Maternal and Newborn Health in Ethiopia Partnership Global Health Grant Agreement
Maternal and Newborn Health in Ethiopia Partnership Global Health Grant Agreement OPPGH 5309 i Table of Contents Table of Contents ……………………………………………………………………………………….. Acronyms…………………………………………………………………………………………………. Report to the Bill and Melinda Gates Foundation…………………………………………………….. Section 1: Business Plan………………………………………………………………………………… Section 2: Monitoring, Learning and Evaluation (MLE) Plan………………………………………… 2.1 Action Theory and MLE Framework……………………………………………………………..... 2.2 Outcome and Process Evaluation…………………………………………………………………. 2.3 Cost Analysis……………………………………………………………………………………….... Section 3: Approach for Uptake and Sustainability of Successful Interventions………………….. ii ii iii 1 1 10 11 11 17 17 Acronyms AAU AP BCC BDU BMGF CHBLSS CMNCH Co-PI FHD FLW FMOH GHS HC HEP HEW HP IFHP IHI JSI JSI L10K JSI R&T LS MaNHEP MLE MNH MOH NCHS NGO PDSA PI QI RHB SNL TBA TBD TOT TWG UN UNICEF URC vCHW WHO WorHO ZHD Addis Ababa University Activity Period Behavior Change Communication Bahir Dar University Bill and Melinda Gates Foundation Community and Home - Based Life Saving Skills. Community Maternal, Neonatal and Child Health Co Principal Investigator Family Health Department Front Line Workers Federal Ministry of Health Ghana Health Services Health Center Health Extension Program Health Extension Worker Health Post Integrated Family Health Project Institute for Healthcare Improvement John Snow Incorporated JSI Last 10 Kilometers JSI Research and Training Institute Learning Session Maternal and Neonatal Health in Ethiopia Partnership Monitoring, Learning and Evaluation Maternal Neonatal Health Ministry of Health National Catholic Health Service Non Government Organization Plan Do Study Act Principal Investigator Quality Improvement Regional Health Bureau Saving Newborn Lives Traditional Birth Attendant To be decided Training of Trainers Technical Working Group United Nations United Nations Children Fund University Research Corporation, Inc Voluntary Community Health Worker World Health Organization Woreda Health Office Zonal Health Department iii This report contains three sections: (1) Business Plan; (2) Monitoring, Learning and Evaluation Plan; and (3) Approach for Uptake and Sustainability of Successful Interventions. The report also includes information pertaining to current status of activities against the proposal activity milestones. Section 1. Business Plan The Business Plan includes detailed descriptions of: (1.1) implementation plan for life of the project; (1.2) organizational and individual faculty/staff roles; and (1.3) working relationships with the public sector. 1.1. Detailed implementation plan for the life of the project. Goal The goal of the Maternal and Newborn Health in Ethiopia Partnership (MaNHEP) is to demonstrate a community-oriented model to improve maternal and newborn health (MNH) care in rural Ethiopia and position it for scale up. The proposal Project Framework described the objectives and activities to achieve them, together with the underlying assumptions and critical activity milestones. Objectives #1 and #2 were concerned with enhancing the supply of and demand for focused evidence-based MNH care during the birth to 48-hours postnatal period. Objective #3 was crosscutting, integrating Objectives #1 and #2, and concerned with developing the ability of the frontline worker team (FLW team consists of HEWs, vCHWs, and TBAs) and communities to continuously improve the processes of MNH service delivery and to know when and how to spread their successes to others. Objective #3 was also more broadly focused on developing an enabling environment for communities and frontline workers to deliver MNH care during the critical period from birth to 48-hours using a district (woreda) level collaborative QI approach to community-oriented MNH that may be taken to scale nationally (henceforth called a “Lead Woreda” approach). We define a Lead Woreda as… a district-level health system capable of and committed to finding solutions and continuously improving performance so that an environment is created for frontline teams to effectively meet the health care demands and needs of pregnant women, their newborns and families. The present implementation plan gives an updated description of the project sites; activities, activity milestones by objective, indicating where these may have changed; and concludes with a revised composite timeline across all activities. It draws on knowledge gained over a 6-month period, from December 2009 to May 2010, through the completion of project startup activities including discussions with the Federal Ministry of Health (FMOH) and Regional Health Bureau (RHB) leaders; securing partner subcontracts; hiring and training of key personnel; project planning meetings, conference calls, and benchmarking exercises; identification and location of MaNHEP central and regional offices; and on-theground assessment and selection of project sites. Project Site(s) The project will take place in Amhara and Oromia regions. Within each region, three woredas were selected based on previously determined criteria: need, population size/number of expected deliveries, accessibility of health services, presence of frontline workers, and absence of other development partners working on the same or similar MNH issues. A representative “slice” of the health system is comprised of three woredas, two health centers within each of these woredas, all health posts within the catchment area of the two health centers, and the informal care system within the health post catchment areas/communities (see Figures 1 and 2 below). 1 Figure 1: Regional Level with Multiple Districts Figure 2: Within One District Furthermore, Tables 1 and 2 on pages 3 and 4 show characteristics of MaNHEP sites by region. The sites capture an overall estimated 28% - 39% of the total population and 12,798 births per year, assumed to be sufficient to demonstrate the community-oriented model to improve MNH care in rural Ethiopia. Activities and Activity Milestones by Objective Objective 1 To improve the capability and performance of the frontline worker ‘team’ (HEW, vCHW, TBAs) to provide targeted MNH services around the time of birth. Activities to achieve Objective #1 remain basically the same, with greater detail. Activities 1.1. Design (1.1.a), implement (1.1.b), and analyze (1.1.c) a study of frontline workers (HEW, vCHW, TBAs) to develop a better understanding of the factors that predispose, reinforce and enable capability and performance. To improve the capability and performance of the FLW team, we need to better understand factors that predispose, reinforce and enable capability and performance. We conducted a formative study of these factors in Amhara project area during May-June, 2010, implemented by Emory and Bahir Dar Universities. This will be repeated with Addis Ababa University from July-August 2010. 1.2 Apply the study findings to clarify, and refine frontline worker roles, responsibilities, and working relationships. Information from the study will be used, in conjunction with existing qualitative reports (where available) to inform the baseline surveys, to adapt/develop interventions to improve the FLW team’s direct service delivery capability and performance (both counseling and clinical care), and to inform the development of improvement activities at the community level. 1.3.Review and adopt/adapt both the facility-based clinical training materials and also the community home-based life saving skills (CHBLSS) training materials (1.3.a), obtain stakeholder consensus on them (1.3.b), and produce the approved materials (1.3.c). 