A Digital Revolution in Ethiopia’s Community Health Program

In Ethiopia, approximately 40,000 trained health extension workers (HEWs) act as the nation’s frontline health workforce, each serving about 2,500 individuals with health promotion, disease prevention, and basic curative services. They face a high workload due to the country’s large population. The government is currently digitizing the community health information system, called the electronic community health information system, or eCHIS. This system is expected to bring tools and networks into place to digitize data, and automate workflows, enabling HEW performance management and supervision, while alleviating burdens placed on them by antiquated reporting systems.

Dessalew Emaway, the project director of eCHIS, reflects on the importance of this health information system, its impact on HEWs and in strengthening the country’s health system.

Please give our readers a brief overview of the project and what it aims to achieve.

JSI, in partnership with Dimagi, LivingGoods, Simprints, and Children’s Investment Fund Foundation (who funded this project) supported the scale-up of eCHIS, which will optimize implementation of the Health Extension Program, in general, and improve reproductive, maternal, newborn, and child health (RMNCH) outcomes, in particular. This five-year project, implemented in the five agrarian regions of Ethiopia, has three major objectives: i) improve quality of care, referral linkages, and use of data for evidence-informed decision-making at all levels of the health system; ii) unleash the power of eCHIS to transform community-level health data for health extension worker (HEW) performance management, targeting primary health services; and iii) design and implement performance management, incentive, and fingerprint biometrics interventions on the eCHIS platform that can be scaled nationally.

How is Ethiopia’s post-COVID-19 environment impacting the health system and how does eCHIS fit in the country’s response, especially now with the ebbs and tides of COVID variants?

As it did in most areas of the world, COVID-19 strained Ethiopia’s health system and impacted uptake of essential health services. The country’s Ministry of Health (MOH) and the Health Extension Program leveraged its house-to-house surveillance system in order to detect and respond to the pandemic. In 2020, the MOH and partners, including JSI, developed a digital tool, integrated with the eCHIS digital platform, used by HEWs, community volunteers, and health center workers to conduct house-to-house surveillance and promote non-pharmaceutical COVID-19 interventions (e.g, social distancing, mask-wearing, and handwashing) to the population. It later accelerated administration of COVID-19 vaccinations. JSI and partners supported the MOH to digitize screening guides and tools, train HEWs on COVID-19 and use of tools, and strengthen the quality of house-to-house screening. This supported and digitized house-to-house surveillance network conducted COVID-19 screening and prevention education to nearly 4 million households nationwide every week.

Strengthening Ethiopia’s health system during conflict times is challenging. In your opinion, what approaches will help the project succeed despite these challenges? How did the conflict affect the project?

The conflict in the Northern part of the country (Amhara, Afar and Tigray regions) affected the health system. Many previously functioning health facilities were damaged and/or looted as were their surrounding infrastructures, while the demand for medical supplies and services grew. The conflict also resulted in a shifting of attention and resources away from the health sector. Most of the woredas JSI supports under the eCHIS project were in non-conflict affected geographies. However, in supported regions where conflicts expanded (namely Tigray to Amhara), we moved our staff out of the region to protect their safety, we held the undistributed tablets and other supplies to minimize the impact of looting and damage, and we revised our project plan to intensify to other regions, such as Oromoia and SNNPR. When the situation improved in the affected regions, we developed a catch-up implementation plan and resumed activities to fast-track results in conflict-affected locations.

How does the project provide support to health extension workers even during conflict or in post-conflict circumstances?

JSI developed a risk mitigation plan for HEWs operating in conflict-affected areas. We developed a revised implementation plan for conflict-affected areas that would enable us to fast-track locations where conflict-related delays occurred, once staff safety was assured (we worked with local security experts to make that assurance). In addition, we engaged with the Government to reallocate resources from this activity to conflict-affected areas for recovery and rehabilitation initiatives, which included the repair and restocking of health facilities in conflict regions. We included post-conflict woredas as our priority intervention sites in a new JSI project focusing on primary health care.

