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Dagu aims to develop Ethiopian excellence in public health evaluation and improve quality and utilisation of primary and community-based health care services.

DAGU

Dagu aims to develop Ethiopian excellence in public health evaluation and improve quality and utilisation of primary and community-based health care services.

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About us

The Dagu project gets its name from a northeast Ethiopian word for communication. Dagu works to develop Ethiopian excellence for public health evaluation: measurement, learning and evaluation of improved integrated community case management and community-based newborn care in Ethiopia.

Who we are

The Dagu project is led by a team of researchers from the London School of Hygiene & Tropical Medicine based at the Ethiopian Public Health Institute. The project evaluates the Optimising the Health Extension Program in Ethiopia (OHEP) project which was initiated by the Ethiopian Federal Ministry of Health and implemented by UNICEF, PATHSave the Children, and the Last 10 Kilometers Project.

Resources & publications

Find the latest publications and resources produced by the Dagu project.

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DAGU project

Ethiopia has made significant progress reducing the number of child deaths, but there is potential for further reductions if the use of good quality primary health services is increased.

The Dagu project focuses on three main areas of work. The independent evaluation of the Optimising the Health Extension Program in Ethiopia (OHEP) project which addresses the critical under-utilisation of community-based services, particularly the use of Integrated Community Case Management (iCCM) services and Community Based Newborn Care (CBNC) services. The Ethiopian Federal Ministry of Health initiated the OHEP project and UNICEF, PATHSave the Children, and the Last 10 Kilometers Project implement it. 

Evaluation

The Dagu led evaluation aims to estimate the effectiveness and evaluate the process of the innovations implemented in the OHEP on care-seeking and treatment for suspected pneumonia, diarrhoea, fever, and neonatal sepsis.

The evaluation will use data from baseline and endline surveys in OHEP intervention districts and comparison districts. These surveys are part of the evaluation strategy that uses a plausibility design and analyses ‘difference-in-differences’. In addition, information will be collected regarding the OHEP interventions in order to map the intervention process over time. The PhD students from the four collaborating universities will address different aspects of the evaluation in accordance with their doctoral study plans. The Dagu team and partners will produce reports and scientific papers and will communicate these to stakeholders in Ethiopia and the international research community.

Working with Ethiopian universities

The Dagu team works with the Gondar, Hawassa, Jimma and Mekelle Universities and EPHI to strengthen their capacity for health system research by co-supervising the Dagu PhD students and arranging courses and workshops for PhD students, supervisors and others.

Dagu is cooperating with four Ethiopian universities for mutual capacity development. This includes supporting PhD students who are working on research that contributes to the Dagu project.

The students

University of Gondar

Amare Tariku is focusing on respiratory tract infections and nutrition.

Tigist Getahun is interested in the primary health services for newborn babies.

Hawassa University

Habte Bolka is focusing on the management of diarrhoeal diseases in children.

Habtamu Beyene is addressing referral of sick children within the primary health system.

Jimma University 

Dawit Wolde is studying the quality of the integrated community case management of childhood illnesses and the effect of the OHEP interventions on quality of the service provided.

Alemayehu Hunduma is working on the formulation of his research question.

Mekelle University

Alem Desta studies equity in service utilization cost of the OHEP innovations and cost-effectiveness of the innovations in improving primary child health services utilization.

Fisseha Ashebir is studying the role of the Women’s Development Army in primary maternal, newborn and child health services.

EPHI

Atkure Defar is interested in the spatial (geographic) and time variation in child health problems and service utilisation before and after the OHEP intervention.

Theodros Getachew is studying the quality of care for common childhood illnesses within the integrated community case management.

Supporting implementation partners

A third area of focus for the Dagu project is the support provided to PATH and UNICEF, the implementation partners, in measurement, learning and evaluation.

