Reach Ethiopia

Publication & contribution


How many of persistent coughers have pulmonary tuberculosis? Population-based cohort study in Ethiopia. 

The Paper is here

  1. Abiot Bezabeh Banti1,2,
  2. Daniel Gemechu Datiko3,
  3. Sven Gudmund Hinderaker2,
  4. Einar Heldal4,
  5. Mesay Hailu Dangisso5,
  6. Gebeyehu Assefa Mitiku6,
  7. Richard Aubrey White7,
  8. Brita Askeland Winje4,8
  1. Correspondence to Dr Brita Askeland Winje;

Objective Many individuals with persistent cough and smear microscopy-negative sputum test for tuberculosis (TB) remain at risk of developing the disease. This study estimates the incidence of pulmonary TB (PTB) among initially smear-negative persistent coughers and its risk factors.

Design A prospective population-based follow-up study.

Setting Health extension workers visited all households in Dale woreda three times at 4-month intervals in 2016–2017 to identify individuals with symptoms compatible with TB (presumptive TB) using pretested and semistructured questionnaires.

Participants We followed 3484 presumptive TB cases (≥15 years) with an initial smear-negative TB (PTB) test.

Outcome measures Bacteriologically confirmed PTB (PTB b+) and clinically diagnosed PTB (PTB c+).

Results 3484 persons with initially smear-negative presumptive PTB were followed for 2155 person-years (median 0.8 years); 90 individuals had PTB b+ and 90 had PTB c+. The incidence rates for PTB b+ and PTB c+ were both 4176 (95% CI 3378 to 5109) per 100 000 person-years. We used penalised (lasso) and non-penalised proportional hazards Cox regression models containing all exposures and outcomes to explore associations between exposures and outcomes. In lasso regression, the risk of development of PTB b+ was 63% (HR 0.37) lower for people aged 35–64 years and 77% (HR 0.23) lower for those aged ≥65 years compared with 15–34 year-olds. Men had a 62% (HR 1.62) greater risk of PTB b+ development than women. The risk of PTB c+ was 39% (HR 0.61) lower for people aged 35–54 years than for those aged 15–34 years. Men had a 56% (HR 1.56) greater risk of PTB c+ development than women.

Conclusions PTB incidence rate among persistent coughers was high, especially among men and young adults, the latter signifying sustained transmission. Awareness about this among healthcare workers may improve identification of more new TB cases.

Can mHealth improve timeliness and quality of health data collected and used by health extension workers in rural Southern Ethiopia?

Webalem Mengesha 1, R. Steege 2, A.Z. Kea 1, S. Theobald 2, D.G. Datiko 1

1 REACH Ethiopia, Hawassa, Ethiopia

2 Department of International Public Health, Liverpool School of Tropical Medicine, Pembroke Place, Liverpool L3 5QA, UK Address correspondence to Rosalind Steege, E-mail:

 The paper is here


Background Health extension workers (HEWs) are the key cadre within the Ethiopian Health Extension Programme extending health care to rural communities. National policy guidance supports the use of mHealth to improve data quality and use. We report on a mobile Health Management Information system (HMIS) with HEWs and assess its impact on data use, community health service provision and HEWs’ experiences.

Methodology We used a mixed methods approach, including an iterative process of intervention development for 2 out of 16 essential packages of health services, quantitative analysis of new registrations, and qualitative research with HEWs and their supervisors.

Results The iterative approach supported ownership of the intervention by health staff, and 8833 clients were registered onto the mobile HMIS by 62 trained HEWs. HEWs were positive about using mHealth and its impact on data quality, health service delivery, patient follow-up and skill acquisition. Challenges included tensions over who received a phone; worries about phone loss; poor connectivity and power failures in rural areas; and workload.

Discussion Mobile HMIS developed through collaborative and locally embedded processes can support quality data collection, flow and better patient follow-up. Scale-up across other community health service packages and zones is encouraged together with appropriate training, support and distribution of phones to address health needs and avoid exacerbating existing inequalities.