Many of our readers are not too familiar with the health system in Ethiopia. What would you most like them to know about the opportunities and challenges?

The Ethiopian health system is foundationally rooted in community-driven approaches and is home to a massive network of community health practitioners and programs. The Health Extension Program governs the community structures of our health system and registered tremendous achievements over the last 15 years. In order to guide the Health Extension Program evolution for the next 15 years and achieve the country’s aspiration to realize universal health coverage, the government of Ethiopia developed and launched an ambitious strategy, called the Health Extension Program Optimization Roadmap. The strategy reaffirms the country’s commitment in prioritizing community health as a vehicle to accessing all Ethiopians with essential health care. It also calls for innovation and new technology, including in digital health. Understanding how transformational community-driven health access is, and ensuring its continued support and its modernization, may actually bring Ethiopia closer to health equity. However, the roadmap is so ambitious and needs adequate political focus and investment to truly deliver on its ambition. The challenge, I suppose, is aligning now on priorities, approaches and stakeholders.

How will the project help transform the Health Extension Program in Ethiopia?

The new Health Extension Program Optimization Roadmap, and the country’s five-year health transformation plan, calls to unlock the potential of digital technology as one of its priorities. The eCHIS is an answer to that call: it is an innovative modernization of the national information system and a direct decision-making tool for HEWs who are the primary touch points for so many Ethiopians in the health system. eCHIS is one key in transforming the way health services are provided, information is generated and data is used to inform clinical and programmatic decisions. Apart from improving quality of care and data use, this digital solution also simplifies the work process of HEWs (removing paper-based modalities and alleviating HEWs of the legwork involved in paper-based health report submissions) and ultimately reduces their workload.

Talk to us about the importance of implementing digital health solutions to improve data quality and access.

Unlocking the potential of digital technology for health will have a tremendous impact on access to quality health care. Take for example how eCHIS has embedded treatment protocols, key messages, and supporting tools for both providers and clients – this alone lifts all boats and allows HEWs to provide standardized and high-quality health services to every individual client encountered. By automating reports and facilitating immediate access to data used for decision-making, eCHIS frees HEWs to focus on client engagement and alleviates them of administrative paperwork. Additionally, the platform has geospatial features, enabling HEWs to identify segments of communities with low Health Extension Program service utilization, informing targeted outreach resulting in greater equity in access to health services.

The eCHIS project supports many woredas (districts), and a few of them are designated as “learning woredas.” What does this mean and how were they selected?

Learning woredas are districts, co-selected with the MOH, designated to design and incubate digital, or digitally enabled, innovations on a small scale before going to widespread country implementation. The digital innovations that eCHIS has tested in these learning woredas, to date, have included digitally-enabled performance management, performance-based incentives for HEWs, and fingerprint biometrics.

The eCHIS project includes trials of a number of innovations in the learning woredas. What are these innovations? Can you provide us with a preview of some of the results to date?

Some of the innovations we’ve tested and adopted for wider implementation have included:

• Use of biometrics in identifying service recipients: Program reviews showed that biometrics, such as enrollment of population using fingerprints scanners, have improved data quality by enabling verification of service recipients and reducing false reporting. One MOH official reported that annual routine data quality audits showed reduced data discrepancies in the woredas since biometric implementation.
• Initial learning showed improvement in reproductive, maternal, newborn, and child health service provision following the implementation of performance-based incentives and performance management: Compared to control woredas, learning woredas demonstrated that performance-based incentives and performance management heightened ownership, and created greater opportunity for direct technical and logistic support and better-focused training and follow-up. This support resulted in delivery of reproductive, maternal, and neonatal health services with fidelity to national guidance and the result was better use of antenatal and postnatal care services observed in the learning woredas.

To follow the work of eCHIS and its impact on community health, visit https://www.jsi.com/project/ethiopia-electronic-community-health-information-system-ciff/