Who we are
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Professor Joanna Schellenberg
Principal Investigator
Professor Lars Ake Persson
Professor of Public Health Evaluation
Della Berhanu
Research Fellow
Suzanne Welsh
Programme Manager
Yemisrach Okwaraji
Research Fellow
Martha Zeweldemariam
Project Administrator
Atkure Defar
Dagu lead at EPHI
Desta Wolassa
Data Manager
 

The Dagu project has a Steering Committee, which oversees the activities of the Dagu project, regularly reviews progress and plans, and makes recommendations to support effective implementation of the project’s objectives.

For the duration of the project, the Steering Committee meets twice a year, usually in Addis Ababa.

Members of the Dagu Steering Committee comprise the following institutions and their representatives: The Ethiopian Federal Ministry of Health, the Ethiopian Public Health Institute, the London School of Hygiene & Tropical Medicine, PATH, UNICEF, Save the Children, Last 10 Kilometres, and the Universities in Gondar, Mekelle, Jimma, and Hawassa.

The Dagu project collaborates closely with the IDEAS project and the ORCA project at the London School of Hygiene & Tropical Medicine, to foster mutual capacity building for large-scale public health evaluation in Ethiopia. 

Dagu team photo
Events
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Learning from joint research: Maternal, newborn and child health in Ethiopia 

Maternal and child health coverage indicators in Ethiopia continue to improve, whilst newborn care and survival stagnate and issues of quality of care, equity and use of data for decision-making, require further attention.

These are just some of the results discussed during a joint MNCH learning conference held in Addis Ababa, Ethiopia, on the 7th of November. Approximately 100 researchers, including the Dagu project team, government officials, development partners and implementers met at the conference, co-organised by the Federal Ministry of Health, the Ethiopian Public Health Institute and the London School of Hygiene & Tropical Medicine.

Participants at the MNCH Learning Conference in Addis Ababa, Ethiopia.

Ethiopian Public Health Institute Director General, Dr Ebba Abate, welcomed the strong existing research collaborations between Ethiopia and the London School of Hygiene & Tropical Medicine, and highlighted the importance of reviewing data and knowledge during the conference to support health policies and practice in the country. “The conference acts as a platform to bring together research and practice, and make research work for policy and practice.”

LSHTM Deputy Director, Professor Anne Mills remarked on the wide scope of LSHTM-led research undertaken in the country, which aims to address not just the major causes of ill health and disability, but also how these can be prevented and treated through improved services and systems.

Preliminary results from a ‘Mini’ Demographic and Health Survey presented showed and impressive threefold increase in the number of women receiving antenatal care from a skilled provider since 2005 with similar results in the number of women delivering at a health facility. The data did, however reveal significant geographical and wealth disparities, as well as the stagnating levels of neonatal mortality.

Delegates at the MNCH learning conference during a presentation.

It proved to be especially interesting to hear findings from the IDEAS-led evaluation of the Community Based Newborn Care programme, as well as the Dagu-led evaluation of the Optimizing the Health Extension Worker programme, in addition to the Mini DHS results to provide an even more comprehensive picture of the current status of maternal, newborn and child health in Ethiopia, but also highlighting some issues which require further investigation.

Sessions at the conference were dedicated to four broad themes including: Towards Universal Health Coverage, Quality of Care, Data for Health Planning and Mutual Learning for Change. Presenters included researchers, policy makers, planners, analysts and research students from the Ethiopian health system, the Ethiopian Public Health Institute, Universities, the London School of Hygiene & Tropical Medicine and other partners. The sessions offered an opportunity to compare findings from a number of quantitative and qualitative studies focusing on Ethiopia, as well as studies from another IDEAS priority country – Nigeria.

Two LSHTM-led projects in Ethiopia with a particular focus on capacity building within universities and government institutions received special attention during the conference. The Dagu project, which combines the evaluation of a health extension programme with the support to Ethiopian PhD students was seen as exemplary, as funding for PhD research can be rare. The ORCA project is especially highly regarded due to its importance for sustainability. It works directly with Ethiopian analysts, employed in government institutions, to strengthen their analytical capacities and improve data analysis and use for health decision making and planning.

