Improving immunisation coverage in Ethiopia: a formative evaluation in pastoral communities
3ie evidence programme: Innovations in Increasing Immunisation Evidence Porgramme
Author(s): Hailay Desta Teklehaimanot, Bekana Tolera, Edna G/Michael, Awash Teklehaimanot
Institutional affiliation(s): Center for National Health Development in Ethiopia, Oromia Regional Health Bureau, Ethiopia
Grant-holding institution: Center for National Health Development in Ethiopia
Main implementing agency: Oromia Regional Health Bureau, Ethiopia
Sex disaggregation: No
Gender analysis: No
Equity focus: No
In Ethiopia, approximately 15 million people practice pastoralism. Although there have been significant improvements in the health sector over the last decade, the government’s Health Extension Program static health posts are still unable to address the needs of the pastoral communities adequately. This inability is due to the communities’ physical remoteness, their settlements being dispersed across large geographic areas, their constant mobility and low demand for health services. With the aim of empowering communities and addressing demand-side barriers in the health system, the Ethiopian government introduced a community mobilisation platform called Health Development Army (HDA). This study assesses the effects of extending the HDA network to pastoral communities.
As part of the intervention, health extension workers trained women from the community to become HDA members and drive health-related behaviour change within their communities. Unlike the providers of formal health services who remain static in terms of location, the HDA members remained with their pastoral communities and were responsible for health service-related engagements.
Selected women community members were systematically trained in immunisation, as well as other services that are part of the health extension programme package and in accordance with the government policy. The HDA network consisted of development teams and 1-5 networks. Development teams were organised in 20-30 households clustered in 1-5 networks (organised in a group of six households) living in the same neighbourhood. The network leader reported to development team leaders, who were in turn supervised by HEWs. In addition, the intervention also engaged traditional leaders (locally known as abba ollas), who were consulted during the formation of networks, as well as for the election of the network and development group leaders.
The HDA model is based on diffusion theory, which stipulates that interpersonal contacts through social systems and networks provides information, and influences opinion and judgment among community members. These underlying assumptions support this theory:
- Peer-to-peer counselling and experience sharing on immunisation, through frequent and regular meetings, can produce sufficient behavioural change leading to improved immunisation.T
- The network meetings continue when the community moves away from their kebeles, ensuring continuity in behavioural communication activities.
- The intended beneficiaries (i.e. pastoral women) are correctly identified and women with children are included in the network.
Evaluation design and methodology
This study incorporated both quantitative and qualitative methods. The qualitative component employed 8 community focus group discussions (representing different stakeholders) and 45 key informant interviews, which were digitally recorded. The quantitative component employed pre- and post-intervention household surveys to determine outcome indicators.
Primary evaluation questions
This evaluation answers the following questions:
- What is the feasibility of implementing the HDA network intervention in pastoral communities;
- Is the intervention acceptable to the communities; and
- Does the intervention have an impact on immunisation rates of children in the communities?
Following the implementation of the intervention, the percentage of fully vaccinated one-year-old children in the communities went from 27 per cent at baseline to 52 per cent at endline, i.e. the immunisation rates increased by almost 100 per cent.
The intervention was found to be highly acceptable by health staff, the intended beneficiaries and health extension workers. A survey of 968 women during endline confirmed this finding; 97 per cent of the respondents reported that they had heard about the health development army, and about 96 per cent of these women were members of the HDA network.
Although the acceptability of the intervention was high, there were several challenges in the take-up of the intervention. An assessment of the meeting attendance records showed that only 9 per cent of the HDA members attended all scheduled meetings and only 14 per cent had attended most of the scheduled meetings. The most frequently stated reason for low attendance was the increased mobility of the community members due to severe drought conditions during the intervention period.
During the course of the intervention, it was observed that pastoral communities are organised in a manner wherein a cluster of families, usually residing in geographical proximity, are governed by a common abba olla. Furthermore, not only do the pastoral families migrate outside their village, they also move within their village from one settlement area to another. Due to the frequent location change within the village and to ensure the sustainability of network organisation even after families migrate, pastoral women were organised into networks based on their abba olla.
The HDA model requires temporary reconstitution and regrouping of members when network members partially migrate. To ensure independent reorganisation by the members themselves, the team suggests including the following components in the intervention plan:
- Identifying members and leaders who plan to migrate and establish where they plan to migrate.
- Creating temporary networks prior to their migration based on when and where they plan to migrate.
- Entrusting members with identifying women who migrated with them and initiating the creation of temporary networks of these women.
- Given the findings of feasibility, acceptability and potential benefits in improving immunisation rates, the authors recommend a full impact evaluation to determine the intervention’s impact on immunisation coverage and health status of children, cost-effectiveness and sustainability.