Implementation of the ‘Optimising the Health Extension Program’ Intervention in Ethiopia: A Process Evaluation Using Mixed Methods

Abstract

An intervention called ‘Optimising the Health Extension Program’, aiming to increase care-seeking for childhood illnesses in four regions of Ethiopia, was implemented between 2016 and 2018, and it included community engagement, capacity building, and district ownership and accountability. A pragmatic trial comparing 26 districts that received the intervention with 26 districts that did not found no evidence to suggest that the intervention increased utilisation of services. Here we used mixed methods to explore how the intervention was implemented. A fidelity analysis of each 31 intervention activities was performed, separately for the first phase and for the entire implementation period, to assess the extent to which what was planned was carried out. Qualitative interviews were undertaken with 39 implementers, to explore the successes and challenges of the implementation, and were analysed by using thematic analysis. Our findings show that the implementation was delayed, with only 19% (n = 6/31) activities having high fidelity in the first phase. Key challenges that presented barriers to timely implementation included the following: complexity both of the intervention itself and of administrative systems; inconsistent support from district health offices, partly due to competing priorities, such as the management of disease outbreaks; and infrequent supervision of health extension workers at the grassroots level. We conclude that, for sustainability, evidence-based interventions must be aligned with national health priorities and delivered within an existing health system. Strategies to overcome the resulting complexity include a realistic time frame and investment in district health teams, to support implementation at grassroots level.

Association between a complex community intervention and quality of health extension workers’ performance to correctly classify common childhood illnesses in four regions of Ethiopia

“…However, when combined in the upscaled intervention, there was no effect. A process evaluation to examine the quantity and quality of what was implemented showed that lack of effect could partly be attributed to delays in implementation of some initial activities that would create the condition for the successful implementation of the next activity, interruptions and an overall short implementation period of a complex intervention [ 32 ]. This could shed light on the fidelity of the implementation, the context in which this complex intervention was delivered, and explain why it did not work.…”

“…The lack of effect could partly be attributed to delays, interruptions and an overall short implementation period of a complex intervention. Complex interventions that aim at behaviour changes in the health services as well as in care seeking for sick children may need an extended implementation period [ 32 ]. Previous Ethiopian studies have shown that the health extension workers were insufficiently prepared for all the tasks that fall within their scope of work [ 33 ].…”

Health extension workers’ perceived health system context and health post preparedness to provide services: a cross-sectional study in four Ethiopian regions

“…Complex interventions that aim to change health services and care-seeking for sick children may need an extended implementation period. 45 Lack of effect could also be due to some of these contextual factors necessary for improving quality.…”

Caregivers’ and Health Extension Workers’ Perceptions and Experiences of Outreach Management of Childhood Illnesses in Ethiopia: A Qualitative Study

“…The strategies included home-based preventive and curative child health services to enhance equity in coverage [ 16 ]. Various contextual factors limited the scale-up of these outreach activities [ 17 ]. Services provided in outreach activities had greater equity in coverage, although these were highly affected by geographical characteristics [ 18 , 19 ].…”