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Monitoring equitable health development in Tigray Regional State, Ethiopia

Research project The main objective of this programme is to build a culture of rigorous operational and implementational research in Tigray Region, in northern Ethiopia, as a natural partnership between Mekelle University's Department of Public Health and the Tigray Regional Health Bureau.

Collaboration with Umeå University in Sweden will foster this process, providing additional external expertise as well as professional development opportunities for the Tigrean team. This will take place as the Millennium Development Goals reach their conclusion in 2015 and the global community possibly sets new targets for key health outcomes.

Project overview

Project period:

2013-01-01 2015-12-31

Participating departments and units at Umeå University

Department of Epidemiology and Global Health

Research area

Public health and health care science

Project description

Specifically, this collaboration will address four key areas of health in Tigray: 1. implementing bottom-up approaches to measuring maternal, newborn and child mortality 2. evaluating malaria control strategies through a health systems lens 3. monitoring the effectiveness of the new Health Extension Worker and Family Folder programmes on monitoring population health 4. assessing progress towards MDG outcomes from a health equity perspective. The significance of the collaboration is twofold. Firstly it will contribute directly to health in Tigray, since the close partnership between the University and the Health Bureau ensures that evidence-based findings can readily be translated into policy decisions. Secondly it will create an on-going culture of practical research in the Region, which will provide a long-term basis for evidence-based health care delivery.

The main objective of this research programme, during a critical period as the existing Millennium Development Goals (MDGs) come to a conclusion and the world possibly sets new health-related goals, is to undertake rigorous operational and implementational research to better understand the health status and health equity of people in Tigray Regional State, Federal Democratic Republic of Ethiopia.
The meta-objective behind this research programme is to build solid research competency in the relatively young professional teams at the Department of Public Health in Mekelle University and the Tigray Regional Health Bureau, strengthening local collaboration and exchange between academia and health service providers.
The specific objectives within this research programme include: 1. implementing bottom-up approaches to measuring maternal, newborn and child mortality 2. evaluating malaria control strategies through a health systems lens 3. monitoring the effectiveness of the new Health Extension Worker and Family Folder programmes on monitoring population health 4. assessing progress towards MDG outcomes from a health equity perspective

Survey of the field
Tigray Regional State is the northernmost area of Ethiopia, comprising an area of 50,000 km2 and having, according to the 2007 national census, a population of 4.3 million, of whom 80% live in rural conditions [1]. Tigray is therefore larger than a number of sub-Saharan African countries. Geographically it is a mountainous and relatively arid area, presenting appreciable challenges for health service access and delivery. The regional capital, Mekelle, is a fast-growing urban centre housing approximately 200,000 people. Mekelle University was established after the end of the Ethiopian civil war in the mid 1990s, initially with a limited range of faculties, but has expanded rapidly into a comprehensive and modern university, which now has over 24,000 students and 1,400 academic staff. The College of Health Sciences, which includes the Department of Public Health, was established in Mekelle’s new teaching hospital in 2005. 2 A process of decentralisation was applied to health services in Ethiopia in the 1990s, with each region establishing a Health Bureau charged with the main responsibility for delivering health services, under the overall umbrella of the Federal Ministry of Health. Health development and reform is well underway on a national basis [2]. Tigray Health Bureau (THB) pre-dated the establishment of Mekelle University’s Department of Public Health (MUDPH), but nevertheless has a good track record in health service research, particularly in the area of malaria control. Sida supported a major project in the 1990s to investigate the effects of water harvesting and irrigation projects on malaria [3] and schistosomiasis [4] transmission, led by agronomists from Mekelle University and the vector-borne diseases unit at THB, led by Dr. Tedros Adhanom Ghebreyesus (who subsequently became head of THB and is now Federal Minister of Health). Operational research on malaria control, in conjunction with the World Health Organisation (WHO) [5], has been successfully carried out in the Region, and a PhD thesis on malaria diagnosis and treatment in Tigray has recently been finalised in collaboration with Umeå University [6]. Now that MUDPH is well established under the leadership of Dr. Afework Mulugeta, there is considerable potential for synergistic efforts in operational public health research between that department and THB, now led by Mr. Hagos Godefay. Together these two institutions have the potential to address the very real health needs of the Tigrean people, finding best approaches for continually monitoring and improving standards of health and health care. To realise this potential, there is a need to bring collaboration and support from more experienced researchers into the Tigrean team, which is the purpose of this application. The four specific objectives in this programme all relate closely to existing Millennium Development Goal targets (MDGs 4, 5 and 6). The timeframe of this research coincides with the conclusion of the current MDG target period (1990-2015) and very likely the start of newly emerging post-MDG objectives. It is therefore very important for Tigray to be able to effectively assess its position on maternal (MDG 5) and child (MDG 4) mortality, malaria control (MDG 6), and other MDG-related parameters as 2015 approaches. Equally it is clear that the original MDGs failed to include contain some important elements. For example, there was no target for civil registration (of births, deaths and other vital events) [7] and the MDG targets did not carry any equity-based outcome criteria. WHO and the Health Metrics Network (HMN) are now pressing for universal population registration on a much wider scale [8], supported by the recent Commission on Information and Accountability for Women’s and Children’s Health [9]. It is likely that post-2015 global objectives will include an equity dimension, as called for in the recent Addis Ababa Declaration on Global Health Equity [10].