2 Table 1: Targeted woredas and kebeles for MaNHEP implementation, Amhara Region. Zone Woreda Name Health Center Health Post or Village Woreda Population W. Gojam Mecha Merawi Bachima Enachenifalen Enaminret KuretBahir Meder Genet ZemeneHiwot TatekGebrie Birakat Sub total AbchekliZuria Ahuri Care Guta Korench Lalibela Dilamo Sub Total LibenZuria Kongerie Dembola YismalaJankit Shambela Ambeshen Kuala Baka Sub Total Total 307,703 Birakat S. Achefer Durbete Lalibela N. Achefer Liben Yismala 165,800 184,255 Total Population Male Female 5096 4772 3182 3550 2931 4828 3074 4094 31527 4787 5542 4888 4859 3023 4534 2373 30006 3108 3597 3072 4267 3419 4710 3185 25358 86891 4996 4629 3119 3480 2873 4752 3013 4013 30875 4884 5654 4986 4957 3084 4626 2421 30612 3170 3669 3134 4353 3488 4804 3250 25868 87355 3 Total 10092 9401 6301 7030 5804 9580 6087 8107 62402 9671 11196 9874 9816 6107 9160 4794 60618 6278 7266 6206 8620 6907 9514 6435 51226 174246 Percent Woreda Population 20.3 36.6 27.8 28.20 Estimated Births (3.73%) Distance to Health Centers (km) 376 351 235 262 216 357 227 302 2328 361 418 368 366 228 342 179 2261 234 271 231 322 258 355 240 1911 6499 10 8 8 15 26 38 36 -0.5 11 5 7 21 18 23 9 8 12 24 20 16 Table 2: Targeted Woredas and Kebeles for MaNHEP implementation, Oromia Region. Zone Woreda Name Health Center Health Post or Village Woreda Population N. Shoa Degem Hambisso TumanoAbdi Anokere ElemuEferso AnoDegem RasoMenya AligoroAbo AnajiruGedam YayaHaro Sub Total DebanaAgalu SanboCheka WuyeGose Liban Kura Dire Hacho Birity HariroDerso BondeGidabo HamumaWuchale RogeKolati Sub Total Wale Chilelu LenchoBorsu AboKeku JarsoTuti JemoBardada AboYeyebena MeleyuChewa NonoGondin Bitomilky Sub Total Total 109215 Ali Doro Kuyu G.Guracha Birity Warajarso Gohatsiyon Tulu Milky 138513 182251 Total Population Male 3671 2402 2529 2286 1718 2683 2334 3598 21221 3170 1620 3551 4327 2467 3499 1344 3527 1923 3144 28572 1650 4493 4319 2153 3558 4373 3874 3762 3243 31425 81218 4 Female 3821 2502 2634 2380 1790 2793 2430 3746 22096 3300 1688 3696 4505 2568 3642 1399 3671 2003 3273 29745 1718 4677 4497 2242 3704 4552 4034 3916 3377 32717 84558 Total 7492 4904 5163 4666 3508 5476 4764 7344 43317 6470 3308 7247 8832 5035 7141 2743 7198 3926 6417 58317 3368 9170 8816 4395 7262 8925 7908 7678 6620 64142 165776 Percent Woreda Population 39.7 42.1 35.2 39 Estimated Births (3.73%) 285 186 196 177 133 208 181 279 1646 246 126 275 336 191 271 104 274 149 244 2216 128 348 335 167 276 339 301 292 252 2437 6299 Distance to Health Centers (km) -4 3 4 6 10 15 15 15 5 11 6 15 23 14 14 25 28 6 5 11 14 16 19 26 24 18 1.3.a. Existing Facility-based Safe Clean Delivery training materials and CHBLSS training materials and related documents were reviewed during February-March 2010 against existing national documents. Based on the results of the review, the existing Safe Clean Delivery materials will be used for facilitybased clinical training, and the Family Health Card will be integrated into the CHBLSS postpartum visits via Take Action Card Booklets to encourage care of the woman and baby through year 2 of life (Objective #2). The materials from this review may be used as the basis for broader information, education and communications activities in the community and in communities that do not participate in the CHBLSS program during the life of the project. 1.3.b. The project team and MOH counterparts will approve all training materials before their use following the baseline surveys. 1.3.c. The MaHNEP/Addis Ababa office will procure and distribute the existing Safe Clean Delivery materials for use in the facility-based clinical training. They will produce and distribute the CHBLSS materials. 1.4. Conduct HEW clinical training needs assessment (1.4.a), conduct a facility-based clinical training for HEWs as needed (1.4.b), and evaluate the training (1.4.c) focusing on, knowledge, skills, and confidence to provide birth-to-48-hour care. 1.4.a. Training needs assessment will be captured through survey (knowledge) and pre-test (skills). 1.4.b. For the HEWs who need refresher training, the MNH Specialists will work with RHB counterparts to identify and prepare appropriate clinical training site(s). The MNH Specialists will conduct a site assessment for equipment, medications, infection prevention measures, and Clinical Trainers’ competency. Training sites exist at Durbete Health Center and Merawi Health Center for Amhara region and Fitche Hospital for Oromia region. Then, under MNH Specialist supervision, the Trainers will train HEWs on safe delivery. 1.4.c. Evaluate facility-based HEW training (See MLE Section 2). 1.5. Conduct CHBLSS training needs assessment (1.5.a), prepare for and conduct CHBLSS training of trainers (TOT) for HEWs, vCHWs and TBAs (1.5.b), and evaluate the training (1.5.c). HEW clinical training will be reinforced and expanded through CHBLSS TOT for HEW, vCHW and TBAs (Table 3). The QI Learning Sessions, Activity Periods and Coaching visits will provide an opportunity for MNH knowledge and skills refreshers and updates (See Objective #3). 1.5.a. The CHBLSS training needs assessment will be captured in activity 1.4.a. 15.b. The TOT will use a cascade approach and include the three woredas in each of the project regions. TOT-1: Week 1: MNH Consultants will conduct a pretest and 6-day training of Lead Trainers in CHBLSS for key Federal Ministry of Health, Regional Health Bureau staff, the Regional team managers, three Regional MNH specialists from Amhara and Oromia regions. The Lead Trainers will share lessons learned and finalize plans for the training of local CHBLSS training teams. Week 2: The Lead Trainers will then train 18 HEW Supervisors from each of the targeted regions. TOT-2: These Lead Trainers will then work in pairs to conduct pretests with 6-day CHBLSS training sessions for up to 60 HEW from the selected woredas and kebeles (12 HEWs per session) in each region. (See Table 3) TOT-3: The new HEW Trainers will work in pairs to conduct CHBLSS sessions to train vCHW and TBAs CHBLSS Facilitators. Two vCHW and two TBAs will be selected from each of targeted kebeles, for a total of 20 vCHW-TBA pairs per woreda. Selection of vCHW and TBAs will be based on interest, experience, current roles and responsibilities and community preference. On completion of TOT 3, each kebele will have two vCHW-TBA Facilitator ‘teams’ ready to implement CHBLSS for approximately 2,000 pregnant women and family caregivers/decision makers per year (typically small groups of 6-8 women and caregivers), with support from their HEWs and HEW Supervisors. In total, there will be 60 such facilitator teams across the three woreda in each of the two regions. (Table 3) Kebeles in each woreda are organized into small units (25-50 households) called “Gare” in Oromia region and “Gote” in Amhara region. There are a total of 813 Gares in the targeted kebeles in three of the Woredas in Oromia region and 353 in the targeted kebeles of Amhara region. The training cascade will select representatives from these smaller units, one TBA and one vCHW. After the TOT of the HEWs, a 2 day training will be given to vCHWs and TBAs by the HEWs and HEW Supervisor or Midwife from the supervising Health Center with support from the MNH Specialists. A total of 12 volunteers will be trained 5 in one session until all the units have one vCHW-TBA facilitator team. Each one of them will be given a Take Action Booklet and one Demonstration kit per Gare/Gote to be used by the FLW team. 1.5.c. Evaluate CHBLSS TOT. The CHBLSS will be evaluated using pre-post training testing on the skills included in the MNH package (See MLE Section 2). 