Essential Elements of Ensuring Equitable Access to High-Quality Primary Healthcare in Ethiopia’s Pastoral Regions Part 1

Strengthening and Adapting Service Delivery and Improving Infrastructure

An estimated 14 million people in Ethiopia are pastoralists, members of often nomadic communities who depend on livestock for food and income. These communities occupy 61% of the total land mass in Ethiopia, and 97% are found in the lowland areas of Afar, Somali, Oromia, and SNNPR  (Southern Nations, Nationalities, and People’s Region), according to the United Nations Development Programme. Pastoralists face numerous challenges, including competition for grazing land and water, conflict, poverty, and the growing impacts of climate change, such as increasing drought. 

Because most pastoralist communities are mobile and live in remote areas, they have limited access to basic services such as water, education, and healthcare. Several measures of health status show pastoralist communities in Ethiopia to be more disadvantaged than their counterparts in settled agrarian communities, including those related to reproductive, maternal, newborn, child, and adolescent health and nutrition (RMNCAH-N). For example, limited access to contraception, antenatal care, skilled attendance at birth, and post-natal care leads to higher rates of maternal and newborn morbidity and mortality among pastoralist populations. Immunization rates and nutritional status among children are significantly lower than among other groups, too. 

“Pastoralists’ needs are the same as other populations, but of greater magnitude, because for a long time, they have not been given enough attention or investment, and the context is so different,” said Jemal Kassaw, EngenderHealth’s country representative for Ethiopia. “There is a huge need to address the inequity between pastoral and other regions.”

EngenderHealth has more than 30 years of experience supporting Ethiopia’s Federal Ministry of Health to improve the quality and accessibility of RMNCAH services, including for marginalized populations such as young people, internally displaced persons, and pastoralist communities. Our work over nearly a decade in predominantly pastoral and semi-pastoral regions—including Afar, Somali, Oromia, Benishangul-Gumuz, and SNNPR—has yielded important lessons upon which we are building as we expand efforts to reach long-neglected pastoralist communities with RMNCAH-N care.

“Pastoralists often have to move across large areas, even across country borders,” Kassaw said. “It is not easy to reach them through traditional health service delivery models.”

In this two-part blog series, we examine factors that EngenderHealth has found essential to ensuring sustained high-quality primary healthcare for pastoralist communities. In Part 1, we share our experience addressing infrastructure challenges that affect healthcare delivery, through focused collaboration at all levels among government, local partners, and community stakeholders and supporting and adapting service delivery models, to meet clients where they are. In Part 2, we address the importance of supporting long-term, community-led efforts to address barriers to care based in sociocultural and gender norms and integrating multisectoral approaches that engage a range of stakeholders, with attention to building resilience and readiness to respond to crises.

Ensuring basic primary healthcare infrastructure

“Availability of basic amenities like water, electricity, and toilet facilities is very poor in pastoral regions,” said Kassaw. “Addressing these gaps is fundamental to improving and sustaining high-quality healthcare, and requires strong support and collaboration among government and other partners.” 

EngenderHealth’s role in improving physical infrastructure for health services often focuses on renovating health facilities and ensuring the availability of essential equipment and supplies for  RMNCAH-N care, especially at the primary healthcare level. Under the A’ago program, which strengthened sexual and reproductive health (SRH) and other services for semi-pastoralist adolescents and youth in Afar, Amhara, Oromia, and SNNPR, we renovated 40 of the 260 healthcare facilities supported in the Afar region. These renovations included installing sanitary toilet facilities and a sewage system, ensuring reliable electric supply, and building adolescent and youth health corners. We also ensured that facilities were well-stocked with contraceptive methods, infection prevention supplies, and other vital materials. 

Strengthening service provision and management

EngenderHealth’s comprehensive approach to expanding the availability, accessibility, and quality of care also relies on preparing and supporting the healthcare workforce to deliver improved services, across the RMNCAH-N spectrum. Key strategies include training, mentorship, and ongoing support for clinical service provision, quality improvement, facility management, supply forecasting, improving data quality, use of data for decision-making, and enforcing implementation of national and regional policies and strategy guidelines. 

One strategy that has proven very successful in Ethiopia is embedding EngenderHealth technical experts at all levels of the health system, including in regional and zonal health bureaus, woreda health offices, and other locations. These experts are paired with and work alongside government staff to solve problems and institutionalize clinical, management, policy, and other practices to best serve clients. Across the three programs and seven regions where we have used this strategy, it has been critical to fostering local ownership, most notably by the government, for sustained, improved care. In Afar, for instance, it resulted in expanded access to basic emergency obstetric and newborn care. This approach was also important to the recent transition to full government responsibility for comprehensive contraceptive care at 632 Ethiopian healthcare facilities previously supported by EngenderHealth.

Another innovation we have used successfully in Ethiopia to improve health system performance is the Rapid Breakthrough Initiative (RBI), which combines measures to strengthen staff skills, motivation, and leadership at healthcare facilities with community-based activities to build demand for high-quality services. Recent implementation of RBI in the Afar region was associated with significant increases in clients’ adoption of a contraceptive method of their choice across the six pilot facilities in only 100 days: an increase of 1.8-fold for short-acting methods, 2.8-fold for implants, and 9.1-fold for IUDs. 

Adaptive service delivery

EngenderHealth has also found it crucial to ensure health services fit the unique needs of each community to reach as many people as possible.

“Static services are not well equipped and tailored to serve pastoralists’ needs because these communities are mobile by their very nature,” Kassaw said. “EngenderHealth’s approach is to strengthen differentiated service delivery modalities that take into account the realities of pastoralists’ lives.” 

In implementing this approach with pastoralist communities, EngenderHealth draws on our varied experience successfully adapting mobile outreach mechanisms to the needs of marginalized communities in Ethiopia and other countries. In Tanzania, for example, we effectively served several hard-to-reach populations with contraceptive services through designated family planning (FP) outreach days and by integrating contraceptive information, counseling, and services into community health activities such as immunization and tuberculosis (TB) and HIV screening. Between October 2018 and March 2020, these outreach services reached 341,503 clients—including 174,115 through integrated FP/HIV/TB services, 77,599 through FP/immunization outreach, and 87,758 through HIV care and treatment clinics. 

For pastoralist communities in Ethiopia, Kassaw said, it also makes sense to integrate provision of RMNCAH-N information and care where pastoralists take their animals to get veterinary services, to address human, animal, and environmental health in a cross-sectoral, or One Health, approach. 

EngenderHealth also embraces technological innovation to overcome barriers to health service access and to improve health-seeking behavior. One intervention of A’ago, implemented with our partner Triggerise, introduced a digital app to encourage positive health-seeking behaviors and facilitate access to care. In only one year, approximately 14,000 app users in Afar were referred for care, and 86% received it. 

We also collaborated with a private-sector partner, Philips Healthcare Africa, to equip mobile health outreach workers with portable ultrasound machines, greatly facilitating access to this critical diagnostic tool. “Such innovations hold great promise for pastoralist populations in Ethiopia,” Kassaw said. 

Beyond the health system

Improving basic health infrastructure, strengthening service provision, and adapting service delivery models to clients’ unique needs are critical to ensuring pastoralist communities’ access to healthcare, but these steps are not enough on their own to ensure that all pastoralists can access high-quality healthcare, including SRH services. Also key are supportive sociocultural norms and ensuring local resilience, including government’s and other local actors’ ability to respond quickly and effectively to crises. Learn more about how EngenderHealth addresses these needs in Part 2 of our blog series next week.