Project description and mode of cooperation
The project will provide support and mentoring to researchers in Tigray working in areas relating to the four specific research programme objectives, as detailed below. The mode of cooperation will consist of two main components: [a] field visits by senior external 3 researchers to Tigray, to provide mentoring on the implementation and conduct of operational research; and [b] research workshops involving groups of Tigrean and external researchers, to provide opportunities for rigorous analysis and writing-up of operational research findings, including translation for policy and programme decision-making. 1. Implementing bottom-up approaches to measuring maternal and child mortality There is increasing concern that top-down methods (typically modelled global estimates) for estimating levels of maternal and child mortality, important though they may be for charting progress towards MDGs 4 and 5, are not sufficient for understanding the real situation, particularly at sub-national level [11-13]. There is therefore an urgent need to implement effective and affordable procedures for measuring mortality on a bottom-up basis. It is important to address, at the micro-level, why some health facilities are more successful and better utilised than others. WHO will shortly release new standards for verbal autopsy (VA), which have been developed in close collaboration with the Umeå University team, building on their previous work ( This will considerably simplify and shorten the process of VA interviews, together with an improved standard procedure for cause of death attribution. This new system will be implemented on hand-held devices as an e-health strategy that can be utilised by relatively low-level staff, working in the local language [14]. This is consistent with national initiatives to establish mobile-phone based reporting by HEWs. The operational effectiveness of this new system will be evaluated in Tigray, as part of a drive towards implementing routine cause of death ascertainment and registration across the Region. Within this framework, it will be possible to effectively document mortality among women of reproductive age and among children under 5 years of age. This coincides with one of the objectives of the Evidence for Action for Ethiopia (E4A-4E) programme, commissioned by the UK Department for International Development (DfID), which is being implemented in Tigray under the direction of Prof. Wendy Graham, Aberdeen University, involving support to the Federal Ministry of Health and Regional Health Bureaux in setting up an actionoriented Maternal Death Review System. 2. Evaluating malaria control strategies through a health systems lens Malaria is a serious problem in Tigray, following a hypoendemic to mesoendemic highland pattern of transmission with relatively low population immunity. Consequently all age groups are at risk of the disease, and infections with low-level parasitaemia can be associated with clinical illness, so therefore the effects of any outbreaks can be quite devastating. Diagnosing malaria and delivering effective treatment, with full adherence to appropriate dosage, is difficult in a challenging environment like Tigray. MDG6 focuses on stopping and reversing the spread of major infectious diseases, including malaria, which is recognised as a major impediment to development and poverty reduction, as well as a significant contributor to maternal and child mortality. 4 This objective aims to contribute to the improvement of malaria programmes in Tigray, specifically through effective delivery of essential health services to poor and vulnerable individuals. Specifically it will explore the potential epidemiological impact of scaling-up the previously tested strategy for diagnosing and treating malaria by community health workers (CHWs) using rapid diagnostic tests [15] and assess any implications for drug resistance and costs in using this approach to the control of malaria. In association with this, a communitybased intervention to increase the diagnostic effectiveness of providers and the adherence of patients to malaria treatment will be implemented and assessed. 3. Monitoring the impact of the new Health Extension Worker and Family Folder programmes A national programme is currently underway to give every household in Ethiopia a “Family Folder” (FF) in which the health of its members will be documented by locally deployed Health Extension Workers (HEWs), who will also retain their own records of the information to feed into the national health information system. This is a potentially important development in terms of accounting for vital events at population level, but its effectiveness needs to be operationally evaluated and assessed. This will be done in Tigray in specific areas, including in the Kilte Awlaelo demographic surveillance site maintained by MUDPH in the Region, to triangulate FF data with other population data. There is scope for incorporating the mortality follow-up procedures outlined under (1) above into the scope of the HEW/FF system, providing that the field effectiveness of both the new VA approach and the identification of deaths through the HEW/FF system can be demonstrated, leading towards a position where all the deaths in the Region (approximately 50,000 annually) could be routinely documented and used as a crucial evidence base for regional health planning. This would lead in the longer-term to higher quality health services through strengthening local government health service providers by targeted training and technical support. Focusing on the work of the HEWs will also lead to bottom-up strengthening of health systems in the Region. 4. Assessing progress towards MDG outcomes from a health equity perspective The MDG framework is increasingly being criticised for not having incorporated any measures of health equity. Consequently, it is possible, in some countries, that achievements at national level against MDGs may reflect greater improvements among better-off groups rather than in the population as a whole. At the conclusion of the recent World Congress on Public Health, hosted in Ethiopia, the Addis Ababa Declaration on Global Health Equity called specifically to “Make health equity an integral part of local, national and global policy and development agendas and to ensure that structural issues such as food insecurity, rapid urbanization, migration, man-made environmental degradation, conflict and militarization, climate change and economic crisis are taken into consideration” [10]. 5 Like the rest of Ethiopia, and indeed Africa in general, there are major differences in health status between urban residents of cities such as Mekelle and the majority of the population, who live in rural areas. Additionally there are substantial within-urban and within-rural health inequities. It is therefore critically important to be able to evaluate health outcomes in a Region like Tigray across its entire population, and not just in the most accessible locations. This leads to greater understanding of the nature and extent of inequity, which can then be fed back into health policy and planning processes on a continuous basis in order to improve health equity. Taking a Region-wide approach to health assessment is therefore the first step towards improving equity, and will lead to the development of robust and operationally effective indicators for measuring equity.