1.6. Procure supply of misoprostol. The project will work in collaboration with Venture Strategies and DKT to procure and ensure an adequate supply and distribution of misoprostol. Procurement has been arranged at an approximate cost 0.30 USD per dose. 1.7. Introduce and communicate the MNH care package, role descriptions, materials, job aids, and checklists to other implementers and stakeholders including other RHBs, development partners, NGOs to encourage uptake (part of Objective #3 QI Learning, Activity and Coaching Sessions, as well as other dissemination activities under Objective #3). Objective 2 To increase demand for targeted MNH services and increase healthy self-care behaviors around the time of birth. Activities 2.1. Design (2.1.a), implement (2.1.b) and analyze (2.1.c) a study of factors predisposing, reinforcing and enabling demand and uptake of birth-to-48-hours care by women and family caregivers. As part of the study described in activity 1.1, we also assess local norms (and variants) about maternal and newborn care, care giving, and care seeking during pregnancy, birth, and the early postnatal period that may predispose, reinforce and enable a change in behavior on the part of childbearing women and families. The information from the study will be used, in conjunction with existing qualitative reports to inform the baseline surveys and to adapt/develop BCC strategy and materials to generate demand for service use and improved home care behaviors. 2.2. Develop/Adapt (2.2a), pretest (2.2b), implement (2.2.c) and evaluate (2.2.d) a behavior change communications (BCC) strategy to influence demand and uptake of birth to 48-hour care by women and family caregivers, incorporating information from the study and from a review of existing FMOH approved materials. 2.2.a/b. The Communications Director and BCC Manager (TBD) will facilitate the adaptation of the current BCC materials and development of BCC strategy. They will collaborate with the MOH counterparts, Regional Team Managers and MNH Specialists. 2.2.c. The BCC Manager, Regional MNH Specialists and the Regional Team Managers will implement the BCC strategy across the targeted sites. 2.2.d. Evaluate BCC strategy (See MLE, Section 2). 2.3. Introduce, (2.3.a), roll out (2.3.b) and evaluate (2.3.c) the CHBLSS program to increase demand among women and family caregivers for improved birth to 48-hour care by frontline workers as well as to improve healthy self-care behaviors in the birth to 48-hour period. The BCC interventions developed in activity 2.2, and CHBLSS TOT and planning from Objective #1 will be applied through CHBLSS program rollout. 2.3.a. The HEW and vCHW-TBA Facilitators will introduce the MNH evidence based package and CHBLSS program to key community stakeholders and community groups in their own kebeles. They will identify and invite all pregnant women to register for and attend the program in their third trimester of pregnancy. 2.3.b. The vCHW-TBA Facilitators will then implement the CHBLSS, covering four CHBLSS meetings with small groups of pregnant women along with key family caregivers and decision-makers. The CHBLSS meetings each last about 2 hours and will be held at a time and place agreed by the vCHW-TBA Facilitators and participants. The CHBLSS program will be repeated with successive cohorts of pregnant women until first all pregnant women are registered and then all women of childbearing age have participated in all four meetings. 6 2.3.c. Evaluate CHBLSS program (See MLE Section 2). 2.4. Introduce and communicate the study results, the BCC materials, CHBLSS materials to other implementers and stakeholders including other RHBs, development partners, NGOs to encourage uptake (part of QI Learning Sessions and Coaching, as well as other dissemination activities under Objective #3). Objective 3 Under national leadership, with regional support, demonstrate a lead woreda approach to improve MNH practices and services. Objective #3 activities have been refined, incorporating activities from Objectives 1 and 2 that will become part of the QI learning/coaching sessions. Lead Woreda Concept We envision a “lead woreda” to be a district-level health system capable of and committed to finding solutions and continuously improving performance so that an environment is created for FLW teams and communities to effectively meet the health care demands and needs of childbearing women and their families. A lead woreda will be able to: (1) improve health outcomes for women and newborns at community level; (2) build capacity of the district health system and communities to improve care at the community level; and (3) introduce new methods for spread. A lead woreda will serve as a model and learning laboratory for others. A collaborative quality improvement approach will be used to develop this model and build capacity. A collaborative QI approach brings together a large number of quality improvement teams (QI teams) with common aims and measures to rapidly achieve significant improvements and learn from each other in a specific area of care, with intention of spreading these methods to other sites.1 In the lead woreda approach, QI teams will be formed at the community-level comprised of representatives of FLWs, community leaders, pregnant women and their families. There are two key improvement aims for this project: Ensure that a FLW or CHBLSS-trained family caregiver delivers the MNH care package to 100% of women and newborns during labor, birth and the immediate postnatal period (0-1 hour); Ensure that a HEW delivers the MNH care package to 100% of women and newborns in the early postnatal period (2- 48 hours). In order to see improvement for these two aims, the FLW teams, pregnant women, and their family caregivers must understand and be confident to effectively provide the MNH care package. They also must agree that the MNH care package is culturally appropriate and will make a difference in pregnancy outcomes. Objectives #1 and #2 activities address many of these aspects of supply and demand-- but not all aspects. Given the locus of birth in rural Ethiopia, the home in most cases, the FLW teams, pregnant women and their family caregivers also must organize themselves and their communities, consider and improve processes so that the MNH care package can be reliably provided to all women and newborns that need it. Transportation and communication systems require coordination and cooperation of the community and frontline health workers to address. The project will facilitate the formation of communitylevel QI teams to improve the processes of MNH care. Activities 3.1. Set the stage for developing lead woredas using the QI approach. As part of project planning, the project will work closely with MOH counterparts to set the stage for developing lead woredas using a QI approach. This will entail defining the vision for success, the overall goals and aims, how the project team and MOH will interface and who will be involved in which 1 USAID Health Care Improvement Project. 2008. The Improvement Collaborative: An Approach to Rapidly Improve Health Care and Scale Up Quality Services. Published by the USAID Health Care Improvement Project. Bethesda, MD: University Research Co., LLC (URC). http://www.hciproject.org/node/1057 7 components to maximize efficiencies, and overall expectations at the end of the project period. During this time, and once baseline data have been obtained, we will set targets for indicators for success. 3.2. Conduct a 5-day launch workshop for the regional project teams and MOH counterparts to implement the QI approach A 5-day workshop was held in April 2010 to prepare the project team and key project counterparts to implement the QI approach. The Sr. QI Advisor conducted the workshop, with coordination and support from the West Africa Regional Director for URC. 3.3. Benchmark other programs for QI design help - benchmarking tour to Ghana’s IHI/NCHS/GHS program to learn from others who have implemented a similar approach. A 4-day study tour was organized and undertaken during May 2010 to learn about the design and implementation of a similar health systems improvement project in Ghana and to understand the healthcare improvement collaborative context, strategy, processes, materials, potential challenges and pitfalls as experienced by the Ghana team. Key project personnel participated in the tour (PI, Deputy Director, Program Manager, Communications Director, Sr. QI Advisor, QI Advisor, Regional team Managers and FMOH and RHB counterparts). 