Business Case
Reducing Barriers and Increasing
Utilisation of
Reproductive Maternal and Neonatal
Health Services
InEthiopia
DFID Ethiopia
November 2012
Acronyms
ANC
BCC
BEmONC
CPR
DFID
DRS
EDHS
EHSP
FBO
FGC/M
FGOE
FMA
FMOE
FMOH
FP
GOE
GTP
HC
HDA
HEP
HESP
HEW
HMIS
HIV
HP
HRD
HSDP IV
HSEP
HTP
INGO
JFA
JSI
KPI
M&E
MDG
MDG PF
MMR
MOWCYA
MSIE
MSP
MVA
MWRA
NGO
OR
PHCU
PrG
RH
RHB
RMNH
RTC
SAC
SBA
SRMNHR
Ante Natal Care
Behaviour Change Communication
Basic Emergency Obstetric and Neonatal Care
Contraceptive Prevalence Rate
Department for International Development
Developing Regional States
Ethiopian Demographic Health Survey
Essential Health Service Package
Faith Based Organisation
Female Genital Cutting/Mutilation
Federal Government of Ethiopia
Financial Management Assessment
Federal Ministry of Education
Federal Ministry of Health
Family Planning
Government of Ethiopia
Growth and Transformation Plan
Health Centre
Health Development Army
Health Extension Programme
Health Extension Service Package
Health Extension Worker
Health Management Information System
Human Immunodeficiency Virus
Health Posts
Human Resource Development
Health Sector Development Programme IV
Health Service Extension Programme
Harmful Traditional Practices
International NGO
Joint Financing Arrangement
John Snow Incorporated
Key Performance Indicators
Monitoring and Evaluation
Millennium Development Goals
Millennium Development Goals Performance Fund
Maternal Mortality Ratio
Ministry of Women Children and Youth Affairs
Marie Stopes International Ethiopia
Marie Stopes procedure
Manual Vacuum Aspiration
Married Women of Reproductive Age
Non-Governmental Organisation
Operational Research
Primary Health Care Unit
DFID’s Procurement Department
Reproductive Health
Regional Health Bureau
Reproductive, Maternal and Newborn Health
Regional Training Centre
Safe Abortion Care
Skilled Birth Attendant
Sexual Reproductive Maternal and NeonatalHealth and Rights
STI
SWAp
TAG
TBA
TFR
TOR
UNFPA
UNICEF
USAID
VfM
WHO
Sexually Transmitted Infection
Sector Wide Approach
Technical Advisory Group
Traditional Birth Attendant
Total fertility rate
Terms of Reference
United Nations Fund for Population Activities
United Nations Children’s Fund
United States Agency for International Development
Value for Money
World Health Organisation
Intervention Summary
Title: Reducing Barriers and Increasing Utilisation of
Reproductive, Maternal and Neonatal Health Services
What support will the UK provide?
The UK will provide up to £25 million over four years (2012/13-2015/16)1to establish a Reproductive
Maternal and Neonatal Health Innovation Fund (RIF) to complement on-going efforts to increase access to
services for poor and excluded communities.
Why is UK support required?
Despite increased access to health services and impressive gains in health outcomes in Ethiopia the use
of many reproductive, neonatal and maternal health (RMNH) interventions remains low. There are striking
disparities in service utilisation between regions and between urban and rural populations. Only 23% of
women in rural areas use modern family planning methods and unmet need remains high. Two thirds of
women receive no antenatal care; only 10% of women (5% in rural areas) deliver safely with a skilled birth
attendant (SBA); and 92% of women receive no postnatal care. Whilst the national Total Fertility Rate
(TFR) has reduced from 5.6 children per women to 4.8, developing regional states like Somali lag behind
with a fertility rate of 7.1. Adolescents face particular challenges in accessing user-friendly services and
experience the high risks of child-bearing when too young. The result is continuing high fertility and high
maternal and neonatal mortality (which accounts for 40% of under-five mortality).
In recent years the focus has been to increase access to services through expanding coverage of
government health infrastructure and trained staff and through a community level health extension
programme. However available services are often of low quality and may not be seen by women as
culturally appropriate. Less attention has been given to addressing the range of geographic, financial and
socio-cultural barriers that limit service utilisation. There remain wide variations in access and use between
regions, between urban and rural areas and among vulnerable groups such as adolescents and pastoralist
communities.
Without targeted efforts to remove barriers and increase use of high-impact RMNH interventions, Ethiopia,
and in particular the developing regional states, are unlikely to make progress in improving maternal
health and reducing neonatal mortality by 2015 (MDG 4 and 5).
What will we do to tackle this problem?
We will establish a Reproductive Maternal and Neonatal Health Innovation Fund (RIF) to complement ongoing efforts to increase access to services for poor and excluded communities. The RIF aims to increase
the utilisation of RMNH services, enhance accountability of service providers (civil society, regional
development agencies) to the government and improve regional equity. The RIF will support interventions
aimed to:
 Reduce barriers and increase demand for, and use of, modern family planning methods by
population groups with the least access: poor women in rural areas, and sexually active
adolescents;
1
The project will run into DFID FY 2016. Most calculations of benefits are made to 2015 to fit in with national goals, the MDG
targets and the next planned Demographic and Health Survey that will produce impact and outcome data.
1

Prevent unintended pregnancies and assure safe pregnancy and child birth through the
increased use of family planning, antenatal, childbirth and postnatal care;

Make services more accessible and responsive to the needs of women and youth by scaling
up approaches to empower young women and increase their reproductive health choices.

Reduce disparities in health indicators and the inequitable access to RMNH services in
the Developing Regional States (DRS).

Build further evidence of what works in the diverse cultural and geographical settings of
Ethiopia.
The RIF will support interventions in three regions where fertility is high, use of reproductive maternal and
neonatal health services is low and where communities lack access to services e.g. pastoralist women.
Specific regions and districts will be identified by the Federal Ministry of Health (FMOH) but are likely to
include Somali, Afar and parts of Oromia regions (a highly populated agrarian region that has pockets of
remote communities with poor health indicators). The RIF will be managed by the FMOH in a specific
earmarked account. The FMOH will invite proposals from Regional Health Bureaus (RHBs), Regional
Development Agencies (RDA), Civil Society Organisations (CSOs), Faith Based Organisations (FBOs) and
others to:
 Increase demand for RMNH services (for instance though behavioural change communication to
increase cultural acceptability of Family Planning and desire for smaller families);
 Reduce/overcome socio-cultural barriers to women and girls utilising RMNH services (for instance
through girls empowerment programmes);
 Overcome barriers and bottlenecks that hamper service utilisation and effectiveness (for instance
through provision of youth friendly family planning services, building mother waiting homes,
increased outreach services, improved service quality, increased capacity of districts to plan,
manage and monitor service delivery);
 Enhance accountability (for instance through monitoring providers through score cards,
consultation exercises with adolescents on needs, maternal death reviews and strengthening
community health boards.); and
 Generate evidence of what works (for instance through operational research on cultural influences
and barriers, effective interventions to increase use of services).
Proposalsto the RIF will be reviewed by DFID and the FMOH under the Ministry’s Maternal and Child
Health Technical Working Group (MCHTWG) and appraised based on the following criteria:

Increase equity in access to RMNH services;

Increase local level accountability and respond to the needs of women and girls;

Increase health seeking behaviour around pregnancy and deliveries;

Unlock key bottlenecks in service delivery and key socio cultural barriers based on assessment on
needs and situation analysis;

Focus on the needs of adolescent girls and most neglected populations; and

Feasibility of measuring results and evaluating impact of the programme.
A tripartite agreement will be made between the RHBs, CSO/FBO and FMOH on what is to be delivered.
The successful applicants will then report and account to the FMOH.
2
DFID in consultation with the FMOH will contract Technical Assistance (TA) to support the FMOH to
manage the RIF. Under the direction of the FMOH the TA will :
(i) Support the FMOH to disburse grants and fulfil its fiduciary requirements;
(ii) Provide technical support, where appropriate, to RHBs and CSO/FBOs to identify critical
bottlenecks, innovations and write proposals.
(iii) Support the FMOH to prepare the financial and programmatic reporting required byDFID; and
(iv) Capture best practice and lessons learnt.
DFID will also contract a Monitoring and Evaluation (M&E) partner to support the FMOH to monitor the
programme, document best practice, collate lessons learnt and dissemination among implementing
partners. The M&Epartner will also conduct the annual reviews and end of project review to meet DFID’s
corporate requirements.
This intervention is in line with the priorities of Ethiopia’s Health Sector Development Plan (HSDP IV),
DFID’s strategic priorities set out in ‘Choices for Women: planned pregnancies, safe births and healthy
newborn’ and in DFID Ethiopia’s Operational Plan.
What are the expected results?
The impact of the programme will be a reduction in maternal and neonatal mortality. It will contribute to
Ethiopia’s ambitious goals for 2015 of:
 Reducing maternal mortality from 676 deaths per 100,000 live births to 267
 Reducing neonatal mortality from 37 deaths per 1,000 live births to 15
 Reducing the Total Fertility Rate from 4.8 children per women to 4.
The outcome of the programme is increased demand for and use of quality, acceptable reproductive,
maternal and newborn health services by the poor and excluded populations in three regions to prevent
unintended pregnancies and increase safe pregnancy and childbirth. This will be measured by increases in
the contraceptive acceptance and prevalence rates2, a reduced teenage pregnancy rate, and increased
skilled attendance at birth. It is estimated that the programme will lead to an estimated 20% change at
national level in each indicator above the expected change (the counterfactual) by 2015.
Table 1: Effect of intervention on national outcome indicators
60%
12.4%
2015 with RIF
54%
2015 without
RIF
2011 DHS
27%
2011DHS
2015 with RIF
87%
2015 with RIF
2015 without
RIF
83%
Skilled Birth Attendance
rate
2015 without
RIF
2011 DHS
62%
Teenage pregnancy rate
2015 with
RIF
National
Contraceptive Prevalence Rate
2015 without
RIF
2011 routine
data
Contraceptive
Acceptance Rate
9.3%
8.8%
10%
20%
22%
Planned outputs attributable to UK support include:
1) Increased supply of culturally appropriate and acceptable services for women and youth;
2) Improved community attitudes to RMNH needs of women and girls resulting in increased demand
2Contraceptive
acceptance is routinely measured by the national health information system, contraceptive prevalence is
measured every five years by the EDHS.
3
and uptake of services, especially among youth;
3) Women and girls empowered and confident to make RMNH choices;
4) Enhanced accountability and responsiveness of service providers to communities; and
5) Increase knowledge and evidence of innovative new approaches to increase utilisation of RMNH
services.
As the RIF will be implemented in regions that are lagging behind on RMNH indicators the programme will
help to address the disparities between regions and the inequities of access to RMNH services.
It is difficult to specify beneficiary numbers, given the uncertainties of what interventions will be funded by
the RIF. However, based on an analysis of implementing proven effective interventions in the regions of
Afar, Somali and Oromia we can estimate the following results:



