Anne Narayan and Melanie Tam’s Blog

January 8, 2013

After arriving in Ethiopia on Jan 5th and settling in to our new home at Canaan Pizzeria and Rooms (which we highly recommend!), we’re ready to get started working on the IDEAS project. IDEAS, or Informed Decisions for Actions to Improve Maternal and Newborn Health, is a five-year measurement, learning, and evaluation grant being implemented by the London School of Hygiene and Tropical medicine, and spans from 2010-2015; the grant supports the evaluation of several Bill and Melinda Gates Foundation interventions across three countries: Ethiopia, North-East Nigeria, and Uttar Pradesh, India.

In Ethiopia, these interventions are intimately linked to the country’s current health system, which is divided amongst nine administrative regions, 80 zones, 551 districts (woredas), and approximately 12,000 villages (kebeles). In 2003, the country launched the Health Extension Program (HEP) as means to expand and strengthen the primary healthcare system and, ultimately, to achieve universal primary healthcare coverage. Key to the HEP are the Health Extension Workers, who are assigned in pairs to a health post at each kebele, and provide services in five primary areas of care: maternal and child health, family planning, immunizations, adolescent reproductive care, and nutrition. Despite the success of many of these efforts, however, Ethiopia still faces some of the highest maternal mortality rates in the world – an estimated 673 per 100,000 live births as of 2005.

Currently, several efforts supported by the Bill and Melinda Gates foundation work through the Health Extension Program, including those IDEAS is currently evaluating. They include: Last 10 Kilometers, whose aim is to strengthen the bridge between Ethiopian families, kebeles and the Health Extension Worker program; Saving Newborn Lives, which is working to increase the use and delivery of proven newborn health interventions such as counseling on newborn care practices, antibiotic use, and optimal breastfeeding; and MaNHEP (the Maternal and Newborn Health in Ethiopia Partnership), whose goal is to demonstrate a community-oriented model to improve maternal and newborn health care in rural Ethiopia and position it for scale-up. The objectives of IDEAS are as follows:

  1. To build capacity for measurement, learning & evaluation.
  2. To measure efforts to enhance interactions between families & frontline workers and increase the coverage of critical interventions.
  3. To explore scale-up of maternal and newborn health innovations
  4. To investigate the impact on survival of maternal and newborn health innovations implemented at scale.
  5. To promote best practice for policy.

As new members to the project, we will be working to meet these objectives through IDEAS’ current activities, which include workshops with the Technical Resource Center, qualitative and quantitative survey studies related to intervention success and enablers, inhibitors, and catalysts of scale-up, as well as collaboration with Jarco Consulting—the research consulting firm through which IDEAS operates. We’ve just been warmly welcomed by Dr. Della Berhanu, the IDEAS coordinator in Ethiopia, and look forward to the exciting work to come!!!!

January 21, 2013

During our internship with Informed Decisions for Actions (IDEAS), we have been working closely with the country coordinator in Ethiopia, Dr. Della Berhanu, who is creating a data informed platform for health (DIPH) to guide decision-making and priority-setting. To help us get better acquainted with IDEAS when we first arrived, she introduced us to each member of the team and the different components of the project.

IDEAS utilizes a mixed methods approach to evaluate maternal and newborn health interventions being carried out by three project partners in-country. The quantitative portion of the project is led by Zewdu Sisay. He explained their process of designing a survey to evaluate efforts for improving interactions between families and frontline health workers. Additionally, he shared several examples of challenges the team has faced along the way, such as the long distances that researchers have had to travel to reach remote villages, the difficulties of collecting data using PDAs versus paper, and the process of translating and backtranslating survey questions and responses between four different languages. Learning about the complexities of study design and implementation certainly gave us newfound appreciation for the final results of these research studies.

We also met with Dr. Addis Tamire, who heads the qualitative portion of the project focused on enablers and barriers to scale-up of interventions and mechanisms used to catalyze scale-up. The results gathered from this qualitative work will enhance the quantitative data obtained with personal accounts, illustrative examples, and lessons learned by experts working in the field. During our first week with IDEAS, we had the opportunity to accompany Addis on an interview with the head of a renowned organization working in maternal and child health who shared his experiences with scaling up interventions from both the demand and supply side. Insights from these qualitative interviews in Ethiopia will be analyzed alongside findings from Uttar Pradesh, India and Northeast Nigeria.