3.4. Develop project leadership in QI approach. The Sr. QI Advisor is working to develop the capacity of the project team and MOH counterparts at all levels through mentoring, joint coaching visits, co-facilitation of trainings and learning sessions and just-in time training on QI methods, theory and tools. The local project QI Advisor will be in regular contact and receive one-on-one mentoring from the Sr. QI Advisor. The QI Advisor also attended a training course in Uganda hosted by URC in June 2010. The QI Advisor, PI and Oromia Regional Team Manager will attend the 18-month IHI Improvement Advisors Development Program in Ghana, beginning in June 2010. These individuals will work with the project team to build capacity. 3.5. Adapt the QI approach for operationalizing the lead woreda concept focusing on community-oriented MNH. Using the information and materials from the Ghana program, and other information and materials from the URC and IHI, the project team and MOH counterparts will adapt the QI approach for developing the lead woredas. This activity will include the development and/or adaptation of training materials and tools and will be undertaken by the Sr. QI Advisor and QI Advisor. 3.6. Orient key stakeholders to the project goal and objectives, to the MNH package, and the QI approach to lead woreda development in stages, beginning with the central and regional stakeholders (3.5.a), followed by orientations for zone, woreda and kebele stakeholders (3.5.b). A one-day orientation will be undertaken by the PI, Deputy Director, Sr. QI Advisor, QI Advisor and Regional Team Managers at a venue in or near the RHBs, beginning the process of developing champions for the lead woreda concept and the QI approach. 3.7. Develop capacity of key MOH personnel (Woreda Health Office staff, health officers, HEW supervisors and/or active Health Center nurse midwives) in QI and skills for coaching. Following development of strategies and materials for coaching, the project team will build the capacity of HEP officers from the woreda and health center beginning with a 3-day training on improvement methods, coaching and the lead woreda approach. The Sr. QI Advisor and QI Advisor will conduct the workshop, with coordination and support from the PI, Deputy Director, Regional Team Managers, RHB and Zonal Health Department. The project team will provide on-the-job support to HEW supervisors and nurse midwives as part of the QI coaching site visits to reinforce their supervisory and mentoring roles and activities. In addition, there will be on site practicum in supporting and coaching QI teams throughout project implementation. 3.8. Implement the lead woreda development using the QI approach in the target woredas and kebeles including set up QI teams and analyze current care processes (3.8a), conduct Learning Sessions (3.8b), action period for testing and implementing changes (3.8c); provide regular coaching and support. (3.8d), hold woreda sharing meetings (3.8.e); Conduct regular measurement, documentation and analysis. (3.8.f) 8 The project staff and frontline QI teams begin the process of lead woreda development (Table 4). 3.8.a. Project staff and HEW supervisors and midwives will work with communities and HEWs to set up QI teams. The QI teams should include representatives of each group of community members. Each community will be given the flexibility to choose these QI team members, who are likely to include FLW teams, community leaders, and representatives of mothers and families. Communities may choose to base the QI teams with the Health Committees and/or include representatives from women’s groups. The QI team will start by reviewing their current care processes and practices through information from the formative research, baseline assessment, and process mapping. 3.8.b. We anticipate that the QI teams will meet every four months in two-day Learning Sessions (LS) to acquire improvement methods and tools, share improvement work with their peers, learn from their peers’ work, and plan new tests of change. The first Learning Session will include training on QI methods and tools, including measurement for quality and update and reinforcement of MNH skills. 3.8.c. Activity Periods (AP) are the three months in between Learning Sessions giving QI teams time to test and implement changes and collect data to determine their effectiveness. The QI teams will continuously identity solutions, or changes, for pregnancy identification, Misoprostol distribution, birth notification, pregnancy outcome documentation, distribution of BCC materials and referral communications and transportation, thus fostering a broader community partnership. These QI teams take the lead in developing and reinforcing locally appropriate ideas, new roles and responsibilities of the FLW and family members during birth and the early postnatal period. They will liaise with the community leadership to solicit input on current barriers and potential solutions. 3.8d. Key RHB staff, Regional Teams, and HEW supervisors, and midwives who will be trained in the QI approach and consulting skills will act as onsite coaches during monthly scheduled APs. Their role will be to assess the effect of the changes being tested, help the QI team problem-solve or reduce bottlenecks and barriers, transfer knowledge about best practices across facilities in between LSs, as well as update, support and reinforce clinical MNH knowledge and skills. This will occur during coaching visits. Additionally, the visits will provide opportunity to develop and reinforce new roles and responsibilities of FLW team through team-building activities. Making the shift in the roles and responsibilities of FLW (and family members) during birth and the early postnatal period will require time and a common understanding of current and future contributions of these ‘team’ members on the parts of the key stakeholders and the team members themselves. 3.8e. The project will work with Woreda Health Office (WorHO) to hold a woreda sharing meeting once per activity period in which all of the target kebeles will come together to discuss progress in testing changes, determine the best approaches for their woreda and discuss possible solutions to problems at the woreda level. 3.8f. QI teams will continually measure process and output/outcome indicators to determine if their solutions/changes are effective. They will begin with a baseline where available and plot data on time series charts monthly. The process of implementing the QI approach to lead woreda development and the solutions that are tried and implemented will be documented and analyzed at the kebele, HC, woreda, zonal, regional and project-wide levels. Project staff, coaches and QI team members will determine the best practices based on the commonality and number of changes in the kebeles. This information will contribute to the overall “learning” that will support sustainability and spread. The Sr. QI Advisor, QI Advisor and Regional Team Managers will oversee this activity. All coaches will have the responsibility to support QI teams in collection and analysis of data. The QI data will be integrated with the overall project MLE. 3.9. Disseminate successful MNH solutions from the target kebeles to new kebeles within the target woredas using low cost avenues. There are low-cost ways to disseminate successful MNH solutions as they evolve. The RHB counterpart(s), Regional Team, HEW supervisors QI team members will use the Learning Sessions (LS) to identify improvements and spread to other participating kebeles. The RHB counterpart(s), Regional Teams, and HEW Supervisors might use existing venues for reporting progress and sharing these solutions. For example, the RHB counterpart(s) could share progress and effective solutions at regularly scheduled FMOH annual review meetings, perhaps inviting counterparts from other regions to attend. The HEW Supervisors, HEW and vCHW could also do this. 9 The project team will work with RHB, ZHD and WorHO counterparts to find mechanisms to support and follow-up on implementation in new kebeles. The Sr. QI Advisor, QI Advisor and Regional Team Managers might use venues, such as development agency and donor meetings in which they participate. Finally, the QI Advisor and MOH counterpart will introduce successful solutions in the FMOH, thus promoting wider spread. 