Ethiopia’s Community Health Workers Are Saving Tens of Thousands of Lives

For the nearly 6 million women in the United States living in a county without an obstetric care provider, and the 26 million people who face language or cultural barriers to care, the gap between their community and the health system can feel daunting. Around the world, countries like Bangladesh, Brazil, China, Nepal, and Pakistan have pioneered community health worker (CHW) programs to bridge these care gaps.

CHWs are trusted liaisons who typically live in the communities where they work. They offer health education, connect people with providers, and, in some cases, even administer vaccines. For a non-English-speaking mother-to-be in rural Texas, access to a CHW could mean the difference between a healthy or an unhealthy delivery.

As U.S. policymakers explore options like telehealth to expand access to health care, less expensive CHWs remain underutilized nationally. CHW programs have been shown to improve population health outcomes and quality of life, all while lowering overall health care costs and reducing hospital admissions, particularly in the context of racial and geographic health disparities.

No country demonstrates this better than Ethiopia, which has managed to dramatically reduce maternal mortality and mortality for children under age 5 since the implementation of their CHW program almost 20 years ago.

How Ethiopia Became the Gold Standard for Community Health Work

Two decades ago, over 60 million rural Ethiopians were struggling to access health care because of provider shortages and long distances to health facilities. In 2003, the Ministry of Health introduced the Health Extension Program (HEP) to train and employ people in rural areas with the aim of achieving universal primary care.

By January 2024, there were some 3 million CHWs in the country. These included about 42,000 health extension workers (HEWs), who are trained health care providers, and 3 million volunteers called the Health Development Army (HDA), who are tasked with supporting HEWs. HEWs receive one year of training prior to their deployment as well as in-service training to continually update their knowledge and skills as their responsibilities expand. They are also paid a salary to help their communities with health promotion, disease prevention, first aid, immunizations, and treatment of common illnesses like malaria, diarrhea, and malnutrition. HEWs are overseen by the woreda, or a district-level team, made up of a health officer, public health nurse, hygiene expert, and health education expert.

HDAs focus mainly on promoting safe hygiene and sanitation practices, serving as a “model household” within their communities. While they are not formally integrated into the health system, new pathways are being implemented to allow them to become HEWs. HDA volunteers, who are unpaid, receive training at the discretion of their local HEW and work less than two hours per week.

Ethiopia’s CHW program has contributed to dramatic improvements in health outcomes, including a more than 100 percent drop in maternal mortality and mortality for children under age 5. It’s globally recognized as a standard for community health work. Studies also demonstrate the cost-effectiveness of the program, as measured by health spending relative to health outcomes.

Still, CHWs face persistent challenges, including a lack of medical equipment and drugs, inconsistent supervision and training, high turnover, low salaries, and some resistance from communities due to lack of trust.

U.S. Community Health Worker Programs Need Support

More than 100 million Americans either lack access to a regular source of primary care or face a provider shortage in their communities. In addition, a growing lack of trust in a complex health system inhibits some patients from getting the services they need to stay healthy. CHWs are in a unique position to address these challenges, which disproportionately harm people of color living in residentially segregated communities.

While CHWs exist in some U.S. localities, they have not been integrated into the broader health system as in Ethiopia. In part, that's because of the greater emphasis on care delivered in hospital and clinical settings in the U.S. Health care providers in the U.S. are also paid for the services they’ve already delivered — rather than for the quality or outcomes of their services — which disincentivizes the preventive and maintenance support CHWs provide. Additional barriers include inadequate reimbursement rates and lack of training opportunities. In 2024, only 29 of 48 state Medicaid agencies reported reimbursements for CHWs, and just 11 states had state-operated CHW certification programs.

Fact: In the U.S., the top four populations served by CHWs are people without insurance, rural residents, non-English-speakers, and those with complex health care needs.

Despite these challenges, there are some successful CHW programs underway:

• The Community Health Worker-Based Chronic Care Management Program, which operates in 31 U.S. counties across three states, provides weekly home visits to address people’s care plans, medication adherence, self-management goals and progress, and any broader needs that impact health. The program has led to significant reductions in participants’ blood sugar levels, emergency room visits, and hospitalizations, along with saving $5,000 per patient over four months.
• Kentucky Homeplace has trained hundreds of CHWs serving nearly 197,000 clients in Appalachian Kentucky since 1994. The program has reduced emergency room visits by 10 percent, lowered inpatient admissions by 23 percent, and saved an estimated $2,300 annually per patient through its chronic disease pilot program.
• The Nurse Navigator and Recovery Specialist Outreach Program operates in rural Pennsylvania counties by pairing nurses with CHWs to support about 360 people with substance use disorders. The program has decreased hospitalizations, improved self-reported health outcomes, and reduced emergency department visits from 91 percent to 59 percent over three years.

Community health workers have delivered impressive returns on investment in countries like Ethiopia and in some counties in the United States. But unless policymakers consistently fund these programs and incorporate them into the health system, they will never reach their full potential.

The author would like to thank Dr. Anand Shah and Tigist Astale for their review of this Insight.