Wednesday, January 15, 2014

A healthy exchange - learning from Ethiopia's maternal care system

At a time when South-South cooperation is being feted as a new model in development, it was insightful to get an opportunity to study Ethiopia’s maternal and child healthcare system on a recent trip to Africa. Designed on similar lines as India’s National Rural Healthcare Mission (NRHM), Ethiopia too locates women healthcare workers at the centre of its maternal health system and hinges on a bottom-up approach.

Comparing India and Ethiopia might be unfair on many counts given that the latter is much smaller in size despite being Africa’s second most populous country. It is home to 47 million women, nearly one-tenth of India’s 586 million female population. Comparisons then are questionable as the scale of challenges and outcomes is often linked to a country’s size, topography and social dynamics.

But a closer analysis of both systems throws up lessons that can be traded across boundaries, albeit after tailoring to country-specific needs.

Ethiopia’s maternal health programme called the Health Extension Progamme has been in place since 2003 and is credited hugely for the success in bringing down maternal mortality as well as improving the health status of newborns. One evaluation paper for instance credited the health extension workers for doubling contraceptive prevalence in Ethiopia from 2005 to 2011.

The programme is best understood through the eyes of health extension workers like Faayituu Dhaaba (24) who is liasoned with a health post in the Arsi zone, Oromia region of Ethiopia. “Our focus is on community mobilisation, so, health link workers like Dhaaba are recruited from the community itself,” says Negussie Kebede, director of the health post. The link he speaks of is the bond Faayituu forges between the community and the government-run healthcare centre he is in charge of. For the past three years Faayituu has been a foot soldier, going from door to door coaxing women in her village to use contraceptives, get themselves admitted to public hospitals for safe deliveries and immunising their babies to keep them healthy. She along with her fellow health link workers have taken charge of nearly 972 homes in the village. They in turn have trained women volunteers in the village, popularly called the Women’s Development Army, who inculcate broader behavioural change in terms of sanitation or better cleanliness in the village.

The Ethiopian model bears close resemblance to India’s NRHM which involves 8.5 lakh-odd trained female community workers popularly called ASHA (Accredited Social Health Activist) to mobilise the community in similar fashion.

But there is much to be learnt. Ethiopia’s programme holds out better incentives for its health link workers. It pays its foot soldiers a salary of 1,233 birr (roughly equivalent Rs 4,000) per month and incentivizes them to better their on-the-job performance. The best performers are rewarded with enrolment into a diploma and given higher responsibility at work. In contrast, ASHAs in India are regarded as voluntary workers and promised a meagre performance-based honorarium for their work. They receive for instance, a measly Rs 600 per delivery or Rs 150 for every family planning operation in states such as Bihar and Chattisgarh, with payments often delayed and staggered. A working paper by Columbia Global Center, South Asia in 2011 had shown that an ASHA in an EAG (Empowered Action Group) state was likely to earn a measly average of Rs 14,220 per annum in a state like Bihar. Rajasthan is the only state that gives ASHAs an assured salary and that too is as low as Rs 500 in addition to the performance-related incentives. West Bengal recently announced similar assured pay. “Payments to ASHA are frequently delayed, often due to procedural issues (e.g. funds not transferred to sub-district, unfamiliarity with e-banking, confusion over what incentives are available),” the analysis had pointed out.

Ethiopia on the other hand could learn from India’s recruitment mechanisms. The NRHM for instance, has a nuanced clause which ensures that the foot soldiers are daughters-in-law (married into the village) rather than daughters (who may get married and move out of the village) which gives the programme a more sustainable structure. Ethiopia’s programme in contrast is open to recruitment of girls who have completed their tenth grade. The married woman model has shown success in Bangladesh as well which recruits married women above 25 years as community health workers or Shasthya Sebika.

There is no denying the potential that such community-driven programmes play in improving health indicators. Abera Mulugeta, a village elder in Arsi perhaps captured it best for me. With folded hands he apologised for supporting female genital mutilation in his village in the years gone by. But for the sustained effort of those like Faayituu, he may never have realised the harm the practice carries.

A south-south exchange of practices could then go a long way in improving the efficiency of healthcare programmes across borders.