The Sustainable Development Goals (SDGs) through its pledge of “leave no one behind” in the 2030, affirmed the global commitment of nations to achieving the development needs of people by addressing avoidable disparities (1). Promoting health equity has been a global agenda widely promoted by national and global agencies, for several decades (2–4). Substantial progress has been made in improving overall health status of populations throughout the world. However, there are still significant health disparities within and between nations (5, 6).
In the health sector, equity has been broadly defined as the absence of avoidable, unfair, or remediable differences in health among subgroups of a population and/ or locations. Operationally, health equity is measured and monitored in terms of the extent of disparities in health status and health outcomes, including the occurrence of disease, disability, or death among populations in different socioeconomic, demographic, and geographic categories (7).
Disparities in health service coverage and health outcomes remain to be a challenge in Ethiopia despite some progress (8–11). The Ethiopian health sector takes into account socio-economic and geographic differences in health status and health service-related indicators as dimensions of equity that require mitigation actions. Geographic disparities, which overlap substantially with disparities across regions and livelihood categories, has been a primary focus of programs intending to promote health equity in the country (12). The difference between Economically Advanced Agrarian Regional States (EAARS: Tigray, Amhara, Oromia, SNNPR) and Developing Regional States (DRS: Afar, Somali, Benishangul Gumuz, Gambella) has been a major focus during the periods of the Health Sector Development Program (HSDP) and Health Sector Transformation Plan (HSTP) (13, 14).
The Health Extension Program (HEP), launched in 2003, is one of Ethiopia’s major investments designed to improve the health of communities. The HEP is a community-based health program that was initially designed to deliver 16 packages of health services to agrarian communities (15, 16). Later, the program evolved in various ways, including adaptations for pastoralist and urban communities, making changes to existing packages, and including two additional packages and upgrading training of Health Extension Workers (HEWs). In 2019, the program involved more than 39,878 HEWs and 17,587 community health posts (HPs) (17). The program has been acknowledged as a flagship program and a major contributor to recent gains in health outcomes in the country. This program has made a significant contribution in improving access to and coverage of basic health services in Ethiopia (18).
Despite remarkable improvements in health service coverage, evidence from the 2019 Mini-EDHS,(11) and the 2018 Service Availability and Readiness Assessment (19, 20) indicated that there are substantial disparities between regions, urban and rural, and agrarian and pastoralist settings (21–23). Health indicators in DRSs are much lower than national averages. For instance, modern contraceptive use is 12.7% in Afar and 3.4% in Somali compared to over 30% in agrarian regions. Only 11.1% and 31.1% of pregnant women in Afar and Somai regions, respectively, have four or more antenatal care visits during their recent pregnancies as compared to 64% in Tigray region and 51% in Amhara region. Similarly, only 20% of children in Afar and 18% of children in Somali region have received all basic vaccinations as compared to 83% in Addis Ababa, 73% in Tigray and 62% in Amhara (24).
Though disparities in health service coverage and health outcomes at population levels have been investigated, there is limited evidence on equity and disparities in the implementation of HEP and their impacts on access to and coverage of basic health services across regions in Ethiopia. Therefore, the aim of this study was to examine disparities in the implementation of HEP in Ethiopia. More specifically, the study examined disparities in availability of basic inputs of HEP, accessibility of selected HEP services to the target populations, and coverage of selected HEP services.