67,000 additional births in safe conditions
1 million additional users of family planning
28,000 fewer teenage pregnancies
The support from this programme will help bring Ethiopia closer to achieving its national targets than if the
existing levels of support to the sector continued. For instance with existing government and DFID funding
Ethiopia is likely to achieve a CPR of 54%, far short of its 2015 target of 66%. However with this
programme delivering an additional 1 million family planning users creating a CPR of 60% by 2015.
Similarly for teenage pregnancy the additional resources from this programme will reduce the rate to 8.8%
from a forecasted 9.3% bringing Ethiopia closer to its 5% target. The additional programme resources will
again increase SBA rate from a forecasted 20% to 22%. Whilst this is still far short of the 2015 target of
40% it will help women in Afar and Somali where the risk of maternal death is highest.
According to the economic appraisal these benefits would be achieved at a rate of £4.46 per birth, £10.22
per Couple Year Protection from Family Planning, £31 per DALY averted and £218 per girl empowered. As
the cost per DALY saved is well below Ethiopia’s GNI per capita of £250 these benefits are judged to be
highly cost effective and represent value for money.
Detail on beneficiary numbers and assumptions made in calculating the potential gains are elaborated in
the Strategic Case (Section B).
How will we determine whether the expected results have been achieved?
Implementing partners will be required to submit annual progress reports to the FMOH; which will in turn
be reported to the multi stakeholder Maternal and Child Health Technical Working Group (MCHTWG) and
DFID. In addition we will contract an independent M&E partner to conduct annual evaluations and
document/disseminatelessons learnt. Progress of the programme will be assessed against the logframe
indicators and milestones. An end point evaluation will assess the contribution of all DFID investments in
RMNH in Ethiopia.
4
1. Strategic Case
A. Context and need for DFID intervention
A1.
The country context
Ethiopia is important to the UK. It is one of the world’s poorest countries with more than 24 million
people (30% of the population) estimated to live in extreme poverty. The country lies at the heart of an
unstable region in the horn of Africa where ethnic nationalism and underdevelopment fuel instability and
undermine national development. Conflict drives migration to Europe and contributes to radicalism. UK
interests include resolving conflict and bolstering stability, accelerating sustainable growth and
development, mitigating climate change, tackling migration and countering terrorism.
Ethiopia has made substantial progress over recent years. The country has maintained stability
through a decentralised federal structure. Strong leadership has sustained double-digit growth rates for the
past eight years, rapidly expanded basic services in education, water and health3 and reduced poverty
levels by 35% since 1995. Government has an impressive record of pro-poor spending, sound financial
management and there is relatively little corruption. The Prime Minister and others in government play a
prominent role in global policy dialogue. The country has yet to manage its democratic transition and while
progress is being made there remain challenges with respect for human rights illustrated in recent
legislation to regulate NGOs working in this area. The country is comparatively under-aided yet has
demonstrated that it can use aid well and has potential to absorb increased levels.4
Ethiopia has made impressive progress towards realising the Millennium Development Goals
(MDGs) albeit from a low base. Since 2005 the child mortality rate has fallen from 123/1000 to 88/1000,
the incidence of malaria has halved and immunisation rates doubled5; a social safety net now protects
eight million of the most vulnerable people6, and 16.7 million children (7.9 million girls) are enrolled in
primary school7. Increased access to health services has been achieved through community-based
services led by 34,000 Health Extension Workers (HEWs), and substantial expansion of health
infrastructure and services. However the functionality of many health facilities is limited and there remain
substantial gaps in access and significant variation between regions and between rural/urban settings.
Health outcomes are better than the average for least developed countries.8
A2.
Reproductive Health context
Reproductive health is a high priority of government. The Government of Ethiopia and the Federal
Ministry of Health (FMOH) provide strong leadership. A number of comprehensive strategies prioritise high
impact interventions9. While service coverage has increased in recent years there remains significant
geographic, financial, and socio-cultural barriers services being accessed and used. Women are at risk of
death and disability as a result of complications of pregnancy or child birth due to teenage
pregnancies,high fertility rates, limited access to skilled care and safe abortion services; the low status of
women and girls, and harmful traditional practices. Use of all RMNH services is closely correlated with
levels of poverty, education of mothers and rural residence.
3MOFED,
2012, Ethiopia’s Progress Towards Eradicating Poverty: An Interim Report on Poverty Analysis Study (2010/11)
data extracted on 20 Jul 2011 07:17 UTC (GMT)
5 Ethiopian Demographic and Health Survey (DHS) 2011
6
Devereux et al (2006) Ethiopia’s Productive Safety Nets Programme. Trends in PNSP Households with Targeted
Transfers.Institute of Development Studies, Sussex.
7 Federal Democratic Republic of Ethiopia (2010) Education Statistics Annual Abstract 2010/2011, Ministry of Education, Addis
Ababa
8 Pearson M. 2010 Impact Evaluation of the Sector Wide Approach, Ethiopia HLSP
9The National Health Sector Development Programme (HSDP IV), the 2011 Reproductive Health Strategy, and the Roadmap
to Accelerate Action on Maternal Health.
4OECD.STAT:
5
There is a momentum to family planning withnear universal awareness10 and increasing
demandhowever substantial inequalities exist with least developed regions and particular population
groups (pastoralists, adolescents) lagging behind. The Contraceptive Prevalence Rate (CPR) increased
from 6% in 2000 to 29% (27% modern methods) in 2011. Yet unmet need remains high at 25% with the
greatest need amongst those aged 15-19 years old (33%) and those in rural areas (28%)11. Less than 10%
of married adolescents use a modern contraceptive method. Reasons include inadequate knowledge,
limited ability to make decisions about contraception or when to have children, and lack of experience in
obtaining services.12More than 70% of women who want to avoid pregnancy do not practice contraception
or use a relatively ineffective traditional method. Meeting just half of this unmet need therefore, could result
in 754,000 fewer unintended pregnancies each year, leading to a drop in maternal mortality by almost onethird from the current level. Unplanned births and unsafe abortions would decline by 89–92%.13Many
informants considered that the CPR is likely to reach or approach the national target of 66% by 2015. The
challenges will be to raise CPR in all areas of the country not just urban areas, maintain reliable supplies of
contraceptives, and to increase choice of contraceptive methods and the proportion of long term and
permanent methods. Many barriers to accessing family planning remain in rural areas, for the poor and for
adolescents, particularly the unmarried.
Ethiopia's fertility rate of 4.8 births per woman has fallen in recent years but remains amongst the
highest in the world. 45% of the population are under the age of 15 and the population of 83 million is
set to rise to around 120 million by 203014,15. Fertility is much higher in rural (5.5) than urban (2.6) areas,
with some regions such as Somali still experiencing very high fertility (7.1).
The maternal mortality rate remains veryhigh (676 per 100,000) and use of skilled antenatal,
childbirth and postnatal care is low. Two thirds of women receive no antenatal care, 92% receive no
postnatal care and only 5% of rural women deliver with a skilled birth attendant (SBA). 40% of child deaths
occur in the first month of life and most in the first few days when women have little or no contact with a
health worker. Maternal and neonatal morbidity and mortality rates in Ethiopia are among the highest in the
world with little improvement over the past five years. This is attributable to low coverage and use of critical
interventions and in part to the high number of births among adolescents when risks are far greater.16Most
neonatal deaths will be prevented by safe antenatal, childbirth and early postnatal care.
Attended birth in a health facility is not regarded as a normal or desired practice and most women deliver
at home, supported by a family member or traditional practitioner. Only 10% of women (51% urban, 5%
rural) reported their most recent live birth in a health facility.
Each year, an estimated 22,000 women and girls die due to pregnancy related complications
andmore than 500,000 women and girls suffer disabilities due to complications during pregnancy and
childbirth. The direct causes of maternal deaths are all potentially treatable and reflect limited access to
safe delivery and emergency obstetric care and the disparities in access to health services between and
within regions17.
10EDHS
2011
Statistical Agency (2011) Ethiopia Demographic and Health Survey 2011. Preliminary Report, Addis Ababa.
12 Singh S, Darroch J, Ashford L, Vlassoff M. Adding it up: the benefits of investing in sexual and reproductive healthcare.
UNFPA: Guttamacher Institute; 2009. Available at: www.guttmacher.org/pubs/AddingItUp2009.pdf
13Guttmacher.Benefits of Meeting the Contraceptive Needs of Ethiopian Women. 2010 Series, No. 1
14 Population Division of the Department of Economic and Social Affairs of the United Nations Secretariat, World Population
Prospects: The 2010 Revision, http://esa.un.org/undp/wpp/index.htm, data extracted on Wednesday July 20, 2011; 4:33:42
AM
15Population Reference Bureau 2011 World Population Datasheet.Washington, DC: PRB.
16Haberland, N, et, al. “Early Marriage and Adolescent girls,” Youthnet: Youthlens on RMNH and HIV/AIDS, Brief no. 15,
August 2005.
17Federal Ministry of Health (2008) National Baseline Assessment for Emergency Obstetric and Newborn Care, Addis Abba,
Ethiopia.
11Central
6
In 2008 it was estimated that one in ten pregnancies in Ethiopia ended in abortion amounting
to382,500 induced abortions each year of which less than 40% were performed safely. 52,600 women
received care in a health facility for complications of unsafe abortion. Unsafe abortions are estimated to
account for 6% to 30% of maternal deaths18. The law is permissive and access to safe abortion is
increasing through public and private facilities. Use of emergency contraception is also increasing, largely
in urban areas.
HIV/AIDS contributes to maternal deaths withthe risk of death from pregnancy-related complications for
HIV positive women double that for HIV-negative women.19 Ethiopia has a low HIV prevalence at 1.5% of
the population aged 15-49 years. The epidemic is concentrated in urban areas where 5.2% of women and
2.9% of men are HIV positive and is driven by commercial sex. 62% of girls and 18% of boys are sexually
active by 18 years and the massive expansion of higher education in recent years poses a significant risk
with high levels of unsafe sex among students.20
Girls and women are subjected to a range of discriminatory and harmful traditional practices that
put them at risk. Disadvantage and discrimination against women and girls is evidenced in social, cultural,
economic and political life and exert strong influences which impact on women’s and children’s health.
Ethiopia ranks 122 out of 134 countries worldwide for inequality between women and men.21
The median age of marriage among women- 16.5 years- is one of the lowest in Sub Saharan Africa.
About one in five women is married by her 15th birthday, and 17% of girls aged 15-19 have already become
mothers or are pregnant with their first child. Girls who bear children before the age of 15 years are five
times more likely to die from pregnancy related causes (than older mothers).22The high prevalence of
obstetric fistula, at 80 cases per 1,000 live births, is a direct consequence of pregnancy at a very young
age when the pelvis is not fully developed, thus increasing the chance of prolonged and obstructed labour.
Female Genital Cutting/Mutilation (FGC/M) is common despite its criminalisation in 2004. The 2005
Ethiopian Demographic Health Survey (EDHS) indicated that more than 74% of women between the ages
of 15 and 49 had undergone some form of cutting. This figure was estimated at 97% in the Somali region
and 90% in the Afar region where the most extreme form of cutting is practiced. These women are
significantly more at risk during delivery and require skilled attendance. Their infants are also at greater
risk of perinatal death. Due to advocacy efforts by the Government of Ethiopia (GOE) and CSOs, including
Muslim leaders the rates of circumcision seem to be declining.23 2011 data shows that 23% of girls aged
0-14 years are circumcised ranging from 7% in Gambella to 60% in Afar24.
Gender-based violence against women is common. The Ethiopian Young Adult Survey shows
widespread acceptance of violence, especially among rural females. 15% of sexually experienced young
women had experienced forced sex/rape and a considerable number blamed themselves for the event and
didn’t inform anyone. 25
A3.
The policy context
There are clear imperatives for scaling up support for RMNH in Ethiopia. Achieving the MDG targetsin
Ethiopia would make a significant contribution to achieving the MDGs in sub Saharan Africa and globally.
18Guttmacher
Institute (2010) Facts on Unintended Pregnancy and Abortion in Ethiopia.InBrief.Guttmacher Institute, New York.
AK et al (2010) HIV and maternal mortality: turning the tide.TheLancet(375:9730): 1948-1949.
20EDHS 2011
21World Economic Forum, Global Gender Gap Report 2010. The Global Gender Gap Index examines the gap between women
and men in four categories: economic participation and opportunity; educational attainment; health and survival and political
empowerment.
22 Murphy and Carr (2007) Powerful Partners: Adolescent Girls’ Education and Delayed Childbearing, PRB brief
23 Ethiopia Young Adult Survey: A study in seven regions, Population Council 2010
24 Welfare Monitoring Survey 2011
25Population Council.Ethiopia Young Adult Survey. A Study In Seven Regions. Erulkar et al. 2010
19Quarraisha
7
DFID’s global business plan (2011-2015) prioritises efforts to reduce unintended pregnancies and
maternal and newborn deaths. DFID Ethiopia’s Operational Planseeks to increase the number of births
with a skilled birth attendant and enable an additional two million couples to use modern methods of family
planning.
The National Health Sector Development Plan (HSDP IV) sets ambitious targets to reduce the maternal
mortality ratio, reduce the total fertility rate, increase access to safe abortion services, increase the
contraceptive prevalence rate and increase the proportion of young people aged 15-24 years who use
condoms consistently.
Ethiopia suffers from many of the problems of ineffective aid: inadequate support to the budget, an
imbalance in allocations with most donor health funding supporting AIDS, TB and malaria, fragmentation of
effort with many small projects resulting in high transaction costs and concerns over the sustainability of
much aid. While funding to the health sector has increased in recent years theGOE health spend is low at
7% of the budget and there remains a substantial financing gap in meeting the level of ambition of the
national plan.
A4.
Current DFID interventions to support RMNH
DFID provides substantial support to the health sector with a high proportion supporting RMNH
interventions. 80% of funding is provided through pooled funds managed by the GOE through the
Protection of Basic Services Grant and the FMOH’sMDG Performance Fund (MDG PF). These are federal
funding instruments that distribute grants and goods to the regions. Complementary programmes include
service delivery in Somali Region, the civil society multi donor supported fund, ending child marriage in
Amhara Region, social marketing of contraceptives and empowerment of adolescent girls through the Girl
Hub. Ethiopia also benefits from DFID multi-country programmes including Evidence for Action
(E4A)26,Preventing Maternal Deaths from Unwanted Pregnancy (PMDUP)27and the IPPF managed Safe
Abortion Action Fund.
A5.
Rationale for intervening
If Ethiopia is to further improve RMNH indicators it must complement on-going efforts to increase the
supply of services with targeted approaches to reduce barriers to access and utilisation in particular
geographical areas and for specific vulnerable groups. While physical access is increasing, functional
access lags behind especially in the developing regional states (DRS).Quality of services is low28 two
thirds of new health centres have no water or electricity and are unable to provide Basic Emergency
Obstetric and NewbornCare (BEmONC).
To date the focus has been largely on increasing geographical coverage of services with less attention to
understanding and overcoming barriers to use. The efforts of the HEW, supported by community health
networks such as the Health Development Army (HDA)-the network of five households led by one model
family- is leading to increased demand for services. But additional targeted interventions arerequired to
address inequalities and reach underserved groups including adolescents, women in rural areas, and
those living in the pastoralist regions where a strong Islamic influence rejects family planning.
A number of community initiatives are influencing entrenched harmful traditional practices and empowering
adolescent girls. These are slowly demonstrating changes in attitudes and practices including reduction in
early child marriage and FGC/M, and increased use of contraception. However these operate at a small
scale and a successful approach in one region may not be transferable to another.
26
Evidence for Action (E4A) is a multi-country programme that brings together evidence, advocacy and accountability efforts to
address poor maternal and newborn health outcomes across six sub Saharan African countries
27 Preventing Maternal Deaths from Unwanted Pregnancy (PMDUP) managed by MSI and IPAS is a bi-regional programme,
covering 14 countries in Africa and Asia.
28EMONC study
8
The FMOHRMNH strategy prioritises delivery of proven, high impact interventions. However the
assumption appears to be that if services are made available – health facilities capable of delivering
emergency care, with skilled birth attendants, and emergency transport - women will choose to deliver in
health facilities. Yet 61% of women do not see giving birth in a facility as necessary or desirable. Health
providers need to understand what women want from maternity services and adapt established practices
to encourage every woman to deliver at least her first baby in a health centre. There is a divide between
providers and clients’ understanding of accessibility. Providers tend to see accessibility in terms of
availability and (possibly) quality. But for the client availability, cultural accessibility and affordability,
acceptable quality and adaptability have to be met. Where women have been asked it is clear that they do
not perceive current maternity facilities to be ‘woman friendly’29 and until the services provided are seen to
meet their needs it is likely that the use of facilities for childbirth will increase too slowly to see any major
change in maternal and newborn outcomes.
Programme design has been informed by extensive mapping of the RMNH landscape in Ethiopia and
through consultation with the FMOH, regions and partners30. The analysis revealed a number of areas
where additional investment could add value and accelerate progress towards achieving RMNH targets.
Targeted interventions in the following areas could complement DFID’s substantial ongoing investments in
Ethiopia’s health system and improve health outcomes.
 Increase the use of skilled antenatal, childbirth and postnatal care including postnatal family
planning and facility-based skilled birth attendance. This would be achieved through: improving
understanding of cultural influences and determinants, improving the quality of care, increasing
awareness of the benefits of safe pregnancy care, investing in ‘woman-and newborn friendly’
approaches, supporting innovative approaches to address transport and financial barriers, and
enhancing accountability between communities and service providers.
 Increase access to family planning information and services, particularly for adolescents.
This would involve provision of appropriate and sensitive youth friendly services in formal and nonformal outlets, making health workers more client friendly by changing their attitude to youth;
overcoming traditional and cultural barriers through engagement with communities and faith leaders
and through media based approaches. There is a particular need to increase coverage of
appropriate sexual and reproductive health services for unmarried youth and those in rural areas. A
number of programmes (e.g. Integrated Family Health Project, MSI clinics) target youth with RMNH
and HIV information and services and have potential for scale up.
 Scale up girls’ empowerment programmes. There are opportunities to scale up effective but
small-scale community interventions that aim to empower girls and women and change
communities’ acceptance of harmful traditional practices (HTP). The challenge is to identify how
these can be taken to scale economically and embedded into policy and practice.
 Research the barriers and lessons learned from effective approaches and determine what can
work at scale in the diverse settings of the country. Proven interventions from other countries may
not be effective in Ethiopia. We do not know what mix of interventions will change views on safe
childbirth and prove to be effective and applicable at scale.
 Communication, advocacy and monitoring and evaluation will be cross-cutting themes.
These recommendations should ideally be implemented as a package.
The mapping identified a plethora of CSOs/FBOs that are working on RMNH in the country. They often
work in isolation and not always in the areas or with the populations that have the greatest need. There is
little accountability of these organisations to the Regional Health Bureaus (RHB), making it difficult for the
government to deliver a coordinate effective package of services. There are clear opportunities to improve
29A
woman-centred or mother-friendly approach to maternal healthcare emphasises the provision of high quality, evidence
based care that is culturally sensitive, empowers the woman for informed self-care, and treats the woman with dignity and
respect. JHPIEGO. Women-centred Care. Best Practices. www.mnh.jhpiego.org
30 Reducing barriers and increasing utilisation of reproductive health services in Ethiopia: Business case mapping report. June
2012
9
collaboration between the public and private sectors, cooperation across disciplines and to leverage
existing programmes to achieve greater reach and impact.Innovative approaches are needed to reach
neglected and underserved groups and to enhance accountability between communities, health facilities
and government.
Output
Improved community attitudes to
RMNH needs of youth
Empower girls to make
healthy RMNH choices
Community education/conversations by Health
Development Armies (HDA)to increase awareness of
RMNH needs of youth and reduce harmful traditional
practices
Girl Mentoring Schemes
Social networks and safe spaces
Family life education in school
After school clubs
Community health networks (HDA)
Behaviour change communication (BCC) through
communities and media
Women’s groups
Support to ensure that rights and protections established in
national laws (e.g. access to contraception and abortion,
prevention of early marriage and female genital cutting) are
implemented.
Targeted voucher schemes to reduce financial barriers to
accessing services
Community emergency transport schemes
Work with religious authorities and local government to
encourage women to use RMNH services and deliver their
babies in facilities
Work with health workers to change their negative attitudes
and improve customer services in facilities that are
responsive to local needs and culture
Create an enabling environment to
encourage and support girls and
women to use family planning and
deliver their babies in health facilities.
Youth friendly RMNH services through formal & non-formal
approaches
Women friendly birth practices in health facilities
Maternity waiting homes
Social marketing of RMNH commodities
Increased supply of culturally
acceptable and appropriate services
Support social accountability approaches to improve health
provider performance (e.g. provider monitoring through
scorecards and audits that compare actual with stated
services)
Consultation exercises with women on needs
Maternal Death Reviews
Increased accountability of health
providers to communities and greater
responsiveness to local needs
Operational research into cultural influences and barriers
and effective interventions to increase use of services
Increased knowledge and innovative
approaches
Research
Enhance
Accountability
Expand
quality
services
Possible interventions
Remove barriers that prevent
utilisation
Table 2 Possible complementary interventions to increase use of RMNHservices
A6.
Young women and girls empowered
and confident to make RMNH choices
and utilise services
Consequences of not intervening
Not intervening will compromise Ethiopia’s ability to achieve their ambitious RMNH and MDG targets.
DFID’s investment through the MDG Performance Fund and other programmes will help strengthen the
supply of RMNH services and achieve progress towards the targets. However as long as barriers exist to
women and girls utilising services, there is a risk that these investments will not yield the maximum results
possible.
10
On-going government efforts will lead to further increases in coverage and quality of RMNH services.
However, it is not clear whether women will choose to use the available services without additional efforts
to reduce cultural, financial and other barriers, and to make services more responsive to their needs. It is
also possible that, whilst nationalRMNH indicators improve due to increased service utilisation in the more
developed regions of Ethiopia, without targeted efforts on the least developed regions, inequalities will
increase as the rural areas and pastoralist communities lag further behind.
Increased use of family planning will prevent unwanted pregnancies and reduce the number of maternal
deaths. But service gaps will remain- in rural areas, for those who are sexually active but face barriers to
accessing services, such as unmarried adolescents and where religious and cultural norms are not
supportive.
For those women who do become pregnant the risks will remain very high. The gap between current
coverage and that needed to impact on maternal and neonatal mortality is enormous. Even if Ethiopia’s
level of skilled birth attendance doubles by 2015, the level will be only 20% nationally and 10% in rural
areas. These would be among the lowest rates anywhere in the world and would be associated with
continuing high rates of death of mothers and neonates. More women would seek postnatal care but a
doubling of current coverage would only reach 18% with far lower rates in rural areas. Continuing high
levels of new born deaths would limit further reductions in under-5 mortality.
11
B. Impact and Outcome that we expect to achieve
B1.
The impact
The impact of the programme will be a reduction in maternal and neonatal mortality. This will be
measured by a contribution to the ambitious national 2015 goals to:
 Reducethe maternal mortality rate from 676 deaths per 100,000 live births in 2011 to 267;
 Reducethe neonatal mortality from 37 deaths per 1,000 live birthsin 2011 to 15; and
 Reduce the total fertility rate from 4.8 children per women in 2011 to 4.
B2.
The outcome
The outcome of the proposed intervention is increased demand for and use of quality, acceptable RMNH
services by the poor and excluded in three regions, specifically prevention of unintended pregnancies and
assurance of safe pregnancy and childbirth. This will be measured by increase in contraceptive
acceptance and prevalence rates31, reduced teenage pregnancy rate,and increased skilled attendance at
birth.The intervention will lead to an additional 20% change in each indicator above the expected level of
change with the current investments in the sector (the counterfactual) by 2015.
B3.
1)
2)
3)
4)
5)
The outputs
Increased supply of culturally appropriate and acceptable services for women and youth;
Improved community attitudes to RMNH needs of women and girls resulting in increased demand
and uptake of services, especially among youth;
Women and girls empowered and confident to make RMNH choices;
Enhanced accountability and responsiveness of service providers to communities; and
Increase knowledge and evidence of innovative new approaches to increase utilisation of RMNH
services.
As the programme will be implemented in regions that are lagging behind on RMNH indicators it will help
address the disparities between regions and the inequities of access to RMNH services.
B4. Estimated benefits and beneficiaries, and assumptions made
Based on performance since 2000 many indicators including CPR and SBA are likely to double between
2011 and 2015 without any additional support from DFID. This judgment is based on extensive investment
underway to expand access and increase quality of health services; the expansion of promising youth
friendly health services; the increasing impact of the HEWs and the potential for HDA to influence use of
RMNH services. The doubling in these indicators, without additional DFID support, is the counterfactual.
Changes in teenage pregnancy rates are more difficult to project given the limited availability of services
targeting youth. A more cautious estimate of the teenage pregnancy counterfactual is therefore a 25%
improvement by 2015.
There are challenges in defining numbers of beneficiaries due to the lack of rigorous data in some
areas;not knowing in advance the specific interventions that DFID’s investment will support;and the
unreliability of projecting national data at the regional level. As any population is split into smaller groups,
the national average (such as 20% increase in CPR) becomes less reliable. One region might havea 10%
rate and another 40% and any assumptions about how these might change (such as doubling over the
next fouryears) become increasingly unreliable.
The tables, below, therefore only shows the estimated numbers of benefits and beneficiaries at national
31Contraceptive
acceptance is routinely measured by the national health information system, contraceptive prevalence requires
a survey.
12
level and how this can help bring Ethiopia closer to its ambitious targets for 2015.
Table 3: Contraceptive Prevalence Rate
2011
2015 Counterfactual
2015 with DFID £25m investment
MWRA
CPR
FP Users
MWRA
CPR
FP Users
Additional FP
Users
attributed to
the
programme
Total FP
Users
CPR
16.7m
27%
4.51m
18.0m
54%
9.72m
1.04m
10.76m
60%
MWRA – Married Women of Reproductive Age
CPR – Contraceptive Prevalence Rate
FP – Family Planning
The number of women using modern family planning is estimated to rise from 4.51 million to 10.76
million(an increase of 6.25 million) with the existing government and donor funds to the sector. This will
create a CPR of 54% and not be sufficient to reach Ethiopia’s goal of 66% CPR by 2015. An additional
contribution from DFID could create 1.04 million new users of family planning, or 20% of the total increase.
This would add 6% to the national CPR, and help bring Ethiopia closer to its 2015 target of 66% CPR.
The estimated number of beneficiaries helped by this programme
1.04million
to use family planning:
Table 4: Teenage pregnancyrate
2011
2015 Counterfactual
2015 with DFID £25m investment
Girls 15- Teenage
19 years pregnancy
rate
Number of
teenage
pregnancies
Girls 15- Teenage
19 years pregnancy
rate
Number of
teenage
pregnancies
Reduced
Total teenage
teenage
pregnancies
pregnancies*
Rate
5.6m
694,400
6m
558,000
27,280
8.8%
12.4%
9.3% (25%
fall from
2011)
530,720
The 2011 population of girls aged 15-19 of 5.6 million will increase to 6 million in 2015. With the existing
government and donor funds to the sector the number of teenage pregnancies will reduce from 694,000 in
2011 to 558,000 in 2015 ( a reduction of 136,400 pregnancies) and reduce the teenage pregnancy rate
from 12.4% to 9.3%. This is still almost double the government’s target of 5% by 2015. An additional
contribution from DFID would further decrease this number by 20% i.e. by averting a further 27,280
pregnancies to 530,720and reducing the teenage pregnancy rate to 8.8% - closer to the government’s
target.
Estimated benefits as a result of this programme : 27,280 teenage pregnancies averted
Table 5: Skilled Birth Attendance (SBA)
2011
Births
2.83m
2015 Counterfactual
SBA
Births
rate
Number of
women
delivering
with SBA
10%
283,000
3.1m
SBA
2015 with DFID £25m investment
Additional
skilled
births*
Total births
with SBA
SBA rate
rate
Number of women
delivering with
SBA
20%
620,000
67,400
687,400
22%
13
The FMOH aims for 40% of deliveries to be attended by a skilled attendant by 2015. With current
government and donor funding to the sector it is estimated that the SBA rate will increase from 10% in
2011 to 20% in 2015. With an additional contribution from DFID it is estimated that the number of births
attended by a SBA could increase by 20% to 22% by 2015. Although still far from the government’s target
this will ensure that an additional 67,400 are attended by skilled qualified providers.
Estimated benefits from the programme: 67,400 births with skilled attendant
The table, below, outlines the distribution of benefits across the regions. The estimated impact on regional
coverage indicators is less reliable than the national figures used above. It also assumes that any national
increase in the indicators will be equally distributed across the country and does not take into consideration
the challenges of delivering services in the developing regional states to sparsely disbursed mobile
populations. It could be surmised that as the programme will be targeting these regions and communities
that the increases in indicators will be higher. One of the tasks for the inception phase will be to refine the
regional targets.
Table 6: Outcome of proposed intervention on regional indicators
2015 with DFID
programme
additional DFID
support
2015 without
2011DHS
Skilled attendance at birth
2015 with DFID
programme
DFID additional
support
2015 without
2011 DHS
2015 with DFID
programme
DFID support
Teenage pregnancy
2015 without
additional
2011 DHS
DFID programme
2015 with
DFID support
CPR
2015 without
additional
2011 routine data
CAR
Afar
6.4%
12.8%
14%
9.5%
19%
21%
15.1
11.3%
10.5%
7%
14%
15.%
Oromia
61.7%
82%
82%
26.2%
52.4%
57.6%
15.8%
12%
11.25% 8%
16%
17.6%
Somali
7.1%
14.2%
16%
4.3%
8.6%
9.5%
19.2%
14.4%
13.4%
8%
16%
17.6%
National
62%
83%
87%
27%
54%
60%
12.4%
9.3%
8.8%
10%
20%
22%
Notes:
The higher Oromia figures are explained by greater coverage of health facilities and human resources and the effect of the health
development army.
CAR – the contraceptive acceptance rate – is used as an annual measure of family planning use. It is based on distribution of
contraceptives and uptake rates reported by the authorities at different levels. It is acore indicator in the planning process
andismeasured through the routine health information system. Its reliability is as for other sources of routine information. Other
indicators (CPR, teenage pregnancy, SBA) are measured through population surveys such as the EDHS and are more robust.
The proposed funding allocation of £25m was deemed appropriate in relation to our existing investments in
health (£275m to the FMOH’s MDG Performance Fund) and to achieved an additional 20% change in key
RMNH health indicators. The marginal costs of return to achieve further progress beyonda 20% change
diminishes as the number of people to be reached with services declines.
14
2. Appraisal Case
A. What are the feasible options that address the need set out in the Strategic case?
The evidence base for what works to reduce unintended pregnancies and maternal and new born deaths is
set out in Choices For Women: Planned Pregnancies, Safe Births, And Healthy New borns, The UK’s
framework for results on reproductive, maternal, and newborn health in the developing world32. It is closely
linked to DFID’s Strategic Vision for Women and Girls. The framework identifies four pillars for action:
empower girls to make healthy RMNH choices; remove barriers that prevent access to services particularly
for the poorest and most at risk; expand the supply of quality services; enhance accountability for results at
all levels. The framework is the basis of the theory of change below. To realise the national goals on MDGs
4 and 5 will require a comprehensive approach across all four pillars. There is no alternative approach that
can deliver the impact and outcome.
The focus of government efforts has been to expand the supply of services throughout the country and
strengthen core health systems. FMOH sets policy and RHBs lead implementation. A wide range of partners
(CSOs, FBOs and private providers) support government services, support community initiatives, increase
the quality of services and test new approaches to reach underserved groups such as youth. CSOs and
FBOs play an important role in encouraging demand and in supporting communities to hold service
providers accountable to the needs of users. Most CSOs/FBOsprovide targeted, often small-scale
interventions although a number (e.g. the Integrated Family Health Project) provides substantial coverage.
The mapping exercise outlined in the strategic appraisal revealed a number of areas where additional
investment may add significant value to GOE and DFID investments towards achieving MDG 4 and 5
targets.
A1.
The Theory of Change