Following the conference partners and LSHTM alumni took the opportunity to further network at an alumni and partner reception.

 

Overcoming adversities: completing the Dagu endline survey data collection 

All data collection for the Dagu endline survey has now been completed. The survey team visited a total of 180 enumeration areas and collected data from 11,292 households and corresponding health posts and health centres. The tablets were programmed using CSPro 7.1 software to collect the data. The survey used Dagu PhD students as regional data correctors and a supervision plan was developed by the students and controlled by the central office.

Dagu endline survey data collectors
The Dagu endline survey data collection team in Mekele Credit: IDEAS/Christopher Smith 2019

Oftentimes the data collectors had to overcome difficult conditions to access all selected areas. “Many of the villages where we collected data have difficult terrain and are hard to reach. Some villages are located deep in a valley and the only way to get there is by climbing down with ladder and some villages can only be accessed using a mule.  In such sites the data collectors will have to take with them sleeping bags and dry food and have to stay 2- 3 days until they complete collecting the data for that village." says Yemisrach Okwaraji, who is part of the team of Dagu researchers based in Ethiopia and was coordinating the survey. Atkure Defar, who is Dagu lead at EPHI highlighted the strength of the field team in coping with difficult circumstances. "The field teams were very hard workers in doing this survey while it has all these hardships. Teams were supposed to use a field guide to direct them where the villages are located in the kebele (lowest administrative level). These guides have lived there longer than anyone and are well-known in the community. Identifying the right household needs extra care of the field staff and understanding of the maps of the area to delineate which households are within the enumeration area."

The volatile security situation in Guje zone meant that 13 clusters had to be excluded from the endline survey. The Dagu partner Jarco Consulting has started with cleaning the data, which includes merging data sets and removing duplications. Once Jarco completes the data cleaning process the Dagu team will begin the analysis and preparation of the final evaluation report. 


Dagu endline survey: December 2018 to February 2019 

The Dagu endline survey started in December 2018 in 200 clusters. The survey extended across 100 intervention and 100 comparison areas. The distribution of the clusters is as follows: Tigray with 29 clusters, SNNP with 23 clusters, Oromia with 69 clusters, and Amhara including 73 clusters.

Data collectors in Mekele during the Dagu endline survey
Data collectors in Mekele during the Dagu endline survey. Copyright: IDEAS/Christopher Smith 2019

Advanced Implementation Science Workshop at EPHI, June 9-13 2018


R workshop 

The software that helps students and teachers - learning how to use software without writing code

“Currently there are so many different statistical programmes for the analysis of health data. The “R” software is free and robust, being able to use it is a skill which will be beneficial for my future research career and in advising and mentoring students.” Dr Kassalen Alemu, the Director of JPH and Phd supervisor summarised his experience of a recent Dagu organised workshop.

Researchers, students and data analysts are faced daily with daunting tasks of analysing, visualising and interpreting vast amounts of data. The Dagu team together with the Associate Professor Katarina Selling and Senior Statistician Jonas Selling working on International Maternal and Child Health at Uppsala University, Sweden therefore worked with Dagu PhD students, staff from the Ethiopian Health Institute and partner organizations to learn how to use “R” software in data analysis and visualisation. This specialized software is a powerful and comprehensive tool to manage complex tasks, however is not without its challenges for users. “R” is a programming language, which means users have to learn to write code, a substantial threshold for many users. The workshop therefore introduced participants to the use of R-commander, which comes with a simpler user interface bridging the gap for users wanting to use “R”, but without the time to learn to write code.

The main objectives of the workshop were for participants to learn how to use R-commander for data management, visualisation, descriptive statistics, basic statistical tests and their assumptions, and as an introduction to statistical models including their assumptions.

