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The last three decades have seen an impressive reduction in under-five mortality in Ethiopia, however utilisation of child health care services has remained low. This evaluation looked at the effectiveness of the 'Optimising the Health Extension Program' across four regions of Ethiopia.

Despite a range of programmes and initiatives introduced in Ethiopia since 2003 care-seeking for sick under-five children has remained low. The Ethiopian Government initiated the two-year Optimising the Health Extension Program (OHEP) with the aim to introduce community engagement activities, which would enhance caregiver knowledge and household practices. Furthermore, capacity strengthening to improve the availability of quality services in the Community Based Newborn Care (CBNC) and integrated Community Case Management (iCCM) programmes, and promotion of district-level ownership and accountability to integrate these services into the district-level planning and budgeting. These different components together would hypothetically lead to increased utilisation of CBNC and iCCM services.

This study, undertaken by Della Berhanu et al and published in BMJ Open, aimed to assess the extent to which the OHEP intervention increased care-seeking for children under the age of 5 years, by comparing changes over time in intervention and comparison areas.

Intervention districts were selected by the government of Ethiopia and implementing partners for having both a relatively low utilisation of primary child health services and the availability and ability of partners to support implementation. The implementers were four nongovernmental organisations (PATH, UNICEF, Save the Children and Last 10 Kilometres/John Snow Inc.). The intervention started in 2016 and lasted for a duration of two and a half years and had three components:

1) community engagement;

2) primary care level capacity building and;

3) ownership and accountability of child health services at the district level.

Comparison districts were selected by the Regional Health Bureaus to be similar to the size of the population, the burden of diseases, number of primary healthcare units, health service coverage, length of iCCM and CBNC service delivery and absence of partners implementing other demand generation activities.

A health worker examines Desalew Mired and her newborn. Addis Kidam Health Post. Photo Credit: IDEAS/Christopher Smith 2019


This study found that the OHEP intervention neither had any effect on care-seeking for any illness nor on treatment for diarrhoea or possible pneumonia in children 2–59 months of age. Neither did the authors find any evidence of an effect on care-seeking for neonatal illness nor on the treatment of possible serious bacterial neonatal infection. These findings were based on household surveys and were supported by results from register reviews at health posts and health centres that showed a low level of service utilisation for sick under-five children at baseline and endline surveys. The intervention did not affect caregivers’ participation in community engagement activities. No changes were observed in facility preparedness in health centres and health posts that could be related to the intervention. The health system characteristics at the district level showed small changes, which were not associated with the intervention.


The lack of effect could be attributed to the relatively short period of OHEP implementation, the nature and unmet assumptions of the intervention and implementation interruption. Future funding schemes need to take into consideration that complex interventions with multiple components, including behaviour change, need a more extended implementation period to measure the effectiveness of the programme. Given the overall low care-seeking for childhood illnesses in this study continued efforts are needed to strengthen the primary care services for under-five children.

The Dagu team also undertook a process evaluation to understand why the OHEP intervention didn’t achieve its intended objectives.


Profile picture of Dr Della Berhanu
Dr Della Berhanu

Assistant Professor

Yemisrach Okwaraji

Research Fellow

Atkure Defar

Dagu Lead, Ethiopian Public Health Institute

Profile picture of Professor Joanna Schellenberg
Professor Joanna Schellenberg

IDEAS Co-Principal Investigator and Professor

Professor Lars Åke Persson

Professor of Public Health Evaluation