Introduction

The Health Extension Program (HEP) in Ethiopia has made a significant impact by increasing essential healthcare services, resulting in better maternal and child health outcomes, and increased community health awareness. However, the program faces challenges including inadequate salaries and incentives; lack of training, support and supervision; limited opportunities for career development; high workloads; resource constraint; and mismatch in community expectation and skills of Health Extension Workers (HEWs). To address these challenges, the HEP optimization roadmap outlines strategic shifts, including improvements in human resources, infrastructure upgrades, and the transformation of remote health posts into comprehensive facilities. It also advocates for merging nearby health posts with catchment health centers or hospitals. Importantly, the roadmap stresses the need for community engagement, proposing initiatives like the Village Health Leaders structure to ensure local participation in the healthcare system [1].

Health Extension Workers as community health workers are increasingly being recognized as an essential cadre for the achievement of Sustainable Development Goals (SDGs), Universal Health Coverage (UHC), and the future health agenda, especially in settings where resources are constrained and human resources are limited. To this end, community-based health programs are platform and vehicle for delivering essential health services such as maternal and child health services to the communities [2–4]. If managed and implemented well, community-based strategies improve health outcomes, including increasing antenatal care (ANC) visits, micronutrient supplement uptakes, improving birth planning, and increasing care-seeking for pregnancy complications and institutional delivery [3].

Based on the guiding principle of Primary Health Care (PHC), Ethiopia launched a community-based healthcare system in 2003, the HEP to increase access to primary care and improve population health outcomes by reaching the grassroots community [5,6]. The HEP assigns two female salaried HEWs to implement eighteen packages of health services organized under four main themes: 1) Disease Prevention and Control, 2) Health Education and Communication, 3) Hygiene and Environmental Sanitation, and 4) Family Health through widely dispersed community health posts, home visits, and other means of outreach strategies [5–7]. The HEP is based on the assumption that access to and quality of essential preventive and selected curative primary health care for grassroots communities can be improved through the transfer of health knowledge and skills to communities and households using those trained, salaried, female cadres, as major workforce. Most importantly, the HEP aims to realize UHC through which all Ethiopians can access needed health services, including health promotion, disease prevention, treatment of minor conditions, rehabilitation and palliative care. Over time, the program has gone through several phases and evolutions with the intention of meeting the changing needs of communities and respond to ever-changing health challenges. For instance, in principle, the HEWs who were initially trained for one year has been upgraded to level IV training, and the health service packages they are supposed to deliver has also been upgraded to include basic curative services and other essential packages such as chronic diseases, and mental health aspects [8,9]. Moreover, in 2010, the HEP introduced a new community engagement strategy, the women and men-centered Health Development Army (HDA), to promote participatory community engagement and adoption of healthy lifestyles and to improve the uptake of critical health services. The HDA is composed of five members and referred to as one-to-five women networks [10]. Health Extension Workers and local administrators, in collaboration with community members, identify and train model households who become leader of the one-to-five network. All members of HDA are expected to participate in the implementation of HEP, particularly support HEWs by identifying and linking pregnant women to the health system [11]. In 2020, Ethiopia developed its HEP optimization roadmap 2020–2035 in alignment with the Health Sector Development and Investment Plan (HSDIP). The roadmap contains several transformative initiatives that will be rolled out in phases towards the goal of achieving UHC [12].

Although significant progress has been documented, several poor health outcomes are still high in Ethiopia, suggesting the uptake of the HEP packages is still not optimal despite decades of implementation and efforts. The UN estimates the maternal mortality ratio (MMR) in Ethiopia for 2020 at 267 maternal deaths per 100,000 live births, showing significant progress in reducing maternal mortality, though still far from the SDG target of 70. According to the Mini Demographic and Health survey report, in Ethiopia, 74% of women aged 15–49 had a live birth in the 5 years before the survey received ANC from a skilled provider for their most recent birth. However, the fact that only 43% of women had at least four ANC visits during their last pregnancy highlights the urgent need for improvement in maternal healthcare [13].

