Promising Practices

The Reproductive, Maternal and Neonatal Health Innovation Fund (RIF)

Policy brief July 2018

RIF (2013-2018) has been funded by the UK’s Department for International Development (DFID) and managed by Ethiopia’s Federal Ministry of Health (FMOH) with the assistance of a Technical Assistance Supplier (Pathfinder International).

Promising Practices The Reproductive Maternal and Neonatal Health Innovation Fund (RIF) has aimed to improve the health outcomes of women, newborns and young people in the pastoralist areas of Ethiopia. With RIF funding, FMOH has administered grants to both government and non-governmental implementing partners. They have been tasked with identifying innovative solutions to the barriers that prevent pastoralist populations (especially women and young people) from accessing reproductive, maternal and neonatal health (RMNH) services.

This brief presents the seven promising practices (i.e. successful innovations that have the potential to deliver results over the longer term if sustained and scaled-up) identified by the final evaluation of the RIF programme (2013-2018)1: 1

Co-opting Traditional Birth Attendants

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Maternity Waiting Homes

3

Solar-powered mobile health centres

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Community engagement models

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Solar-powered mini-media kits

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Women’s self help groups

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Social accountability approaches.

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1. Co-opting Traditional Birth Attendants This promising practice involves recruiting and training respected Traditional Birth Attendants (TBAs) as community-based ‘service brokers’. They work with Health Extension Workers (HEWs) to escort pregnant women to health facilities, assist midwives at the time of delivery and can also conduct home visits and make referrals. In some cases, TBAs also convene Monthly Pregnant Mothers Days and Mother to Mother Support Groups; the innovation here consists in strengthening the TBAs’ convening power in their communities, and in formalising their role as change agents who are as important as formal health workers in ensuring that pastoralist women receive the care they need.

According to one trained TBA involved in Pregnant Mothers’ Days, before the introduction of the promising practice women and their husbands never attended a health facility for antenatal care together, but they did afterwards. She also noted increased service use and skilled birth attendance.

(Evaluation Report)

RIF trained more than 450 TBAs over its lifetime. In Somali Region, TBA-facilitated Monthly Pregnant Mothers Days in October-December 2017 are reported to have led to 5,134 referrals for RMNH services. Another Somali implementing partner found increased RMNH service uptake in the 35 districts where 165 TBAs were trained, compared to districts where there were no trained TBAs. Factors in success Co-opting TBAs can add value when it has the support of religious and community leaders, and male partners. However, the effectiveness of TBAs does depend on the buy-in of HEWs, facility staff and district officials. Findings from Afar and Somali Regions suggest that the role of TBAs can be enhanced by providing them with tools such as family health cards, referral slips and ‘pledge cards’.

Sustainability and scalability There may be some costs associated with training, incentivising and managing TBAs. In areas where engagement of TBAs has been discouraged, there may need to be a formal strategy shift.

This promising practice is especially useful where there is no local Health Development Army, since TBAs fill a gap by acting as ‘service brokers’ linking community members to RMNH services. However, these TBAs may experience a reduction in income due to loss of their traditional role (which can include home deliveries and female genital cutting).

Scale-up would therefore need to include provision for incentives or alternative employment. In Afar Region, for example, TBAs were employed as janitors at health facilities. There would also need to be quality control of the health education messages they give – especially with regards to harmful traditional practices and family planning.

Policy/programme implications

“We lost some benefit… the District Administration should take responsibility and give us what we deserve… we have done a lot, we want to work until the community is fully aware of the importance of modern health services such as skilled delivery. If the administration will not support us, we will stop our services to the health system.” (TBA, Brqooot (Birqod) District)

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Where there is no Health Development Army, consider training respected TBAs to support HEWs in RMNH community outreach work.

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Ensure resource allocations for: basic/refresher training; incentives/stipends; operational costs and materials; supportive supervision.

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For both TBAs and Health Development Army: promote the use of Monthly Pregnant Mothers Days, Mother to Mother groups and/or ‘Celebrate Life’ events for demand creation.

