Insights to optimizing health extension workers’ time use and efficiency in Ethiopia: a qualitative study

BackgroundThe Health Extension Program (HEP) is Ethiopia's flagship program introduced in 2003 to ensure equitable access to primary healthcare services. Recently, inefficiency in the time use patterns of staff of the HEP, including absenteeism and non-productive engagements, has been reported as a major challenge.ObjectiveThis qualitative study explored what factors influenced their time use and efficiency.MethodsThis is a qualitative study that was conducted in rural health posts (HPs) across Ethiopia in three rounds over a period of 12 months (17 May 2023 to 16 May 2024). Qualitative data were collected through key informant interviews (KIIs), in-depth interviews (IDIs), and focus group discussions (FGDs) involving HEWs and other staffs of health posts, their supervisors, Kebele leaders, Women's Development Army (WDA), teachers, and other community members. A total of 52 KIIs, 31 IDIs, and 28 FGDs were conducted in three rounds. Data were analyzed using ATLAS.ti 7.1.18 software.ResultsHEWs commonly spent their time on productive non health or non-HEP activities such as those related to community-based health insurance, agricultural and rural development and education sectors, and other political assignments. It was also noted that HEWs could be available in their workplace, but might not be productive. Factors for the inefficiencies across HPs often pertained to environmental and demographic features, community trust and engagement, local administration; human resource development and management practices, multisectoral collaboration; and underlying causes of absenteeism including motivation.ConclusionInefficiencies are common among HEWs. Strategies need to be devised focusing on the identified modifiable factors such as improving accountability and performance management practices, introducing incentive mechanisms to keep HEWs motivated, improving accessibility to transportation services, and security conditions, workforce to population size ratio; and capacity building.