This seminar - hosted by the MARCH Centre at the London School of Hygiene and Tropical Medicine - highlights the experiences of Last Ten Kilometer project (L10K) in community-based approaches leading to improved Reproductive, Maternal, Newborn and Child Health (RMNCH) care behaviours and practices in rural Ethiopia.

1. Engaging Communities for Improving Reproductive, Maternal,
Newborn and Child Health (RMNCH) in Rural Ethiopia:
L10K Experience and Current Strategy
London School of Hygiene &Tropical Medicine
22nd March, London

2. Background
• The MMR, NMR and U5MR in Ethiopia are still high (which are
respectively 4.2, 28, and 68 deaths per 1,000 live births)
• However, Ethiopia is committed towards achieving the MMR, NMR and
U5MR reduction targets of SDG 3
• Ethiopia’s health sector transformation plan (HSTP), 2015–2020, is
aligned with the SDG targets; and aims to reduce MMR, NMR and
U5MR respectively to 2, 10, and 38 deaths per 1,000 live births, by 2020
• Enhancing community empowerment, engagement and participation is
one of the strategic objectives of HSTP

3. Three-tiered health care system of Ethiopia

4. Primary-level health care: Rural
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Health
Center
Health
Center
Health
Center
Health
Center
Health
Center
Primary
Hospital
District Health
Office
HP = Health Post
• 100,000–200,000 people
• 25-50 beds
• CEmONC
• Referral for health centers
• Technical support & training
for health center staff
Primary
health care
unit (PHCU)

5. Primary health care unit (PHCU)
Health Center
15,000 – 25,000
Health
Post
Health
Post
Health
Post
Health Development Teams
(25 HDA teams)
Health
Post
Health
Post
• Serves 15,000–25,000 people
• About 20 staff
• 5 beds
• Preventive and curative
services including BEmONC
• Referral & training for health
extension workers (HEWs)
• Serves 3,000–5,000 people
• 2 HEWs
• 16 package of services; mainly
preventive and basic curative
services including Implanon,
injectables, iCCM & CBNC
• Train & mentor health development
army members (HDAs)
• Serves 25-30 households
• Five 1–5 HDA network
• Led by 1–30
• From model family households
• Provide health education
• Trained to identify danger signs
of pregnancy and sick children

7. The Last Ten Kilometers (L10K) 2020
• Funded primarily by Bill & Melinda Gates
Foundation (BMGF) with additional grants
from UNICEF and USAID
• Aims to ensure optimum coverage of high
impact RMNCH interventions and contribute
towards Ethiopia’s health sector
transformation plan (HSTP), 2015–2020
• Coverage: 240 districts (31 million people,
33% of the population of Ethiopia)

8. L10K’s community engagement: 2012–2015

9. Community-based data for decision making

10. Surveillance for targeted RMNCH services

11. Monitors continuity of care

13. HEW gathering information from HDA

14. HEW providing health education

15. HDA conducting family conversation

16. Participatory community quality improvement

17. Quality improvement team review meeting

18. Examples of community actions
• Facilitate transport of vaccines and other supplies
• Improved health post infrastructure (water, electricity)
• Transporting laboring mothers
• Building accommodations for HEWs

19. Referral Solutions
• Mapping of referral resources: key-
informant interviews, desk review, FGD
• Participatory design of innovations:
Consultative workshop and joint action plan
• Active management of referrals:
implement, monitor and evaluate

20. CBDDM implementation strength
Items
MIS: Supportive supervision data Survey
Jan - Feb ‘15
(n=316)Jul–Sep ‘13
(n=291)
Oct– Dec ‘13
(n=851)
Jan–Mar ‘14
(n=879)
% of HDAs in the kebele mapped their
households
58.8 81.8 94.3 91.3
% of HDAs who reported CBDDM data to the
HEW (or HEW collected data from the HDAs)
last month
23.4 37.6 39.9 49.8
% of Health Posts maintain CBDDM data
records
17.5 27.9 37.6 64.0
% of Health Posts used CBDDM data to
discuss health issues at the kebele command
post meeting during past 3 months
12.4 20.2 33.8 46.9
Mean CBDDM Implementation Strength
score (range: 0 and 10)
3.2 4.7 5.7 6.3

21. L10K MIS: Increase in pregnancy
identification rate attributable to CBDDM

23. PCQI Effects
MNH Indicator
Comparison
(%)
Intervention
(%)
Effect (95% CI)
Any ANC 88.0 92.0 *4.0(0.4, 7.5)
4+ ANC 50.5 55.3 4.8(-1.5, 11)
Neonatal tetanus protected 64.5 72.2 *7.6(1.8, 13.4)
Complete ANC 52.1 71.7 *19.6(10.8, 28.4)
Institutional delivery 53.3 60.9 *7.6(0.9, 14.3)
Any PNC 25.6 34.3 *8.7(2.4, 14.9)
Clean cord care 36.1 36.9 0.8(-11.4, 13)
Thermal care of the baby 48.4 49.8 1.5(-6.5, 9.4)
Delay bathing 78.7 82.8 4.1(-1.1, 9.3)
Immediate breastfeeding 80.8 82.7 1.9(-3.3, 7.1)
Exclusive breastfeeding 94.7 95.4 0.7(-2.8, 4.2)
*Statistically significant effect (p<0.05)

24. Trend in adherence to protocols for referrals from the community
or the health post to the health center
2
6
14
18
29
38
0
10
20
30
40
50
60
Jul-Dec'12 Jan-Jun'13 Jul-Dec'13 Jan-Jun'14 Jul-Dec'14 Jan-May'15
%
Slip Ambulance Advance call Escorting Feedback

25. Policy outcome
• CBDDM is now part of the Integrated Refresher Training
for the HEWs

26. Lessons learned: CBDDM
• Drivers of adopting CBDDM as the national strategy
– Aligned with national priority—community engagement & pregnancy care
– The national HDA strategy needed a focused approach
– Aligned with HEW work flow
– Field visit by policy makers—strategy appeared doable and promising
– Participation in national level working groups
– Demonstrability of credible evidence
– Recognition and trust
– Donor support

27. Lessons learned: PCQI
• Community participation and empowerment can
strengthen the performance of health systems
• Demand to ensure quality of services at health centres
• Communities can be an integral part of quality
improvement strategies

28. Lessons learned: Referral Solutions
• Stakeholders’ ownership of problems and proposed
solution
• Engaging stakeholders across each level of the referral
system created an awareness of the challenges and a
greater sense of commitment to jointly address them
• Consultative and monthly and quarter review meetings
created a platform for building relationships across each
level of the referral system

29. Primary Hospital
HC HC HC HC Health Center
Health
Post
Health
Post
Health
Post
Health Development Teams
(25 HDA teams)
Health
Post
Health
Post
CBDDM &
PCQI
Referral
Solutions

30. L10K 2020 approach, 2015 – 2019: PC-Solutions