The theory of change is outlined in Figure 1, below. To meet the impact (reduced maternal and
neonatal mortality) it will be necessary to bring about a significant increase in use of high impact RMNH
services (the outcome). This will require more and better quality services to be available (the focus of
on-going government efforts) and reduction in the range of barriers that limit access and use (the
proposed intervention). The evidence is strong and set out in DFID’s framework for results: Choices for
Women, and the accompanying reviews of evidence.

Country evidence that increased use of services will lead to accelerated reduction in mortality (outcome
to impact) is strong (e.g. the major reduction in child mortality in recent years linked to expansion in
access and use of health services).

The assumption at the output to outcome level is that availability of services will lead to increased use.
The evidence here is strong in relation to family planning where contraceptive prevalence has doubled
over each five-year period since 1995. Evidence is less robust in relation to pregnancy and childbirth
and suggests that greater attention is needed on quality and cultural issues to stimulate utilisation of
maternal health services. 61% of the population believes it is not necessary to give birth at a facility (with
wide variation between regions).33 Where women have been asked they do not perceive facilities to be
‘woman friendly’34. While the coverage of services will increase in coming years it is not clear whether
women will choose to use available services without additional efforts to make services more responsive
to their needs.
32
Monitoring and evaluation framework: Choices for women: planned pregnancies, safe births, healthy newborns. DFID
2011
34A woman-centred or mother-friendly approach to maternal healthcare emphasises the provision of high quality, evidence
based care that is culturally sensitive, empowers the woman for informed self-care, and treats the woman with dignity and
respect. JHPIEGO. Women-centred Care. Best Practices. www.mnh.jhpiego.org
33DHS
15
16
The Integrated Family Health Project’s (IFHP) pilot project in Tigray, which supports the region with the
HDA, reports impressive achievements with an increasing utilization of maternal health services. It
reported a 128% increase in antenatal and postnatal care; 116% increase in deliveries by skilled birth
attendants; and 112% increase in HIV prevention services.Furthermore, IFHP’s ten-step strategy has been
implemented and replicated with minimal involvement of the project. Encouraged by the positive results from
this pilot, the FMOH, RHB and zonal and woreda (district) administrations have requested scale-up of the
programme35. However there is little evidence of impact beyond the early intensive project model beyond
Tigray nor of the sustainability of the interventions when the project ends.
A recent unpublished study by UNICEF reviewed the benefits of nine identified maternity waiting homes
(MWHs) in Ethiopia and concluded that they are “vital supports to the overall health system readiness in
providing essential obstetric and neonatal care to mothers and neonates” and recommended expansion on
a national scale.36 The data including a retrospective study (22 years) of the Attat Hospital, found that
maternal mortality and stillbirth rates were substantially lower in women admitted via MWHs37 . MWHs are
found in most hospitals in Zimbabwe38 and are now being introduced in other countries where distance is a
problem, and maternal mortality high, such as Afghanistan. To get MWHs used requires consultation with
and involvement of communities. By staying in the MWH for 24 hours after birth neonatal lives can be
saved and exclusive breastfeeding established.
The theory of change for the benefits of family planning in reducing maternal mortality is clear, well
established and supported by extensive evidence39. The use of family planning reduces the total number of
pregnancies (fewer pregnancies correlates to fewer maternal deaths), results in fewer unwanted
pregnancies (reducing the risk of unsafe abortion) and provides greater spacing between pregnancies
(better for the health of the mother and children).
Unmet need for family planning in Ethiopia is 25%. Meeting just half of this unmet need would result in
754,000 fewer unintended pregnancies each year, leading to a drop in maternal mortality by almost onethird from current levels, and unplanned births and unsafe abortions would decline by 89–92%.40A recent
study on family planning in state and non-state sectors found that the highest quality care was attained by
NGO and government facilities, while the greatest access for poor clients is provided by government
facilities. Franchised private clinics had statistically significantly higher quality of care than private
independent clinics.41
There is strong evidence for the focus on meeting the reproductive health needs of adolescents. Babies
born to adolescents aged 15-19 years comprise about 11% of all births. Early childbirth is associated with
greater health risks for the mother. Complications of pregnancy and childbirth are the leading cause of
death of women aged 15-19 years. Unwanted pregnancies may end in abortions which are often unsafe in
this age group. The adverse effects of adolescent childbearing also extend to their infants. Perinatal deaths
(still births and death within the first week of life) are 50% higher among babies born to mothers under 20
years than among those aged 20-29 years. Babies of adolescent mothers are more likely to be of low birth
weight with the risk of associated long-term effects. There is recognition that adolescent pregnancy
contributes to maternal mortality, to perinatal and infant mortality and to the vicious cycle of ill health and
poverty
35USAID.
Pathfinder, JSI, Integrated Family Health Program. Ethiopia: Saving Mothers and Newborns’’ Lives. A strategy for
improving Maternal and Neonatal Health in Ethiopia. April 2012.
36Awaiting publication.UNICEF.Maternity Waiting Homes in Ethiopia – Three Decades of Experience.AsheberGaym, Luwei
Pearson, KhynnWinwinSoe. 2011
37The role of a maternity waiting area (MWA) in reducing maternal mortality and stillbirths in high-risk women in rural Ethiopia
J Kelly etal.International Journal of Obstetrics and Gynaecology. May 2010
38 For details of maternity waiting homes see http://countryoffice.unfpa.org/zimbabwe/2011/12/06/4313/unfpa)_
39Guttmacher Institute. Adding it Up, The Costs and Benefits of investing in Family Planning and Maternal and Newborn Health.
2009
40Guttmacher.Benefits of Meeting the Contraceptive Needs of Ethiopian Women. 2010 Series, No. 1
41Comparing private sector family planning services to government and NGO services in Ethiopia and Pakistan: how do social
franchises compare across quality, equity and cost? Health Policy and Planning.Volume 26,Issuesuppl 1.Pp. i63-i71.
17
Early Child marriage
In Ethiopia approximately one in five women are married by their 15th birthday, and 17% of girls aged 15-19
are already mothers or pregnant with their first child. Girls who bear children before the age of 15 years old
are five times more likely to die from pregnancy related causes than older mothers.42The high prevalence of
obstetric fistula, at 80 cases per 1,000 live births, is a direct consequence of pregnancy at a very young age
when the pelvis is not fully developed, thus increasing the chance of prolonged and obstructed labour.
Girls are under pressure to marry and bear children early, and have limited educational and employment
prospects. Some do not know how to avoid pregnancy while others are unable to obtain condoms and
contraceptives. They may be unable to refuse unwanted or to resist coercive sex. Those that do become
pregnant are less likely than adults to be able to obtain legal and safe abortions and less likely to obtain
skilled prenatal childbirth and postnatal care. Socio-cultural factors both influence and are influenced by
other structural determinants such as education, access to and control of resources, and unequal gender
relations: improved knowledge is not enough. Improving access to family planning services is a prerequisite
in order to enable adolescent girls and boys to protect themselves if sexually active.The direct health impact
is a reduction in adolescent fertility, but a wider impact is expected through empowerment of girls and
women. The evidence is set out in recent WHO guidelines.43
Community empowerment approaches
A number of organisations in Ethiopia support efforts to promote women’s and girls’ empowerment, reduce
early child marriage, improve income generating opportunities and reduce HTP. There is early evidence of
increased use of family planning and reduction of early child marriage and FGC/M in a CARE supported
controlled trial of approaches to girls’ empowerment using facilitated group discussions and community
conversations. BiruhTesfa,is a Population Council-managed programme to assist out-of-school girls in
domestic employment by creating safe spaces through which they can build support networks with other
girls, as well as relationships with supportive adults. The programme funded by DFID has mobilised more
than 60,000 young married/divorced girls through clubs led by adult female mentors that aims to develop
functional literacy, life skills, livelihoods skills, and reproductive health education. The Population Council
BerhaneHewanproject offered economic incentives to parents and guardians of girls to keep daughters in
school and not to marry them during the two-year programme. By addressing the economic and social
factors that promote early marriage girls can increase opportunities for formal and non-formal education.
Significant improvements in school attendance and literacy levels were observed in the project area among
girls between 10 and 14 years.44The programme was successful in delaying the age of marriage among
young girls, but not among older girls45. Girls between the ages of 10 and 14 were less likely to be married
in the project area (2%) compared with those in the control area (22%). Among 15–19year-old girls, the
proportion of ever-married girls was similar in both areas before the programme, but higher in the project
area after the intervention.
Community approaches in Afar led by the Regional Bureau of Women, Children and Youth Affairs and the
Afar Pastoralist Women's Development Organization with the support of UNFPA and UNICEF have resulted
in six intervention districts declaring the abandonment of FGC/M in the region.
A number of assumptions underpin the theory of change:
 RMNH will remain a priority of GOE and DFID (strong based on policy and resource prioritization);
 Additional DFID resources can complement on-going efforts to increase supply of services (strong;
community empowerment interventions, social marketing advocacy):
 The supply of RMNH services will increase to meet demand (strong based on past increase projected
increases in skilled staff deployment, expansion in facilities and expansion of community level health
Murphy and Carr (2007) Powerful Partners: Adolescent Girls’ Education and Delayed Childbearing, PRB brief
on Preventing Early Pregnancy and Poor Reproductive Health Outcomes Among Adolescents in Developing
Countries. WHO, 2011
44Population Council.Delaying early marriage among disadvantaged rural girls in Amhara, Ethiopia, through social support,
education, and community awareness.EuniceMuthengi and Annabel Erulkar.Transitions to adulthood.Brief no. 20. May 2011
45 Ibid
42
43Guidelines
18
initiatives);
There is a clear link between reproductive health and empowerment (strong);
Women will use accessible services (particularly safe birth) that are seen as culturally acceptable
(strong for family planning, less clear for skilled birth);
Community dialogue can lead to profound changes in attitudes and practices (strong).