Strength of evidence The final evaluation found good evidence for this promising practice. However, some health bureau key informants had misgivings about the resource implications of sustaining this initiative at scale.

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2. Maternity Waiting Homes Maternity Waiting Homes (MWHs) are designed to provide temporary accommodation for pregnant women at risk and/or facing geographic barriers to accessing a health facility when in labour. MWHs are well established in agrarian areas of Ethiopia but are relatively new in pastoralist areas and need some cultural adaptation. There are clear government guidelines on construction standards and maintenance.

MWHs have been established in all the RIF programme regions, with a total of 258 MWHs constructed or furnished (Afar 49; Somali 92; Oromia 97; SNNP 19). Over the period June 2016-December 2017 they had 22,355 users, with some regional variation reported (Afar: 2,820; Somali: 3,647; Oromia: 11,459; SNNP: 4,429).

Factors in success The most effective MWHs in terms of construction and use were those that complied with government guidelines. Well-attended MWHs were characterised by a good quality and durable construction with access to water and sanitation. They were also well supported by facility staff and health bureau officials and had reliable strategies in place for provision of food, transport, entertainment/health education activities etc., either by government or a community support group. Effective MWHs had established links to the community and were supported by community leaders; they also supported continued access to families, children and/or companions (such as a TBA).

Sustainability and scalability This promising practice requires resource commitments for MWHs, buy-in from service provider and management, and the establishment and nurturing of working partnerships with the community (and possibly other public sector institutions).

MWHs may not be the best strategy for addressing geographic barriers in all districts and pastoralist zones. Where communities are very remote and linkages to community support strategies difficult to implement, it might be preferable to invest in alternative approaches (e.g. timely transport) or to prioritise ‘at risk’ women. It is also necessary to consider the availability of resources, as capital and recurrent costs (including management costs) can be high.

Policy/programme implications •

Commission regional operational research studies to establish the best approach for each region, and to test whether early successes can be cost-effectively sustained over the longer term in pastoralist areas.

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Ensure full compliance with government guidelines and construction standards for MWHs and ensure there is a robust quality assurance mechanism in place for each pastoralist zone.

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Consider that MWHs are a potential good investment if predictable resources are available and if the key success factors can be put in place.

Strength of evidence Success for this promising practice was found to depend much on location and context. Many MWHs were well-designed and actively used. However, in other cases construction quality varied.

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3. Solar-Powered Mobile Health Centres The aim of Solar-Powered Mobile Health Centres (SPMHCs) is to improve accessibility of RMNH services for hard-to-reach populations. The vehicle is fitted with equipment (e.g. cold-chain and laboratory equipment, delivery couch) to provide energy-efficient mobile RMNH and immunization services and importantly, laboratory support. The vehicle’s Global Positioning System (GPS) software allows it to follow pastoralist movements. It also has media equipment for playing educational video/audio messages, a waiting tent for clients, a detachable toilet and medical waste reservoirs.

The SPMHC is a fully-fledged mobile platform equipped and staffed to offer the same service package as a static health centre, including laboratory support. It is manned by two nurses/ midwives, a laboratory technician and a driver.

Due to early programme closure and procurement challenges, it was only possible to deploy only one SPMHC in Somali Region over a three-month period. However, reports showed that, during this period, the service provided 965 antenatal care consultations and administered 942 immunizations.

Factors in success The SPMHC was managed from the Zonal Hospital and was therefore able to work across district boundaries and to maximise geographical coverage (Figure 1).

Figure 1: SPMHCs can follow pastoralist groups across district boundaries

Sustainability and scalability The significant capital and recurrent costs and provider and management commitments associated with the initiative could all be factors in its sustainability. More research is needed to assess relative benefits and to provide more data on costeffectiveness and feasibility of staffing commitments. Other RIF sub-recipients have supported mobile services and outreach work. Over the longer term, the results from these activities could be usefully compared to those from the SPMHC. Policy/programme implications Mobile and outreach services appear to be useful approaches to bringing RMNH services to hard-to-reach pastoralist communities, especially if they can follow their movements. However, further research is needed to compare the effectiveness and cost-effectiveness of different models of mobile service provision.