3.10. Evaluate the adoption and spread of key MNH solutions from the lead woreda kebeles to new kebeles within each of the targeted woredas. We will conduct an additional study to understand the perceptions of HEW Supervisors and FLW team and other stakeholders about the changes introduced into the health system. The university partners in MaNHEP will work, in collaboration with the with the Sr. QI Advisor, QI Advisor, Regional Teams and MOH counterparts, to undertake this work (see MLE). In addition to this study, the university lead faculty and students will review scale-up experiences of other projects in Ethiopia and in other African countries using various resources e.g., ExpandNet. 19On an ongoing basis, the Sr. QI Advisor, QI Advisor, Regional Teams and MOH counterparts will monitor which kebeles are introducing what changes and the outcomes over time. 3.11. Conduct baseline and endline surveys (3.10.a) and process evaluation (3.10.b) (See MLE). Emory lead faculty will be responsible for each of the evaluations and will work in concert with Bahir Dar University and Addis Ababa University and the Regional Team Managers to ensure successful implementation. An external evaluation will also be conducted as outlined in the proposal. 3.12. Work with federal and regional collaborators to promote adoption and spread of the MNH package, lead woreda concept and QI approach to development. If the lead woreda approach is successful in effectively delivering the MNH package, the project team and MOH counterparts showcase it through presentations, study tours for other RHB heads, sharing success stories through presentations, written accounts and other means. 3.13. Develop a strategy and plan for nation-wide spread of the QI approach to lead woreda development. MaNHEP will anticipate future spread to other woredas and regions. The project design places the project within MOH structures and works to develop the capacity of and advocacy among key counterparts. As a prototype develops MaNHEP will work with counterparts to determine a strategy for spread. (See Table 5 and Section 3) 3.14. Facilitate FMOH hosting a national dissemination event to promote the approach. The project will work with MOH and other stakeholders to promote adoption of the plan. Additionally, we will host a two-day national dissemination event to build broad interest and support among other development partners and donors to support the adoption and scale-up of the plan. Section 2. Monitoring, Learning, and Evaluation (MLE) Plan The monitoring, learning and evaluation plan (MLE) clarifies the (2.1) action theory and evaluation framework (2.2); process and outcome indicators to measure success and how we will reliably obtain and analyze the relevant data, matching of methods to collection, by objective; and (2.3) cost analysis. The findings of formative studies for Objectives #1 and #2 were used to inform the development of the survey instruments used in the evaluation, among other intended uses described in Section 1. The MOH is a stakeholder in all stages of MaNHEP activities, including the development of the MLE plan, selection of key indicators and targets. The MLE plan provides a means for implementers during and after the project’s completion to manage, monitor, and improve MNH services and outcomes. Routine monitoring for service improvement is consistent with MOH’s approach to information systems and a foundation for scale-up and integration in MOH operations. 10 2.1. Action Theory and MLE Framework The Action Theory (Figure 3) and MLE Framework (Figure 4) illustrate the overall project concept and the indicators we have selected for measuring the project goal and objectives, respectively. MNH Package The evidence-based MNH Package shown in Table 7 is defined by time period and elements, for both the woman and newborn. The MNH Package is “provided” when all care elements are provided. The MNH Package (e.g., misoprostol given by correct time, dose and route) will be disaggregated by care element (item) and type of FLW to identify gaps, where these exist. 2.2. Outcome and Process Evaluation In the outcome and process evaluations, we identify goal indicators; as well as the questions and indicators of success, by objective. Goal To demonstrate a community-oriented model to improve maternal and newborn health (MNH) care in rural Ethiopia and position it for scale-up. Figure 3 Figure 4 Indicators by Objective 11 Table 7 MNH Package Elements. Time Period Woman Pregnancy Create a birth plan Labor – 1 hour after birth 2 – 48 hours after birth Newborn Call for assistance when labor began Create a clean birth environment Wash hands before and during labor Give advice on proper positioning during labor Give misoprostol by correct time, dose and route to reduce blood loss Rub womb to slow bleeding Nothing is inserted into the vagina to stop bleeding after birth Properly dispose placenta (buried or burned) Check woman for tearing, fever, bleeding Advise woman/family on nutrition, rest, and cleanliness Advise woman/family on exclusive breastfeeding and positioning and attachment for breastfeeding Advise woman/family on illness recognition and care seeking 12 Keep baby warm and dry Check baby for color, breathing and activity Assist woman to initiate breastfeeding within 1hour of birth Practice clean cord care Check baby for color, activity, feeding Objective 1 To improve the capability and performance of the FLW team (HEW, CHW, TBA) to provide targeted MNH services around the time of birth (shape supply) Questions 1. What changes have been observed in the skill of frontline workers (FLW) to provide MNH Package over the course of the project? 2. What changes are there in the FLWs’ confidence to provide the MNH Package? 