Keywords CHWs, equity, ethics, Ethiopia, Health Management Information system, HEP, maternal health, mHealth, TB

  1. Mengesha, eHealth Project Coordinator
  2. Steege, PhD candidate

A.Z. Kea, Field Director for REACHOUT Project

  1. Theobald, Chair in Social Science and International Public Health

D.G. Datiko, Director

Health System strengthening

REACH Ethiopia contributes Imported LED FM, GENE Xpert machines, motorbikes Mobile phones , Computers, Scanners and Photocopy machines for health system strengthening

REACH Ethiopia has been implementing various TB REACH projects throughout its existence.
TB REACH project focuses on an innovative community-based approach that addresses neglected and poor communities with minimal health access and concentrates on the early identification of TB cases at the community level.
Health extension workers (HEWs)are front runners assigned at the health post level implementing a health extension program (constitutes 17 components) of which the community-based TB care package is one. HEWs are mandated to screen all individuals presenting to the health post and during their regular home visits for TB symptoms with particular attention to contacts of an infectious pulmonary TB. Through the process, identified presumptive TB cases are referred to the catchment health centers for clinical evaluation.
TB REACH project has been implemented to enhance health conditions and address poor communities and individuals who are suffering by TB. The situations were made to improve by procuring motorbikes and 1st technology Fluoresce microscopy as well as Xeprt machine that quality of diagnosis and treatment in SNNPR is better upgraded. REACH Ethiopia is a pioneer organizations to introduce these diagnostic technologies to Ethiopia. In addition, the organization exerted efforts to supporting the poorest of poor to be examined by x-ray all expenses covered.
REACH Ethiopia implemented TB REACH projects in Sidama Zone across 19 districts and 2 city administrations,9 districts of Silte Zone, 5 districts of Hadiya Zone and 13 districts and one City Administration of Gurage zone. Through project implementations the organization has donated the under shown diagnostic tools and other useful electronics to the smooth running of activities.

table1: Contribution of REACH Ethiopia to the community

Policy brief addressing TB and HIV

Expanding innovative community-based approaches:
enhance TB prevention and control efforts for maximum IMPACT

you can download

Author: Gemeda Bora (MEd, MA)
Year: 29 August, 2015
Presented at: Ethiopia National Experience Sharing Meeting, Lewi Resort, Hawassa


Though TB affects or at least used to affect all countries in the world, in most cases it appears to be a disease restricted to poor countries. One of the greatest challenges confronting service providers in these countries is that the best available treatments are of so limited quantity and are reaching only a s-mall fraction of people who need them. Since Ethiopia is categorized in the countries classified as poor, the challenge, if not worse, is no better than other countries. Ethiopia is the ninth high-TB burden country in the world, with an estimated 230,000 new cases of TB (incidence rate 247 per 100,000 populations) reported in 2012. The same is true with regional states, of which SNNPR is one.
Though Ethiopia has implemented a very unique health system extension program (HSEP) of which TB is one, the approach to reaching all corners of the nation and segments of the society was not producing favorable impression within the set time frame. In other words, this does mean, universal access to effective TB treatment is unachievable with current routines and traditional course of implementation. If to be achieved it needs an approach that accelerates it. Consequently, TB-REACH project implemented by REACH ETHIOPIA in collaboration with Ministry of Health, LSTM and The Global Fund was designed a complementary innovative approach. The approach was proven to be effective through the involvement of all stakeholders and within the set time.


A package of interventions include:

  • conducting extensive advocacy, communication and social mobilization (ACSM) activities;
  • engaging all stakeholders, councils, communities and Health Extension Workers (HEWs) in TB control activities;
  • training of HEWs, staff working in TB clinics and TB coordinators;
  • HEWs conduct house-to-house visits as part of the routine community-based activities and identify TB suspects, collect sputum samples, prepare and fix smears;
  • Then, HEWs contact supervisors by telephone to collect and transport smeared slides to laboratories for smear-microscopy;
  • Supervisors initiate treatment for smear-positive TB cases within their community and examine contacts of index cases and initiate Isoniazid preventive therapy (IPT) for asymptomatic young children;
  • HEWs support and supervise treatment and report drug adverse effects and treatment outcome;
  • The field team and the supervisors conduct regular supportive supervision and review meetings with HEWs and staff, discuss progress and challenges encountered and agree on action points2.