“It’s our hospital. In this

region, the mobile health clinic is our hospital.”

(High level Regional Health Bureau official)

Strength of evidence It is difficult to determine whether the results from this single SPMHC are better than for other mobile services. Health bureau officials and service providers were enthusiastic about the ability of the SPMHC to bridge the geographical divide between pastoralist population and RMNH services. Success was also evident from primary records, beneficiary interviews and direct observation.

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4. Community engagement models RIF’s non-governmental partners developed several innovative approaches for engaging key community stakeholders to change RMNH attitudes. For example, a subrecipient in Afar Region established three types of community stakeholder groups: Youth Educators for Success; Be Model Women and Joint Action Leaders – for community and religious leaders.

Using community engagement strategies, programme partners reached over 150,000 religious and community leaders and over 1.7 million young people with targeted RMNH information over the period June 2016-June 2017.

Factors in success The evaluation suggests that these approaches are most effective when they include elements of: a. b. c. d. e.

Peer education; Participatory learning approaches; Public recognition of roles as RMNH ‘ambassadors’, ‘heroes’ and role models; Direct linkages to services, such as youth-friendly health services, ambulances and MWHs; Partnership-building with other institutions and sectors, such as schools, Women and Child Affairs Units, traditional structures (e.g. Aba Gaada in Oromia).

Sustainability and scalability There may be some costs associated with training, incentivising and managing community groups. Opportunity costs can be high when managing and facilitating large numbers of groups – these could be mitigated through strategic partnerships.

The most active member of Be Model Women was nominated “hero” for her commitment in mobilising uptake of RMNH services. She is a woman who is listened to.

Establishing and scaling-up such groups often depends on volunteerism – sometimes the limited time and capacity of members means they cannot deliver on planned activities. Groups need initial training and refresher training, and peer education messages must be quality-assured. Resources are needed for training, follow-up, convening community events and materials – although partnerships with other relevant institutions can support efficient scale-up and cost-sharing.

Policy/programme implications •

Tailor community engagement strategies to the type of stakeholder and context (e.g. young people, women, men, community and religious leaders). Monitor and support groups appropriately to maintain interest and motivation and to quality assure the information shared.

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Allocate appropriate resources for training and convening community events.

Work with other relevant institutions and structures to go to scale and maximise efficiencies.

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Commission operational research studies to identify the best ways to engage the most hard-to-reach groups in each region, such as out-of-school youth and adolescent girls.

Strength of evidence The strength of evidence is mixed. The evaluation found that while some groups thrive, others can be short-lived – and all need active facilitation and follow-up to maintain interest and motivation for prioritising RMNH issues.

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5. Solar-powered mini media kits and key influencers In Somali and SNNP Regions, portable solar technology has been adapted for use in mini media kits. These kits include screens, media players and solar power packs to support RMNH education activities in hard-to-reach areas. Importantly, development of films and other media products for the educational activities is based on local formative research and involves ‘key influencers’ (e.g. local officials, community leaders, TBAs, HEWs and youth champions). They are involved in developing, translating and delivering the RMNH information. Mini media kits are used by HEWs for community meetings and each broadcast is followed by a community discussion.

A RIF sub-recipient procured 200 mini media kits for use in Somali and SNNP Regions and reported that over 140,000 women, men, young people and religious and community leaders in pastoralist communities of the two regions participated in these media events during October-December 2017.

Factors in success The factors contributing to the success of the mini media kits include their portability, energy efficiency and “novelty value” in pastoralist areas. The involvement of recognisable and trusted role-players in presenting the information ensures buy-in and that the information is appropriately translated and communicated. Community conversations after each media event can promote open communication about sensitive topics.

Sustainability and scalability Resource investments are required in procuring and maintaining the mini media kits and in developing and renewing locally-appropriate media products.

Mini media kits have the potential to be used in all pastoralist regions but they need to be procured from Europe (ETB 17,000 /unit). A local media firm needs to be contracted for formative assessments, content development, and for producing and renewing media products. HEWs also need some training in the use of the mini media kits.