The course consisted of a series of interactive lectures combined with computer labs. The teaching was conducted in an interactive manner, encouraging participants to reflect by sharing their own experience. Participants showed a lot of enthusiasm pointing out the benefits of using R-commander for certain tasks. Girum, Senior Researcher at EPHI remarked: “I will try to shift from “SPSS” to “R-commander” for data visualisation.” The usefulness of the workshop and learning to work with this software was moreover highlighted by Dr Mezaebu Yitayal explaining how this would improve his ability to teach and provide guidance to his students: “This workshop will improve my advice to students as well as my data management and analysis for my own research work.” Learning to master R-commander was clearly a benefit for students and PhD supervisors alike.

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2020

Has Ethiopia been successful in increasing health care utilisation for children?

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 before and after study, published in BMJ Open, looked at the effectiveness 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 Programme (OHEP) intervention aiming 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 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 (PATHUNICEFSave the Children and Last 10 Kilometres/John Snow Inc.). The intervention started in 2016 and lasted for a duration of 2.5 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 care worker examines a baby in Addis Kidam Health post
A health care worker examines a baby in Addis Kidam Health post

Findings

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 authors find 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.

Conclusion

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.

Understanding what didn't work: a mixed method process evaluation 

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 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 team initiated this mixed-method study, published in the International Journal of Environment Research and Public Health and led by Yemisrach Okwaraji, 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.

Prevention and treatment of suspected pneumonia in Ethiopian children under five

Amare Tariku, one of the Dagu PhD students, published this paper in Acta Paediatrica, analysing prevention, care seeking and treatment of suspected pneumonia from household to health facility in Ethiopia.

Analyses were based on a survey in four regions.  Caregivers of children aged 2‐59 months responded to questions on awareness of services and care seeking for suspected pneumonia. Pneumonia‐related knowledge of health workers was assessed.

Results show that, when a child had suspected pneumonia, 46% sought care at health facilities, and 27% received antibiotics. Forty‐one per cent had received full immunisation. One‐fifth of the caregivers were aware of pneumonia treatment. Sixty‐four per cent of the health extension workers correctly mentioned fast or difficult breathing as signs of suspected pneumonia, and 88% suggested antibiotics treatment.

The author concludes that caregivers' awareness of suspected pneumonia treatment and the utilisation of these services were low. Some of the health extension workers were not knowledgeable about suspected pneumonia. Strengthening primary health care, including immunisation, and enhancing the utilisation of services are critical for further reduction of pneumonia mortality.

Women's development group leaders' promotion of maternal, neonatal and child health care in Ethiopia: a cross-sectional study

This paper authored by Dagu PhD student Fisseha Ashebir and others and published in Global Health Action seeks to assess the characteristics, knowledge and practice of women's development group leaders  in the field of maternal, neonatal and child health care. 

Results show that the knowledge of women development group leaders of maternal, newborn and child health was relatively low. These leaders were given a wide range of tasks, despite having a low educational level. They showed limited knowledge but initiated a relatively high level of activities related to maternal health, with fewer on neonatal and child health. 

Protocol for the evaluation of a complex intervention aiming at increased utilisation of primary child health services in Ethiopia: a before and after study in intervention and comparison areas

This protocol, authored by Della Berhanu and others, published in BMC Health Services, describes the evaluation of the "Optimising the Health Extension Program" as part of the Dagu project -  a complex intervention that aims at increased utilisation of primary and child health services. This unique collaborative effort includes key stakeholders from the Ethiopian health system, the implementing non-governmental organisations and universities, and combines state-of-the art effectiveness estimates and process evaluation with capacity building. The lessons learned from the project will inform efforts to engage communities and increase utilisation of care for children in other parts of Ethiopia and beyond.

Insufficient referral practices of sick children in Ethiopia shown in a cross-sectional survey

Habtamu Beyene, a Dagu PhD student, published a paper in Acta Paediatrica, aimed at assessing the referral of sick young infants and children from the community, health posts and health centres to higher levels.

