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

2 Assessment site Sudan Kenya Somalia ETHIOPIA

3 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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5 Background health indicators 1 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 1 Devereux, S. (2006). Vulnerable Livelihoods in Somali Region, Ethiopia. Research Report 57, Institute for Development Studies, University of Sussex.

6 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.

7 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 semi- structured interviews. Only women informants scored TBAs.

8 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

9 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

10 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

11 Results: Traditional birth attendants Table 1. Impact of TBAs on mother and child health Indicator of TBA impactYear 2002/32006/7 Use of trained TBAs0%68% Proportion of women with dystocia referred by TBA to health center 0% Proportion of women exclusively breastfeeding to 6 months of age 1.9% Mean (95% CI) number of days to start of breastfeeding 2.1 (1.99, 2.28)0.4 (0.28, 0.95) Proportion of women feeding milk-water mix to infant from day %

12 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. Discussion points : CHAs

13 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 Discussion points : TBAs

14 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. Acknowledgements