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BMJ Glob Health. 2017 Nov 2;2(4):e000390. doi: 10.1136/bmjgh-2017-000390. eCollection 2017.

Health extension workers improve tuberculosis case finding and treatment outcome in Ethiopia: a large-scale implementation study.

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REACH Ethiopia, Hawassa, Ethiopia.
The Global Fund to Fight AIDS, Tuberculosis and Malaria, Geneva, Switzerland.
Faculty of Clinical Sciences and International Health, Liverpool School of Tropical Medicine, Liverpool, UK.
Royal Tropical Institute (KIT), Amsterdam, The Netherlands.
Stop TB Partnership, Geneva, Switzerland.



Tuberculosis (TB) is a major cause of death in Ethiopia. One of the main barriers for TB control is the lack of access to health services.


We evaluated a diagnostic and treatment service for TB based on the health extension workers (HEW) of the Ethiopian Health Extension Programme in Sidama Zone, with 3.5 million population. We added the services to the HEW routines and evaluated their effect over 4.5 years. 1024 HEWs were trained to identify individuals with symptoms of TB, request sputum samples and prepare smears. Smears were transported to designated laboratories. Individuals with TB were offered treatment at home or the local health post. A second zone (Hadiya) with 1.2 million population was selected as control. We compared TB case notification rates (CNR) and treatment outcomes in the zones 3 years before and 4.5 years after intervention.


HEWs identified 216 165 individuals with symptoms and 27 918 (12%) were diagnosed with TB. Smear-positive TB CNR increased from 64 (95% CI 62.5 to 65.8) to 127 (95% CI 123.8 to 131.2) and all forms of TB increased from 102 (95% CI 99.1 to 105.8) to 177 (95% CI 172.6 to 181.0) per 100 000 population in the first year of intervention. In subsequent years, the smear-positive CNR declined by 9% per year. There was no change in CNR in the control area. Treatment success increased from 76% before the intervention to 95% during the intervention. Patients lost to follow-up decreased from 21% to 3% (p<0.001).


A community-based package significantly increased case finding and improved treatment outcome. Implementing this strategy could help meet the Ethiopian Sustainable Development Goal targets.


diagnosis; health extension workers; treatment; tuberculosis

Conflict of interest statement

Competing interests: SS and JC work at the Stop TB Partnership and coordinated the proposal review committee which makes funding allocations for TB REACH, but did not participate in the funding decisions. Their contribution focused on sharing lessons learnt from similar TB REACH projects, the contextualisation of the project within the international initiatives, suggesting ways the project could improve performance and engaging international stakeholders to promote support for the project. LB was the independent monitoring and evaluation expert and interpreted surveillance and the project’s databases over the project lifetime. She reported to TB REACH on project performance. Final decisions on project implementation were taken by DGD, MAY, SJT and LEC.

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