apps for real time transfer of data and training HEWs
  • Provide personal protective equipment
  • Support during and after the epidemic

Urban areas with densely populated and overcrowded nature pose a big risk. Here, HEWs can play an important role in promoting preventive measures, case finding, contact tracing, and linking suspected cases to care as they know the in-and-out of the areas. In rural areas, where information is hard to reach for millions of Ethiopians (especially rural women), the HEWs will be the only way to provide accurate and culturally appropriate information. Due to the relations built over years and trust with the community, the HEWs will clear the evolving myths and misconceptions about the disease; allay fears and reassure the communities to adhere with the preventive measures.  

HEWs are a major resource and must be trained, equipped and upskilled to combat this epidemic. Due to the urgency in the response and the necessity to prevent large gatherings, it is essential to consider innovative ways to upskill HEWs. Training in small clusters and providing guidelines and Information Education and Communication resources on mobile applications are examples of innovations that Ethiopia has prior experience in. Alongside training, the safety of HEWs should be given high priority. It is essential that all HEWs must be provided with personal protective equipment, psycho social support and treatment if they get infected. Though it seems too early, once the COVID-19 is contained, the health care workers need to be supported through their physical stress and mental exhaustion.  

In conclusion, the role of the HEWs will be paramount in curtailing the epidemic in Ethiopia. Training, engaging and supporting both urban and rural HEWs is absolutely essential to curb the COVID-19 epidemic in Ethiopia.  

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Profile of Author(s)

About Azeb Tesema

PHD Student in Health Systems Science, The George institute for Global health, University of New South Wales, Sydney; Public Health Expert at Mekelle University, Ethiopia


About Rohina Joshi

Associate Professor and Scientia Fellow, Faculty of Medicine, UNSW Sydney; Head of the Global Health Workforce Program, Health Systems Science, The George institute for Global health, University of New South Wales, Sydney


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