Developing the Long-Term Capability of Ethiopia’s Health Extension Program Platform (HEPCAPS)

The HEPCAPS2 projects — Developing the Long-Term Capability of Ethiopia’s Health Extension Program Platform – worked with Ethiopia’s Ministry of Health to develop strategies to improve outcomes and sustainability in primary care service delivery and health financing. HEPCAPS was implemented by the Harvard T. H. Chan School of Public Health in collaboration with John Snow Research and Training Institute, Inc. and Yale Global Health Leadership Institute.

Peter Berman, Professor of the Practice of Global Health Systems and Economics at the Harvard T.H. Chan School of Public Health, served as the Principal Investigator of the project and Hibret Alemu Tilahun (PhD), Research Associate at Harvard T. H. Chan School of Public Health, served as the project’s Executive Director. HEPCAPS was funded by the Bill & Melinda Gates Foundation.

The Ethiopian Health Extension Program

The Health Extension Program (HEP) platform is the Government of Ethiopia’s main vehicle for reaching its citizens with a basic package of evidence-based effective primary health care services.  The HEP platform utilizes a relatively low-tech frontline worker based in a simple health facility, which becomes the engine of implementation for a range of priority health interventions. The Health Extension Worker (HEW) also develops community engagement and capacities through working with female community health promoters with the aim of reaching all citizens. HEWs work out of health posts, with substantial time spent in the community, and are linked to higher levels of care (health centers and primary hospitals) and further tiers of the health care delivery system.

Launched in 2003, the HEP is a relatively new initiative to physically and socially expand the health care delivery system to increase access to good quality basic services that can save lives and improve functioning.  The HEP has contributed significantly to Ethiopia’s success in reducing child mortality from 123 per 1,000 live births in 2005 to 64 per 1,000 live births in 2014 among other successes.

Although Ethiopia has achieved rapid progress in improving access to basic health promotion, disease prevention, and selected curative services and making gains in health outcomes, some concerns remain about Ethiopia’s capacity to scale up and sustain the initial successes in terms of effectiveness, quality and overall efficiency of the HEP platform.  In addition, given rapid economic growth in Ethiopia and other social developments, dramatic changes in the disease burden and health service delivery needs and demands can be expected, requiring flexibility and adaptability in the HEP platform over time.

The Federal Democratic Republic of Ethiopia Ministry of Health is working hard to address these concerns by designing a long-term vision for Ethiopia’s primary health care system including the health extension program. HEPCAPS2 is providing support to the Ministry of health and regional health bureaus on these and related matters. Brief descriptions of what HEPCAPS has been doing is presented below.

The HEPCAPS Project (2012 – 2015)

The overall objective of HEPCAPS was to assist the Government of Ethiopia to sustain and improve the effectiveness of its primary health care system, both in urban and rural areas, and to accelerate the achievement of priority maternal, newborn and child health outcomes and disease prevention and control efforts.

Specifically, HEPCAPS provided support for a collaborative program with the MOH, GoE, to:

  • Act as a mechanism to promote coordination of efforts to improve primary care and alignment with the MOH primary health care vision
  • Define and strengthen selected capacities at national and sub-national levels to implement, evaluate, and enhance elements of the existing primary care system to a range of changes as Ethiopia develops and to tailor elements to fit local circumstances, giving priority to agrarian settings
  • Design, demonstrate, and evaluate innovative strategies to improve primary care performance and adapt to changing conditions for a sustainable future primary care system.

The HEP platform also holds promise to spread lessons learned to other countries on the African continent about how to implement and maintain a large-scale health extension service and community linked service delivery model.  In short, ensuring the long-term capability of the primary health care and HEP platform is of vital importance for accelerating and sustaining Ethiopia’s success in improving the health of mothers, newborn, and children.

 Achievements to Date

The HEPCAPS2 project provided support to the MOH to strengthen the primary care system from October 1, 2012 to November 30, 2015.