3. What changes are evident in the quality of teamwork and communication among the FLWs to provide MHN package? Indicators 90% of FLW who provided the MNH Package at last birth attended (overall and disaggregated by element) % of FLW who were observed in a clinical skills assessment to correctly provide the MNH Package (overall and disaggregated by element) % of FLW who feel confident in providing MNH Package % of FLW who feel part of a team responsible for providing MNH care Means of Verification We will collect data on FLW knowledge, practice, and confidence at two points in time, through an interviewer-administered survey conducted with the FLW. The FLW survey is one component of the baseline survey and will be repeated with a second sample of FLW at the endline. The survey will be administered in a local language by the trainers, or locally trained data collectors, and will include: (1) background characteristics; (2) current position and training history; (3) knowledge of each element of the MNH Package, (4) recent application of each element of the MNH Package; and (5) perceptions of team work and confidence. The survey will include closed-ended questions based around the core elements of the MNH Package (Table 7). The survey will ask respondents if they have heard of each of the elements, whether they performed each of the elements in their last home visit (if the visit was for delivery or postnatal care) and their confidence in performing each of the elements. In addition, each of the HEW will undergo a clinical skills assessment, in which the trainers will observe their performance of each of the key skills: the result of the assessment will be recorded on the survey instrument, thus allowing a third-party observation of the respondent’s ability to perform the skills to be linked to the respondents self-reported ability and perceived confidence in performing each of the skills. Given the relatively small number of FLW a sample would not yield enough numbers for adequate analysis, so we intend to conduct a complete census of all FLW targeted by the interventions. The FLW survey will collect the name of the kebele in which the FLW works, thus allowing the FLW skills to be linked to the results of the complementary community survey, below (Objective #2). The analysis plan for the FLW data involves a simple comparison of reported indicators from baseline and endline. The first stage will include a simple univariate analysis of each of the key indicators; the frequencies of each of the indicators will be reported, and appropriate tests will be conducted to examine the random nature of any missing data. Bivariate analysis will involve a comparison of each of the indicators across background characteristics of the FLW, for example, age, type of FLW, previous training history etc, in order to identify whether there are significant variations in any of the indicators by the characteristics of the FLW. Once the endline data is collected, analysis will be conducted to examine whether there has been any significant change in the reporting of the indicators over time. The analysis 13 will consist of appropriate statistical tests to identify changes in means and proportions across the baseline and endline data collection time points. The analysis will also examine the differential change in indicators across FLW with differing background characteristics. Appendix B.1 contains more detailed table of all indicators arising from the surveys is provided, along with the data source, method of data collection and responsible persons. Instrument development, interviewer training and pretesting have been completed and data collection is now underway in Amhara region and will begin in July 2010 in Oromia region. Objective 2 To increase demand for targeted MNH services, including healthy self-care behaviors around the time of birth (shape demand) Questions 1. Are women’s perceptions of the availability and quality of MNH care provided by FLW more positive as a result of the project? 2. Are communications between women and family decision-makers more supportive of MNH service provided by FLW? 3. Are women more likely to have received MNH care from FLWs and/or more likely to have engaged in healthy MNH self-care behaviors? Indicators 80% of women who can identify FLW in own kebele (overall and disaggregated by type of worker) Trust score (1-5) for trust in FLW ability to provide the MNH Package (overall and disaggregated by type of worker) 80% of women and newborns who received the MNH Package at last birth (disaggregated by element and recipient) 80% of households that received the MNH package at last birth 70% of women/families who provided incentives (financial and/or non financial) to the HEW or other FLW for MNH care received as a measure of support Means of Verification To measure whether the project interventions translate into knowledge and practices at the community level, we will conduct a complementary baseline and follow-up surveys with two groups of people: women who have had a birth in the 12 months prior to the survey, and men and women aged over 18. The survey with women who had a recent birth will be used to collect information on whether the project interventions impact on knowledge and practice of MNH care elements among pregnant women, and to examine the attitudes of pregnant women towards the FLW, in particular the HEW. The survey with men and women aged over 18 will be used to collect the levels of knowledge of MNH care elements and attitudes towards FLW among those who are potential stakeholders and key influences on a woman’s pregnancy, labor and postnatal behavior. The content of the two questionnaires will be similar, and will include the following modules: (1) background demographic and socio-economic information; (2) knowledge of FLW; (3) trust and confidence in FLW skills/ practices; (4) knowledge of the MNH Package elements; (5) experience with the elements of the MNH Package; and (6) breastfeeding. In each region, the survey will be conducted in up to 30 kebeles; 10 kebeles will be randomly selected from each of the three woredas in the study area. For the first survey, with women who have had a birth in the last 12 months, we propose to interview 20 women per kebele, for a total sample size of 600 women per region, and a total sample of 1,200 women. For the second survey, with men and women aged over 18, we propose to interview 12 per kebele, for a total sample of 360 per region, and a total sample of 720 men and women aged over 18 years. 14 Respondents for both surveys will be sampled using the same methods. Respondents will be selected with the assistance of HEW and community leaders. A community meeting will be held in each kebele to inform community members of the upcoming survey, to introduce the project team and to explain the purpose of the survey. The sampling methodology will begin with the data collection team starting at a locally defined central point of the kebele: working in teams of two, and each team of two starting out in a different direction from the center of the kebele, the first household called at by each team will be the 5th household from the center of the kebele. From then onwards, data collection teams will call at every other household. If the household does not contain anyone eligible for either of the surveys, the data collection team will move to the household next door and the resume their sampling system once they have identified an eligible household. In households in which there is more than one person who meets the criteria, the data collectors will ask for one to volunteer or – in the event that all volunteer – will randomly choose one person to interview. The surveys will not collect any identifying information. The survey will take approximately one hour, will be conducted in a private area of the house in the appropriate local language. The data collectors will complete the survey by filling in a pre-prepared survey tool; we will not audiotape the household survey responses. The follow-up survey will be conducted in the final year and will adopt a similar sampling methodology. To avoid both contamination of the samples and loss to follow-up, we will not attempt to interview the same respondents in the baseline and follow-up surveys. A team of locally trained data collectors, who will be trained by the Emory University, Bahir Dar University and Addis Ababa University faculty leads, will collect the data. An intensive one-week training course will be conducted immediately prior to both the baseline and follow-up surveys. The training course for data collectors will cover basic interviewing techniques, a review of MNH (so that data collectors understand the questions they are asking), a discussion on local terminology around MNH, and instruction on ethical treatment of participants. A focus on training will allow the data collectors to