The JaRco Consulting office (IDEAS’s partner organization in Ethiopia)

In addition to working with the IDEAS team, we have also had the opportunity to learn more about JaRco Consulting, IDEAS’s measurement, learning, and evaluation partner in Ethiopia. Several team leaders have taken the time to speak with us about their work and we have taken part in a planning meeting for one of JaRco’s new projects with the World Food Program on HIV/AIDS and nutrition.

It has been a busy two weeks thus far and we have already learned so much from working with IDEAS and JaRCO. We are excited to share more of what we are working on and look forward to what this next week will bring!

January 23, 2013

To learn more about the basis for the Data Informed Platform for Health (DIPH), we joined our supervisor, Della, at a conference on the Independent Evaluation of the Catalytic Initiative/Real-Time Results Tracking/National Evaluation Platforms in Debre Zeit, a city about an hour away from Addis Ababa. Traditional methods for evaluating large-scale programs compare areas where the programs are being implemented with areas where they are not. However, in many countries, programs are scaled-up nationally, so there are no districts completely free of the interventions. The proposed national evaluation platform approach enables countries to evaluate programs through continuous monitoring of indicators within districts; interim and summative evaluation analyses can then be performed to assess how well interventions are being delivered.1 Presenters at the meeting discussed applications of this approach, such as in the field of nutrition.

After the sessions, we had a chance to meet and have lunch with a few of the attendees including Shelby Wilson, who was kind enough to speak with us about her work at the Bill & Melinda Gates Foundation. The beautiful Lake Kuriftu served as our backdrop as we ate, giving us a glimpse of the breathtaking views that Ethiopia has to offer.

Sunset on  Lake Kuriftu

Sunset on Lake Kuriftu

Excited to see more of the country before the end of our internship, we also spent a weekend in Awassa, the capital of the Southern Nations, Nationalities, and Peoples’ region. This lakeside town offered a relaxing change of pace from the city life of Addis Ababa, with gorgeous sunsets, amazing views of the town from atop Tabour Hill, and sightings of hippos and Marabou storks (the size of small children!).

With so much beauty left to see in the country, we know we must plan a trip back soon!

1. Victoria, C.G., Black, R.E., Boerma, J.T., & Bryce, J. (2011). Measuring impact in the Millennium Development Goals era and beyond: a new approach to large-scale effectiveness evaluations. Lancet, 377, 85-95.

January 28, 2013

After making it back safely from Ethiopia, we miss it already. The last three weeks were a whirlwind of work and productivity (and fun, of course!). We spent the bulk of our time at JaRco Consulting (IDEAS’s partner organization in Ethiopia), where we continued to sit in on research strategy meetings, had the opportunity to interview a practitioner at one of the Bill and Melinda Gates grantee organizations—Save the Children—and worked tirelessly on a literature review for IDEAS. Through the review, we synthesized available information on facilitators and barriers to skilled delivery in Ethiopia, where the maternal mortality rates are amongst the highest in the world. We individually did extensive searches on PubMed and Popline on the topic, peer-reviewed each other’s work in the process, and eventually settled on analyzing 16 relevant papers, including both quantitative and qualitative studies across different geographic regions in Ethiopia. Certain findings were not surprising at all – namely that individuals in urban areas and of higher educational achievement were more likely to deliver in facilities assisted by skilled health professionals. However, other findings, such as that young age, low parity, and access to prenatal care services were predictors of skilled delivery, will likely be pertinent to future maternal health interventions and research.

We were particularly stricken while analyzing the qualitative studies to find that many individuals seek home deliveries due to poor resources in health facilities, distrust of medical providers, and culturally-insensitive—yet easily modifiable—practices prevalent in the health facilities. From our findings, for example, it seems quite possible that including a simple cultural coffee ceremony at health facilities might increase utilization of skilled deliveries and reduce maternal mortality. These qualitative findings also supported many of the barriers we discussed with the Gates’ grantee mentioned above, who described that unless practitioners improve services and make the supply-side of maternal healthcare more attractive to mothers and families, intervention efforts will suffer due to the lack of service demand.

We found this work extremely rewarding, both by exposing us to specific research methods and studies throughout the country and by broadening our perspectives of maternal health care, access, and utilization. We are currently polishing this literature review to report to IDEAS, and hope they will find it valuable in their current and future intervention evaluations. We both feel very passionately about the work IDEAS has underway in Ethiopia and are grateful to have been able to take part in the short (but full!) three weeks we spent with new family, friends, and colleagues. Thanks Maternal Health Task Force and IDEAS for an amazing and unforgettable experience!