A2.
Defining the programme focal area
Deciding the scope of the programme considered the need to balance value for money and equity
objectives. The EDHS reported a substantial unmet need for RMNH services across the country. However it
has also identified serious disparities among the regions and a growing inequity between parts of the
country (see below). Initial mapping of RMNH interventions led to a focus on Amhara and Oromia, highly
populated agrarian regions, with potential to reach large numbers of beneficiaries. DFID already provides
substantial investment in Amhara through the ending child marriage programme. Oromia offers the potential
to reach about 35% of all women of reproductive age in the country. It has low coverage rates for many
RMNH interventions and the programme could help accelerate national progress towards the MDGs at a
low cost.
Whilst focusing on the most populated regions would achieve an increase in the number of women
accessing services it would not address the growing inequities in the country. To do so requires focusing on
the DRS where sparsely populated mobile communities struggle to meet their RMNH needs. Somali and
Afar are lowly populated pastoralist regions with only 8% of the national population but include 82% of
women of reproductive age from the DRS. These regions are seriously lagging behind the rest of the
country on RMNHservice utilisation(see table 7) and contribute to Ethiopia’s high maternal and neonatal
mortality rates. Focusing on Afar and Somali region would target a large proportion of underserved and
vulnerable women in the country and help address the growing disparities between regions. The selection of
Oromia, Afar and Somali regions offers a balance of reaching a high number of beneficiaries with reaching
the most vulnerable populations. The selection of regions and then districts will further be discussed with the
FMOH and RHBs to target the most vulnerable and marginalised women and girls.
Table 7: Regional populations of women of childbearing age and key RMNH indicators
Region
Women 15-59
years as % of
national total
2011/12
TFR
ANC
Skilled Delivery
PNC
FP
Unmet FP Need
5.9%
1.5
94%
48%
48%
63%
11%
2%
5.0
32%
7%
6%
10%
16%
23.5%
4.2
34%
10%
5%
34%
22%
1%
5.2
35%
9%
7%
27%
25%
Dire Dawa
0.6%
3.4
57%
39%
19%
34%
21%
Gambella
0.5%
4.0
55%
28%
19%
34%
19%
Harari
0.3%
3.8
56%
32%
28%
35%
24%
Oromia
34.6%
5.6
31%
8%
5%
26%
30%
Somali
6%
7.1
22%
8%
5%
4%
24%
Tigray
5.7%
4.6
50%
12%
13%
22%
22%
SNNP
20.2%
4.9
28%
6%
6%
26%
25%
National
100%
4.8
34%
10%
Source: EDHS 2011 and FMOHEFY 2004 HSDP IV Annual Core Plan
7%
29%
25%
Addis Ababa
Afar
Amhara
Benishangui-Guma
A3.
Synergies with existing programmes
19
As laid out in the Theory of Change enabling more women and girls to use RMNH services can only be
achieved through a multi prong approach. The provision of health services is not enough. Social and cultural
barriers have to be recognised and overcome, attitudes within communities changed and the desire for
smaller families and for modern maternity services created. Even when there is a desire for services girls
need to be empowered so that they can exert their rights and choices. These goals can only be achieved
through inter sectoral working and building links and synergies with other programmes outside of the health
sector.
Therefore the design of this programme has drawn on the lessons fromDFID’s support to the health
sector;successful RMNH interventions in the country (described in the mapping document46); success in
increasing skilled deliveries in Tigray using the HDA; efforts to expand youth friendly services (IFHP
programme) and to engage communities and empower girls (Population Council, CARE).
The programme will build on our support to the government’s Health Extension Programme (HEP) that aims
to increase service utilisation and improve RMNH outcomes. The HEP, working through the HEW and HDA
has been shown to be effective in providing a basic level of RMNH care and in changing communities’
health seeking behaviour. Although not yet formally evaluated, HDA have been instrumental in increasing
the number of deliveries in facilities in Tigray region and are being rolled out across the country. It will be
critical that the programme supports and enhances these efforts and does not create parallel structures at
the community level.
The programme will need to be designed in a way that enablesinter sectoral working and funding to ensure
that other government ministries work in partnership with the service providers. The Ministry of Women,
Children and Youth Affairs is charged with mainstreaming women, children and youth issues, mobilizing
women and youth through: strengthening empowerment and enhancing care and support for vulnerable
groups including orphans and other vulnerable children. They will be a critical partner at regional and district
level.
The education sector at all levels plays an important role in by integrating sexual health education into
formal and non-formal education: through school curricula, programmes for out-of-school youth and building
linkages between schools and health services. The sector has non-formal education sites -both alternative
basic education and adult learning sites able to reach out-of school youth and adults. The programme could
support adaptation of sexual health education to different age groups and cultures, introducing differentiated
and flexible teaching strategies to meet the different needs of female and male students as part of its
intervention on youth friendly services.
Programme design will need to be able to harnesses the expertise of non-government organisations and
faith based organisations and generate tailored responses to the needs of the community it is trying to
serve. Reaching vulnerable groups and working in difficult environments requires the adoption of different
delivery models depending on the geographical and culturally context. Challenging cultural norms and
attitudes is often best done by religious or cultural leaders. In some circumstancesCSOs, FBOsand RDAs
may be better placed to deliver this programme to a particular population group or in a particular
geographical context than the government. However to achieve optimal effectiveness the programme must
also ensure that implementing partners coordinate with and are accountable to the RHB and FMOH.
The programme has synergies with a number of existing DFID programmes. Those with a strong RMNH
component are outlined in the Strategic Case above (section A4). Other programmes include the Civil
Society Support Fund, the Peace and Development Programme (supporting delivery of basic services and
justice in Somali Province) and the Community Security and Justice Programme that addresses women
friendly access to justice.
46Reducing
barriers and increasing utilisation of reproductive health services in Ethiopia: Business case mapping report. June
2012
20
A4.
Options considered
The range of potential interventions that could be funded by this programme is very wide (see Table 2). To
assist with the development and appraisal of programme design options we have determined a set of
selection criteria that interventions should comply to.These criteria have been developed based on the
mapping exercise that identified gaps and suggested areas where this programme could add value (see
Strategic Case A5). The UK’s framework for results on RMNH and DFID’s Choices for women paper also
identify intervention areas that need to be implemented to improve women and girls’ health (see Appraisal
Case) and the evidence of what works that underpins the Theory of Change. Interventions must:






Increase equity in access to RMNH services and reduced disparity in RMNH indicators among
Ethiopia’s regions;
Increase local level accountability and respond to the needs of women and girls;
Improved health seeking behaviour around pregnancy and deliveries;
Reduce barriers to access and utilisation of RH services;
Focus on the needs of adolescent girls; and
Be able to measure results and evaluating impact of the programme.
As describe in the section above there is also a number of considerations that will influence the selection of
options:
 The resources available;
 Potential coverage;
 Need to balance reaching the greatest number of beneficiaries and targeting the most vulnerable
and hardest to reach populations with the greatest health needs;
 Need to work beyond the health sector and to influence community attitudes;
 The diversity of the country and need for context-specific solutions;
 Opportunities to leverage support from established RMNH programmes; and
 The imperative to implement the programme without a prolonged start up.
Based on these considerations four options for programme design have been identified:
Option1 Additional contribution to the FMOH’sMDG Performance Fund
Option2Establishment of a Reproductive, Maternal and Neonatal Health Innovation Fund managed
by the FMOH.
Option 3 Establishment of a Reproductive, Maternal and Neonatal Health Innovation Fund managed
by the a non-government organisation (UN agency or Contractor)
Option 4 Do nothing further beyond ongoing health investment (the counterfactual).
These options are described below. An appraisal of the options against the selection criteria and the
potential to deliver a range of interventions is then outlined in Table 8.
A4.1
Option 1: Additional contribution to the FMOH’sMDG Performance Fund (MDG PF)47
What it looks like
The MDG PF is a mechanism for development partners to pool funds in support of Ethiopia’s Health
Sector Development Program. The MDG PF provides flexible resources to fund priorities within the health
sector, particularly those not receiving earmarked funding, such as RMNH.The MDGPF primarily
procures essential medicines and medical equipment for the country which are then distributed to RHBs
and woredas. A smaller part of the Fund is used to pay for health centre rehabilitation and training of
HEWs.
The Fund is managed by the FMOH and uses government systems and procedures for planning,
47
A Business case was produced for DFIDs 5 year contribution in 2011.
21
budgeting, disbursement, financial management, procurement of goods, and reporting. It is governed
through a Joint Financing Arrangement (JFA) and currently receives funds from nine donor agencies.The
annual sector planning process maps resources and prioritises activities at the federal level which leads
to a plan for the MDG PF. This is reviewed by the Joint Core Coordinating Committee (a steering group of
FMOH and development partners). Quarterly progress reports of the MDG PF reports on activities and
expenditure and an annual review of the health sector reports progress against output and outcome
targets.Independent financial and procurement audits are conducted annually.
The evidence
The design of the MDG PF is guided by experience and lessons learned from Sector Wide Approaches
(SWAps) and the principles of the International Health Partnership. (i.e. all funding supports one plan and
one budget framework, ideally using common procedures). Many of the basic building blocks of a SWAp
are in place: a technically sound strategic plan, processes for common planning, management and
governance, a multi-year budget, shared indicators for monitoring sector progress and joint annual
reviews, and a strong focus on achieving results. 48
The Fund’s resources have increased from US$34 million in 2009 to US$105 million in 2012 and the
World Bank and GAVI are considering joining in 2013. DFID is providing £275 million over four years and
is by far the largest contributor. A recent independent Financial Management Assessment (FMA)
highlighted areas where procurement and financial management can be strengthened, including the need
for timely audits, clearer financial and activity reporting49, and greater management capacity. Action has
been taken on the assessment’s recommendations and safeguards are in place. The strategies and
interventions being employed by the FMOH to meet the targets of HSDP IV are appropriate and evidence
based.
Benefits
The MDG PF uses and strengthens national systems and builds capacity, it provides flexibility and enables
GOE to use funds to fill gaps in financing the health plan. It offers predictability and facilitates rational
planning and procurement. It encourages cost efficiencies by achieving economies of scale through large
scale procurement orders for the country.
It provides support to all regions based on population figures. The Fund does favours the DRS by matching
region’s health centre construction budget 3:1 compared to 1:1 in other regions and is providing technical
assistance to the RHBs. However the MDG PF cannottarget specific communities and cannot be used to
support work with other sectors, CSO/FBOs or community-based work.Nor can it be used to pay for salaries
of health workers or others. The Fund is primarily for funding large-scale procurement of medicines and
equipment for the country. It has been an instrument to address large-scale supply issues but cannot
address the cultural determinants of RMNH service utilisation. The FMOH does not want the remit or the
nature of the MDG PF to change as this would involve renegotiating the JFA with all of its donor partners
and distract the Fund from its primary purpose.
Risk
With ‘un-earmarked’ funding, it is unlikely that the entire resources will be spent on removing barriers for
RMNH.Although approximately 28% of the MDG PF is spent on maternal and child health, this is mainly on
procurement of vaccines, training of health workers and construction of health clinics. There is no funding
allocation for increasing demand for services or for addressing the barriers to service utilisation. As outlined
above the MDG PF is a federal procurement fund and would have to be substantially redesigned if it was to
meet the requirements of this programme. The other MDG PF donors may not accept this redesign and
there is a risk that they could withdraw support from the sector. It would also delay or prevent the joining of
the World Bank and GAVI who are currently negotiating with the FMOH to join the MDGPF.
48Ortendhal
et al (2008) Appraising the MDG Performance Fund, Addis Ababa.
In draft Talai et al (2010) Financial Management, Procurement and Supply chain Management Assessment of the MDG
Fund, Addis Ababa.
49
22
Evidence on public sector performance on demand creation:
There are positive benefitsin using the public sector. Strengthening the government health system and
integrating RMNH in routine services offers potential for sustained change beyond the period of DFID
funding. The public sector owns the majority of health facilities and has the widest reach to all parts of the
country. HEP has increased demand for most services with the exception of safe birth and postnatal care.
The HDA has potential to break some of barriers related to low demand, but scaling up best practices using
a single government blue print may not be most effective approach, especially in the DRSs.
Whilst providing more money to the MDGPF would help the delivery of better quality health services it will
not address all of the demand side issues that influence utilization of services. In addition the fund would not
be flexible enough to target specific communities and work with a range of partners.
Evidence strength: Medium.
A4.2. Option 2: Establish a Reproductive, Maternal and Neonatal Health Innovation Fund (RIF)
managed by the FMOH.
What it looks like
The RIF will provide resources to Afar and Somali and specific districts in other regions that are lagging
behind. It will be open to support a range of implementing agencies: government (including health and other
sectors such as education), RDAs, international NGOs,CSOs, FBOs, the private sector, academia, media or
a combination of the above). The RIF would provide grants to support innovative approaches to address the
barriers that various groups, particularly women and girls, face in using services. It will encourage
stakeholders to work in partnership and across sectoral boundaries.The RIF would aim to accelerate
progress in reducing maternal and neonatal mortality and morbidity through activities across the four
strategic areas of intervention:




Increase the use of skilled antenatal, childbirth and postnatal care;
Increase use of family planning, especially among the youth;
Scale up girls’ empowerment programmes; and
Research the barriers to service utilisation and share lessons learned.
The RIF would be managed by FMOH in an earmarked account separate from the MDG Performance Fund.
Intervention proposals would be reviewed by a subcommittee under FMOH’s Maternal and Child Health
Technical Working Group (MCHTWG). Regional/Zonal Health Bureaus, CSOs and FBOs will be invited to
submit proposals and grants would be awarded on a competitive basis. It would support activities in the
target regions and would be designed to:





Increase use of services;
Reach marginalised and underserved groups particularly adolescents and poor women;
Support interventions that deliver maximum benefits and best value for money;
Increase collaboration between the public and private/NGO sectors;and
Encourage beneficiary engagement.
A tripartite contractual agreement would be made between the grantee, RHBs and FMOH on the results to
be delivered. The successful applicants with then report and account to the FMOH.
General approach
Although Technical Assistance (TA) would be provided to the FMOH to minimise the added administration
burden and help them to fulfil their fiduciary responsibilities, the programme is designed to strengthen
national systems. Implementation will be based on government policies, strategies and guidelines. Training
will use the national curricula and community level activities will strengthen rather than duplicate existing
structures like the HDA. It is expected that the interventions to be supported would be harmonised with
regional and district plans and priorities. Innovative proposals that strengthen the country health systems
23
would be encouraged.
Benefits
All support can be earmarked to reduce barriers and increase use of RMNH interventions. Given that most
services will be provided through public sector facilities, this instrument has a potential to strengthen publicprivate partnership. It will encourage innovation and the tailoring of interventions to different contexts within
Ethiopia’s diverse settings. The support can be targeted to the most populous region to generate the
greatest gains and to pastoralist regions or districts with greatest needs to enhance equity. Support can be
provided for interventions that lie outside the health sector and facilitate multisectoral approaches. It will
enable scale up of innovative interventions that have impacted positively on community attitudes and girls
empowerment.
It could scale up existing programmes of agencies engaged in RMNH and avoid the substantial start up
delays and costs of a new programme. It enables action across a broad range of interventions by a range of
providers. It enables testing of a model of government contracting private sector to deliver demand side
programmes to complement their service delivery in remote difficult environments to poor and excluded
communities.
The evidence
Competitive funds are a well-established development instrument. The funds will be available to CSOs,
FBOs and Regional Health Bureaus which are in a best position to identify, understand and respond to the
local level, context specific socio cultural barriers that prevent women and girls utilising services. Evidence
shows that these organisations are innovative by nature in working at the community level. A government
led and CSO implemented programme are proved to be the best mechanisms to address the demand side
barriers. Meeting the programme outcome and impact will require a wide range of interventions on
empowerment, removal of barriers, expansion in the quality of culturally appropriate services, enhanced
accountability, and research. The RIF will facilitate targeted interventions in the three regions through a wide
range of implementing partners. All interventions will be based on evidence of impact in Ethiopia or
elsewhere in relation to demand and health seeking behaviour in pregnancy, family planning, adolescent
reproductive health needs, community empowerment and research. The evidence of successful country
approaches in these areas is outlined in the theory of change and the mapping report.
Risk
Improvements in demand must be matched with improvements in quality and acceptability of the supply of
services. Evidence from numerous countries, including Ethiopia, shows that if communities do not receive
the services they have been encouraged to seek; it will be harder to convince them to try again.
The development of a new fundwill have two types of additional transaction costs: (i) establishing a
subcommittee within the MCHTWG to oversee the RIF and (ii) the time it takes to request screen and
approve proposals. The new fund will require technical assistance to administer it and will incur
administrative overheads costs. It also risks creating a parallel system to the government’s demand creation
effort through the HEWs and HDA. The RIF offers the opportunity to scale up small-scale approaches that
have demonstrated effectiveness.
The exact results of a RIF are difficult to calculate given the uncertainty of the range of likely proposals and
interventions.
Evidence: Strong
A4.3. Option 3: Establish a Reproductive, Maternal and Neonatal Health Innovation Fund (RIF)
managed by a non-government organisation (UN agency or contractor)
What it looks like
This option would contract a UN agency or a private company to deliver a targeted or verticalRMNH
programme in focal regions. As in option 2 the programme would deliver a comprehensive set of
24
interventions to reduce barriers and increase RMNH service utilisation that are tailored to the needs of
specific communities and geographical areas. The contractor may choose to form a consortium with other
UN agencies/CSO/FBOs and others in order to have sufficient expertise and reach. The contractor would
work closely with the FMOH and RHBs to design, implement and monitor programme activities.
The benefits
A vertical approach can be effective where the health system is weak and where the health issue can be
addressed through a relatively narrow range of interventions. Focusing substantial resources on a
particular issue can deliver quick results. For instance this approach has been successful in significantly
reducing the incidence of malaria in Ethiopia. External funding for malaria is predominantly channelled
through a range of agencies (Government, NGOs, academia and UN). Each agency covers part of the
range of interventions related to prevention, diagnosis and treatment of malaria- behaviour change
communication, training, procurement and logistics, information and surveillance, research. The
programme is planned and implemented with the government and in line with national malaria control
strategy and plans. Country assessment, planning and evaluation are consultative and held in
collaboration with the National Malaria Control Program and in-country partners. Ensuring an effective
response requires effective coordination and leadership and is aided by substantial funding and multiple
partners. However achieving a truly coordinated national response to malaria control is challenging when
funds come from many different sources. The transaction costs for government of coordinating and
managing the plethora of activitiesis high and fragmentation is common with agencies duplicating
services or only working in favourable geographical areas.
Benefits of this approach are:
 Greater service specialization and concentration on a few focused interventions is an effective
way to maximize impact in the short term. The HSDP is designed to provide a uniform range of
services to the general population and cannot be expected to deliver interventions that respond to
the specific needs of a community or geographical area.
 Waiting for improvements in the health system to deliver better services such as staff training and
reliable supply systems can take longer than the current funding period. A vertical programme
specifically targeting a particular service or need can deliver results faster.
 Vertical funds such as the Global Fund to fight AIDS, TB and Malaria and GAVI (immunisation)
pay for results and incentivises better performance.
 By making clear who is responsible for delivering what, to whom and with earmarked
resourcespromotes greater accountability and allows for attribution of results to the inputs.This
makes tracking value for money of the investment easier and helps build up the evidence base of
what works.
The evidence
There are many examples globally and in Ethiopia where a targeted approach managed outside of
government has led to substantial gains. Examples include smallpox and polio eradication, malaria,
immunisation and family planning in the past. Malaria funding in Ethiopia has made a very important
contribution to efforts to prevent, diagnose and treat malaria. In 2010, this programme directly supported
indoor residual spraying for 27.2 million people; effective treatment for 41 million people; and insecticidetreated mosquito nets (ITNs) for 17.5 million people. However there is also evidence that a targeted
approach managed outside of government systems does not lead to sustainable gains and do not lead to
activities being integrated into government plans and budgets. Targeted approaches outside of the
government system often compete with government activities and can distort incentives and capacity
away from delivering a comprehensive package of care. Whilst results may be delivered in the short term
these usually decline dramatically once the project finishes and the expectation for government topick up
the costs of continuing such interventions is not realised. This is further explained below in the risk
section.
Risks
The major concern of this approach is that the gains made in the short term will not be sustained without
continued external funding and support. In Ethiopia the public sector provides most health services. When
25
donor interest and funds move to new agendas it is the national health system that must continue to
deliver services. The immunization gains of the 1970’s were lost in many countries when UNICEF, the
largest donor, moved to new challenges. Similarly high rates of family planning were not sustained as
donor support moved to address new challenges such as AIDS, TB and malaria. Strengthening health
systems and embedding RMNH in routine services offers the potential for sustained change beyond the
period of DFID funding.
Government is responsible for delivering comprehensive health services that address all the major health
problems facing the population and cannot only focus on a few high profile diseases or issues. Targeted,
well-funded programmes often draw trained staff away from the health system. The parallel systems
established (supply, training, information) often undermines efforts to build national capacity and leads to
duplication and inefficiencies. A focus on a few issues may look to short-term gains at expense of longterm sustainable benefits.
A targeted approach is less suited to a complex agenda such as RMNH that is not amenable to a
technological fix but needs access to a continual supply of highly trained staff, community health workers,
a network of health facilities able to provide complex emergency care, a working emergency transport
system, a reliable supply of a wide range of commodities -in short a working health system.
UN organisations and contractors typically cover narrow elements of the RMNH agenda. UN agencies
(WHO, UNICEF, UNFPA) have set out a division of labour for RMNH with each working to their
comparative advantage. This has led to many gaps with no single agency being ideally placed to deliver
the mix of interventions. Contractors like international NGOs also tend to cover narrow areas of the
RMNH agenda. A consortium approach would be possible butcould involve multiple administrative costs
and challenges in coordination.
FMOH does not encourage partners to establish vertical funds for specific health issues or areas,
although it continues to receive and administer them. Such vertical programmes are recognised to
contribute to the ineffectiveness of aid through fragmentation of effort through many small projects,
duplication and service gaps, and distortion of incentives in the sector. Much of donor funding to health in
Ethiopia supports AIDS, TB and malaria yet important health issues such as maternal and child health
and non-communicable diseases receive limited support.Vertical approaches incur substantial transaction
costs for government through coordination and parallel management, financing and reporting systems.
The major concern is over the sustainability of the gains from an approach that works outside the
government health system.
Government recognizes that it is unable to address all health issues and that non state actors have an
important complementary role to play, particularly in community based interventions and in addressing
socio-cultural barriers. Both horizontal (health systems strengthening) and vertical (disease targeted)
approaches can have their merits in different settings.
Evidence strength – Medium
A4.4. Option 4: Counterfactual - do nothing other than ongoing health investment
The supply and quality of RMNH services are likely to continue to improve to 2015 as more skilled staff are
deployed, health facilities are upgraded to deliver BEmONC and access to emergency transport improves.
The expanded health infrastructure, continuing impact of the HEWs and HDA and an expanding private
sector will maintain the momentum in family planning acceptance. However, even if Ethiopia achieves its
2015 target of 66% CPR this would only prevent up to 40% of maternal deaths and still leave substantial
geographical disparities.
Given the current very low levels of use of skilled antenatal, childbirth and postnatal services it is unclear
what the level of demand will be for safe birth in a health facility. Even if skilled birth doubles by 2015, the
figure will be only 20% nationally and 10% in rural areas. These would be among the lowest rates anywhere
in the world and would be associated with continuing high rates of death of mothers and newborn. More
women would seek postnatal care but a doubling of current coverage would only reach 18% nationally and
26
far less in rural areas. Such low levels of newborn care would be associated with continuing high death
rates. As neonatal deaths account for 40% of under-five deaths it will prevent substantial reduction in underfive mortality. Many women in rural areas and unmarried adolescent girls will continue to face barriers in
utilising services. Women who become pregnant will still face high risks and the maternal mortality ratio will
remain high.
Progress towards MDG 4 and 5 will be slow and it is unlikely that the goals will be met. The results of
DFID’s substantial ongoing investments in reproductive health including the MDG Performance Fund,
Protecting Basic Services Grant and social marketing of RMNH commodities would be compromised.
Removing barriers will enhance the utilization of commodities procured through social marketing, promote
effective use of health facilities and health workers that are financed through the MDG PF and the
Protection of Basic Services grant.
Will other partners fill the gap?
The scale of need is such that it is unlikely that other donors will fill the gap. Many support limited
operations, often in urban areas or in a few districts in a particular region. Those with more substantial
coverage work in ways that raise concerns over the sustainability of any gains made.
The projected outcomes are:
 CPR doubles to 54% (modern methods);
 ANC doubles to 60% ;
 Skilled attendance at birth doubles to 20% but maternal mortality will remain high ; and
 Post natal care will double to 18%.
Without a concerted effort to address the barriers which prevent women from accessing RMNH services,
there is a risk that by 2015 Ethiopia will have both a relatively high take up of contraceptives and continuing
high maternal mortality ratio.
Evidence strength :Medium
A5: Appraisal of Options
We have carried out qualitative appraisal of the four options based on a set of criteria as summarized in
Table 8 below. This appraisal revealed out-right rejection of Option 1 (additional support to the MDG PF) as
it was considered ineffective in reducing regional inequalities,enhancing local accountability and in
responding the needs of women and girls. It is also judged less effective in improving health seeking
behaviour around pregnancy and could have limited scope to reducing barriers to access and utilisation of
RMNH services. Doing nothing (option 4) is not the preferred option either since not intervening will
compromise the results of DFID’s investments in reproductive health and limit national progress towards
reducing child (particularly neonatal) mortality and improving maternal health (MDG 4 and 5).
Table 8:Appraisal of options 1-4 against the selection criteria
Selection Criteria
Option 1:MDG
Performance Fund
Option 2: RMNH
Innovation Fund
Increase equity in
access to RH
services
HSDP has a focus on
reducing regional
inequities but
MDGPFis a central
procurement fund
with limited ability to
target specific
communities and
reducing inequities.
Enables focus on
regional inequities
and work with
specific
communities
27
Option 3:Third
party
implementation
(UN/contractor)
Able to focus on
equity issues by
targeting
interventions to
specific
communities and
geographical areas
Option 4: Do
Nothing (the
counterfactual)
The EDHS shows
that whilst current
implementation of
the HSDP is
reducing child
mortality, Maternal
and neonatal
mortality are
stagnating and there
Increase local level
accountability and
respond to the needs
of women and girls
Not inclusive of all
stakeholders -only
funds procurement of
commodities and
training for public
health system. Does
not fund
CSOs/FBOs/RDAs..
Cannot pay for
salaries.
Improved health
seeking behaviour
around pregnancy
and deliveries
Focused on
increasing supply of
services rather than
on understanding
and addressing
barriers and health
seeking behaviour.
Although improving
the quality of services
will encourage
utilisation.
MDGPF supports a
very wide health
agenda and has
limited scope to
reduce barriers to
care
Reduce barriers to
access and
utilisation of RMNH
services
Focus on the needs
of adolescent girls
Not possible to
ensure strong focus
on single group or
most needy
are growing
inequalities between
the regions.
The HSDP
recommends the
creation of health
centre boards to
encourage
accountability but
these are still rare.
Most responsive to
local needs, can
support wide range
of implementing
agencies, and
ensure that
activities
harmonised with
local plans and
complement work
of others. The fund
would be managed
by the FMOH and
grant recipients
would be required
to report to the
RHB and FMOH on
what they are
doing – thereby
improving
accountability and
coordination
Can support
innovation and
lesson learning to
improve health
seeking behaviour
Could respond to
local needs. Some
UN agencies and
international NGOs
have regional
offices and could
help ensure that
activities are
harmonised with
local plans and
complement work
of others.
Would need a
consortium of
providers to cover
range of
interventions
The FMOH are
scaling up the HAD
to address health
seeking behaviour
but these are still in
their infancy.
Complements
ongoing efforts to
increase supply by
addressing barriers
to use. Flexible
grant making
facility would
mean funds can
support a range of
different
approaches in
different
geographical and
cultural settings
dependent on
need.
Allows expansion
of promising
interventions
across
empowerment,
service delivery
and accountability
Due to defined
mandates and
scope of
organisations it is
unlikely that one
agency would be
able to address
the full range of
possible
interventions. A
consortium
approach would be
required.
As above
Able to focus on
needs
The FMOH
recognises the need
to address
adolescent girls’
health needs but few
health centres have
the resources and
capacity to do so.
28
Feasibility of
measuring results
and evaluating
impact of the
programme
Strong health
information and
results culture but
little data generated
on equity or who was
reached.
Fiduciary assurance
and commercial
considerations
Strong track record in
managing and
accounting for DFID
funds through the
MDG Performance
Fund. Financial
management,
reporting and audit
procedures well
established.
Commercial capability
for providing services
to address barriers
not known. DFID
funds would be comingled with other
donor funds and so
could not be tracked
to individual activities.
Other
Broad reach, builds
national health
system, delivers
national priorities but
funds fall far short of
need. FMOH do not
want the remit of the
MDGPF to change
and be used for this
programme.
Evidence
Medium
Funding awarded
on projected
results and impact.
Strong evaluation
and lesson
learning
component
included
Strong track record
in managing and
accounting for
DFID funds
through the MDG
Performance Fund
Financial
management,
reporting and audit
procedures well
established. This
track record can
be built on to
manage the RIF.
Grant Management
Unit newly
established in
FMOH to manage
funds and disburse