Over the past decade, a substantial amount of research has been conducted on HEP, yet there is still need to understand factors that could enable the performance of the HEP cadres and the program. Given that HEP is the backbone of the national health system and will remain the primary strategy to enhance Ethiopian health status, it is imperative to map and synthesize existing evidence to construct the enablers of HEWs/HEP over the decades of implementations experience. In this regard, it is essential to understand how the multiple enabling factors with its multiple levels operate to influence the provisions of HEP services positively. However, in-depth evidence is lacking on the subject, and an evidence base need to be built up to through examine literatures to map what factors could enable the performance of the program, which lead to building up the pathways to better performance optimization of the performance of the HEP/HEWs. Such knowledge will contribute to identifying critical intervention pathways for optimization of the performance in Ethiopia and similar settings. Therefore, it is timely and imperative to identify and document important enabling factors for the HEP in Ethiopia. Understanding critical enabling factors to HEP/HWs would have several implications and significance to the program

This scoping review maps evidence on enabling factors that influence the implementation of the HEP in Ethiopia, which could offer insights that support its effective execution. It also contributes to the existing literature and informs strategies to strengthen HEP implementation in Ethiopia and similar community-based health programs elsewhere.

Methods

This scoping review was conducted using the methodology developed by the Joanna Briggs Institute 98 (JBI) [14]. The review followed a priori protocol, which is publicly available in Open Science Framework (https://osf.io/z2wf6/metadata/osf).

Deviations from the Protocol: There were some deviations were made from the original protocol. Firstly, the authors expanded the scope of the review question to comprehensively explore the multidimensional performance enablers of Ethiopian HEP. This broader approach aimed to construct and leverage available literature documenting enablers on this program since its inception. In contrast to the original protocol, which had a narrower focus, the current review prioritizes identifying key enabling factors that are essential for enhancing and optimizing HEP implementation. The authors believe that this expansion to include questions about performance enablers allows for a deeper understanding of the multifaceted elements that empower and facilitate the program’s success.

Our analysis in this review focused specifically on identifying the enabling and facilitating factors that influence the performance of HEWs and the HEP. The review process involved developing specific inclusion criteria based on the Population, Concept, and Context (PCC) framework [15,16]. Population, Concept, and Context allowed us to identify the target populations involved in or impacted by the HEP, specify the key concepts related to the performance of HEWs and the HEP, and define the contexts and settings relevant to the review. The following sections detail the specifications used to conduct the review, with a focus on mapping the enabling and facilitating factors of the Ethiopian HEP.

Results

Study selection

A total of 9733 records were identified through database searches and an additional 149 records were found via other methods after the removal of 187 duplicates, 9694 records were screened based on title and abstract, and 9336 of those were excluded. The full texts of 210 records were assessed for eligibility, and 11 were excluded. Reasons for exclusion were due to context, concept, population and content irrelevances. A total of 141 documents included in barriers and enablers review out of which 44 documents were reviewed and included in this review. The search results and study selection process are summarized in Fig 1.

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Fig 1. PRSIMA flow diagram of study selection process.

https://doi.org/10.1371/journal.pone.0324377.g001

Review findings

Availability of resources, supporting facilities and basic infrastructures

This review highlights the crucial role of adequate resources, including medical supplies (e.g., essential medicines, contraceptives, vaccines, and consumables) and basic yet essential equipment (e.g., thermometers, fetoscopes, and stethoscopes), in enabling HEWs to effectively perform their duties [18,19,46,49,58,59]. For instance, one of the documents reviewed reported that health posts which got drug supply are 7.19 times functional than when compared to those who did not [58]. The review also indicated that the availability of office materials (such as furniture, stationaries), electric supply, water supply, and telephone at health post as well as transportation for HEWs, maternity waiting homes, and exempted medical services at nearby health centers could enhanced HEWs performance [3,18,19,26,43,46].

