Lomita Bekele, Photo Credit: Dominic Chavez

As seen in the June 4th edition of The Lancet.

Lomita Bekele grew up in southwestern Ethiopia in a place called Western Welega, just over 300 km due west of the capital, Addis Ababa. She was the ninth of ten children born into a farming family who grew teff (used to make the Ethiopian bread called injera), maize, and, most important of all, coffee. Lomita's family put a great emphasis on education and she went through secondary school with dreams of being a doctor. Her test scores, though, weren't high enough and she was unsure what to do. But then she heard of a new government programme for “junior nurses”. She took the test, aced it, and found herself enrolled as part of Ethiopia's grand health vision—the creation of more than 30 000 health extension workers spread throughout the vast rural country.

After 11 months of training, Lomita became one of two health extension workers in Shera Dibandiban, a village of 3067 people about 80 km southeast of Addis Ababa. 28-year-old Lomita is now in her sixth year in the village, and together with her co-worker, Almaz Alemu, aged 22 years, the two women offer a kind of one-stop-shop for health in Shera Dibandiban. Lomita and Almaz each earn US$55 a month, which is 50% more pay than they received a year ago. They deliver babies and if there is a complication during birth they make arrangements to get the woman to a hospital. They distribute bednets to protect against malaria. They even go out to homes and show men how to construct a sanitary latrine. “We do almost everything”, Lomita explained while she worked at the tiny three-room health post, which included one room for childbirth. Outside, five women waited their turn to see the health workers. “I've been spending a lot of my time lately talking to people about nutrition and showing them how to prepare nutritious foods”, said Lomita.

When Ethiopia started its programme to train health extension workers more than 5 years ago, many outsiders saw it mainly as a way to bring basic health care to the village level. But that was just part of the plan. The Federal Ministry of Health saw the programme as the first step towards reaching not just a village, but a family as well. And so one of its first initiatives was for the health extension workers to oversee a “model families” programme in which if a family met a certain number of criteria for healthy living—vaccinations for the children, checkups during pregnancies, for instance—they would get the designation “model family”.

That isn't all, though. In the coming months, there are plans for health extension workers such as Lomita and Almaz to start training people in the community who will become liaisons from the health post to five families each. And after that takes hold, the Ministry hopes one person per family is tapped as the advocate for good health. This is part of the “Health Transformation Army” idea that is currently being discussed among senior health leaders.

In Shera Dibandiban, the walls of the health post document the two workers' victories. Almost every inch is covered with a poster showing bar graphs and charts of the state of people's health in Shera Dibandiban. Malaria cases have dropped to 60 in 2010, compared with 110 in 2007. Basic immunisation coverage is now close to 100% for all children younger than 1 year. And the charts show that they had given family planning counselling to every woman of childbearing years who sought care last year.

Victories aren't just displayed on the wall. One walked in: 28-year old Tsihay Degefa who came for a checkup because of worries that her persistent cough could be tuberculosis. She is HIV positive and explained how Lomita's intervention on her behalf with the village elders dramatically improved her life. “I had kept my status hidden, but the health extension workers helped me come forward”, she told The Lancet. “Before, there was a lot of stigma around HIV. That has changed so much for the better.” Lomita had told the elders that several HIV-positive people in the village could not afford nutritious food and their health was at risk. In a series of community meetings that involved more than 200 residents, the village agreed to set up a special fund for HIV-positive patients. Now, 22 of the village's 38 people who have tested positive for HIV have gone public with their status. They see no reason to hide it in a place that is so supportive.

Not everything goes smoothly, of course. The health post had run out of blood-clotting medication to stem haemorrhage during birth, and recently one woman nearly died from bleeding after delivery. Lomita complained about the shortage and said she now has enough medication. And then there was the time when she taught a farmer how to prepare a latrine, only the farmer didn't do his job so well. “The farmer made a mistake—he dug a big hole and did not cover it properly”, she said. “One day his cow fell in the hole and died. The farmer started threatening me and said he would kill me.” She complained to the district authorities, and since then the farmer has stayed clear.

Despite the angry farmer, and persistent long hours, Lomita said she is happy in her work. “I really enjoy serving the community. And you can see the results here. The community respects us, and we know we are helping them stay healthy.”

As originally appeared in The Lancet.