Policy/programme implications •

Commission regional operational research studies to assess the cost-effectiveness and sustained effects of the mini-media approach.

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Apply the principles of involving ‘key influencers’ in the development and dissemination of RMNH education products to other behaviour change initiatives.

Strength of evidence The success of this initiative is well supported by evidence from primary records, key informant, stakeholder and beneficiary interviews, and direct observation.

Ethiopia has a rich social and behaviour change communication intervention landscape. The innovation brought by this initiative lies in the development of content with full participation of influencers and decision-makers, as well as in its technology. Meaningful engagement of key influencers, gatekeepers and/or change agents is a well-known success factor in interventions addressing sociocultural barriers.

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6. Women’s Self-Help Groups Women’s Self-Help Groups (SHGs) have been set up by NGO partners in each region to promote women’s empowerment. Members of the groups are provided with tailored RMNH information and opportunities to participate in savings and credit schemes; these can generate resources for accessing health services This promising practice responds to women’s inability to access RMNH services due to cost of transport, needing men’s permission and financial contributions, and distance.

Similar barriers to independence also prevent women from addressing their children’s ailments.

RIF involved over 15,500 women in economic empowerment initiatives over the period June 2016-June 2017. In Oromia Region alone, more than 100 SHGs were established with support by district micro-finance institutions and Women and Children’s Affairs officers. In SNNPR, 150 SHGs were organised and 1,200 women trained in RMNH issues, credit, finance and income generation.

Factors in success The success of Self-Help Groups for income generation depends on partnerships with experienced micro-finance institutions. There is added value from these groups if they include adult literacy opportunities. Links to improved RMNH outcomes need to be managed, for example, by building on Safe Motherhood Groups and adopting responsibility for MWHs or ambulance services. Male involvement initiatives also strengthen the viability of Self-Help Groups.

Sustainability and scalability To make the initiative sustainable there is a need for additional partnerships. Service provider buy-in will also be needed to make the link to improved RMNH service access.

Scaling up also depends on establishing partnerships with specialist institutions, as health bureau official consider responsibility for women’s Self-Help Groups as outside their mandate.

Policy/programme implications Consider investing in institutional partnerships (e.g. with micro-finance institutions and Women and Children’s Affairs units) to promote women/girl’s empowerment and improved autonomy in health decisions. These approaches may also be used strategically to help maintain MWHs and overcome financial barriers to RMNH service access.

Strength of evidence The final evaluation found mixed evidence of success depending on context. Many Self-Help Groups did well, especially in terms of generating savings through revolving funds; however, some were short-lived. The viability of groups depended on the buy-in of male partners and guardians, and some income generation activities proved unsustainable (especially at times of drought).

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7. Social accountability approaches A RIF operational research study in Somali Region highlighed how the attitudes of health care providers can significantly affect the quality and uptake of RMNH services.

RIF partners have identified several interventions for addressing the values and responsiveness of service providers. Key interventions have included: training in social accountability; use of a Standards-Based Management Recognition Tool; and engagement of District Advisory Committees.

RIF implementing partners provided training to over 2,400 health care workers on issues relating to accountability and responsiveness to communities and women over the period June 2016-June 2017, and trained 420 health facility boards on issues of accountability and community responsiveness.

Factors in success The evaluation suggests that the effectiveness of these interventions is enhanced by: a) good and sustained supportive supervision; b) links to the provider performance review system; and c) regular meetings between providers and community representatives that result in successful implementation of joint action plans.

Sustainability and scalability Social accountability approaches need service provider training, buy-in and management support. The time, buy-in and motivation of community members also needs to be considered – although community involvement can improve the sustainability of any corrective action taken. Depending on problems identified and the actions agreed, resource investments might be needed for new constructions, repairs, equipment and for convening community meetings.

Scaling up of such initiatives ultimately depends on the commitment and leadership of regional, zonal and district health bureau officers. Additional resources and time investments might be needed for community meetings and problem-solving, as well as facility and supply chain improvements.