Improved living and supportive work environments for HEWs have been shown to positively impact their retention, performance, and the overall effectiveness of HEP [39,40,80]. For instance, one of the reviewed documents found that providing better housing for HEWs led to a 15% increase in the number of households visited and 20% improvement in the quality of health services delivered. Similarly, improved working conditions and support lower attrition by 25% when compared to their peers with poorer work environments [76]. The factors that enhance the performance of HEWs and the HEP is highlighted in the conceptual framework in Fig 2.

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Fig 2. Conceptual Framework of Enabling Factors Influencing Health Extension Workers’ Performance.

The figure highlights the conceptual framework’s focus on factors that enhance the performance of HEWs and the HEP as emerged through synthesis of evidence from the review. As depicted in the figure there are multidimensional enabling and facilitating factors contributing to pathways for enhanced or better HEWs/HEP performances.

https://doi.org/10.1371/journal.pone.0324377.g002

Discussion

This scoping review synthesized the enabling factors that enhance the performance of HEWs and Ethiopian HEP. The findings were conceptualized into eight major themes and sub-themes: motivation factors, diversification and adaptation of services, capacity building and support, community engagement, trusting relationships, and resource availability. Intrinsic and extrinsic motivation are crucial drivers of HEW performance. Diversifying and adapting HEP services, workforces, and target populations improve program reach and impact. Continuous capacity building and robust support systems are essential for maintaining HEW performance. Engaging communities, utilizing local structures and leadership, and coordinating stakeholders are key strategies for improving HEP outcomes. Trusting relationships between the community and HEWs fosters collaboration and program success. Additionally, improved resources, facilities, and infrastructure at health posts, along with better living and working conditions for HEWs, enhance their performance and the program’s efficiency. These themes highlight strategies to optimize HEW performance and improve the effectiveness of the Health Extension Program.

The review indicated that Intrinsic and extrinsic motivational factors play a substantial role in enabling HEWs to perform their jobs effectively, thereby contributing to the enhanced performance of the HEP. Consequently, from the review, several intrinsically driven motivation mechanisms that motivate HEWs to engage in HEP for their own sake rather than for external rewards, such as being satisfied with their job, inherent passion and desire to serve the society they came from and were born from (community and social connections) conceived as fulfilling societal obligations and sense of belongingness were documented as powerful motivators of HEWs to perform their jobs. When these workers experience job satisfaction, they are more likely to be engaged, committed, and effective in their roles, leading to improved retention rates and better program outcomes. Many HEWs are driven by a strong desire to help their communities and make a positive impact, which can lead to increased effort and dedication. Additionally, fulfilling societal obligations is a powerful motivator, as these workers often view their roles as a way to give back to their communities and uphold cultural values. These factors could lead to higher job satisfaction and motivation, such as recognition, opportunities for advancement, and the nature of the work itself [81]. These intrinsic factors, on the other hand, could play an important role in enabling and boosting Hew’s commitment and performance. It is essential to focus on their intrinsic motivations by ensuring and reinforcing their sense of societal obligation and belonging and their work is meaningful, offering growth opportunities, and supporting their community ties and social connections, integrating cultural and personal values to ensure that the HEP work aligns with the health HEWs’ personal values and cultural beliefs, reinforcing their sense of purpose.

The review highlighted that extrinsic motivation factors can be powerful drivers of Hew’s performance. Factors such as career development opportunities, incentives (both in-kind and financial), competitive compensation, and recognition from supervisors, peers, and the broader community were identified as particularly effective motivators. Providing access to training, education, and pathways to advancement can effectively increase motivation and job performance through improved career development opportunities. By catering to HEWs’ desires for professional growth, financial rewards, and social recognition, organizations can tap into powerful extrinsic motivators that complement intrinsic sources of motivation. A multifaceted approach that addresses extrinsic and intrinsic factors is likely to yield the best results in driving sustained high performance. It should be noted that combining intrinsic and extrinsic motivational factors is key to unlocking the full potential of this vital cadre of frontline health providers to enable them to perform better performance. By addressing intrinsic and extrinsic motivational factors, the Ethiopia HEP can create a holistic approach to supporting and empowering HEWs, ultimately leading to improved healthcare service delivery and better health outcomes for their communities.