practice interviewing and to become comfortable with collecting sensitive data. Recent experience of the Emory study team in rural Ethiopia show that a data collector can conduct between 4-6 surveys per day; thus a sample size of 600 requires between 100-150 person days. We aim to utilize a team of 20 data collectors, thus putting the total time for the survey data collection to 5 days. A two-day pilot test of the survey instrument will be conducted, with each data collector having the chance to conduct at least two interviews to both gain confidence in interviewing and to identify issues with the questionnaire. The analysis plan for the community survey data will involve 4 stages. For the first stage, univariate analysis will be conducted on each of the data sets. This will include the simple reporting of frequencies (means and proportions) for each of the indicators. At this stage we will also examine the extent of missing data in each of the data sets, and test the random nature of the missing data. The second stage will involve bivariate analysis; at this stage, each of the indicators shown in Appendix B.2 will be examined to test whether their distribution varies across the background characteristics of the respondent. The third stage of the analysis will involve appropriate statistical tests to examine differences in the distributions of each of the outcomes between the baseline and endline. For the final stage of the analysis, multivariate analysis will be conducted. Three outcomes will be created: knowledge of the MNH Package, receipt of the Package, and attitudes towards the Package. Each of the outcomes will be continuous, and will be created from respondent responses to survey questions on the receipt of each of the elements that comprise the MNH Package, their knowledge of each of the items, and the perceived importance of each of the elements. Regression models will be fitted to each of the outcomes: the key covariates of interest in each of the models will be the respondent’s background characteristics, their exposure to FLW, their trust and perceived competence of FLW, and their geographic location. Each of the models will also include a variable indicating baseline or endline: this will allow us to identify whether the knowledge, receipt or attitudes towards the intervention elements has changed significantly over time, after controlling for all other possible influences. The multivariate analysis will also explore other regression models: models will be fitted to examine trust in FLW, perceived competence of FLW, breastfeeding practices, and exposure to FLW. 15 Instrument development, interviewer training and pretesting have been completed and data collection is now underway in Amhara region and will begin in July 2010 in Oromia region. Objective 3 Under national leadership, and with regional support, to demonstrate a lead woreda’ approach to improve MNH services and practices (redesign care delivery processes) Questions 1. What are the results in outputs and outcomes that we are seeing at the community level? 2. What kinds of changes developed and implemented by the QI teams in collaboration with their communities have led to improved MNH care for mothers and newborns? 3. What best processes for improving MNH care have emerged, based on data from the collective changes developed and implemented by the QI teams and communities? 4. What infrastructure for spreading best processes has been developed through the QI approach to lead woreda development including the identification and development of champions and a supportive policy environment? Indicators 80% of successful solutions to MNH Package delivery to identify and reach women for birth to 48hour care adopted by new kebeles MNH Package provided all of the time to all women and newborns in targeted kebeles Increase in average number of days between neonatal deaths among those receiving the MNH Package Scale-up the project’s community-oriented model of MNH care approved and adopted by MOH Means of Verification The evaluation of Objective 3 will involve four components. First is monthly monitoring of process and outcome indicators to reflect best processes for delivering the MNH Package. These data will be collected through simple pictorial checklists to be used as a job aid and means of documenting MNH Package implementation. The pictorial checklist will include the following components: (1) pregnancy identification; (2) antenatal care; (3) birth preparedness; (4) birth notification; (5) labor and birth up to 1 hour; (6) postnatal care from 2 – 48 hours; (7) pregnancy outcome for mother and newborn. Secondly, MNH Package implementation relies on solutions for pregnancy registration, birth notification and communications which local QI teams and communities will develop and test. These community QI teams will use time series analysis to determine which solutions will have a positive impact on the ability to provide the MNH Package. Communities and coaches will document the solutions tested and track the results of the tests using this data. Development of best processes (prototype) for MNH Package delivery will rely on analysis across kebeles, woredas and regions to determine the common solutions that result in improvements. The project will maintain a database to track changes across QI teams and will analyze how ideas are spreading throughout the project sites. Thirdly, the assessment will focus on development of the lead woreda’s capacity and commitment to continuously improving quality of care delivery processes. In order to replicate this approach, the project, the RHBs and FMOH need to understand what worked, why and how as well as what did not work. This assessment will be conducting through document review including all documents relating to study tours, stakeholder meetings, orientations, coaching/learning sessions and planning meetings. The document review will also examine documents such as meeting minutes, budgets, planning documents, proposals, and technical reports to identify whether the necessary steps to develop the lead woredas occurred, gaps in implementation, and key stakeholders in the process. 16 Lastly, we will conduct in-depth interviews with key stakeholders at a range of levels/positions, to examine their experience of the development process and to identify lessons learned that could inform the rollout of the approach. We envisage between 10-20 in-depth interviews that will take place in the follow-up phases (per region). These means will provide information to allow us to ascertain the degree of lead woreda functioning and to identify champions for the model at FMOH and regional levels. 