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Kerina Tull, University of Leeds Nuffield Center for International Health and Development
1. Summary
This rapid review is one of a three-part series related to reproductive, maternal, newborn, and child health (RMNCH) interventions. The other two rapid reviews include information on gender norms and barriers affecting demand for RMNCH services in Ethiopia and other developing countries (Birch, 2020; Browne, 2020). Therefore, those topics will not be discussed in detail here. Consequently, this rapid review will focus on lessons learned from donor-funded interventions in Ethiopia and the surrounding region, specifically for pastoral communities.
Key points on achievements and challenges to highlight:
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Health extension workers (HEWs) and health development armies (HDAs) are very trusted in RMNCH interventions (World Bank, 2016; Asfaw et al., 2019). This finding adds to the growing body of evidence that health workers at the community level can work with women’s groups to improve maternal health, thus reducing the need for emergency obstetric care in low-income countries (Jackson et al., 2016).
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Most donor RMNCH interventions in Ethiopia involve using HEWs to improve healthseeking behavior, e.g. AusAID, DFID, Global Affairs Canada, and USAID (Jackson et al., 2016; Asfaw et al., 2019; Jalu et al., 2019). However, HEWs are not always available at health posts, as almost all their time is spent providing outreach community services (Jalu et al., 2019). Top-down supervision and provision of training is important to improve relationships between HEWs and woredas (districts) (Diaz et al., 2018; Kok et al., 2015).
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Community study findings from Ali & Woldearegai (2019) imply the presence of a positive health-seeking behavior among pastoralists to using modern health services, which can be further strengthened with interventions promoting these services.
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Elmusharaf et al. (2015) suggest three challenges that need to be addressed to create a supportive environment in which demand-side strategies can effectively improve access to maternal health services. These are: addressing decision-making norms, engaging in intergenerational dialogue, and designing contextually appropriate communication strategies.
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Disability of mothers and children also needs to be addressed: research shows that Ethiopian caregivers are often worried about being treated differently, feeling ashamed or embarrassed about their child’s condition, and make efforts to keep their child’s condition a secret rather than seek health services (Miftah et al., 2017). Neither previous or current national Reproductive Health Strategies in Ethiopia include information on achieving improved health-seeking behavior for women with disabilities.
There is a dearth of evidence available focussing on intervention design strategies in Ethiopia.
However, lessons learned are available from other countries / regions: -
In Kenya, JICA funded MCH handbooks (Kawakatsu et al., 2015) and women’s self-help groups used by USAID-funded research in Uttar Pradesh, India have been successfully used to improve RMNCH health-seeking behavior (Araldus et al., 2017 ).
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One project funded by USAID and NORAD, the Results-based Financing for Maternal and Neonatal Health (RBF4MNH) Initiative, Malawi – which has community health workers (CHWs) rather than HEWs – did not report greatly improved use of services. Results from an evaluation on the Initiative found this to be due to insufficient program structure and staff (Jordan-Harde, 2013).
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Improving early antenatal attendance requires integrated interventions that address both community and health systems barriers, including spouses (Maluka et al., 2020).
Greater communication between communities and service deliverers is also essential in improving RMNCH seeking behavior (Zwi et al., 2009).
