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Roundtable discussion: Community Engagement Strategies in Ethiopia

Watch as Wakgari Deressa tells Anna Kalbarczyk about the community engagement strategizes that were used successfully in Ethiopia. (Step 5.10)
ANNA KALLBARCZYK: Hi, everyone. I’m Anna Kalbarczyk. And today, I’m here with Dr. Wakgari Deress. Dr. Wakgari, I’d like to talk to you a little bit about community engagement. In the lecture that the students just watched, they learned about some strategies in community engagement. And I want them to have the opportunity to think about how that might look different in different contexts. So could you tell me about some community engagement strategies in Ethiopia?
WAKGARI DERESSA: Yeah. Thank you, Anna. Thank you very much. I’m very happy to be part of this discussion. As you know, Ethiopia is a big country. There’s more than 100 million population. And there are also different parts of the country where there are mobile population, like in the areas of, for example, the Somali region in the eastern part of the country, the Benishangul-Gumuz in the western part of the country, the Gambela region in southwestern part of the country. And also, we have parts of Oromia, especially southern Oromia bordering Kenya, where the population is very mobile.
And in those areas, there are more than 4 million population living in these remote areas, low land areas where the accessibility, the problem there, the health infrastructure is very poor. The health workforce is very limited due to hostile environment and other insecurity issues in those in those areas. So in those particular areas, we generally call it hard-to-reach population or hard-to-reach areas, where there is poor reporting, where there is pastoralist community, and knowledge in this key local population about health in general, and polio in particular, is very limited.
So for this reason, the government is currently doing a lot of initiatives to reach this population, particularly, in terms of health service provision and also EPA, improving EPA coverage in the form of routine immunization, in the form of campaign such as supplementary immunization activities, and also in the form of surveillance, polio surveillance, acute flaccid paralysis. And also, in terms of reaching the last child in the community. So currently, the strategy that the government– the minister of health has– there is a health extension program. And in this health extension program, there are health extension workers, female health extension workers, who are now working best in the health posts. And these health posts are generally community based health facilities.
So there are more than 40,000 health extension workers in those areas.
ANNA KALLBARCZYK: And these are all female, you said?
WAKGARI DERESSA: Yes, female health extension workers.
ANNA KALLBARCZYK: Can you tell me why there’s such a focus on having female workers?
WAKGARI DERESSA: Yes. Yeah, generally, it is assumed that females are giving more care for the family, for the household, and also for the children, who are also a lot of burden with the household chores, the houses including children, including overall family, including the health, including the health-seeking behavior are more so dependent on the woman. So like, if you think pregnancy, like if you think a child carrying, everything is about woman in general. So that’s why the government has elected to make the health extension workers 100%, they are females. And then to support, to complement the activities of the health extension program, then there is also a woman development army. So this women development army are living in the community.
And they are organized in a village. And they have direct communication with the health extension program, with the health extension workers. So they mobilize the community in terms of health promotion, in terms of disease prevention. Like for example, when I’m saying health promotion, health services, vaccination is one of that. Campaign is one of the activities. They mobilize and sensitize the community. And they also work with the community leaders, and also with the village leaders. So this is the general aspect. But when we come to the hard-to-reach areas, there are still a lot of problems. There are harder to reach areas still unreachable, still with a difficult setting, with a difficult situation.
So the government is doing even in those areas to ensure the participation of the community in terms of their involvement, in terms of their engagement– not only engagement of doing activities, but also receiving the service. Like, for example, antenatal care, like EPA service, health information, nutrition, and the same.
ANNA KALLBARCZYK: And how do the community engagement strategies vary? Or how are they tailored for some of these more difficult-to-reach populations? And in particular, I want to ask about the nomadic populations. You talked about them earlier on. How does that change the way that the government engages with the communities?
WAKGARI DERESSA: Generally, we have, over the last couple of years, we have recognized that the setting of the mobile population, the pastoralist population, is different from the highland areas, the agrarian areas where the population is not nomadic, where the population is not moving. The population is settlers, for example, in the case of the highland areas. But in these cases, in the pastoralist area, people move from one place to another. But it is not the old people. It’s not the whole family which is moving. It is those– the adults, the men who are moving with the livestock, with the cattle in search of pasture and in search of grazing area, in search of water during the dry season and so on.
So the woman and the children, they stay in the family. They don’t move completely from their village and so on. So when the rain comes, when the situation gets better at the original home, then those adults who moved away for search of pasture or water or grazing area for the cattle, they come back. So we are focusing on the household. And the children are not moving, but still, there is a problem there. Because there is a low awareness. There is low knowledge of this community. And detecting a sick child less than under the age of 15 years with the polio virus is a problem.
But there is recently, which is called Pastoral Health Extension program, which is focusing according to the setting there, according to difficulty there. And they are mobilizing the kind of mobile health service. This mobile health service is a sort of campaign where they go to the family. They give vaccination and they give other health services to people in those villages. And they come back, and then they frequently do this as a mobile one. Maybe the other very important aspect is about the involvement of the religious leaders. It’s very, very important because in those mobile population in those eastern part of the country, southern part of the country, majority of them are Muslims.
So there is a sort of resistance in terms of accepting the vaccination, for example, during the first phase of the eradication. Due to the involvement of the religious leaders, like Muslim leaders in the mosque, and also in the other areas, like priests, they teach the community. They teach about the importance of the routine immunization. They teach the importance of, for example, supplementary immunization activities, the surveillance, and also the mobile campaigns. And they mobilize and sensitize the community. And the community awareness has been risen.
WAKGARI DERESSA: So it’s very important that the goal of the polio eradication– I think it is going well, but still, we have challenges. Like I’ve said there is a cross-border movement, between Ethiopia and Somalia, between Ethiopia and Kenya, between Ethiopia and South Sudan, between Ethiopia and Sudan. So people are moving. And in those border areas, on the Ethiopian side, on the Kenyan side, on the Ethiopian side, on the Somali side, and so on, there are insecurity issues. And the government has been trying to work with a kind of cross-border collaboration. And this is becoming a focus for them in Horn of Africa, which is including Somalia, Ethiopia, Kenya, Sudan, South Sudan, and Djibouti, and also Eritrea.
ANNA KALLBARCZYK: Sounds like a very complex context. Thank you so much for sharing your thoughts today about community engagement in Ethiopia. I appreciate your time. Thank you.
WAKGARI DERESSA: Thank you so much, Anna. Thank you very much.

Experts discuss community engagement strategies in Ethiopia.

Wakgari Deressa, MPH, PhD School of Public Health, Addis Ababa University, Ethiopia

Anna Kalbarczyk, DrPH, MPH Bloomberg School of Public Health, Johns Hopkins University, USA

Compare the successful strategies used in Ethiopia to the successful strategies used in India, as we learned about earlier in the week.

  • What were similar successful strategies?
  • What strategies worked in one context, but would not have worked in the other?
  • Why do you think this is?
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