Studies in low-and middle-income settings and other contexts indicated that a combination of intrinsic and extrinsic motivational elements is essential for enabling and maintaining high-quality performance among community health workers in resource-constrained settings. A systematic review found that intrinsic motivators such as altruism and community embeddedness and extrinsic factors like financial incentives and career advancement opportunities were critical for driving strong performance [39]. Similarly, a qualitative study in Tanzania by Greenspan et al. identified key intrinsic motivators for community health workers, including a sense of purpose, personal growth, and connection to their communities; extrinsic factors like financial remuneration, supplies, and pathways for career development were also important motivators [81]. They emphasized the need for a comprehensive approach to improving community health worker performance, addressing intrinsic motivators (e.g., recognition) and extrinsic incentives (e.g., compensation, training). This multi-pronged strategy is crucial for optimizing the contributions of community health workers and sustaining their engagement over the long term [82].

The review revealed several interesting findings regarding how diversifying the Ethiopian HEP could enable the HEWs and the overall program to perform more effectively. The concept of diversification was explored from multiple perspectives: Contextualization and Adaptation of the HEP to the varied socio-cultural contexts, health needs, and experiences of different communities - whether urban, rural, pastoral, or agrarian - was considered crucial. Accommodating this diversity in settings and community characteristics would make the program more responsive to local realities. This suggests that the HEP should have the flexibility to tailor service delivery approaches, training, and support structures based on the unique circumstances of different regions, urban/rural areas, and pastoral/agrarian communities. It should be noted that adapting the HEP to local contexts would require decentralized planning and decision-making to empower regional and district-level implementers, and this will have an important policy implication because it calls for programmatic, practical, and policy-level adaptations to enable the HEP to fulfill its potential through having a flexible nature, and enabling framework that allows for contextual adaptation of the HEP. This may require revisiting national guidelines and standards to provide the necessary latitude for local decision-making regarding HEP, such as creating policies that should also support the diversification of the HEWs cadre, the formal engagement of community volunteers, and the strategic integration of traditional birth attendants within the realm of HEP-community ecosystem.

Diversifying the HEP workforce was also highlighted as an essential factor. This included incorporating male HEP cadres and service providers and integrating clinical nurses to strengthen the program and empower Hew’s technical capacity. Making the HEP more gender-equitable by including males as HEP cadres was also cited as a crucial enabler for the HEWs and the overall program performance. The inclusions of males as an enabling factor for the HEWs and the program was viewed in terms of the males’ quality, such as the ability to work in challenging work conditions, such as travelling long distances by carrying medical necessary medical supplies such as vaccines; ability travel at night to serve the community at home such as in case of emergency and delivery assistance; and also able to influence and mobilize community when broader community engagement is needed. Evidence from other settings also suggests that having a gender-balanced mix of community health workers (CHWs) can positively impact their performance and effectiveness: can improve access and acceptability of services, especially for addressing sensitive health issues such as gender-matching between CHWs and clients as a factor that positively influenced CHW performance [39]; can better connect with and gain the trust of diverse community members [81]; enables to reach marginalized groups more effectively [83]; enable complementary skills and perspectives and better opportunity to provide more holistic and comprehensive services care [84].