Key achievements under HEPCAPS2 included:

Health Finance Projection Model: The project team worked closely with the MOH, particularly the Resource Mobilization Directorate, and produced a report entitled “Financing Ethiopia’s Primary Care to 2035: A Projection Model of Resource Mobilization and Costs”. The questions that the model aims to answer are as follows:

  • Given the historical trends, what is the likely projection (2035) for Ethiopia’s resource mobilization and primary care costs?
  • Given different economic, demographic, and health service scenarios, what are the possible effects on resource needs and resource availability? What are the gaps in financing implied by different scenarios and how might they be addressed?
  • How much domestic resources are needed for health care spending to reach lower-middle and upper-middle income country spending per capita in 2025 and 2035 respectively?

Financing Ethiopia’s Primary Care to 2035: A Model Projective Resource Mobilization and Costs

This paper presents the results of modeling to project Ethiopia’s future resources to finance primary health care and compare them with the likely costs of providing primary care according to current government plans. The paper explores different scenarios related to health financing contributions and costs, as well as economic, financial,and demographic situations. This model serves to promote financially viable actions towards primary care expansion and reform.


A Study on Health Extension Workers: the project team, in collaboration with MOH, completed a study on HEWs and produced report entitled “Health Extension Workers’ Time Motion Study Complemented by In-depth Interviews Within Primary Health Care Units in Ethiopia”.

The purpose of the study was to quantify how health extension workers (HEWs) across selected regions spend their time and to understand relationships among health extension workers (HEWs), Health Development Army (HDA), health centers, woreda health office, and hospitals.

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Health Extension Workers Time Motion Study Complemented by In-depth Interviews with Primary Health Care Units in Ethiopia

This report documents the findings of the time motion study.




Primary Health Care Unit Reforms in Agrarian Regions: The project worked with regional health bureaus in the four agrarian regions (Amhara, Tigray, Oromia, and SNNP) to implement reforms to the primary health care unit (PHCU). Reforms centered on the following areas:

  • Establishing PHCU working groups
  • Improving governance and leadership of the PHCU
  • Increasing management capacity of staff to implement, sustain and evolve key reforms
  • Strengthening structures and processes for performance management
  • Refining the service package and outreach team
  • Strengthening referral linkages within the PHCU

Urban Primary Health Care Reforms: The project provided close technical and financial support for the implementation of urban health reforms in Addis Ababa city administration. Under the leadership of a technical working group led by the deputy head of Addis Ababa Regional Health Bureau, the project provided overall support for the implementation of the reform in two districts (Bole Woreda and Gulele Woreda). Household level census data was collected, family health teams (a new model for service delivery to the community) were established, health kits were organized for health workers to carry with them to the community, and ground level implementation is underway.  Clients were categorized based on household level data collected at the beginning of the reform to prioritize and target the most needy population groups.

The following booklets have been produced to document the implementation successes and challenges.

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Family Health Team: Lessons from Field Implementation; Bole Subcity

This booklet highlights the community’s experiences with the Family Health Team




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Interactions Between the Community and Family Health Team: Community Perspectives

This booklet shares the experiences of the family health team members.



Public-private partnerships: In collaboration with team of experts from MOH HEPCAPS2 conducted a review of local case studies and key informant interviews, as well as a review of global practices to produce a report titled

PPP Report CoverStrengthening Public Private Partnerships for More and Better Health Outcomes in Ethiopia: Expert Reviews and Case Studies”. This review was intended to contribute to developing policies and programs to enable PPPs for health in order to contribute to better health outcomes by understanding existing structures, experiences, and practices both globally and in Ethiopia. The project also provided support to MOH in the development of a PPP implementation guideline.

Community engagement: The MOH is introducing a formal training and certification program for the volunteer community health workers, also called the Health Development Army (HDA), to be certified as Level I in order to increase their competency and motivation. This will also give them the opportunity to be considered part of the formal primary health care system. HEPCAPS provided overall support to the MOH in the designing of the program and its pilot testing.

Evidence-Informed Policy capacity: HEEIP Report CoverPCAPS provided close technical support to MOH in the development of national policy and planning documents, in addition to supporting the effort of the Ministry to enhance use of evidence for decision-making and action oriented policy analysis practices. A review paper titled “Review of Local and Global Practices On Evidence- Informed Health Policy: Recommendations for Ethiopia” was produced by the project to inform the Ministry on how best to establish policy analysis practice within MOH.