Model villages: a platform for community-based primary health care
Authors: Kesetebirhan Admasu, Taye Balcha, Haileyesus Getahun
Journal: The Lancet Global Health (2015)

The 1978 Declaration of Alma-Ata on primary health care1WHOUNICEFAlma-Ata declaration: report on International Conference on Primary Health Care. World Health Organization, United Nations Children's Fund, Geneva1978Google Scholar states that governments have a responsibility for the health of their people that can be fulfilled only by the provision of adequate health and social measures. In Ethiopia, the Health Extension Programme (HEP), run by trained female health extension workers (HEWs) who provide a package of 16 integrated community-based services, forms the pillar of primary health care. Local recruitment and familiarity with the social make-up of their community enable the HEWs to apply tailored approaches to provision of this standard package of services.2Ministry of Health of EthiopiaHealth Extension Program in Ethiopia.http://www.moh.gov.et/en_GB/hsepGoogle Scholar, 3Ministry of Health of EthiopiaHealth Sector Transformation Plan.http://www.moh.gov.et/en_GB/home/-/asset_publisher/Mfl2/content/ethiopia-s-five-year-health-sector-transformation-plan-2008-2012-efy-2015-16-2019-20Google Scholar The HEP has continuously evolved and contributed to the significant progress and achievement in the health sector of the nation.4Balcha T Getahun H Admasu K Local innovations and country ownership for sustainable development.Bull World Health Organ. 2015; 93: 742Crossref PubMed Scopus (5) Google Scholar The primary goal of the programme has been training and graduation of model households. Model households refer to families that have embraced locally tailored health behaviour criteria (eg, having children vaccinated, constructing and using latrines, and sleeping under mosquito nets). There is a critical mass of nearly 3 million model households that have graduated over the years. Building on this concept, participatory engagement of women's groups to disseminate health information and facilitate uptake of critical health services was initiated in 2012. This movement, commonly referred to as the health development army (HDA), is led by a group of women volunteers who are from model households and complement the work of HEWs and further augment the engagement and leadership of community members in their own health. The HDAs are trained by HEWs and have facilitated sustainable community engagement and ownership, including establishment of community solidarity funds to finance priority challenges identified by the community. For example, by 2015, more than 200 ambulance vehicles were procured through exclusive community financing. Ethiopia has just launched an ambitious 5-year Health Sector Transformation Plan (HSTP).3Ministry of Health of EthiopiaHealth Sector Transformation Plan.http://www.moh.gov.et/en_GB/home/-/asset_publisher/Mfl2/content/ethiopia-s-five-year-health-sector-transformation-plan-2008-2012-efy-2015-16-2019-20Google Scholar As a progressive evolution of the HEP, the HSTP focuses on the establishment of model "kebeles" (villages) throughout the country. The recognition of kebeles as model will be based on a set of verifiable criteria including at least 80% coverage of model households within their geographic area. Households will be encouraged and monitored to take up tailored and predefined health promotion, disease prevention, and basic curative interventions. High impact interventions will be defined regularly on the basis of national and local priorities and efforts will be exerted to ensure their maximum coverage. The main priority of the model kebele concept is to ensure that responsive services to local needs are fully available to every individual and family in the village. HDAs will play a critical role in facilitating the involvement and service use of all members of the community. They will provide differential support to subsets of the community with problems in accessing essential services. Furthermore, a community-based health insurance scheme to cover citizens in the informal sector will be scaled up over the next 5 years and the HDA is expected to be instrumental in generating demand for the scheme and providing oversight in its implementation. Financial barriers to seeking care will be removed through achieving full insurance coverage by 2020 in such model kebeles. The government will subsidise financial expenses until model kebeles are able to generate social innovations, including financing, to sustainably confront local health-related challenges. Robust monitoring and evaluation, as well as the use of technologies, will be an integral part of the model kebele scheme based on the local context. Data on the sustained engagement in the HDA and governance of local health facilities, use of critical health interventions, and community insurance coverage will be collected regularly. With the aim of achieving 80% model villages nationally over the next 5 years, kebeles will continually be evaluated and classified as model or not. Model kebeles with extraordinary performances particularly in social innovations with a potential to nationwide scale-up will be recognised. The government will support the community structures to ensure coverage of all the essential health services and social protection schemes. For example, targeted nutritional support will be provided to vulnerable subsets of the community including pregnant and lactating women and children under 2 years of age. In July, 2015, The Government of Ethiopia launched a multisectoral political commitment, the Seqota Declaration, to end childhood undernutrition by 2030.5Ministry of Health of EthiopiaSeqota declaration: ending undernutrition in Ethiopia by 2030. Ministry of Health, Addis Ababa2015Google Scholar The robust information and early warning system of the health sector has been at the forefront of addressing impending food insecurity. Protecting human health from the consequences of climate change should be a priority action.6Admasu K Debessa K Action to protect human health from climate change: an African perspective.Lancet. 2015; 386: e31-e33Summary Full Text Full Text PDF PubMed Scopus (6) Google Scholar In this regard, we welcome the recent Paris Agreement on the adoption of the Framework Convention on Climate Change.7United Nations Framework Convention on Climate ChangeAdoption of the Paris Agreement: proposal by the President.http://unfccc.int/documentation/documents/advanced_search/items/6911.php?priref=600008831Google Scholar In conclusion, we believe the global aspirations of universal health coverage will be realised in Ethiopia through community engagement and ownership, which in turn depends on the number and quality of model households and kebeles. This will bridge the gap in health outcomes within and between communities and bring quality health services without catastrophic cost to every citizen. KA and TB are employees of the Government of Ethiopia. KA is the Minister of Health. HG is staff member of the World Health Organization. The author alone is responsible for the views expressed in this publication. Transforming health care in EthiopiaTo judge from recent news stories, 2015 has not been a good year for Ethiopia. It has seen the country's worst drought since the dark days of 1984–85; 8·2 million people are currently in urgent need of food aid. And the government was widely criticised in June when the ruling People's Revolutionary Democratic Front party won an unlikely 100% of parliamentary seats in the general election. Yet at the INDEPTH Scientific Conference in Addis Ababa last month, the mood was upbeat. The conference showcases research carried out within the INDEPTH Network's 53 Health and Demographic Surveillance Systems (HDSS). Full-Text PDF Open Access