to implementers
but capability not
yet known. TA to
be provided to
FMOH to assist
manage the fund
and ensure timely
submission of
fiduciary
requirements.
DFID funds would
be managed in a
separate bank
account and not
co-mingled with
other donor funds.
Flexible,
encourages
innovation/
collaboration.
Supports scale up
of proven
interventions and
leverages support.
All support
earmarked to
reduce barriers
and increase use
of RMNH
interventions.
Often strong focus
on results but use
parallel information
systems
Strong health
information and
results culture but
little data generated
on equity or who was
reached.
A strong financial
management
capability would be
key criteria in the
selection of the
contractor. Funds
would be in a
separate bank
account outside of
government
systems and so
could be tracked.
The commercial
capability of the
contractor will also
have to be
assessed during
the procurement
process.
n/a
Main concern is
sustainability;
potential to distort
priorities and
undermine local
priority setting.
Greatest gains of
approach when
targeting single or
limited
disease/issue.
Approach
discouraged by
FMOH
The HSDP and HAD
will help address the
RMNH needs of
women and girls in
Ethiopia. However
the sector is still
underfunded and
under capacitated,
and is trying to
address a multitude
of priorities.
Strong
Medium
Medium
29
B. Strength of the evidence base for each feasible option
Option
Evidence rating
1
Medium
2
Strong
3
Medium
4
Medium
B1.
Likely impact on climate change and environment
Rapid population growth is likely to exert pressure on environmental resources (water and land availability
and food security)and public services.It is also associated with rising greenhouse-gas
emissions50,51.Population increase leads to migration and movement into areas of greater environmental
hazard52. Migration is rising in Ethiopia with environmental and climate pressures the key drivers. Family
planning can improve the health and well-being of women and families, increasing resilience in the face of
climate change and slow population growth.Climate change experts have identified family planning as the
best single buy to reduce carbon emissions53.
RMNH services include the use of condoms, syringes and needles and hormonal preparations. Clinical waste,
expired medicines and sanitary towels can pose serious health risks to people and the environment if not
disposed properly. These risks include infections with HIV, hepatitis, sexually transmitted infections (STIs),
and other diseases transmitted via body fluids or environmental pollution. According to a World Health
Organization Situation Analysis Regarding Health-Care Waste, such risks are greatest among health care
workers, waste handlers, scavengers retrieving items from dumpsites, people receiving injections with used
needles or syringes, and children who may come into contact with contaminants by playing in areas without
restricted access to waste disposal sites. The programme would ensure adherence to appropriate waste
disposal by effective communication through contracted providers.
The proposed options are classed as having low potential risk and moderate opportunity for
climate/environment in this reproductive health programme. In order to minimize risks and maximise
opportunities from the programme, the selection of the grantees will involve climate and environment
considerations by building in such criteria in the tendering process.
Option
Climate change & environment
risk category
Climate change & environment
opportunity category
1. MDG Performance Fund
C
C
2. RMNH Innovation Fundmanaged
by FMOH
C
C
3. RMNH Innovation Fundmanaged
by non-government organisation
C
C
4. Do nothing (Counterfactual)
C
C
50
Population Action International, by Mogelgaard, K. at http://www.grist.org/article/2009-06-01-bonn-climate-change-is-sexist .
C, Hardee, K. Population and Reproductive Health in National Adaptation Programmes of Action (NAPAs) for
Climate Change, Working Paper WP 09‐ 04. Population Action International 2009
52Foresight Report on Migration and Global Environmental Change (2011) – see www.bis.gov.uk/foresight/migration for the full
report and background papers; and accompanying Nature article, Climate change: Migration as adaptation.
www.nature.com/nature/journal/v478/n7370/full/478477a.html.
53 See Wheler D and Hammer D The Economics of Population Policy for Carbon Emissions Reduction in Developing
eCountries. Centre for Global Development Working Paper 22. 9 November 2010
51Mutunga
30
C. What are the costs and benefits of each feasible option
C1. Option One: Additional Support to MDG PF
As highlighted above the qualitative appraisal has identified option 1 not to be a viable option as it has failed
to pass the feasibility test against the selection criteria. Therefore it will not be considered further. Option 4, do
nothing is provided as a counterfactual, and included for comparison sake.
We are left with two options for analysis: management of the RMNH Innovation Fund by the FMOH (option 2)
and management of the RMNH Innovation Fund by a non-government organisation such as a UN agency or
contractor (option 3). The exact activities of the RIF are unknown and will depend on the needs of the
areas in which it is implemented. To enable a Value for Money (VfM) analysis of the two options we
have selected a hypothetical set of possible interventions from Table 2 that would deliver the outputs
outlined in the Theory of Change. These are increasing the use of RMNH services by: building MWHs near
health centres; providing a supply of youth friendly family planning services; girl empowerment activities and
generating evidence of effective RMNH interventions for policy makers. The VfM of implementing these
interventions though the two options is assessed below. Unit costs have been taken from programmes
currently implementing these activities in Ethiopia. Whilst costs may change if the programme is implemented
at a different scale of in a different location these are seen as reasonable benchmarks to use. A table
comparing the cost benefit analysis of the two options is provided in Section E. Full details of these
programmes and unit cost calculations can be found in the economic appraisal annex.
C2. Option 2: Reproductive Maternal and Neonatal Health Innovation Fund managed by the FMOH.
Option 2, a Reproductive Maternal and Neonatal Innovation Fund (RIF) focuses on four strategic
areas: Building Maternal Waiting Homes (MWH); supply of youth friendly family planning services,
extension of girls’ empowerment programmes and evidence generation (research). The VfM of
implementing these four programme activities through a government managed RIF is outlined below.
The costs for this option comprise of administrative overhead, costs for the supply of mother and youth
friendly services for family planning, cost for empowerment activities, research, M&E and DFID staff time. The
budget/estimated cost breakdown across the four strategic areas is given in Table 9 below. Of the total £25
million planned investment, building of maternal waiting homes and evidence generation consumes a
respective £9 million and £6 million while £3 million and £2 million is allocated to the other two strategic areas
(supply of youth friendly family planning services, extension of empowerment programmes) respectively.
Table 9: Budget breakdown across activity areas (£)
Years
1
2
3
4
Total
625,000
625,000
625,000
625,000
2,500,000
Building MWHs
2,250,000
2,250,000
2,250,000
2,250,000
9,000,000
Demand and supply of Youth Friendly services
for family planning
1,500,000
1,500,000
1,500,000
1,500,000
6,000,000
750,000
750,000
3,000,000
Administrative overhead charge (10%)
Girls’ Empowerment Programmes
750,000
Evidence generation
500,000
600,000
700,000
700,000
2,500,000
M&E
500,000
500,000
500,000
500,000
2,000,000
6,125,000
6,225,000
6,325,000
6,325,000
25,000,000
Total:
31
750,000
DFID staff time @ 50% FTE
75000
75000
75000
75000
Discount rate (10%)
1.000
0.909
0.826
0.751
6,200,000
5,726, 700
5,286,400
4,806,400
PV costs
300,000
22,019,500
C2.1Option 2(a)Building of Maternal Waiting Homes
Incremental Costs
As a proxy for understanding the costs and benefits of skilled birth attendance, we examine the intervention of
building Maternal Waiting Homes. There are 115 hospitals and 675 healthcare centres providing maternity
services in Ethiopia. Eight of these hospitals and one of the healthcare centres have MWHs, which provide
residential services close to the full medical facility for expecting mothers.54
The Strategic Case has demonstrated that the maternal mortality ratio in Ethiopia is unacceptably high. Many
of the complications that give rise to this rate can be predicted in advance. Such ‘at risk’ pregnancies have a
higher associated mortality rate. MWHsare basic structures built near a health centre where a mother can
stay in the lead up to the birth. Without this facility, the risks associated with a short-notice journey to the
hospital would have to be tolerated. Therefore, MWHs serve women with identified risk factors that would be
likely to require skilled medical attention. However, if capacity and demand are large enough, the usage of
MWHs by women without risk factors/complications could also be increased.
The inputs are the MWH structure and required staff. These are transformed into outputs: increased number
of pregnant women staying in MWH prior to birth. The outcomes are the benefits of MWH in terms of
reductions in maternal and neonatal mortality and morbidity.
A strong causal empirical link between outputs and outcomes is difficult to ascertain: whilst there is a clear
chain of logic as to how MWH should improve maternal outcomes, there is no robust causal evidence.
Evaluation data to estimate the effectiveness of MWH on these outcomes is not available.55
Despite this lack of evidence linking outputs to outcomes, we can instead model the cost effectiveness of a
programme to expand the supply of MWH. This is drawn from the available knowledge of the costs of inputs
(the costs of MWH and staff), and the impact on outputs (the number of women who can give birth in these
MWH).
To estimate the incremental cost of the intervention, we considered the number of available MWHs in the
existing hospitals and health centres. This revealed a maximum of 781 MWHs that can be built by DFID
funding. Based on assumptions summarized in the economic appraisal annex and using construction and
yearly operating costs of MWHs from existing programmes adjusted for inflation, we estimated the total
incremental costs of this intervention to be £8,955,207. Using10% discount rate, this translates to a total
discounted cost of £6,778,561.
Wider non-quantified costs
There are also wider costs to be considered not borne by the DFID programme budget, such as child care
costs, opportunity costs of being away from home, food and other necessities,transport costs, and additional
54UNICEF
- Health Section, UNICEF Ethiopia, September 2011
study by Kelly et al. provides the mortality rate comparison between those admitted to the MWH and those admitted
directly to hospital. This shows that those who are admitted via MWH have much lower mortality rates. However, they are not
comparable groups as those admitted directly to hospital are those who have experienced serious complications at short
notice. Therefore it is not possible to know how much to attribute the better health outcomes of women in MWH to the MWH
itself.
55The
32
medical costs. Some MWH charge fees - this will be an additional cost to the family, although a benefit to the
MWH.
Incremental Benefits
By reducing the geographical barriers to using medical facilities, more women will be able to stay close to the
hospital in advance of giving birth. This will reduce the risks of complications during transport if left too late,
and allow the transfer of the woman to the main healthcare facility in the event of early complications. It may
also encourage women without risk factors to make use of medical facilities, increasing immediate access to
care and further reducing mortality.
This will lead to better health outcomes as women in the most need of medical facilities (by being at risk) will
be close to skilled medical workers and have a much stronger chance of being seen to in a timely manner
compared to having to travel from their house. As MWH also have regular attendance of nurses, women also
will be able to have more regular check-ups. Many MWH also provide antenatal and postnatal care.
We estimate the maximum number of additional births that can benefit from MWH by multiplying the number
of additional MWHs by the maximum number of women it can accommodate throughout the year (based on
the number of beds and the average length of stay). These resulted in a total of 1,520, 347 new births will be
taking place in MWH over 10 years (see Economic Appraisal Annex for the details).
There is no MWH evaluative evidence, to our knowledge, that robustly demonstrates the benefits of MWH on
maternal mortality. However, it is worth noting that the MWH is intended to reduce the mortality rate and
increase DALYs of women who have indicated risk factors prior to birth. Without being close to a healthcare
facility, the MMR of these women is likely to be high, therefore MWH target the most at risk pregnancies.
Value for Money
The cost-effectiveness of this indicative intervention is shown below. The efficiency of converting inputs
(number of MWH) to outputs (number of additional births in health facilities with SBA) is assumed for
convenience here to be 100% efficient – i.e. all beds that are built will be filled. Although it is unlikely that all
beds will be filled all of the time, given the current demand for existing facilities, it may be reasonable to
assume that there will be high transformation of inputs into outputs. We have tried to test the sensitivity of the
cost effectiveness estimates to this assumption in the next sub-section. Reported below is the cost per output
at the upper-bound assumption that all beds are filled.
Table 10: Cost-effectiveness analysis of Option 2(a)
CBA
Option 2a
Number of additional births in health facilities with SBA
1,520,347
Total cost (undiscounted)
£8,955,207
Total cost (discounted- at 10% discount rate)
£6,778,561
Cost/birth through MWH (undiscounted)
£5.89
Cost/birth through MWH (discounted)
£4.46
DALYs saved
30635
Cost/DALY (undiscounted)
292
Cost/DALY (discounted)
221
PV of health benefits
£4,778,477
Using 2004 WHO’s DALY estimate for Ethiopia, we have converted the number of additional births in MWH in
to DALYs. This resulted in 30635 DALYs to be saved as a result of this intervention. This is equivalent to
monetized health benefits of £4,778,477 The estimated cost/DALY stood at £292 (undiscounted) and £221
(discounted at 10% discount rate). See Economic Appraisal Annex for more details.
33
We do not investigate the quantifiable impact of MHW on reduced maternal mortality, as evidence is weak,
although we might expect it to have a significant impact on unmet need for these services.
Sensitivity analysis
We test sensitivity to changes in parameters that have the weakest evidence base by: adjusting average
MWHs size and lifetime downwards by 25% and by adjusting the costs of MWHs upwards by 20% whilst
holding other parameters constant.
Table 11: Scenario analysis of Option 2(a)
Original Assumption
New
Assumption
Scenario 1 - Average size of MWH or
Maximum yearly capacity of MWHs
8 beds
195 (100% capacity)
6 beds
146 (75% capacity)
Scenario 2 - Construction costs
£8,341
£10,009
Scenario 3 - On-going yearly costs
£313
£375
Scenario 4 - Lifetime of MWH
10 years
8 years
We re-examine the VfM under each of these scenarios:
Table 12: Cost Benefit Sensitivity Analysis
CBA
Base
Scenario 1
Scenario 2
Scenario 3
Scenario 4
Number of additional births
in health facilities with SBA
1,520,347
1,140,260
1,520,347
1,520,347
1,216,278
Total cost (undiscounted)
8,955,207
8,955,207
10,746,248
9,443,332
8,955,207
Total cost (discounted)
6,778,561
6,778,561
7,860,343
7,052,490
6,778,561
Cost/birth through MWH
(undiscounted)
5.89
7.85
7.07
6.21
7.36
Cost/birth through MWH
(discounted)
4.46
5.94
5.17
4.64
5.57
DALYs averted
30635
22967
30635
30635
24508
Cost/DALY (undiscounted)
292
390
351
308
365
Cost/DALY (discounted)
221
295
257
230
277
We can see that the number of beds per MWHs or the maximum yearly capacity of MWHs is among the key
drivers of the cost per birth and cost per DALY. Yet the estimated cost effectiveness indicators still represent
VfM. A 25% fall in the average size of MWH would result in the undiscounted cost per birth to increase to
£7.85 from £5.89 under the base case scenario, which is more than one-to-one change. Also, for Scenario
four, there is more than one-to-one change in the undiscounted cost per birth. But, there is one to one or a
less than a one-for-one change in undiscounted cost per birth for scenario two and three, respectively. That
is, cost per birth is most sensitive to the number of beds in the MWH and the life time of MWHs. A fall in the
number of beds that can be built for this cost and the life time of the MWHs will be the main drivers that may
raise costs per birth.
A proportionate rise in construction costs for a given number of beds is also a significant driver of increases in
costs per birth.. This is primarily because this is the biggest expenditure. It also has the biggest effect on
discounted costs per birth as these costs are borne up front.
34
To summarise the sensitivity analysis: the number of beds per MWH, the lifetime of MWHs and the
construction costs are the most important drivers of the cost per birth and cost per DALY. In reality, due to the
weak evidence base for these parameters, they could vary by more than 25%. However, the sensitivity
analysis shows that costs will not increase disproportionately due to a change in these parameters.
Table 12VfM indicators for Option 2 (a) MWH
Score out of 5
(1= poor, 5 =
excellent)
NAO framework
Option 2 (a)
Economy
Likely to be good economy, given that it will be competitive tendering.
4
Efficiency
Likely to be efficient as MWH are simple structures often constructed and
maintained by the community.
3
Effectiveness
Depends on the design and usage of the MWH.
2
Equity
Will enable women from remote areas to be closer to services
4
Average (equal
weighted) score
C2.2
3.25
Option 2(b): Youth friendly supply of family planning services
Incremental costs
To estimate the benefits, it is necessary to estimate the number of Couple Years Protection (CYPs) that are
likely to accrue over the four years, with a given budget of £6m. Marie Stopes International provided figures
on the average cost per CYP for their outreach services, which best match the costs for youth friendly
services. To estimate the number of CYPs that the total budget of £6m can deliver, the total budget is divided
by the cost per CYP.
Based on detailed budgets given by MSI and assuming uplifts associated with demand creation, M&E and
logistics, we estimate a finalcost per CYP figure of £10.22.
Incremental benefits
This strategic area focuses on the supply of family planning service to youths, currently with a high unmet
need. As these are hard to reach and underserved, adolescents are considered to be new adopters, and the
benefits of reaching them are incremental to the counterfactual scenario.
The direct benefits of increasing the demand for taking up FP services can be described as follows:
Welfare gains to society:
(a) A reduction in unwanted pregnancies
(b) A reduction in infant and maternal mortality
(c) Animprovement in maternal and infant health due to less unsafe abortions, pregnancy
complications, better birth spacing.
Economic gains to society:
(d) A saving in healthcare costs (for those who have access to healthcare) incurred due to the welfare
gains, thus freeing up household income to spend on more productive activities. This is a direct
gain to households and leads to allocation efficiency56 improvements.
(e) A contribution57 to a reduction in fertility for Ethiopia, thus reducing pressure on resources,
environment etc. However, for youths, this is less of a benefit, as this intervention is likely to delay
56
A more productive allocation of resources
35
pregnancies rather than reduce them.
Equity (distributional) gains:
(f) The vast majority of beneficiaries are youths from vulnerable groups as discussed in the strategic
case. Thus the benefits are highly equitable, resulting in a direct transfer from relatively rich
taxpayers to the poor and marginalised.
Wider (indirect) benefits to households:
(g) Reduced household expenditure required on education and other services due to fewer children in
