Impact assessment of community-based
health workers in the Somali Region,
Ethiopia
Gezu Bekele, independent consultant, Addis Ababa, Ethiopia
Andy Catley, Feinstein International Center, Addis Ababa, Ethiopia
Alison Napier, Feinstein International Center, Addis Ababa, Ethiopia
Adrian Cullis, Former Director, Livelihoods Unit, Save the Children US, Addis Ababa, Ethiopia
Sudan
Assessment
site
ETHIOPIA
Kenya
Somalia
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Background
• Somali Region of Ethiopia is one of the least developed areas of the
world.
• Characterized by insecurity, harsh environment and limited
infrastructure.
• Human livelihoods dominated by mobile pastoralism.
• Somali ethnic groups, closely linked to neighboring Somalia and
northern Kenya.
• Recurrent humanitarian crises – drought, conflict.
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Background health indicators1
• Crude life expectancy: women 33 years; men 41 years (cf. USA 78 years)
• Male infant had a 22 per cent higher chance of surviving to the age
of five than a female infant
• Pastoralist (nomadic) communities, only 24% children fully
immunized
• Only 12% of pastoralists reported a health clinic in their community
and at a nearest average distance of 36km
1Devereux,
S. (2006). Vulnerable Livelihoods in Somali Region, Ethiopia.
Research Report 57, Institute for Development Studies, University of Sussex.
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Save the Children US Health Program
• Aimed to improve primary healthcare in Dollobay and Hargelle
districts.
• Strategy was to introduce and support local community health
agents (CHAs) as a complementary approach to fixed-point health
facilities.
• CHAs could provide health information, administer oral rehydration
solution, and recommend referral to a health clinic; government
policy restricted CHAs to these tasks only.
• Strategy also included support to traditional birth attendants
(TBAs), and referrals by TBAs to higher-trained workers
• Implemented from 2002 to 2007.
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Impact assessment design
• Limited baseline and monitoring data available.
• Retrospective measurement of three indicators of service provision
viz. accessibility, affordability and quality.
• Different health service providers – including CHAs and TBAs –
were compared using these five indicators.
• Random sample of 200 women and 200 men in program areas.
• Standardized participatory matrix scoring method, with semistructured interviews.
• Only women informants scored TBAs.
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Results: Accessibility
Figure 1. Relative accessibility of health service providers in SC US
program areas, Hargelle and Dolobay woredas, 2007
Women informants n=200
Men informants n=200
Results derived from matrix
scoring. Women scored 4
service providers and men score
3 service providers. Scores were
adjusted to enable a direct
comparison of mean scores
between men and women for
CHAs, health clinics and ‘other’
service providers.
‘Other’ includes village doctors,
health posts, hospitals.
CHA – community health agent
TBA – traditional birth attendant
CI – confidence interval
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Results: Affordability
Figure 2. Relative affordability of health service providers in SC US
program areas, Hargelle and Dolobay woredas, 2007
Women informants n=200
Men informants n=200
Results derived from matrix
scoring. Women scored 4
service providers and men score
3 service providers. Scores were
adjusted to enable a direct
comparison of mean scores
between men and women for
CHAs, health clinics and ‘other’
service providers.
‘Other’ includes village doctors,
health posts, hospitals.
CHA – community health agent
TBA – traditional birth attendant
CI – confidence interval
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Results: Quality
Figure 3. Relative quality of health service providers in SC US program
areas, Hargelle and Dolobay woredas, 2007
Women informants n=200
Men informants n=200
Results derived from matrix
scoring. Women scored 4
service providers and men score
3 service providers. Scores were
adjusted to enable a direct
comparison of mean scores
between men and women for
CHAs, health clinics and ‘other’
service providers.
‘Other’ includes village doctors,
health posts, hospitals.
CHA – community health agent
TBA – traditional birth attendant
CI – confidence interval
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Results: Traditional birth attendants
Table 1. Impact of TBAs on mother and child health
Indicator of TBA impact
Year
2002/3
2006/7
Use of trained TBAs
0%
68%
Proportion of women with dystocia referred by
TBA to health center
0%
0%
1.9%
1.9%
2.1 (1.99, 2.28)
0.4 (0.28, 0.95)
98.0%
98.0%
Proportion of women exclusively breastfeeding to
6 months of age
Mean (95% CI) number of days to start of
breastfeeding
Proportion of women feeding milk-water mix to
infant from day 1
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Discussion points : CHAs
• CHAs received relatively high scores from both women and men for
all service indicators, apart from quality
• Although all CHAs were male, they were significantly more
accessible and affordable to women compared with men.
• Men’s preference for health clinic quality over CHAs, reflected their
ability to travel to and afford health clinic services relative to women;
this reflected cultural discrimination against women and girls in
Somali pastoralist communities.
• The main opportunity for improving the system was to improve CHA
quality i.e. their clinical roles - this would need government
endorsement of an expanded clinical role for CHAs, allowing them
to diagnose and treat a wider but specified list of diseases.
• Further piloting of the CHA approach is needed, drawing on lessons
from community case management.
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Discussion points : TBAs
• Difficult to identify any specific health outcomes arising from greater
use of TBAs.
• Zero referral of dystocia cases explained by inaccessible health
clinics, presence of male health workers at health clinics, and poor
clinic facilities and hygiene.
• Major improvements needed e.g. quality and cultural acceptance of
referral options; measurement of TBA health outcomes.
• Limited impact on breastfeeding behavior requires further
assessment, including women’s reasons for adopting some
improved practices and not others
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Acknowledgements
• The Save the Children Health Program was implemented under the
Southern Tier Initiative Livelihoods Enhancement for
Agropastoralists and Pastoralists (LEAP) Program, funded by the
United States Agency for International Development (USAID).
• The impact assessment was also funded by USAID under the
Pastoralist Livelihoods Initiative in Ethiopia.
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