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This process evaluation of the implementation of the 'Optimising the Health Extension Program' in Ethiopia studies factors that could contribute to evidence which shows that the intervention did not achieve its objectives.

The ‘Optimising the Health Extension Program’ was implemented between 2016 and 2018 in four regions of Ethiopia. It included community engagement, capacity building, and district ownership and accountability. The Dagu project at the London School of Hygiene & Tropical Medicine is leading an evaluation of the programme. A pragmatic trial, as part of the evaluation, comparing intervention and non-intervention districts found no evidence to suggest that the intervention increased utilisation of services.

To better understand findings from the trial the Dagu project initiated this mixed-method study, published in the International Journal of Environment Research and Public Health, to further explore how the intervention was implemented. A fidelity analysis was performed for each of the 31 intervention activities to assess the extent to which activities were carried out according to plan. Furthermore, qualitative interviews with implementers were undertaken.

Study findings show that the implementation of intervention activities were delayed. Key barriers that prevented a timely implementation included: complexity of the intervention and administrative systems, inconsistent support from district health offices and infrequent supervision of health extension workers.

The study authors conclude that for sustainability, evidence-based interventions should be aligned with national health priorities and delivered within existing health systems. Strategies to overcome the resulting complexity should include a realistic time frame and investment in district health teams, to support implementation at the grassroots level.


Yemisrach Okwaraji

Research Fellow

Atkure Defar

Dagu Lead, Ethiopian Public Health Institute

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Dr Della Berhanu

Assistant Professor

Professor Lars Åke Persson

Professor of Public Health Evaluation

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Professor Joanna Schellenberg

IDEAS Co-Principal Investigator and Professor