Community health extension workers' training and supervision in Ethiopia: Exploring impact and implementation challenges for non-communicable disease service delivery

Azeb Gebresilassie Tesema; David Peiris; Seye Abimbola; Whenayon S Ajisegiri; Padmanesan Narasimhan; Afework Mulugeta; Rohina Joshi

doi:10.1371/journal.pgph.0001160

Community health extension workers' training and supervision in Ethiopia: Exploring impact and implementation challenges for non-communicable disease service delivery

PLOS Glob Public Health. 2022 Nov 9;2(11):e0001160. doi: 10.1371/journal.pgph.0001160. eCollection 2022.

Authors

Azeb Gebresilassie Tesema^{1

2}, David Peiris¹, Seye Abimbola^{1

3}, Whenayon S Ajisegiri¹, Padmanesan Narasimhan⁴, Afework Mulugeta², Rohina Joshi^{4

5}

Affiliations

¹ The George Institute for Global Health, University of New South Wales (UNSW), Sydney, Australia.
² School of Public Health, Mekelle University, Mek'ele, Ethiopia.
³ School of Public Health, University of Sydney, Sydney, Australia.
⁴ School of Population Health, University of New South Wales, Sydney, Australia.
⁵ The George Institute for Global Health, New Delhi, India.

Abstract

Training and supervision of health workers are critical components of any health system;thus, we assessed how they impact health extension workers' (HEWs) role in non-communicable disease (NCD) service delivery in Ethiopia's health extension program (HEP), using an in-depth qualitative study conducted in 2019.The study covered two regions-the Tigray and the South Nations, Nationalities and Peoples Region (SNNPR)-and involved the Federal Ministry of Health. We conducted twenty-seven key informant interviews with federal and regional policymakers, district health officials, health centre representatives and HEWs.Participants highlighted substantial implementation challenges with training and supervision practices delivered via the HEP. Training for NCDs lacked breadth and depth. IT was described as inconsistently delivered with variable availability within and between regions;and when available, the quality was low with scant content specific to NCDs. HEP supervision was inconsistent and, rather than being supportive, mainly focused on finding faults in HEW work practices. Supervisors themselves had skill gaps in critical areas overall, and specifically concerning NCDs. HEWs' performance appraisal encompassed too many indicators, leading to excessive complexity, which was burdensome to HEWs. This, negatively impacted HEW motivation and compromised service delivery. HEW involvement in non-HEP activities (such as promoting other government programs) often competed with their core mandates, thus affecting HEP service delivery.Efforts to address training and supervision constraints in Ethiopia's HEP should focus on improving the quality of NCD training for HEWs and supervisors, shifting from authoritative to supportive supervision, simplifying performance appraisal and reducing competing attention from other programs.

Copyright: © 2022 Tesema et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Grants and funding

The project was supported by the George Institute for Global Health, Australia through the Seed Grant fund dedicated for under-served populations in low middle income countries for 2019/2020. The UNSW Scientia Scholarship program supports AGT and WA. The UNSW Australian Government Research Training Program Scholarship supports AGT. SA was supported by the Australian National Health and Medical Research Council (NHMRC) through an Overseas Early Career Fellowship (APP1139631). RJ is supported by the Australian National Heart Foundation (APP 102059) and a UNSW Scientia Fellowship. DP is support by NHMRC career Development Fellowship, Level 2 and Australia National Heart Foundation Future Leader Fellow. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.