REACH Ethiopia made a concerted effort to engage community members, councils, other stakeholders, TB programmers at all levels, former TB patients and religious and community leaders to increase awareness about the disease as well as expanding availability of TB services at the community level. TB case finding nearly doubled in the first nine months of the initiative. Focusing on the elderly and disabled, women and children, the project has not only brought the million people living in Sidama, Hadiya, Silitie and Gurage Zones within the healthcare system, but the team turned TB into a disease that can be talked about out loud.

The innovative community-based approach has demonstrated that making TB diagnostics and treatment accessible at the community level increases the detection of cases, enhances treatment completion and reduces the stigma associated with the disease. ACF has significantly contributed for such achievement thus needs to be replicated across the nation.

REACH ETHIOPIA hopes such fruitful experience will soon be replicated all over the country and beyond.

Gaps In Non-Program Implementation Areas

Nearly in all parts of the nation TB notifications remain low despite major expansion of health services;

  • Efforts made to identify and treat those cases are far below satisfactory;
  • Though the disease seems to affect all segments of the society indiscriminately, poor continued to be more affected at far greater rates than their richer counterparts;
  • Much of the efforts focus on curative aspect and interventions as the community based approach is totally ignored if not, not well promoted;
  • Passive case finding approach followed/employed and TB cases are identified among patients visiting health facilities;
  • TB diagnostic centers in most cases are located in urban and semi-urban areas and patients often need to make several visits before initiating treatment;
  • These visits are burdensome for rural population, women, children, elderly and patients with disabilities;
  • Geographic accessibility, socioeconomic and cultural barriers affect health seeking behavior of the communities;
  • Stigma associated with TB and lack of awareness about the disease and availability of the services further compromise service utilization;

Key Recommendations

  1. Expand Active Case finding (ACF) across the region and Ethiopia, and address TB more effectively and for maximum IMPACT;
  2. Include all health professionals, build their capacities and apply task-shifting on activities like sputum collection, smearing, etc;
  3. Put concerted effort towards strengthening community education program in order to combat ignorance, fear and stigma with knowledge of how to diagnose, prevent and treat TB;
  4. Invest in facilities, human and other resources to properly isolate and treat TB;
  5. Overcome the compounded problem by improved laboratory infrastructure and diagnostic equipment;
  6. Expand and enhancement DOTS in every corners of the region and nation;
  7. Engage all care providers;
  8. Empower patients and communities;
  9. Strengthen follow up that adherence to TB treatment is maintained as this is the main cause of drug resistance;
  10. Promote researches;
  11. Contributing to health systems strengthening;


  1. TB and HIV Concept note, 15 October 2014
  2. TB-REACH short summary, unpublished
  3. BMC-Public health 2015; Patient and community experience of tuberculosis diagnosis and care within community based intervention in Ethiopia: a qualitative study 25February,2015
  4. The complexity of attending TB diagnostic services for adults in resource poor settings, November, 2012



Objectives: This study assesses the feasibility of female health extension workers (HEWs) using eHealth within their core duties, supporting both the design
and capacity building for an eHealth system project focussed initially on tuberculosis, maternal child health, and gender equity.

Participants: Health extension workers, Health Centre Heads, District Health Officers, Zonal Health Department and Regional Health Bureau
representatives in Southern Ethiopia.

Setting: The study was undertaken in Southern Ethiopia with three districts in Sidama zone (population of 3.5 million) and one district in Gedeo zone
(control zone with similar health service coverage and population density).

Methods: Mixed method baseline data collection was undertaken, using quantitative questionnaires (n= 57) and purposively sampled qualitative
face-to-face semi-structured interviews (n= 10) and focus group discussions (n= 3).

