Abstract
Creating community health worker jobs in the public sector is a prominent goal in the global health development industry. According to industry leaders, Ethiopia’s government has created community health worker jobs at a scale and in a way that other countries can look to as a model. Based on extensive document review and interviews with district, national, and international health officials, we show that narratives about saving lives, empowering women, and creating model citizens in a context of resource scarcity allow Ethiopia’s ruling party to obtain international admiration for creating salaried community health worker jobs and to simultaneously avoid criticisms of its concurrent use of unpaid women’s community health labor. Public sector community health worker investments in the twenty-first century reveal the layered narratives inherent in global development practices that entangle states, international donors, NGOs, and citizens.
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Notes
It is important to note, however, that experts do not really know just how successful the Health Extension Program has been, in terms of reducing maternal and child mortality in particular. The Global Health Workforce Alliance admits in a 2008 profile of the program that, “Some improvement has been observed in health indicators over the last five years, for example, infant mortality in 2005 was 77 per 1000, down from 97 in 2000. However, this cannot be attributed to the HEWs because the first graduates of the programme were only deployed in 2005. More time is needed before their impact can be fully evaluated” (GHWA 2008: 2). Teklehaimanot and Teklehaimanot (2013: 9) also clarify that while observed changes in mortality and health indicators are “likely” due to the Health Extension Program, mediated by increased health service coverage and health-seeking behaviors, “formal systematic evaluation” is nonetheless required to know the real impact of the program.
In contrast, global donors have in recent history been more motivated to raise and spend the money to pay for high-level “expert” labor (i.e., NGO officers, consultants, and auditors) and medical technologies (i.e., the products sold by for-profit pharmaceutical and medical technology corporations). The sustainability doctrine has thus generated a salient inequality between the local, underpaid laborers, and the salaried, transnational professionals involved in health programs in Africa.
The WHO policy recommendation and the designers of Ethiopia’s Health Extension Program implicitly argue that the widespread reliance on unpaid labor ironically creates programs that are unsustainable, in part because unpaid “volunteers” are usually poor and hopeful of receiving better opportunities and that truly sustainable programs must create jobs backed up with a long-term commitment to funding by governments and global donors (Ooms et al. 2007).
For years, Dr. Tedros Adhanom, the previous Minister of Health who presided over the rollout of the Health Extension Program, has sat on the executive committee of the TPLF, the central core of political power in Ethiopia. Until his death in 2012, Prime Minister Meles Zenawi was the undisputed leader of the central committee of the TPLF. After his death, Dr. Tedros was reassigned as Minister of Foreign Affairs.
There is a great need for ethnographic work investigating exactly how domestic and international NGOs as well as bilateral, multilateral, and private donors have responded and adapted to this law.
The Amharic translation is yesetoch lemat serawit. Sometimes the Army is called, in English, the “Health Development Army,” and sometimes the “Health Transformation Army.”
During the guerilla struggle, the TPLF (the precursor of the EPRDF) also organized women’s associations in Tigray and denounced women’s oppression under feudal and capitalist regimes (Hammond 1999). However, as recounted by Yewubmar Asfaw, one woman who fought in the struggle and served as a TPLF cadre member for several years, the TPLF ultimately sought to subordinate women to the cause of gaining political control over the country. Some TPLF women sought to pursue a feminist agenda only to face intimidation and disempowerment from men within the TPLF leadership (http://www.ipsnews.net/2008/11/politics-ethiopia-disappointed-but-not-defeated/ [accessed May 29, 2015]). More recently, Azeb Mesfin, the wife of former PM Meles Zenawi and a former woman fighter during the guerrilla struggle, has been the sole woman on the TPLF central committee (International Crisis Group 2012).
The document was apparently written circa 2011 by someone near the top of Ethiopia’s ruling party.
He added, “the government doesn’t want us to go below the Health Extension Workers.” His NGO had also been clearly directed to do “no training whatever” of army leaders and members. When asked why this restriction on training was in place, the official responded that the government wants to show its people that health-development “is a government effort, without any external input.” Other NGO officials also speculated that restrictions on training and remuneration were to ensure that the government had control over motivations and incentives, thus increasing their influence vis-à-vis NGOs.
One district level official hoped that the “hard” work—physical labor and extensive recordkeeping—would soon become the responsibility of the Women’s Development Army once the army was “strengthened.” Noting their responsibilities, one high-level NGO official commented, “Of course [what the army does is] work.”
The extent to which they believed it is not knowable given our methods, but they incorporated the narrative fully into their rhetoric.
This is not to say that the empowerment narrative does not exist within discourse about HEWs. Dr. Tedros Adhanom, other ministry leaders, and their development partners make much of providing health extension workers with not only a salary but also opportunities for some to continue their education and careers (USAID 2012).
From our preliminary observations in three districts of rural Amhara, the intended empowerment of Women’s Development Army leaders appears to reference only potential empowerment within the family, and not empowerment within the health bureaucracy. Neither health extension workers nor army leaders appear to be more “empowered” by these programs in the sense of holding higher level officials accountable, openly questioning policy and practice, and advocating for social and political changes (Maes et al. 2015). Recent qualitative work conducted in another part of Amhara regional state by Banteyerga (2014) suggests that through these same programs, Ethiopia’s government is in some cases genuinely encouraging more women to make open requests and demands of government, pertaining to their desires for more easily accessible health centers (not just the smaller and less comprehensive health posts), better selection and stock of medicines at government pharmacies, and warmer, better quality health care within health centers and hospitals. Future work in various parts of Ethiopia is needed to understand this variation.
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This research was funded by a National Science Foundation Cultural Anthropology Program grant to PIs Kenneth Maes and Svea Closser (#1155271/1153926).
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Maes, K., Closser, S., Vorel, E. et al. A Women’s Development Army: Narratives of Community Health Worker Investment and Empowerment in Rural Ethiopia. St Comp Int Dev 50, 455–478 (2015). https://doi.org/10.1007/s12116-015-9197-z
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DOI: https://doi.org/10.1007/s12116-015-9197-z