On the other hand, proper integration of community volunteers, especially the Women Development Armies and traditional birth attendants with clearly defined roles and engagement guidelines, and establishing formal engagement mechanisms were identified as a crucial enabling factor and would help leverage this additional resource for optimization of the HEP. Engaging these community-based resources could help leverage their unique insights and connections to influence the community. Particularly, the review suggests that engaging traditional birth attendants (TBAs), whose trusted relationships with communities could complement the formal HEP, is also warranted and could significantly help HEWs perform better. This proper integration, engagement, and leveraging of their knowledge should be carefully managed to ensure that TBAs complement rather than compete with formal health services. This involves integrating TBAs into the health system through training and collaboration. Policies should formalize TBA involvement, ensuring their roles are well-defined and contribute positively to maternal and child health without undermining the quality of care. Studies in different similar connect reflected that integrating traditional birth attendants (TBAs) into community health worker (CHW) programs can enhance CHW performance by leveraging TBAs’ community trust and connections, positively influence CHW effectiveness improve CHWs’ motivation and job satisfaction [39,81,82]

Another crucial enabling factor the review identified was the inclusion of curative services within the HEP’s mandate, which could enhance HEWs and the HEP acceptance as it meets community expectations and contributes to their performance. The evidence from elsewhere on whether the inclusion of curative or clinical services into community health programs that primarily focus on preventive and promotive services has a positive or negative impact on program performance is mixed. A systematic review [39] found that including curative services was one of the factors that positively influenced community health worker (CHW) performance. This is because it can improve community acceptance and utilization of the CHW program. A study in Pakistan showed that integrating [85] curative services for childhood illnesses into the Lady Health Worker program enhanced the program’s effectiveness in reducing child mortality. However, there are potential risks in integrating curative components into the program because it could potentially undermine and neglect the preventive and promotive focus of the CHW program and can divert their attention from core public health functions, potentially weakening the overall impact of the program [39,86,87]. The integration of curative services should be approached cautiously to maintain the program’s preventive and promotive focus and addressed through policy guidance. The key is to find the right balance and ensure that the expansion of services does not undermine the core strengths and focus of the community health program. Careful program design, training, supervision, and monitoring are crucial to maximize the benefits while mitigating the potential risks.

Altogether, this concept of diversification of HEP as enabling factors requires creating regionalized HEP packages and training of an HEP workforce varied by the regional context, moving away from a one-size-fits-all strategy towards a “tailored” or “customized” strategy that responds to the specific requirements, characteristics, or conditions of different individuals or groups.

The evidence from the review highlights that ongoing, regular and continuous capacity building and support are crucial for enabling HEWs to perform their duties effectively. Continuous on-the-job training and refresher courses are vital as they address emerging needs, fill knowledge gaps, and reinforce key competencies to keep HEWs up-to-date. Supportive supervision and mentorship also play essential roles. Consistent, constructive feedback from supervisors through regular performance reviews, clinical mentorship, and guidance helps HEWs tackle challenges and improve practices. Positive reinforcement and encouragement further foster a learning environment. Open communication and trust-building are equally important. Frequent, transparent communication between HEWs and their supervisors allows for discussing challenges, sharing successes, receiving timely feedback, and cultivating a relationship of mutual understanding and trust. Collaborative, multi-stakeholder supportive supervision was cited as a key enabling factor. This joint supervision could help HEWs to gain adequate support, advice, mentors, necessary resources and expertise during the supervision session in a well-coordinated and consistent manner, which is, in contrast, when stakeholders separately in an uncoordinated manner try to support and approach the HEWs. Thus, the review reflected that coordinating efforts in supervision and support systems, together with ensuring HEWs have access to necessary information, reference materials, and updates as part of supportive supervision, are important enablers. The evidence from the literature strongly supports the notion that ongoing and needs-based capacity-building strategies such as continuous and tailored training, constructive feedback and supportive supervision [39,81,84], collaborative support combined with adequate resourcing is can create a supportive work environment that empowers CHWs to effectively carry out their responsibilities and deliver quality community health services. This notion of continuous capacity building and support systems as critical enablers would have several key implications for Ministry of Health stakeholders supporting the Ethiopian Health Extension Program (HEP). Firstly, the Ministry should ensure regular, tailored training and refresher courses for HEWs to keep them equipped to handle evolving community health challenges. Secondly, a robust supportive supervision system, with constructive feedback, mentorship, and positive reinforcement, is crucial for helping HEWs improve their practices and navigate challenges. Investing in HEW supervisor capacity is key. Thirdly, facilitating transparent communication between HEWs and supervisors will build mutual trust and understanding, allowing HEWs to discuss issues and receive timely feedback. The Ministry should also engage diverse stakeholders to coordinate efforts and mobilize additional support for HEWs.

