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Adoption and Sustainability of Community Based Maternal and Newborn Health Innovations by Decision-makers in Ethiopia

Oot, Lisa Katharine (2011)
Master's Thesis (95 pages)
Committee Chair / Thesis Adviser: Stephenson, Robert
Committee Members: McFarland, Deborah A
Research Fields: Health Sciences, Obstetrics and Gynecology
Partnering Agencies: Emory University schools, faculty or affiliated programs ; International Non-governmental organization (e.g., CARE, Inc.) ; University, college or educational institution (other than Emory)
Keywords: maternal health; decision-makers; Ethiopia; newborn health
Program: Rollins School of Public Health, Hubert Department of Global Health
Permanent url: http://pid.emory.edu/ark:/25593/92kg4

Abstract

Maternal and child mortality rates in Ethiopia are among the highest in the world, with a woman in Ethiopia having a 1 in 27 lifetime chance of dying of pregnancy related causes. As in many resource poor settings, the Ethiopian health system is relatively weak with limited resources allocated and expended for maternal and child health. This study examines maternal and child health service provision from the perspective of key stakeholders who have decision making roles in the allocation of resources. This study uses qualitative in-depth interviews and focus group discussions to explore levels of maternal and child health (MCH) knowledge among stakeholders, and examines how this knowledge influences attitudes towards service provision, perceptions of community needs and priorities in resource allocation. Decision-makers interviewed include village/ kebele administrators and woreda (district) health officers (WHOs). Results suggest that while key decision-makers endorse and support Health Extension Workers (HEWs) and the Health Extension Program, both groups identify problems within the program and the health system that limit the effectiveness and sustainability of the program. Community leaders express skepticism over the ability of HEWs to provide quality delivery services and remain hesitant to advocate for deliveries in the health post. Despite advocating for HEWs to provide delivery services, WHOs report that HEWs lack the training and supplies to provide skilled attendance. Both groups of decision-makers feel it is the responsibility of other parties (the Ethiopian government and donor partners) to create the necessary changes to improve maternal and child health outcomes. Our results suggest that decision-makers want HEWs to provide delivery care but feel they lack the necessary training and equipment. Training of HEWs in delivery skills can be an effective medium for providing skilled attendance at birth; however HEW trainings need to be incorporated into the government health plan to be sustainable. Decision-makers currently perceive that they are unable to influence maternal and neonatal outcomes in their communities, thus preventing action. The Ethiopian government and MaNHEP should commit to improving the health infrastructure in Ethiopia, while empowering decision-makers to act within their own locus of control.

Table of Contents

Table of Contents -- Abstract......................................................................................................................iv -- Acknowledgments ......................................................................................................vi -- Introduction.................................................................................................................1 -- AIMS.............................................................................................................................2 -- Research Question...........................................................................................................2 -- Primary Objective............................................................................................................3 -- Specific Aims..................................................................................................................3 -- Background..................................................................................................................3 -- Maternal and Child Health in Ethiopia ..................................................................................3 -- The Ethiopian Health System ............................................................................................5 -- Health Care Financing .....................................................................................................7 -- Health Extension Program (HEP) ........................................................................................9 -- Health Service Utilization..................................................................................................9 -- Literature Review ......................................................................................................12 -- Review of the HEP in Ethiopia........................................................................................... 12 -- Community Health Worker Programs................................................................................... 16 -- Purpose and influence of programs: ..................................................................................16 -- Stakeholder influence:.....................................................................................................18 -- Implementation problems of community health worker programs ............................................. 19 -- Health system infrastructure and community acceptance......................................................19 -- Need for recurrent training:..............................................................................................21 -- Community leader and government stakeholder perspectives ................................................. 23 -- MCH funding and sustainability ......................................................................................... 25 -- Summary...................................................................................................................... 27 -- Methodology .............................................................................................................28 -- Study Setting: Amhara Region, Ethiopia............................................................................. 28 -- The Maternal and Newborn Health in Ethiopia Partnership (MaNHEP) ....................................... 29 -- Description of qualitative research with decision-makers...................................................... . 29 -- Justification of qualitative methods.................................................................................... 30 -- Population and sample...................................................................................................... 31 -- Description of study population.......................................................................................... 33 -- Study instrument: qualitative guides ...................................................................................34 -- Selection and training of data collectors...............................................................................35 -- Final data collection .........................................................................................................36 -- Data Analysis ................................................................................................................. 37 -- Ethical clearance ........................................................................................................... 38 -- Results.......................................................................................................................39 -- 1. Both groups of decision-makers.................................................................................. 40 -- 1.1 Health priorities and attitudes towards maternal and newborn health.................................40 -- 1.2 Prioritization of MCH .................................................................................................41 -- 1.3 Knowledge regarding maternal and child health ..............................................................42 -- 2. Woreda health officials................................................................................................ 43 -- 2.1. Perspectives on maternal and child health ...................................................................43 -- 2.2. Perceptions regarding delivery....................................................................................43 -- 2.3. Gap regarding child and neonatal health ...............................................................................45 -- 3. Community leaders perspectives on maternal child health........................................................... 45 -- 3.1. Perspectives on access to care...........................................................................................45 -- 3.2. Traditions surrounding pregnancy and childbearing ....................................................................46 -- 3.3. Service utilization for delivery care.........................................................................................48 -- 3.4. Gap regarding child and neonatal health ................................................................................49 -- 4. Decision-maker attitudes towards the health system, health extension workers and the -- health extension program.......................................................................................................... 50 -- 4.1. Attitudes towards HEWs...................................................................................................50 -- 4.2. Attitudes towards the health system and health extension program......................................52 -- 5. Woreda health official attitudes towards the health system and the HEP .............................. 54 -- 5.1. Attitudes towards HEW benefits ..................................................................................54 -- 5.2. Attitudes towards HEW training ..................................................................................55 -- 6. Community leader attitudes towards the health system and delivery services ................... 56 -- 6.1 Attitudes towards HEWs and delivery services............................................................56 -- 6.2. Attitudes towards the health system.......................................................................57 -- 7. WHO Attitudes towards current MCH programming and sustainability ................................. 59 -- 7.1. Attitudes towards the funding of trainings ...................................................................60 -- 8. Community leader attitudes towards MCH programming ..................................................... 61 -- Summary...................................................................................................................... 63 -- Discussion..................................................................................................................65 -- Main Findings ................................................................................................................ 65 -- Issues influencing prioritization of MCH................................................................................ 67 -- Decision-maker perceptions regarding the ability to improve MCH ............................................ 70 -- Creating a sustainable program ........................................................................................... 74 -- Recommendations for MaNHEP............................................................................................. 74 -- Limitations and delimitations ............................................................................................... 75 -- Conclusion....................................................................................................................... 76 -- Appendix ...................................................................................................................78 -- Appendix A. Woreda Health Official Guide ......................................................................... 78 -- Appendix B. Community Leader Guide .............................................................................. 80 -- References.................................................................................................................83

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