Female students in an Ethiopian classroom


Ethiopia has the second largest population in sub-Saharan Africa of over 80 million, with 44% under the age of 15 and 82% living in rural areas. Recognizing that a healthy, educated workforce is needed to achieve and sustain economic development, the Government of Ethiopia is leading an ambitious health sector development program, now reflected in its Health Sector Development Program IV (HSDP IV).

Ethiopia has made significant gains in the areas of child survival and family planning use. The total fertility rate declined from 5.4 children per woman in 2005 to 4.8 in 2011; modern contraceptive prevalence increased from 13 to 27 percent. Deaths of children under five declined by 28 percent, and corresponding improvements were seen in measures of nutritional status, immunization and treatment-seeking behavior for under-fives. Results from the 2011 Ethiopian Demographic and Health Survey show less progress in the areas of maternal and newborn health. Although there have been steady reductions since 1990, Ethiopia has one of the world’s highest maternal mortality ratios in the world at 676 maternal deaths for every 100,000 live births. While child mortality dropped by a quarter, neonatal mortality remained virtually unchanged at 39 deaths per 1,000 live births in 2005 and 37 in 2011.

Integrated Family Health Program (IFHP)

IFHP Plus (IFHP+) USAID Ethiopia’s flagship project for family planning and maternal and child health service delivery, was implemented through the E2A project, and E2A collaborated closely with IFHP Plus on its activities in Ethiopia.

Community Health Worker Use of Data Assessment

Since the ability to strengthen service delivery and increase access to family planning and reproductive health services depends to a large extent on the availability of relevant data to plan, monitor and improve performance, E2A developed strategies to increase data use for decision making among frontline health workers. A major component of the strategy was to undertake studies to examine factors that facilitate or constrain the use of data by frontline health workers. Ethiopia presents an excellent opportunity since its reformed health management information and monitoring and evaluation systems (HMIS/M&E) promote data use by health workers at the national, regional, woreda (district) and community levels.

E2A assessed the extent to which Health Extension Workers (HEWs) in Ethiopia use the data that they gather in their day-to-day work to strengthen service delivery. Data use refers to the process in which HEWs analyze and interpret data and use the results to plan, monitor and improve services they provide to community members.

In Year 1 of our project, E2A conducted a literature review of articles related to the use of the HMIS in Ethiopia, designed and implemented a study that gathered information from health providers, managers and service statistics. Data analysis is underway, with a report on this activity forthcoming.

The report of the study will inform E2A’s recommendations to the Ministry of Health and USAID regarding interventions to improve data use for decision making among HEWs. Based on the findings of the study, E2A will also be able to recommend ways for the information which HEWs collect from the community and health posts to feed into woreda (district)- based health planning. This initial study also informs subsequent, planned work to broaden the research to other countries, with an eye toward building stronger evidence for community-based services.

Sustainability of Management Approaches for Health Care Delivery at Woreda and Primary Health Care Units Study

For the past 12 years, USAID/Ethiopia has supported interventions in community-based FP and child survival. USAID’s support has evolved along with the Government of Ethiopia's priorities and plans. Currently, the IFHP fully supports the government’s Health Extension Program and Health Sector Development Program III (HSDP III). As government transitions from HSDP III to HSDP IV, USAID is also reviewing how to best support government priorities and plans, while maintaining the gains made in the core areas of FP and child survival.  This study is intended to provide input into that review process. The IFHP has been working jointly with its government counterparts at the regional, zonal, woreda (district) and primary health center unit levels to support implementation of government policies and procedures for effective management, oversight and performance of the Health Extension Program. IFHP has worked in 292 woredas in four regions of Ethiopia – Amhara, Oromia, SNNP and Tigray – and with the primary health care units located in those woredas. The ultimate objective of IFHP’s support to the woredas and units is to assure broader coverage and delivery of higher quality priority primary health services, effective mobilization and behavior change at the community level and effective referrals to the health center.

To attain this objective and improve systems performance, IFHP support has focused on building capacity and institutionalizing the following management approaches (policies and procedures) at the woreda and primary health care levels:

  • Woreda Based Planning
  • Integrated Supportive Supervision
  • Use of HMIS data for decision making at all levels
  • Review meetings at woreda and kebele (ward levels)

E2A conducted an assessment to determine which of these management interventions, currently supported byIFHP, can be sustained by districts and primary health care units when the project ends and the circumstances under which these interventions can be continued. The study also looks at the effects of the management interventions on service delivery performance by comparing project focused and non-focused woredas and primary health care units.