This review demonstrates that community structure, networks, and leadership are vital enablers for HEWs and the success of Ethiopia’s HEP. These elements provide a strong foundation for HEP operations and significantly enhance the program’s effectiveness when communities actively plan and execute HEP activities. Key components of this involvement include the engagement of model families and the support of local leadership. Active participation by community networks, notably the Women’s Development Army (WDA) and various community groups, is essential. These groups offer ongoing support and serve as a bridge between HEWs/HEP and the community, facilitating information exchange and community mobilization. Households trained and graduated as model families play a crucial role by serving as role models and encouraging their communities to adopt healthy practices. Formal leadership at the village/kebele and sub-village levels is a significant enabler for HEWs. To maximize the impact of the HEP, it is crucial to leverage community networks and structures, along with committed and motivated community-level leaders, both formal and informal. The HEP should focus on providing clear directions, guidance, and support to engage community actors and structures for improved outcomes effectively. From its inception, the HEP has integrated organized community engagement with the women-centered HDA strategy, serving as a strong enabling structure for HEWs. This presents an opportunity to capitalize on these community networks to boost HEWs and the program further. By integrating community structures, networks, and leadership, HEWs can enhance their capacity to deliver comprehensive and culturally sensitive health services. This approach helps build stronger partnerships, address contextual barriers, and ensure that the HEP is responsive to the needs and priorities of the communities they serve, ultimately enhancing the performance and impact of HEWs and the HEP. By leveraging these community-level resources, community health workers can better tailor their interventions, access necessary support, and build community trust, ultimately enhancing their capacity to deliver effective health services. Evidence from various LMICs highlights the critical role of community-level factors in enabling the work of community health workers. In Bangladesh, the engagement of community-based organizations and local leaders has been shown to improve the performance and coverage of Community Health Workers (CHWs). Across these diverse settings, the evidence consistently demonstrates that the engagement of community structures, networks, and leadership plays a pivotal role in enabling community health workers to perform their jobs more effectively [88–90].

Trusting relationship as crucial enabler of HEWs and the HEP program is one of the important enablers identified in this review. According to the evidence, key qualities that HEWs should embrace in order to establish trust with the communities are effective Communication and Interaction skills, interpersonal collaboration abilities, strong work ethic, regular availability of HEWs at their work station, relevant work experience and perceived competency by the community was identified as strong enablers for their performance. When the community trusts HEWs, it encourages greater acceptance, engagement and participation in the program’s activities. This trust-based relationship facilitates open communication, allowing HEWs to better understand the community’s needs, concerns, and preferences. Moreover, the community is more inclined to offer practical and emotional support to HEWs they view as partners rather than outsiders, further enhancing the HEWs’ ability to perform their duties effectively. Beyond individual-level impacts, a trusting HEW-community relationship fosters a sense of ownership and commitment to the HEP at the community level. When the program is seen as a collaborative effort, rather than an external imposition, the community is more likely to take an active role in maintaining the program’s infrastructure, mobilizing resources, and advocating for its continued support. Evidence from elsewhere also supports that trusting relationships between community health workers and the communities they serve are crucial for the effectiveness of community health worker programs in low and middle-income countries (LMICs). In Bangladesh, the trust and rapport between Community Health Workers (CHWs) and the community members have been identified as key factors contributing to the performance and coverage of community health interventions [88–90]. A study in Uganda found that trust led to higher participation in health programs, with community members more likely to attend education sessions and engage in disease prevention activities [39]. Similarly, in Bangladesh, trust increased the acceptance and uptake of health interventions, such as vaccinations and maternal health services, resulting in improved health outcomes, including reduced infant mortality [91]. In Kenya, trusted CHWs communicated more effectively with community members, allowing for open discussions and tailored health advice [92]. In South Africa, CHWs with strong relationships saw higher adherence to health recommendations, such as medication compliance, due to trust in the guidance provided [93]. Furthermore, trust enhances access to vulnerable populations and reduces barriers within the health system. In India, trusted CHWs gained better access to groups like women and children, improving health equity [94]. In Nigeria, CHWs with trusting relationships acted as advocates, helping community members navigate the health system more effectively [89]. Additionally, in Peru, trust fostered a sense of empowerment and ownership over health initiatives, leading to sustainable improvements [95]. Thus, by building trust, community health workers can better understand the local context, tailor their interventions to community needs, and foster community engagement and ownership, ultimately leading to more effective and sustainable health service delivery.