Results: Themes were identified relating to HEW commitment and role, supervision, and performance management. The Health Management
Information System (HMIS) was seen as important by all participants, but with challenges of information quality, accuracy, reliability and timeliness.
Participants’perceptions varied by group regarding the purpose and benefits of HMIS as well as the potential of an eHealth system. Mobile phones were
used regularly by all participants.

Conclusion: eHealth technology presents a new opportunity for the Ethiopian health system to improve data quality and community health.
Front-line female HEWs are a critical bridge between communities and health systems. Empowering HEWs, supporting them and responding
to the challenges they face will be an important part of ensuring the sustainability and responsiveness of eHealth strategies. Findings have
informed the subsequent eHealth technology design and implementation, capacity strengthening approach, supervision, and performance management approach

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Long-term outcome of smear-positive tuberculosis patients after initiation and completion of treatment: A ten-year retrospective cohort study



The status of tuberculosis (TB) patients since initiation of treatment is unknown in South Ethiopia. The objective of this study was to assess the long-term outcomes of smear-positive TB patients since initiation and completion of treatment, which includes TB recurrence and mortality of TB patients.


We did a retrospective cohort study on 2,272 smear-positive TB patients who initiated treatment for TB from September 1, 2002—October 10, 2012 in health facilities in Dale district and Yirgalem town administration. We followed them from the date of start of treatment to either the date of interview or date of death.


Recurrence rate of TB was 15.2 per 1000 person-years. Recurrence was higher for re-treatment cases (adjusted hazard ratio (aHR), 2.7; 95% CI, 1.4–5.3). Mortality rate of TB patients was 27.1 per 1,000 person-years. The risk was high for patients above 34 years of age (aHR, 2.1; 95% CI, 1.2–3.9), poor patients (aHR, 1.3; 95% CI, 1.0–1.8), patients with poor treatment outcomes (aHR, 6.7; 95% CI, 5.1–8.9) and for patients treated at least 3 times (aHR 4.8; 95% CI, 2.1–11.1). The excess mortality occurred among patients aged above 34 years was high (41.2/1000 person years).


High TB recurrence and death of TB patients was observed among our study participants. Follow-up of TB patients with the risk factors and managing them could reduce the TB burden.

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‘The phone is my boss and my helper’ – A gender analysis of an m Health intervention with Health Extension Workers in Southern Ethiopia


There is considerable optimism in mHealth’s potential to overcome health system deficiencies, yet gender inequalities can weaken attempts to scale-up mHealth initiatives. We report on the gendered experiences of an mHealth intervention, in Southern Ethiopia, realised by the all-female cadre of Health Extension Workers (HEWs).


Following the introduction of the mHealth intervention, in-depth interviews (n = 19) and focus group discussions (n = 8) with HEWs, supervisors and community leaders were undertaken to understand whether technology acted as an empowering tool for HEWs. Data was analysed iteratively using thematic analysis informed by a socio-ecological model, then assessed against the World Health Organisation’s gender responsive assessment scale.


HEWs reported experiencing: improved status after the intervention; respect from community members and were smartphone gatekeepers in their households. HEWs working alone at health posts felt smartphones provided additional support. Conversely, smartphones introduced new power dynamics between HEWs, impacting the distribution of labour. There were also negative cost implications for the HEWs, which warrant further exploration.


MHealth has the potential to improve community health service delivery and the experiences of HEWs who deliver it. The introduction of this technology requires exploration to ensure that new gender and power relations transform, rather than disadvantage, women.
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Context Analysis: Close to Community Providers in Ethiopia

Many countries are striving to achieve the Millennium Development Goals (MDGs) and universal health coverage. In the 1970s, countries invested in Community Health Workers (CHWs) who received basic training and were often volunteers. However, programmers involving CHWs went into decline due in part to political instability, economic policies and difficulties in financing. There has been recent and renewed interest in strengthening community-level services, using a variety of close-to-community (CTC) providers.

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About Us

REACH Ethiopia grew out of a TB project that started in 2010. This project introduced an innovative community package that engaged health extension workers (HEWs) to increase TB case detection and treatment adherence.

Address: Addis Ababa, Ethiopia