Published in PLOS One on 2026-07-20, this study is presented as an attributed evidence briefing. The excerpts below are the original researchers’ words, reproduced under their Creative Commons Attribution licence. Health Signal has selected the abstract and, where needed, opening background paragraphs; the complete methods, results, limitations and references remain in the linked paper.
Original authors: Kora Tushune Godana, Zewdie Birhanu, Gugsa Nemera, Kasahun Eba, Fikadu Balcha, Yibeltal Assefa, Wim V. Damme, Peter Decat
Source: PLOS One • DOI 10.1371/journal.pone.0351989
Read the complete primary study ↗ · Creative Commons Attribution licence
From the researchers
Abstract
Ethiopia’s Health Extension Program (HEP) aims to improve primary care access through community-based delivery of essential preventive and promotive services. Despite progress, some health outcomes remain suboptimal, underscoring the need to optimize HEP implementation. Identifying barriers of the HEP and its Health Extension Workers (HEWs) is critical for enhancing program effectiveness. This scoping review aims to identify and synthesize evidence on the barriers impacting the performance of the Ethiopian HEP and HEWs.
A comprehensive search strategy was conducted across multiple databases, including PubMed, EMBASE, Web of Science, and relevant institutional websites, as well as hand searches via Google Scholar and Google engine, to identify both published and unpublished documents (documents (government reports and policy documents (strategic plans, program reviews, annual performance reports), development partner publications, doctoral dissertations, and masters theses) related to the HEP. The review encompassed studies published since January 2003. Data extraction was performed using Atlas.ti software version 7.5.18, which facilitated the collection of verbatim excerpts and the application of thematic coding to highlight key findings. The results are organized and presented through thematic analysis, focusing on multi-dimensional barriers and challenges.
The review reveals multi-dimensional barriers, including a misalignment between the HEP’s preventive design and the community’s demand for curative services, which undermines community trust and program acceptance, and gender-imbalanced workforce, which creates barriers to service delivery in certain cultural contexts. Additional barriers include a lack of training and retention strategies, and digital literacy and access gaps which further impede effectiveness of the program. Excessive workloads, non-health tasks, and poor living conditions, divert HEW’s focus from their primary responsibilities. Weak community engagement, inadequate integration of Traditional Birth Attendants (TBAs), and inefficiencies in model family development limit the program’s impact. Misconceptions in the community, resource constraints, fragmented stakeholder interactions, ineffective supervision, governance issues, and political interference directly impede performance.
The HEP faces deeply entrenched, multi-dimensional barriers that limit its potential to achieve optimal health outcomes. Key policy recommendations include integrating curative services, ensuring a balanced gender mix in the workforce, improving working conditions and expanding community engagement. Further research is needed to quantify barriers, assess their impact, and identify key influencing factors, with stakeholder engagement and implementation research being essential for developing effective solutions.
Introduction
The Health Extension Program (HEP) is a community-based primary healthcare initiative established by the Ethiopian government in 2003 to enhance healthcare accessibility and outcomes in rural and remote regions [1]. Focusing on essential preventive and promotive care [2,3], the HEP has played a pivotal role in achieving Ethiopia’s health-related Millennium Development Goals [4].
Despite widespread recognition of the HEP as a critical component for advancing health-related indicators, empirical evidence reveals systemic and operational barriers impeding its performance. For instance, one study reported barriers related to Health Extension Worker (HEWs) productivity working environment, and living conditions in addition to capacity of health posts and, social determinants of health [5]. Several other research works identified factors like insufficient medical equipment and pharmaceutical supplies, limited supervision, the absence of a robust referral system, high turnover rates among HEWs, a lack of clear career progression for HEWs, uncompetitive salary structures, and the constrained scope of the Health Extension Program (HEP) as barriers to its efficacy [6–8]. Furthermore, studies have highlighted that HEWs often lack essential skills due to limited support and that socioeconomic barriers impede access to healthcare services, particularly for marginalized groups [9,10].
Reading this evidence
Use the full paper to check the study design, participant selection, comparator and outcome definitions before drawing a practical conclusion. An association does not by itself show cause and effect. A reported performance measure needs its denominator and uncertainty. A finding from a particular facility, sample or time period should retain that scope when it is discussed elsewhere.
This briefing makes the source accessible within the wider hospital systems desk. It does not assess an individual patient or certify a product. When considering relevance to another health system, examine the original authors’ account of context and limitations, then seek local implementation evidence. The related reporting below provides other studies to read alongside this one; it is a topic connection, rather than a claim that their results are directly comparable.
© 2026 Kora Tushune Godana, Zewdie Birhanu, Gugsa Nemera, Kasahun Eba, Fikadu Balcha, Yibeltal Assefa, Wim V. Damme, Peter Decat. Excerpts reproduced under CC BY. Selection, formatting and contextual notes by Health Signal. The researchers are the authors of the source study, not members of Health Signal’s staff.
Explore connected evidence
- Evidence brief: Balancing adaptations and fidelity of implementation strategies to optimize primary healthcare in Ethiopia: Lessons from embedded implementation research
- Evidence brief: Barriers of last mile supply chain management and reproductive, maternal, new born, and child health product availability in Ethiopia
- Evidence brief: Perceptions and experiences of women and providers on barriers and facilitators of quality emergency obstetric and newborn care services in public hospitals of West Shoa Zone, Oromia, Ethiopia: A phenomenological qualitative study