A cross-sectional survey was conducted in four of the largest Ethiopian regions from December 2016 to February 2017. Referral practices were assessed at each level in 46 districts of these regions. Interviews were supplemented by reviews of registers at health posts and health centres.

Results showed, that the women's development group leaders, who do not provide health services, referred half of the sick children they visited in the community to the health posts. The health extension workers referred 16% of the sick young infants and 6% of older infants and children to higher levels. From health centres, the health workers referred 6% of sick young infants and 1% of older infants and children to hospital. Many cases of possible severe bacterial infection were not referred to higher levels. A functional ambulance was available for a bit more than a third of the health centres.

Habtamu Beyene et al concluded that referral practices of sick young infants and children at all levels were weak that may threaten the continued reduction of child mortality in Ethiopia. Referral logistics were insufficient, which partly could explain the missing referrals of severely ill infants and children.

2019

Wealth-based equity in maternal, neonatal, and child health services utilization: a cross-sectional study from Ethiopia 

This paper, authored by Dagu PhD student Alem Desta Wuneh, and published in the International Journal for Equity in Health. aims to assess equity in utilization of a range of maternal and child health services. 

Data on maternal and child health utilization were collected through the OHEP intervention in four regions of Ethiopia. Results showed that maternal health services uitilization was low and inequitably distributed favouring the better-off women. Basic immunizations in children were equitably distributed. 

In conclusion the authors note that maternal health services utilization is low and inequitably distributed. In comparison, preventive child health services are equitably distributed. Efforts are needed to increase both utilization and reinforcement of pro-poor and pro-rural strategies for maternal, newborn and immunization services in Ethiopia. 

Geographic differences in maternal and child health care utilization in four Ethiopian regions

Atkure Defar, a Dagu supported PhD student has published his first paper in the International Journal for Equity in Health

Maternal and child health care utilization often vary with geographic location and this paper analysed the geographic distribution and determinants of utilization of four or more antenatal care visits, health facility delivery, child immunization and care utilization for common childhood illnesses across four Ethiopian regions. 

The cross-sectional community-based study found evidence for geographic clustering in coverage of health facility deliveries and immunization at the district level, but not in the utilization of antenatal care and utilization of health services for common childhood illnesses. Identifying and improving district-level factors that influenced these outcomes may inform efforts to achieve geographical equitability and universal health coverage. 

Stronger diagnostic abilities for common childhood illnesses needed in Ethiopia 

Theodros Getachew, a PhD student supported through the Dagu project, authored and published his first paper in Acta Peadiatrica. 

The paper entitled: Health Extension Workers’ diagnostic accuracy for common childhood illnesses in four regions of Ethiopia: a cross-sectional study looks into the capacities of Health Extension Workers in Ethiopia to correctly classify common childhood diseases. Data were collected through a survey, as well as observations and re-examinations. Findings show that most cases of diarrhoea were correctly classified, while other illnesses were not frequently identified. The identification of malnutrition was especially at fault. These findings suggest that a significant number of sick children were undiagnosed that could lead to absent or incorrect management and treatment. The paper calls for increased efforts to improve the quality of HEW's diagnostic ability for childhood illnesses and their adherence to the guidelines for the examination, classification and treatment of childhood illness.

2018

Dagu workshop at Gondar University May 14-18, 2018

Dagu Implementation Science Workshop II June 9-13, 2018

Second Paper Writing Workshop, EPHI, Addis Ababa, November 5-7, 2018

2017

December 9-13, 2017: Qualitative research methods workshop at EPHI 

December 6, 2017:  Release of the Dagu Baseline Survey Report 

21 -25 August 2017: Implementation science workshop in Hawassa University 

10-14 July 2017: Writing scientific research papers workshop for PhD students at Gondar University 

30 January - 1 February 2017: Workshop for PhD supervisors 

Dagu R-workshop update March 2018