2.3. Cost Analysis The cost analysis will measure input costs associated with the key interventions that will be the responsibility of the government and communities when the project period is completed and has demonstrated the benefit of the community oriented model to improve MNH care. We will also collect expenditures related to the training and supervision of the HEWs during the period of project implementation. The following are the key inputs that we will track with their respective definitions. Transportation (costs associated with vehicular transport, namely fueling, insurance, maintenance, repairs, road taxes or fees, and rental costs if any vehicles are rented) Supplies (costs associated with supplies used for project activities and general office function including stationery, photocopying, IEC materials, refreshments, computer supplies, equipment hire/maintenance, telephone, internet and communications costs) Per Diems (per diems and extra allowances paid by any funding course for carrying out specific activities) Trainings (CHBLSS, QI and refresher course on facility-based safe and clean delivery) Intervention drug (misoprostol) Time (allocated by key personnel by activity and value the time based on salary input data) Since virtually all costs will be paid from the grant, we will use the expenditure reports from the respective partners to collect relevant costs for the training activities that comprise the intervention in this study. Indicators Cost per FLW trained in the MNH care package Cost per QI learning sessions Cost per QI coaching sessions provided to QI teams Cost per MNH package (including checklists and job aids, drugs and equipment) Section 3. Approach for Uptake and Sustainability of Successful Interventions Sustainability is based on effectiveness of MNH care delivery processes identified and implemented by kebeles through the lead woreda approach. Determining which care process should be spread will depend on their ability withstand different situations, within and across kebeles and woredas within regions. Any new surveillance systems like birth notification or transport processes must continue without reliance on external inputs. Sustainability relies on advocacy and support by the MOH at all levels. MaNHEP aims to utilize and support existing MOH mechanisms and structures, rather than develop parallel structures. The acting Co-PI and QI Advisor will be embedded into the FMOH by the end of the first year to develop MOH ownership of the project, support policies and build capacity. In addition, they will advocate on a national-level for the communities’ and project’s activities. Both the acting Co-PI and QI Advisor will serve 17 as advisors to the FMOH on MNH at the community level and quality of care issues. As process improvements are spread, the embedded staff will work with the FMOH to identify mechanisms for national scale up and opportunities for integrating lessons learned into national guidelines and policies. MaNHEP will work with Zonal Health Departments to keep them informed of activities, encourage participation in coaching visits and learning sessions, and engage them in problem-solving. MaNHEP will embed Regional Team Managers in each of the RHB offices. They will work with RHB staff to implement and monitor the project, problem-solve, coordinate learning sessions, and identify successful changes and solutions. RHBs will play key roles in identifying existing mechanisms and structures for informal spread within their regions, and encourage uptake in other areas after the project’s conclusion. At the local level, woreda-level coaches will become more independent. As information becomes available for analysis, MaNHEP staff will assist coaches in identifying potential practices for spread, and spread mechanisms. Spread Spread is an intentional process; it requires developing support mechanisms, policy environment, and a plan for the next phase. Dissemination of results is key for building advocacy for spread. Development of a prototype will lay the foundation for spread. Existing mechanisms for sharing information will be employed to introduce successful practices and share data to new kebeles. MaNHEP regional staff will assist the Zonal and WorHO in finding ways to introduce and support the adaptation and implementation of these practices in new areas. MaNHEP will also work with the WorHO, Zonal and RHBs to identify new mechanisms for transferring best MNH care processes and practices to new kebeles. MaNHEP will not directly support these activities, but will assist the WorHO, Zonal and RHB in determining how these can be transferred to new kebeles. Throughout, MaNHEP will address issues around spread with the FMOH, RHB, ZHD, WorHO, HC, HEW, and communities. In the last six months of the project, a formal spread plan will be developed. Specific questions that will be answered are: 1. What are we planning to spread and what evidence do we have? Are these changes transferrable? 2. To whom are we going to spread? Will it be additional communities in a given woreda, new woredas, and new regions? Can we do this all at once or do we need a phased approach? 3. What are lessons learned? What will be needed to support the spread activities? What support activities can be integrated into existing mechanisms (trainings, supervision, etc)? 4. Do we need to build additional capacity for this effort? Who should be involved? How will this be organized? How will this be funded? 5. What other development partners might be interested in becoming engaged in national scale-up? Communications and Advocacy for Spread Communications with target audiences, especially stakeholders, is key to building political support for spread. A variety of channels will be employed to provide updates and highlights of lessons learned. They include a project website, quarterly e-newsletter, and regular face-to-face meetings with officials in the FMOH and RHBs, as well as woreda and kebele leaders. HEWs and other FLWs will provide granular accounts of successes and best practices that will be showcased in stories on the MaNHEP website and newsletter. Video testimonials will also be produced highlighting successes of the project, building credibility of the community-based model and support for nationwide scale-up. 18 Media engagement will provide additional momentum for sustainability of the community-based model. Stories about training activities and project successes will be regularly pitched to newspapers in Amhara and Oromia. Radio advertisements will also be purchased to encourage pregnant women to seek FLWs for MNH care. Positioning Positioning the project effectively constitutes another important prong of the MaNHEP strategy to ensure sustainability. MaNHEP will create an identity based around the following positioning statement: MaNHEP works with the Ministry of Health to strengthen systems for the health of pregnant women and newborns. Claiming this identity in the minds of donors, government partners, and stakeholders will contribute to the consensus needed for nationwide scale-up. A professionally designed MaNHEP logo depicting a mother holding a newborn will be used to brand job aids, checklists, promotional items, and publications. With consistent application across all communications channels, the logo will help create a recognized MaNHEP identity. A well-branded MaNHEP will be more readily embraced by stakeholders. Forging Partnerships With a well-recognized brand, MaNHEP will be positioned at the end of the project to forge new partnerships with other governmental and non-governmental organizations involved in MNH in Ethiopia and other developing countries. MaNHEP will identify activities that complement and dovetail other projects to strengthen community and facility-level MNH services. Other MNH projects with strong results and successful approaches will be invited to Learning Sessions for MaNHEP-supported communities. To keep potential partners engaged with the project, an extensive electronic distribution list will be developed for disseminating the newsletter and project updates. Dissemination of Best Practices and Project Outcomes Dissemination of best practices and project outcomes will be central to building engagement with project activities and ultimately building support for nation-wide spread. The bulk of dissemination activities are reserved for the conclusion of the project when MaNHEP will sponsor a dissemination conference for stakeholders and the donor community. However, realizing that sustainability depends on long-term engagement, MaNHEP will pursue an ongoing effort to keep various audiences informed about the project. This will be accomplished through the project website, quarterly newsletter, social network sites, and face-to-face meetings with RHB and FMOH officials. In addition, project staff will submit manuscripts about project outcomes to peer reviewed journals in Ethiopia and elsewhere. 19
© Copyright 2024