The findings emphasize the crucial role of consistent availability of essential medical resources, equipment, and supporting infrastructure serves as a key facilitator, empowering HEWs to deliver timely and appropriate care to the communities they serve. Access to necessary tools such as drugs, contraceptives, vaccines, consumables, and vital medications like ORS, supplements, and anti-malaria medicines, along with basic equipment such as thermometers, fetoscopes, and stethoscopes, enables HEWs to meet community expectations and build trust. Additionally, properly furnished health post offices equipped with reliable electricity, telephone services, and water supply create a conducive environment for effective service delivery and serve as critical enablers. These facilities provide a conducive environment for HEWS to conduct health education sessions, consultations, and treatments, thereby enhancing the quality of care delivered. Reliable infrastructure, such as transportation and communication networks, is essential for the mobility and connectivity of health extension workers. Access transportation systems enable them to reach remote and underserved areas, while effective communication tools help them stay informed and connected with other healthcare providers, the community networks and their supervisors. Access to necessary stationery and a well-organized health post setup further facilitate HEW performance. Transportation and communication services, including coordinated ambulance services and the use of traditional ambulances when necessary, enable HEWs to respond swiftly to emergencies and provide comprehensive care. Thus, the governments need to ensure the supply chain of health posts and need to equip and support it well to enable the HEP to fulfill its mission of providing accessible and quality healthcare services to all Ethiopians. In several other settings, consistent availability of essential medical resources, equipment, and supporting infrastructure has been identified as a key facilitator that empowers community health workers to perform their duties effectively [39,96,97], with robust community health systems with adequate medical infrastructure, logistical support, and information systems have been linked to better outcomes for community health worker programs [39,96]. Frustrated community health workers due to stock outs or malfunctioning equipment can experience eroded trust in the communities they serve and undermine their effectiveness [97,98] and as a result, investing in ensuring consistent resource availability is often cited as a best practice for successful community health worker initiatives [94,99].

Improved living and work conditions have been shown to positively impact their performance and the overall effectiveness of the CHWs [40]. One study found that supportive work environments were critical for the motivation and performance of community health workers, including HEWs in Ethiopia [39]. Another study depicted that when HEWs work in supportive environments, they are more capable of delivering essential health services, resulting in better maternal and child health indicators [100]. Better living and working conditions contribute to higher retention rates among health workers. The retention of skilled workers is crucial for maintaining consistent and effective health service delivery [80]. The study found that providing better housing for health extension workers in Ethiopia led to a 15% increase in the number of households visited and a 20% improvement in the quality of health services delivered [54]. Another study indicated that health extension workers with higher job satisfaction due to improved working conditions and support had 25% lower attrition rates compared to their peers with poorer work environments [76].