the household.
In modelling the benefits associated with the investment in this strategic area, only (a), (b), (c) and (d) have
been quantified as it is too difficult for this appraisal to model the remaining benefits. Moreover, attribution
would be a problem, as many other policies and factors would contribute to these. For a benefit like (g),
quantifying it would ignore the potential loss in future output of children not born, and the costs associated
with that. This would involve complex macroeconomic general equilibrium modelling, which is unlikely to exist
in the Ethiopian context.
The benefits of youth friendly supply of family planning services are defined by the number of CYPs. The
CYPs are simulated from the unit cost figure by dividing the total budget by the cost per CYP. This is equal to
£6m/£10.22 = 587,120 CYPs for the duration of the 4 year programme. In order to determine the number of
DALYs averted from the CYPs, the MSI impact estimator58 is used to estimate the impacts in terms of deaths
andDALYs averted. Accordingly, the total DALYs to be averted as a result of the intervention is estimated at
183,092 and the cost per DALY at £31.37. The intervention would avert a total of 175,970 unintended
pregnancies, 16,674 abortions, 434 maternal deaths, 4,636 child deaths and 9620 unsafe abortions. In
addition, £818,712 will be generated as total health care cost savings.
Table 14: Benefits of youth friendly supply of family planning services
Total no CYPs
Total DALYs averted
Cost per CYP
Cost per DALY
Total unintended pregnancies averted
Total abortions averted
Total maternal deaths averted
Total child deaths averted
Total unsafe abortions averted
Total healthcare cost savings
For 4 year intervention duration
587,120
183,092
£10.22
£31.37
175,970
16,674
434
4,636
9,620
£818,712
As can be seen in table 14 the cost per DALY is £31.This is deemed as extremely cost effective; WHO
guidance indicates that such ratios are cost effective if they are less than the GNI per capita (Atlas method) of
the countries in question. The GNI per capita figure for Ethiopia is £250 (source World Bank).
Valuing the DALYs and cost benefit analysis
In order to value the DALYs and undertake a cost benefit analysis, the DALYs are valued at GNI per capita
for Ethiopia (£250 in 2011). Using a discount rate of 10%, this gives rise to a present value of benefits of
£38.9m. Adding in the healthcare savings benefits of £818,712, this gives rise to a total benefits figure of
£39.7m. As seen below, this gives rise to a health NPV of £34.6m, and a BCR of 7.8.
Table 15: Cost benefit analysis results for youth friendly supply of family planning services
57
Other factors are important also in reducing fertility, such as women’s empowerment and education
MSI Impact Calculator, Version 2.0 – Marie Stopes International, May 2012
58The
36
CBA metrics
GNI per capita £
£250
PV costs
PV benefits (DALYs)
5,102,746
38,928,006
PV Benefits (healthcare savings)
Total benefits
NPV
BCR
£818,712
£39,746,718
£34,643,972
7.8
Risk and uncertainty
The greatest riskof this activity is the effectiveness of targeting adolescents – a hard to reach vulnerable
group. Whilst some of the private sector service providers have outreach services, it is not clear how
successful they are in actually reaching adolescents. Related to this point, the demand creation activities
would be central for the targeting and programme in general to be effective. Thus close attention would have
to be paid to this to minimise the risk of ineffective targeting. It is useful to undertake a sensitivity analysis of
the effectiveness of targeting and demand creation. Suppose, in the worst case scenario that only half the
amount of intended beneficiaries are reached, this would imply that the cost per CYP is double than that in
the central case scenario above.Such a pessimistic scenario would give rise to a cost per DALY of £62, and a
BCR of 4.0, which is still clearly highly cost effective.
Table 16:Sensitivity analysis for youth friendly supply of family planning services
Total no CYPs
For 4 year intervention duration
293,560
Total DALYs averted
Cost per CYP
Cost per DALY
Total unintended pregnancies averted
Total abortions averted
Total maternal deaths averted
91,546
£ 20.44
£ 62.74
87,985
8,338
218
Total child deaths averted
Total unsafe abortions averted
Total healthcare cost savings
Total benefits
NPV
BCR
2,318
4,810
£204,678
£20,282,714
£15,179,968
4.0
Value for Money
Table 17 below provides the VfM summary analysis for this strategic area. As can be seen, this activity
represents good VfM with a weighted average scoring of 3.0 out of 5 using NAO four E’s framework
(Economy, Efficiency, Effectiveness and Equity) .
Table 17: VfM indicators for Option 2(b) – youth friendly supply of family planning services
Score out of 5
(1= poor,
5 = excellent)
NAO framework
Option 2(b)
Economy
There should be good private sector incentives to keep costs
down, due to a competitive tender of innovation funds.
37
4
Efficiency
The service providers are relatively established in this field,
so have benefit of learning, knowhow, established systems
and processes, so should be in a good position to deliver
efficiently, productively and cost effectively. This is clear in
the modelling, with good cost effective indicators of cost per
DALY of £31, and cost per CYP of £10.
4
Effectiveness
There is a risk that hard to reach vulnerable groups will not
be effectively targeted, thus comprising impacts
2
Equity
There is a risk that hard to reach vulnerable groups will not
be effectively targeted, thus comprising equity
2
Average (equal
weighted) score
C2.3
3.0
Option 2(c) Extension of girls’ empowerment programmes
The Strategic Case has demonstrated the importance of empowering women and girls, both to improve the
effectiveness of supply side interventions, and also in improving their wellbeing directly.
Funding interventions that would scale up girls’ empowerment programmes would aim directly or indirectly to
improve reproductive health outcomes, and potentially a range of other outcomes. For Option 2c, we provide
a high-level appraisal of an activity to extend the CARE Ethiopia programme, “Towards Improved Economic
and Sexual Reproductive Health Outcomes for Adolescent Girls” (TESFA). This programme aimed to improve
outcomes for 5,000 never-married adolescent girls, in the Amhara Region of Ethiopia.
The CARE TESFA programme
The rationale of the programme is that girls are often married at very early ages (in the Amhara, almost 50%
of girls married under the age of 15, and 75% by age 18). The power imbalance resulting from girls marrying
(typically older men) very young leads to reduced likelihood of completing education, higher chance of
reproductive/sexual health complications (and hence maternal mortality), and reduced/eliminated control over
financial and non-financial assets.
The TESFA programme looks to improve 1) the economic outcomes and 2) the sexual and reproductive
health outcomes of ever-married adolescents in an integrated manner. To achieve this, girls must have
increased access and control over income and assets, have the knowledge and decision making ability over
their sexual and reproductive health, and have access to services and information relating to both economic
empowerment and sexual and reproductive health.
The programme: forms Girls’ Village Savings and Loan Association groups (GSLs); leads community
conversations on norms around girls’ decision making; organises girls’ support and information groups and
promotes girl friendly sexual and reproductive health services. The outcomes are increased knowledge and
skills of adolescent girls in economic activity, increased access and knowledge to health services, and
ultimately improved economic outcomes and improved sexual and reproductive health outcomes for the
targeted adolescent girls.
There is no evaluative information yet available as to how the programme affects maternal or neonatal
mortality. However, evidence underpinning the theory of change suggests that girls’ empowerment is a key to
improving these outcomes. Therefore we provide a cost-effectiveness analysis to demonstrate how many girls
can be reached by this programme by a given amount of DFID funding.
Incremental costs
The programme implementation costs for the current programme is to support 5,000 girls is £1.1m. We
appraise a scenario of DFID providing £3m to this programme, and estimate benefits by pro-rata.
We assume that any programme extension would be in slightly different regions. We provide a cost and group
formation profile for an additional £3m DFID funding. The first row in the table below is the number of groups
38
set up due to the existing CARE programme.
Full cost details are not listed here – instead we provide overall cost figures, and pro-rata with DFID
contributions. The key cost components are staff salaries, administrative overheads, and consultancy and
M&E costs.
Table 18: Profile of costs and group formation for Option 2(c)
Year 1
Year 2
Year 3
Total
Number of groups set up without DFID funding
(counterfactual)
60
120
120
300
Additional number of groups set up due to DFID funding
160
320
320
800
DFID funding (undiscounted)
£1m
£1m
£1,875m
£3,875m
DFID funding (discounted)
£1m
£0.91m
£0.83m
£2.7m
Incremental benefits
The benefits of the programme are to increase access to services and information, and ultimately autonomy
of girls over resources, assets and sexual and reproductive health decisions. The number of girls reached is
similarly pro-rated from the CARE programme; a linear increase is assumed.
Table 19: Benefits profile for Option 2 (c)
Year 1
Year 2
Year 3
Total
Number of girls reached without DFID funding
(counterfactual)
1,000
2,000
2,000
5,000
Additional number of girls reached by new groups
2,740
5,480
5,480
13,700
In addition to these direct beneficiaries, CARE also affects many indirect beneficiaries through discussions
with the broader community.
Table 20: Indirect beneficiaries
Year 1
Year 2
Year 3
Total
Number of community group members reached without
DFID support (counterfactual)
500
1000
1000
5000
Number of households reached through community
group members’ cascade without DFID support
(counterfactual)
2500
5000
5000
13700
Additional number of community group members
reached
1370
2740
2740
6860
Additional Number of girls reached by new groups
6850
13710
13710
34280
There are no rigorous impact evaluations to date which give empirical evidence on the benefits of
programmes such as this.The Nike Girl Hub, a similar initiative, was evaluated by the Independent
Commission for Aid Impact with limited evidence of impact so far, although an acknowledgment of some
positive impacts. The report states that whilst better ways of measuring attribution should be explored, they
conclude that in addition to its influence on DFID, the Girl Hub can be reasonably attributed a degree of
impact in energising and promoting a focus on girls.
The existing programme does not focus entirely on sexual and reproductive health. One third of the groups
focus only on economic empowerment. Therefore only two thirds of the girls reached by this programme will
39
benefit directly in terms of reproductive health.
The above analysis makes the following key assumptions:
 That an increase in funding contribution will increase, in a linear manner, the number of groups set up
and hence the number of girls reached
 That the programme will have positive benefits on maternal mortality and other aspects of maternal
health. The evaluative evidence on how the programme affects these key outcomes does not yet exist
(evaluations are being carried out currently by the existing programme). The benefits of the groups are
therefore assumed, although evidence may be stronger by the time the RIF is established.
Value for money
The following gives an indication of the cost per beneficiary (direct and indirect) for the duration of the
programme. The efficiency of transforming inputs (creation of adolescent girls’ groups) into outputs
(membership of girls in these groups) is assumed as 100%. Reported below is the cost per output of reaching
girls through groups, on the upper-bound assumption that groups are filled to full membership.
The table below shows indicative unit costs from similar programmes. We must be cautious in using these,
as they may not contain all costs relating to the programme delivery, and benefits are likely to vary
significantly. We are thus not comparing like for like. However, from this we can infer that TESFA’s unit costs
are within the right ball park.
Table 21: Cost per beneficiary
Programme duration unit costs
Cost per girl reached through groups
£218
Cost per beneficiary (all)
£55
Table 22: 13indicative unit costs from similar programmes
Indicative unit costs from similar programmes
Programme
Activities (No. beneficiaries)
Unit cost
2003 to 2008 World Bank
female education
Improve access to female secondary education in rural areas
(450,000)
£42.5 per girl per year
2003 to 2006 Bangladesh
access to finance for
women
Female victims of GBV/violence – provision of interest free credit
and training (46,000)
£152 per girl for
duration
2005: Burkina Faso
training
Training boys and girls
£58 per beneficiary
for duration
Safe spaces Kibera
Female mentors, life skills financial literacy training with links to
savings institutions
£38 per girl over 5
years
Moving the Goalposts
Regular football training, league matches, annual tournaments,
leadership/life skills, sexual reproductive health education,
economic empowerment, counselling support
£120 per girl for
duration
Zambia safe spaces
Adolescent girls access to health, financial services, including
savings accounts and health vouchers
£520 per girl for
duration
Table 23provides a summary VfM measures from Option 2(c). Overall the value for money of reaching each
girl through this programme is medium, although it crucially depends on the effectiveness of the programme
which will be determined once evaluations have been completed in 2013. The weighted average scoring out
of 5 for this intervention is estimated at 2.5.
Table 23:Summary of VfM measures of Option 2(c) -Extension of girls’ empowerment programmes
40
NAO framework
Option 2(c)
Score out of 5
(1= poor, 5 =
excellent)
Economy
The costs of extending the programme will be relatively low as the existing
programme can ensure that procurement and training are obtained at
favourable costs. However, the unit cost of reaching each girl is relatively high
at £218.
2
Efficiency
The efficiency of expanding the intervention will benefit from the experience
and expertise of CARE and its associated partners and their governance
arrangements, internal financial management, risk mitigation processes etc.
3
Effectiveness
There is little evidence as of yet as to how this programme will impact on the
outcomes targeted by this DFID programme.
2
Equity
CARE targets vulnerable girls, and focuses on the poorest parts of Amhara.
3
Average (equal
weighted) score
C2.4
2.5
Option 2(d): Evidence generation on RMNH interventions
To document the lessons learned of existing and new approaches of increasing RMNH service utilisation and
determine what can work at scale.
Incremental costs
The incremental costs of the research are estimated at 10% of the total budget (£2.5m). In terms of cost
effectiveness, it is necessary to understand whether this investment is a good one, or whether it is better
spent on more programme delivery.
Incremental benefits
In addition to impacts from the service delivery, there are also impacts to be gained from operational
research. The knowledge and evidence to be documented by this research and analysis is expected to
provide an international public good. Furthermore, research provides methodological and conceptual
advances in the understanding and evaluation of reproductive health interventions and their impacts. The
research element will address an important gap in the evidence base for demand side interventions, working
with youth and those located in remote areas. Such research is particularly pertinent to Ethiopia, as the
targeting of marginalised groups is unchartered territory and it is important to understand their barriers,
choices and effective intervention strategies.
The programme is expected to produce clear, operationally relevant and accessible information that can be
used by policy makers to inform policy and planning in Ethiopia and internationally.
The benefits will accrue after the project has ended, and could take the following forms (via evidence gained
from the research):
 Cost effective solutions in terms of combining interventions;
 Better knowledge of the how to reach different types of marginalised women and girls who are new
adopters – e.g. for family planning services. Better knowledge will allow more effectively and
accurately targeted programmes to be designed in the future;
 Better understanding of the key barriers for marginalised women and adolescents, thus improving
and refining the theory of change, making it more credible, and resulting more efficient and
effective programme delivery in the future;
 Better data generally to track impacts and refine estimated benefits in terms of reduced maternal
mortality, reduced unwanted pregnancies etc.;
 Better data will in turn drive better programme delivery;
 Better sustainability of programmes if research sheds light on how to improve effectiveness and
41
strengthen assumptions underlying the impacts modelling and theory of change.
All of the above will reduce the risks and uncertainty of targeting marginalised groups and will aid programme
delivery considerably, not just to programmes in Ethiopia, but in other countries too.
It is not possible to quantify such benefits, as they accrue in the future and it is not possible to attach figures
on to them. Thus it is difficult assign a value on whether such research is more cost effective compared to
programme delivery.
In terms of risk and uncertainty, the question is whether the research will be effective in delivering the above
outcomes. Given that the provider will be tendered through the RIF, there is reason to believe that the chosen
provider will have strong incentives to put together a good and effective research programme that will deliver
the intended benefits. In order to obtain the required benefits, it is important the TORs are explicit about the
rigorous nature of such research. The research needs to be clearly defined, controlled and measured. It is
imperative that there are suitable baselines and indicators identified upfront, with endlines. The biggest risks
are the lack of data available, and systems in which to collect and measure it. Systems must be established
upfront. With all these safeguards in place, it is reasonable to assume that are no obvious risks attached to
this activity, as research is generally straightforward and there are credible providers in the market.
Value for money
Qualitative analysis using NAO’s framework revealed good VfM for investment for this activity as there is clear
evidence gap in a number of areas. It is expected that this investment will generate operationally relevant and
accessible information which will be used in the design of cost effective solutions to reach the most
marginalized segments of the society. The weighted average scoring out of 5 for this intervention is
estimated at 3 which is acceptable from VfM consideration.
Table 24:VfM indicators for Option 2(d) evidence generation
Option 2 (d)
Score out of 5
(1= poor, 5 =
excellent)
Economy
Likely to be good economy, given that it will be tendered.
3
Efficiency
Likely to be efficient if a rigorous TOR fully stating all the needs of an
operational research design and evaluation is defined and implemented.
3
Effectiveness
Depends on the rigour of the design.
3
Equity
It is designed to shed light on vulnerable groups
3
NAO framework
Average (equal
weighted) score
3
C2.5 Summary of Cost Effectiveness and Cost-Benefit Analysis on Option 2: RIF managed by FMOH.
As revealed above, we are able to generate VfM measures for activities a, b and c when implemented
through a RIF managed by the FMOH. Overall we found out that this option is cost effective in terms of
cost per birth, cost per DALY, cost per CYP, cost per girl and cost per indirect beneficiaries reached.
Table 25: Summary VfM for Option 2: RIF managed by the FMOH
Option 2 – RIF managed by FMOH
Budget
2a: Maternal Waiting
Homes
2b: Youth
friendly FP
services
2c: Girls’
empowerment
programmes
2d: Evidence
generation
Option 2 overall
£9m
£6m
£3m
£2.5m
£25m (incl. M&E
42
and fund admin)
Cost
effectiveness
Cost per safe birth
£4.46
Impacts