The significance of this research programme can be viewed at two levels. At the level of the detailed research that is proposed, it will contribute directly to the understanding of the health of the Tigrean population, and, since it is not just an academic exercise located in a University, the findings of the research will feed directly into policy and programmes because of the University’s close connections to THB and the Regional Government. Thus the proposed research has every chance of leading directly to improvements in population health. Looking at the level of longer-term development, undertaking this collaboration will lead to significant capacity development for personnel at MUDPH and THB, a matter of great significance for ensuring continued operational research into important health issues beyond the time span of this research programme. Establishing and encouraging a culture of robust operational research and the uptake of findings into policy, involving partnership between MUDPH and THB, is a key strategy for improving population health and health service delivery for the future.

Preliminary results
In the most recent Demographic and Health Survey [16] (undertaken on a national cluster sample survey in 2011), under-5 mortality nationally was 88 per 1,000 live births (infant mortality 59 per 1,000 live births). For Tigray, the corresponding estimates were 85 and 64 per 1,000. The same source estimated maternal mortality ratio (MMR) at 676 per 100,000 live births, not estimated by region. However, forthcoming United Nations’ estimates of maternal mortality ratio in Ethiopia for 2010 report 350 maternal deaths per 100,000 live births (uncertainty range 210-630) [17], again not estimated on a regional basis, but highlighting the considerable differences between estimates. Overall this suggests that Ethiopia is on-track for the attainment of MDG 4, and has made considerable progress towards MDG5. But even though these figures reflect encouraging improvements on previous levels, they still represent unacceptably high levels of mortality. The lack of reliable figures 6 for Tigray and discrepancies between estimates highlight the importance of implementing good bottom-up procedures for monitoring these rates. Preliminary results on malaria treatment effectiveness showed that the majority of health posts were technically inefficient. Rapid diagnostic tests for malaria were found to be the most cost-effective strategy, and artemether-lumefantrine treatment administered by community health workers was more effective than when its use was restricted to health facilities [15]. However, among P. falciparum positive patients to whom artemetherlumefantrine was prescribed, more than a quarter did not finish their treatment. This was mainly attributed to perceptions of too many tablets or quickly feeling better [18]. Deploying artemether-lumefantrine with rapid diagnostic testing at community level was demonstrated to be effective and feasible. The use of rapid diagnostic tests reduced costs and possibly reduced the risk of drug resistance development [19]. The rollout of the FF programme is underway as part of a national programme [2] and as yet there are no preliminary data on its effectiveness. More bottom-up data are also needed on mortality and other outcomes, together with data on geographical and socio-economic status, in order to begin to understand and analyse the magnitude and effects of inequity on health in Tigray Region. It is envisaged that the core of these data will come from the FF programme. There are currently no agreed targets on health equity nor any common standard for estimating the burden of health inequity within the MDG framework. Experience from this work in Tigray could lay equity-based foundations for the next generation of global targets. This work area will connect with the call from the WHO Commission on Social Determinants of Health [20] for developing health equity indicators.

Equipment and resources
Because the proposed research is closely aligned with the core activities of the THB, much of the activities will be resourced as part of the routine work of the Bureau. However, there will be a need to provide some equipment and resources to enable the evaluative components of the research to proceed, such as additional computer equipment