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Does a complex intervention targeting communities, health facilities and district health managers increase the utilisation of community-based child health services? A before and after study in intervention and comparison areas of Ethiopia
  1. Della Berhanu1,2,
  2. Yemisrach Behailu Okwaraji1,
  3. Atkure Defar2,3,
  4. Abebe Bekele2,
  5. Ephrem Tekle Lemango4,
  6. Araya Abrha Medhanyie5,
  7. Muluemebet Abera Wordofa6,
  8. Mezgebu Yitayal7,
  9. Fitsum W/Gebriel8,
  10. Alem Desta5,
  11. Fisseha Ashebir Gebregizabher5,9,
  12. Dawit Wolde Daka10,
  13. Alemayehu Hunduma6,11,
  14. Habtamu Beyene8,12,
  15. Tigist Getahun13,14,
  16. Theodros Getachew2,13,
  17. Amare Tariku Woldemariam15,
  18. Desta Wolassa2,
  19. Lars Åke Persson1,2,
  20. Joanna Schellenberg1
  1. 1Department of Disease Control, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, UK
  2. 2Health Systems and Reproductive Health Research Directorate, Ethiopian Public Health Institute, Addis Ababa, Ethiopia
  3. 3Department of Epidemiology and Biostatistics, Institute of Public Health, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
  4. 4Maternal and Child Health Directorate, Ethiopia Ministry of Health, Addis Ababa, Ethiopia
  5. 5School of Public Health, College of Health Sciences, Mekelle University, Mekelle, Ethiopia
  6. 6Department of Population and Family Health, Faculty of Public Health, Jimma University, Jimma, Ethiopia
  7. 7Department of Health Systems and Policy, Institute of Public Health, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
  8. 8College of Medicine and Health Sciences, Hawassa University, Hawassa, Ethiopia
  9. 9Tigray Regional Health Bureau, Mekelle, Ethiopia
  10. 10Department of Health Policy and Management, Jimma University, Jimma, Ethiopia
  11. 11Oromia Regional Health Bureau, Addis Ababa, Ethiopia
  12. 12Southern Nations, Nationalities & Peoples Regional Health Bureau, Hawassa, Ethiopia
  13. 13Institute of Public Health, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
  14. 14Amhara Regional Health Bureau, Baher Dar, Ethiopia
  15. 15Department of Human Nutrition, Institute of Public Health, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
  1. Correspondence to Dr Della Berhanu; Della.Berhanu{at}


Introduction Ethiopia successfully reduced mortality in children below 5 years of age during the past few decades, but the utilisation of child health services was still low. Optimising the Health Extension Programme was a 2-year intervention in 26 districts, focusing on community engagement, capacity strengthening of primary care workers and reinforcement of district accountability of child health services. We report the intervention’s effectiveness on care utilisation for common childhood illnesses.

Methods We included a representative sample of 5773 households with 2874 under-five children at baseline (December 2016 to February 2017) and 10 788 households and 5639 under-five children at endline surveys (December 2018 to February 2019) in intervention and comparison areas. Health facilities were also included. We assessed the effect of the intervention using difference-in-differences analyses.

Results There were 31 intervention activities; many were one-off and implemented late. In eight districts, activities were interrupted for 4 months. Care-seeking for any illness in the 2 weeks before the survey for children aged 2–59 months at baseline was 58% (95% CI 47 to 68) in intervention and 49% (95% CI 39 to 60) in comparison areas. At end-line it was 39% (95% CI 32 to 45) in intervention and 34% (95% CI 27 to 41) in comparison areas (difference-in-differences −4 percentage points, adjusted OR 0.49, 95% CI 0.12 to 1.95). The intervention neither had an effect on care-seeking among sick neonates, nor on household participation in community engagement forums, supportive supervision of primary care workers, nor on indicators of district accountability for child health services.

Conclusion We found no evidence to suggest that the intervention increased the utilisation of care for sick children. The lack of effect could partly be attributed to the short implementation period of a complex intervention and implementation interruption. Future funding schemes should take into consideration that complex interventions that include behaviour change may need an extended implementation period.

Trial registration number ISRCTN12040912.

  • epidemiology
  • community child health
  • primary care

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  • Contributors The study was conceived by JS and ETL with inputs from DB, YBO, ADef, AB, AAM, MY, MAW, FW, ADes, FAG, DWD, HB, AT and LP. Contributions to training of data collectors, piloting and supervision during data collection were done by DB, YBO, ADef, LP, ADes, FAG, DWD, HB, ATW, TGetah, TGetac and AH. DW was the data manager. JS, LP, YBO, DB and AD analysed and interpreted the data. DB prepared the first draft of the manuscript with contributions from JS, LP, YBO and AD. All authors read and commented on the manuscript and approved the final version.

  • Funding This project was funded by Bill & Melinda Gates Foundation (OPP1132551).

  • Disclaimer The funder had no role in the study design, collection, management, analysis or interpretation of data.

  • Map disclaimer The depiction of boundaries on this map does not imply the expression of any opinion whatsoever on the part of BMJ (or any member of its group) concerning the legal status of any country, territory, jurisdiction or area or of its authorities. This map is provided without any warranty of any kind, either express or implied.

  • Competing interests None declared.

  • Patient consent for publication Not required.

  • Ethics approval Ethical approvals were obtained from the Ethiopian Public Health Institute (Ethics Ref 613/52) and the London School of Hygiene & Tropical Medicine (Ethics Ref 16117). Information sheets translated into the three local languages were read out to study participants to obtain their written informed consent.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data availability statement Data are available on reasonable request. Request for data can be made to Della Berhanu ( A data sharing committee has been established. All requests will be reviewed by this committee and if granted, data will be shared without any identifiers.