Recommendations to the Government of Ethiopia and USAID on ways to implement the management interventions to sustain the investment made so far and make appropriate changes for greater impact include:

  • Develop criteria for determining readiness of Woreda Health Offices to graduate from direct financial and technical support.
  • Engage stakeholders in early discussions about the scale of programs to be implemented and provide guidance on what they can do to make programs sustainable.
  • Develop a timetable for graduation from assistance, where possible.
  • Ensure implementation standards for the management approaches are adequately defined and communicated to the Woreda Health Offices.

Read the full study report and policy brief derived from that report.

Assessment of provision of long-acting reversible contraceptives (LARCs) in Ethiopia’s youth-friendly clinics

In collaboration with IFHP+, E2A conducted a study at 20 youth-friendly service sites in Amhara and Tigray regions of Ethiopia to test a model for offering contraceptive counseling and services to young people that includes LARCs. The service-delivery model tested at 10 intervention sites included:

  • Competency-based skills training with youth-friendly service providers on implant and IUD insertion, removal, and infection control
  • Refresher training for peer educators to counsel (dispel myths and misperceptions) on safety and effectiveness of LARCs and refer
  • Supportive supervision

Results indicate that the service-delivery model tested had a positive influence on the uptake of LARCs at intervention sites as compared to nonintervention sites. The study also suggest that there may be a growing pattern among women who have not had a live birth to seek contraceptive services, and in particular, to choose long-acting methods. During the study period, 63 percent of women who attended youth-friendly services, and a remarkable 81 percent of women who accepted a long-acting method for the first time, had not yet had a child. You can read more about the study in this brief.

Subsequently, IFHP+, in collaboration with the Amhara and Tigray regional health bureaus (RHBs) scaled up this ‘tested’ approach to 66 youth-friendly service (YFS) units in Amhara and 62 YFS units in Tigray between April 2015 and December 2016.  Data collection and analysis of the scale-up are currently underway, and results are forthcoming.

Assisting with Ethiopia's National Fistula Elimination Plan

E2A directly assisted with the Government of Ethiopia’s National Fistula Elimination Plan, which sought to intensify efforts to identify, repair, and rehabilitate women with obstetric fistula across 291 woredas (districts) supported by IFHP. The plan included a phased approach that began with applying a fistula-eradication strategy in 20 woredas and then replicating that strategy in the other woredas. With technical guidance from E2A’s core partner Management Sciences for Health, E2A focused on building the organizational capacity of Hamlin Fistula Ethiopia and supporting Healing Hands of Joy, an organization that rehabilitates and reintegrates women who have undergone obstetric fistula repair surgery. Hamlin Fistula Ethiopia runs the Addis Ababa Fistula Hospital, its regional centers, the Hamlin College of Midwives, and the Desta Mender rehabilitation center for fistula patients.

The approach to fistula elimination applied in the 20 woredas is based on the successful approach already applied by Pathfinder International through its leadership of IFHP. A technical publication from Pathfinder—Strengthening the Continuum of Care for Fistula Prevention and Repair in Ethiopia—describes the approach.

Ethiopian Evangelical Church MekaneYesus Development and Social Services Commission (EECMY-DASSC)

Separate from its work with IFHP, E2A provided a grant and technical assistance to EECMY-DASSC, which worked in five woredas of East Wollega Zone in Oromia, the largest and most populous state. Under the grant, EECMY-DASSC held multiple training sessions to sensitize religious leaders, community health workers, community leaders, and ministry of health officials to the value of family planning, and built strong platforms and faith-based service-delivery networks that enhanced demand for and supply of family planning services.  EECMY-DASSC worked to improve service delivery in government health facilities, including conducting clinical training for providers on IUD insertions and implants. The grant was one of three that E2A provided to faith-based member organizations of the African Christian Health Associations Platform. Read about our grantee's work here.

Population:80 million
Population Ages:44% under 15
Country Fertility Rate:4.8
PRB 2014 World Population Data Sheet

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