The research highlighted the critical role that supportive living and working conditions play in enabling HEWs to fulfill their duties effectively. Several key insights emerge from the studies cited. First, supportive work environments, including adequate housing and other resources, are vital for motivating HEWs and enhancing their job performance. HEWs operating in such environments are better equipped to deliver essential health services, leading to tangible improvements in service delivery. Second, better living and working conditions contribute to higher retention rates among HEWs, and retaining skilled and experienced HEWs is crucial for maintaining consistent and effective HEP delivery within communities. Third, concrete interventions to improve HEW living conditions, such as providing better housing, can directly translate into measurable increases in household visits and the quality of services delivered, suggesting that relatively straightforward investments in HEW support can yield substantial dividends in community health outcomes. Finally, job satisfaction among HEWs, driven by improved working conditions and support, is associated with significantly lower attrition rates, highlighting the importance of holistically addressing the needs and concerns of this frontline health workforce to ensure their long-term commitment and performance. These findings emphasize the need for the Ethiopian government and program managers to prioritize the living and work environments of HEWs as a key strategy for strengthening the community-based HEP, as ensuring that HEWs have the resources, infrastructure, and support they need can unlock their full potential to deliver transformative primary healthcare services at the local level. There is substantial evidence that providing supportive living and working conditions for community health workers (CHWs) is crucial for enabling them to effectively carry out their duties and deliver high-quality services in low- and middle-income country (LMIC) settings [39,95,101]. These findings highlight the critical importance of investing in the work environments and personal circumstances of CHWs as a means of unlocking their full potential to serve their communities effectively. Policymakers and program managers in LMICs must prioritize ensuring that CHWs have the resources, infrastructure, and supportive supervision they need to carry out their roles successfully and contribute to improved population health outcomes.

The review identified a comprehensive enabling pathway framework that helps ensure Ethiopia’s HEP can deliver high-quality healthcare services across the country. This framework operates through multiple, interconnected mechanisms. First, it motivates and empowers the HEW workforce by improving their working conditions, living environments, and overall support systems, creating a more enabling atmosphere for them to carry out their duties effectively. Second, the framework leverages the power of community and stakeholder engagement, with coordinated involvement of these groups serving as a powerful enabler for the HEP. Third, it fosters trusted relationships and linkages among all actors in the system, particularly between HEWs and the communities they serve, which is crucial for program success. Fourth, the framework emphasizes capacity building and continuous system development, ensuring the HEP remains robust and responsive to evolving needs. Lastly, the availability of adequate resources and infrastructure is identified as a vital component, providing the functional capacity required to support high-quality service delivery. Together, these mutually reinforcing elements form a comprehensive enabling pathway that equips the HEP to extend primary healthcare access and improve population health outcomes across Ethiopia.

Conclusions

This scoping review synthesized key enabling and facilitating factors that enhance Health Extension Workers’ performance and Ethiopia’s HEP. Six major themes were identified: motivation factors, diversification and adaptation of HEP services and its modalities, continuous capacity building and ongoing support system, community and stakeholder engagement and leadership, trusting relationships, resource availability and conducive and supportive living and work environment. Intrinsic and extrinsic motivations are crucial for HEW performance, with job satisfaction, community connection, and career development opportunities being significant motivators. Diversifying and adapting HEP services and workforce, including integrating males and clinical nurses, can improve program reach and impact. Continuous capacity building and robust support systems, including collaborative supervision and mentorship, are essential for enabling HEW performance. Engaging communities through local structures, leadership, and stakeholder coordination enhances HEP outcomes. Trusting relationships between HEWs and the community foster collaboration and program success. Improved resources, facilities, and infrastructure at health posts, along with better living and working conditions for HEWs, significantly enable and enhance their performance and the program’s efficiency. Together, these elements form an enabling pathway to support Ethiopian HEP’s goal of expanding preventive and promotive services while integrating essential and basic curative elements in a balanced manner.

Supporting information

Acknowledgments

The authors would like to acknowledge the NASCERE program Support Unit for their support in facilitating the conduct of this study.