Policy/programme implications •

Where feasible, provide management support and recognition for facility staff to meet with community representatives regularly to agree and implement problemfocused action plans that aim to improve service quality and uptake.

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Ensure regular values clarifications training for health care workers at every level of the health system to ensure they continue to work to the highest professional standards and promote the Health Sector Transformation Plan principles of caring, respectful and compassionate service provision.

Strength of evidence The final evaluation found mixed evidence of the effectiveness of these interventions depending on the setting. There were several reports of success in addressing provider absenteeism and improving supply-side infrastructure. However, these initiatives require considerable sustained commitment by community volunteers, as well as facility managers and health bureau officials; high levels of staff turnover can compromise this commitment. In addition, some supply-side challenges are beyond the control of local health care workers, which can become demotivating.

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Key observations The evaluation of RIF promising practices has led to three key observations: 1.

The need for ‘systems thinking’. The most effective promising practices are not stand-alone interventions, rather they address a health systems gap, strengthen the RMNH continuum of care and link demand creation work to service supply.

Consequently, in selecting and scaling up promising practices, it is important to adopt a systems approach that maximises linkages between interventions so they can become mutually reinforcing.

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Effective leadership, collaboration and coordination may be key factors in success, especially when they support a systems overview, efficient management of resources and productive cross-sector partnerships. Evaluation evidence suggests that the involvement of Regional Health Bureaus (directly and indirectly) under the strategic leadership of FMOH has been an important element in translating project activities into measurable RMNH results.

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Promising practices as processes. The evaluation found that some of RIF’s promising practices have considerable stakeholder support but have shown mixed results, or there has been insufficient evidence to demonstrate success. It is notable that in some cases, generic interventions (such as MWHs) have needed further adaptation to local context and there have been varying levels of community and institutional buy-in.

Promising practices thus need continuous adaptive management to hone them to the implementation environment. Timely operational research studies could help to capture learning and build up the local evidence base.

Recommendations •

Work closely with regional universities: support completion of intervention-related research and continue building up the body of evidence on effective innovations and their cost-effectiveness at scale.

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Build on productive partnerships: support Regional Health Bureaus to build on partnerships with a small number of implementing partners with a strong performance record; consider establishing a successor innovation fund for this purpose.

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Harness resources and experience: work collaboratively with other development partners to identify opportunities for sustaining and scaling up the most successful RMNH interventions for pastoralist areas.

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Continue addressing supply-side challenges: include a focus on health care worker values, morale and motivation; use a systems approach to strengthen complementary supply and demand-side initiatives.

Methodology The promising practices were selected and evaluated through a mixed method approach, involving a desk review, key informant interviews and consensusbuilding on a shortlist of practices based on a set of criteria (innovation, evidence of effectiveness, stakeholder support, and potential for sustainability and scaleup). Primary data collection was conducted through regional and site visits, individual and group interviews, and direct observation. Limitations (e.g. selection, researcher and respondent biases) were mitigated through systematic triangulation and cross-checking exercises at both the data collection and analysis stages.

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References 1.

Mott MacDonald. 2018. Monitoring & Evaluation of the Reproductive, Maternal & Neonatal Health Innovation Fund. Evaluation of Promising Practices (Evaluation report and regional report annexes submitted to DFID Ethiopia, June 2018).

Photo credits Page 1: Creative commons licensed (CC BY-NC-ND 2.0) flicckr photo: UNICEF Ethiopia, 2001, https://www.flickr.com/photos/unicefethiopia/8169027787/ Pages 3-5: RIF programme Page 7: Creative commons licensed (CC BY-NC-ND 2.0) flicckr photo: Ethiopia/2014/Tsegaye https://www.flickr.com/photos/unicefethiopia/16996226651 Page 10: Creative commons licensed (CC BY-NC-ND 2.0) flicckr photo: UNICEF Ethiopia/2017/Mersha https://www.flickr.com/photos/unicefethiopia/35691822936

This Policy Brief was prepared by the RIF Evaluation Team.