1.5m additional births
in safe conditions *
Cost per direct
girl £218;
Cost per
indirect
benefit. £55
Cost per DALY
£31; cost per
CYP: £10.22
5,070 deaths
averted;
16,774 total
abortions
averted;
9,620 unsafe
abortions
averted;
175,970
unintended
pregnancies
averted
-
Good
13,700 direct
benefit;
34,800 indirect
benefits.
Economy
4
4
2
3
3.25
Efficiency
3
4
3
3
3.25
Effectiveness
2
2
2
3
2.25
Equity
4
2
3
3
3
Average core
3.25
3.0
2.5
3
2.94
Leverage of
private sector
and good
scale up
opportunities?
High
High
High
High
High
Unquantified
benefits
Better maternal health
outcome; greater
DALYs averted
Reduced
household
expenditure,
reduced national
fertility
Risk and
uncertainty (in
terms of
meeting
objectives)
Low
Medium
Better
evidence for
better future
programmes;
more
sustainability
Medium
Low
Medium
*Note that the figure of 1.5 million safe births represents a potential benefit over 13 years from a massive
expansion of MWH to all 781 hospitals and health centres. The corresponding figures for four years are
304,069 births at 781 MWH. As the economic appraisal points out, this assumes all centres built and
operating at full capacity. However, any increase in this intervention is likely to be slow and thus to deliver far
more modest increases in births in safe conditions.
To generate aggregate cost benefit results for this option, we estimated the efficiency benefits that would
accrue over time as a result of system strengthening. Since this option works through the government routes
and would help build institutional capacity, there would be certain efficiency gains by ‘learning by doing’ of
government staff. We assumed 0.4% efficiency gain from system strengthening to estimate the efficiency
benefits of the RIF run by the FMOH. This is half of the assumptions we used for the economic appraisal of
43
MDG PF which was aimed at supporting the HSDPof the Government. Using discount rate of 10%, this
resulted in £8.3 million efficiency benefits. Aggregating this efficiency benefits on top of the health benefits
from MWH, youth friendly family planning services and the health care cost savings, resulted in total
discounted benefit of £52.8 million. Subtracting from this, the total discounted cost of £11.9 million resulted in
net present value of £40.9 million. This translates to 4.4 BCR, i.e. £1 investment in RIF through the
Government system would generate £4.4 benefits to Ethiopia. This is an indication of good VfMfor option 2.
Table 26: Overall Cost Benefit Results for activities 2(a) and 2(b)
Particulars
PV of Costs
PV of Benefits
-Health Benefits from MWH
-Health Benefits from youth friendly Family planning services
-Health care cost savings from youth friendly family planning
services
-Efficiency gain from system strengthening
NPV (at 10% discount rate)
BCR
C3.
In Millions of £
11,881,307
52,808,643
4,778,477
38,928,006
818,712
8,283,448
40,927,336
4.4
Option 3: Establishing a RIF managed by a non-governmental organisation (UN or contractors)
Due to the myriad of different organisations that could deliver this option via non-government channels, the
VfM is difficult to assess. Yet, we have made cost benefit analysis of this option considering the management
cost differential of this option to that of option 2.
Similar to option 2, the VfM of option 3 will be assessed for delivery four activities: building Maternal
Waiting Homes; supply of youth friendly family planning services, extension of girls’ empowerment
programmes and evidence generation.
The costs for this option comprise administrative overheads, costs for the supply of mother and youth friendly
services for family planning, cost for empowerment activities, evidence generation, M&E and DFID staff time.
In the Protection of Basic Services Business Case, the case is made that the efficiency of delivery and
economy of procurement of NGO programmes is lower than delivery through government. For example,
USAID Ethiopia estimates that overheads for its main delivery partners are between 15%-30%. For this
economic appraisal we have taken the lower bound of 15% as the overhead cost of delivery through NGO’s
or UN System.
C3.1
Option 3(a)Building Maternal Waiting Homes
Incremental costs
Since the total budget does not change from option 2, we assumed the management cost differential to be
reflected in the benefit differential between this option and that of the government delivery option. Accordingly,
we have assumed the incremental cost of the programme to be the same as option 2, i.e. the total
incremental costs of this intervention is assumed at £8,955,207 (undiscounted) or£6,778,561 (discounted).
Incremental Benefits
For the purposed of appraisal, we use the 5% increase in the management costs over government delivery to
estimate value for money. We assumed outputs are reduced by 5% due to the cost differential and we
crudely simulate this by reducing benefits by 5%. However this assumes that the effectiveness of the nongovernment delivery is the same, and that spend will be in the same areas.
Accordingly, we estimated 1.4 million additional births to be taking place in MWH over 10 years if the delivery
is through the UN system or a contractor (5% lower than the Government delivery option).
44
Value for Money
The cost-effectiveness of this indicative intervention is shown below. Similar to option 2, the efficiency of
converting inputs (number of MWH) to outputs (number of additional births in MWH) is assumed for
convenience here to be 100% efficient – i.e. all beds that are built will be filled. Accordingly, the cost per birth
through MWH becomes £6.20 which is 5% higher than that of option 2 (a). This implies that this option is less
cost effective compared to option 2.
Table27: Cost-effectiveness analysis of Option 3(a)
CBA
Option 3a
Number of additional births in health facilities with SBA
1,444,330
Total cost (undiscounted)
£8,955,207
Total cost (discounted- at 10% discount rate)
£6,778,561
Cost/birth through MWH (undiscounted)
£6.20
Cost/birth through MWH (discounted)
£4.69
DALYs saved
29,103
Cost per DALY (undiscounted)
£308
Cost per DALY (discounted)
£233
PV of health benefits
£4,539,553
This option would save 29,103 DALYs as a result of this activity an equivalent to monetized health benefits of
£4,539,553. The undiscounted cost/DALY is estimated at £308.
Sensitivity analysis
We test sensitivity of the cost effectiveness indicators to changes in assumed parameters, say 25% decrease
in number of additional births in health facilities by SBA whilst holding other parameters constant.
Table 28: Cost Effectiveness of option 3(a): Sensitivity Analysis
CBA
Base
Scenario 1
Number of additional births in health facilities with
SBA
£1,444,330
£1,083,247
Total cost (undiscounted)
£8,955,207
£8,955,207
Total cost (discounted)
£6,776,561
£6,778,561
Cost/birth through MWH (undiscounted)
£6.20
£8.27
Cost/birth through MWH (discounted)
£4.69
£6.26
DALYs saved
29103
21827
Cost per DALY (undiscounted)
308
410
Cost per DALY (discounted)
233
311
PV of Health benefits
£4,539,553
£3,404,664
We can see that the undiscounted cost per birth has showed a marginal decline with the assumed 25% fall in
the number of additional births in health facilities with SBA. However this will not change the cost
effectiveness story of this option compared to option 2 (a). Option 3 (a) is less cost effective.
45
C3.2
Option 3(b): Youth friendly supply of family planning services
Incremental costs
With a given budget of £6m for this activity we assumed 5% reductions in the total number of CYPs to be
generated. This resulted in 557764 CYPs for the four year period. Dividing the total budget of £6m by the
CYP resulted in cost per CYP of £10.76 which is higher than the cost per CYP for option 2(b)£10.22.We
assumed a similar £5,102,746 total discounted cost for this strategic area to that of option 2 (b).
Incremental benefits
We reduced the DALY benefits of option 2(b) by 5% to arrivethe total DALYs to be averted as a result of the
youth friendly family planning services to be provided by theUN agency or contractor. Accordingly, it is
estimated that173,937 DALYs will be averted. For the given budget of £6 million, the cost per DALY
increased to £34.50 compared to £31.37 for option 2(b). The intervention would avert a total of 167,171
unintended pregnancies, 15,840 abortions, 412 maternal deaths, 4,404 child deaths and 9,139 unintended
pregnancies. In addition, £777,776 will be generated as total health care cost savings. Since the generated
cost per DALY is quite lower that the GNI per capita figure for Ethiopia of £250 this intervention is still cost
effective though it is not as cost effectiveness as option 2(b).
Table 29: Benefits of youth friendly supply of family planning services
Total no CYPs
Total DALYs averted
Cost per CYP
Cost per DALY
Total unintended pregnancies averted
Total abortions averted
Total maternal deaths averted
Total child deaths averted
Total unsafe abortions averted
Total healthcare cost savings
For 4 year intervention duration
557,764
1,173,937
£10.76
£34.5
167,171
15,840
412
4,404
9,139
£777,776
Valuing the DALYs and cost benefit analysis
Valuing the DALYsaverted atGNI per capita for Ethiopia which was £250 in 2011, this intervention would
generate a discounted health benefits (DALYs) of £37 million. Adding in the healthcare savings benefits of
£0.8 million, this gives rise to a total benefits figure of £37.8 million. As seen in the table below, this gives rise
to a health NPV of £32.6m, and a BCR of 7.4.
Table 30: Cost benefit analysis results for youth friendly supply of family planning services
CBA metrics
GNI per capita
PV costs
PV benefits (DALYs)
PV Benefits (healthcare savings)
Total benefits
NPV (at 10% discount rate)
BCR
Option 3(b)
£250
5,102,746
36,981,606
£777,776
£37,759,382
£32,656,636
7.4
Risk and uncertainty
Assuming that only half the amount of targets were reached, this would imply that the cost per CYP is double
than that in the base case scenario above. This would give rise to a cost per DALY of £68.99, NPV of £14.2
million and a BCR of 3.8, which is still good from VfM perspective.
46
Table 31: Sensitivity analysis for youth friendly supply of family planning services
Total no CYPs
For 4 year intervention duration
278,882
Total DALYs averted
Cost per CYP
Cost per DALY
86,969
£21.51
£68.99
Total unintended pregnancies averted
Total abortions averted
Total maternal deaths averted
Total child deaths averted
Total unsafe abortions averted
Total healthcare cost savings
Total benefits
NPV (10% discount rate)
BCR
83,586
7,921
207
2,202
4,570
£194,444
£19,268,578
£14,165,832
3.8
Value for Money
The table below provides the VfM summary analysis for this activity. As can be seen, this represents good
VfM with a weighted average scoring of 2.5 out of 5 ratings using NAO four E’s framework (Economy,
Efficiency, Effectiveness and Equity) .
Table 32:VFM indicators for Option 3(b) youth friendly supply of family planning services
NAO framework
Option 3(b)
Score out of 5
(1= poor,
5 = excellent)
Economy
There should be good private sector incentives to keep costs
down, due to a competitive tender of innovation funds.
Scaling up outside of the government system will be harder
and more expensive
2
Efficiency
The service providers are relatively established in this field,
so have benefit of learning, knowhow, established systems
and processes, so should be in a good position to deliver
efficiently, productively and cost effectively. This is clear in
the modelling, with good cost effective indicators of cost per
DALY of £31, and cost per CYP of £10.
4
Effectiveness
There is a risk that hard to reach vulnerable groups will not
be effectively targeted, thus compromising impacts
2
Equity
There is a risk that hard to reach vulnerable groups will not
be effectively targeted, thus compromising equity
2
Average (equal
weighted) score
C3.3
2.5
Option 3(c) Extension of girls’ empowerment programmes
Similar argument holds for this activity under option 3 (c) as it did under option 2 (c), i.e. funding interventions
that would scale up girls’ empowerment programmes would aim directly or indirectly to improve reproductive
health outcomes, and also potentially a range of other outcomes.
Incremental costs
Similar to option 2(c), the incrementalcosts of this option are generated based on the cost for the current
47
CARE programme which is aimed at supporting 5,000 girls is £1.1m. We appraise a scenario of DFID
providing £3m to this programme, and estimate benefits by pro-rata.
Incremental benefits
Assuming that the 5% management cost differential would translate to 5% lower number of beneficiaries to be
reached by this empowerment component, we estimated 13,015 direct beneficiaries and 33,060 indirect
beneficiaries to be reached as a result of DFID support to this component.
Value for money
Dividing the £3 million planned investment on empowerment by the number of girls and total beneficiaries
reached, we obtain cost per girl reached of £229 and cost per total beneficiary reached of £58 which is higher
compared to option 2 (c), making this option is less cost effective.
Table 33: Cost per beneficiary
Programme duration unit costs
Cost per girl reached through groups
£229
Cost per beneficiary (all)
£58
Table 34provides a summary VfM measures from Option 3(c). Overall the value for money of reaching each
girl through this programme is medium, although it crucially depends on the effectiveness of the programme
which will be determined once evaluations have been completed. The weighted average scoring out of 5 for
this intervention is estimated at 2.5.
Table34:Summary of VFM measures of Option 3(c) Extension of girls’ empowerment programmes
NAO framework
Option 3 (c)
Score out of 5
(1= poor, 5 =
excellent)
Economy
The costs of extending the programme will be relatively low as the existing
programme can ensure that procurement and training are obtained at
favourable costs. However, the unit cost of reaching each girl is relatively high
at £229.
2
Efficiency
The efficiency of expanding the intervention will benefit from the experience
and expertise of CARE and its associated partners and their governance
arrangements, internal financial management, risk mitigation processes etc.
3
Effectiveness
There is little evidence as of yet as to how this programme will impact on the
outcomes targeted by this DFID programme.
2
Equity
CARE targets vulnerable girls, and focuses on the poorest parts of Amhara.
3
Average (equal
weighted) score
C3.4
2.5
Option 3(d): Evidence generation
Incremental costs
Similar to option 2 (d), the incremental costs of the research are estimated at £2.5 million or 10% of the total
budget.
Incremental benefits
There are benefits from this intervention as the knowledge and evidence to be documented by this research
piloting and analysis is expected to lead to methodological and conceptual advances in the understanding
and evaluation of reproductive health interventions and their impacts. We assumed that similar sort of
48
benefits to option 2 (d) will accrue after the end of project.
Value for money
Qualitative analysis using NAO’s framework revealed good VfM for investment in this strategic area as there
is clear evidence gap in a number of areas. It is expected that to this investment will generate operationally
relevant and accessible information which will be used in the design of cost effective solutions to reach the
most marginalized segments of the society. The weighted average scoring out of 5 for this intervention is
estimated at 3 which is acceptable from VfM consideration.
Table35:VfM indicators for Option 3(d) evidence generation
Option 3 (d)
Score out of 5
(1= poor, 5 =
excellent)
Economy
Likely to be good economy, given that it will be tendered.
3
Efficiency
Likely to be efficient if a rigorous TOR fully stating all the needs of an
operational research design and evaluation is defined and implemented.
3
Effectiveness
Depends on the rigour of the design.
3
Equity
It is designed to shed light on vulnerable groups
3
NAO framework
Average (equal
weighted) score
3
C3.5: Summary of Cost Effectiveness and Cost-Benefit Analysis for Option 3: RIF managed by nongovernment organisation ( UN agency or contractor)
As revealed above, we are able to generate cost effectiveness measures for activities a, b and c. Overall we
found out that this option is cost effective though the level of cost effectiveness is lower compared to
delivery through government system (option 2).
Table 36: Summary VfM for Option 3
Option 3 – RIF managed by non-government organisation ( UN agency or Contractor)
3a: Maternal
Waiting Homes
3b: Youth
friendly FP
services
3c: Girls’
empowerment
programmes
3d: Evidence
generation
Option 3
overall
Budget
£9m
£6m
£3
£2.5
£25m
(inc.M&E and
fund admin)
Cost
effectiveness
Cost per birth
£4.69
Cost per DALY
£34.5; cost per
CYP: £10.76
Cost per direct girl
£229;
-
Good
Cost per indirect
benefit. £58
Impacts
1.4m additional
births in safe
conditions *
4816 deaths
averted;
13015 direct
benefits.
15840 total
abortions
averted;
9139 unsafe
abortions
averted
33060 indirect
benefits.
49
Evidence
generated and
disseminated
167171
unintended
pregnancies
averted
Economy
4
2
2
3
2.75
Efficiency
3
4
3
3
3.25
Effectiveness
2
2
2
3
2.25
Equity
4
2
3
3
3
Average 3E score
3.25
2.5
2.5
3
2.81
Leverage of
private sector and
good scale up
opportunities?
High
High
High
High
High
Unquantified
benefits
Better maternal
health outcome;
greater
DALYsaverted
Reduced
household
expenditure,
reduced
national fertility
Risk and
uncertainty (in
terms of meeting
objectives)
Low
Low
Better evidence
for better future
programmes;
more
sustainability
Low
Low
Low
In estimating the aggregate cost benefit measures, we have assumed zero efficiency benefits for this option
as delivery outside of government routes does not build the same level of institutional capacity, and there
would be less efficiency gains by ‘learning by doing’ of government staff.
Accordingly, aggregating the health benefits from MWH, from youth friendly family planning services and the
health care cost savings, resulted in total discounted benefit of £42.3 million. Subtracting from this, the total
discounted cost of £11.9 million resulted in net present value of £30.4 million. This translates to 3.6 BCR, i.e.
£1 investment in Reproductive Health through the UN or a contractor would generate £3.60 benefits to
Ethiopia. This represents VfM but provides a lower net benefit than option 2.
Table 37: Overall Cost Benefit Results for activities 3(a) and 3(b)
Particulars
In Millions of £
PV of Costs
11,881,307
PV of Benefits
42,298,935
-Health Benefits from MWH
4,539,553
-Health Benefits from youth friendly Family planning
services
36981605
-Health care cost savings from youth friendly family
planning services
777,776
-Efficiency gain from system strengthening
0
NPV
30,417,628
BCR
3.6
The VfM assessment for this option should be taken as indicative only as there are many other factors that
could affect it. Which agency is delivering the programme, and which programme will be supported will drive
the VfM. The appraisal looks only indicates that overheads are generally higher in UN agencies or contractors
50
than with government delivery and that efficiencies are less.
C4.
Option 4: Counterfactual - do nothing other than on-going health investment
For this option, there are no new costs to DFID. In terms of benefits, this depends on whether any of the
activities would take place anyway without the programme. If other donors are likely to fund this type of
intervention, it is arguable that such benefits could accrue in the counterfactual scenario. However, there are
no indications that any donors plan to do this at this time.
51
D. Measures to be used to assess Value for Money for the intervention
The table below sets out a range of suggested VfM indicators. These are based on the activities analysed in
the economic appraisal based on a hypothetical set of interventions. Depending on actual programme
activities these or other measures can be used to track VfM through-out the programme life time. In addition
the combination of interventions and their relative cost effectiveness will have to be reassessed in the annual
reviews.
Table 38:Suggested VfM indicators
MWH
Youth friendly FP services
Girls’ empowerment
programmes
Economy
Admin: programme ratio
Construction unit costs; personnel
costs
Commodity unit costs;
administration unit costs for
service provider; staff unit
costs
Administration to programme
costs (should be within the
10% to 20% range)
Accommodation costs
incurred for service delivery
Demand creation costs,
benchmarked against other
programmes in other
countries
Evidence of scale or scope
economies, or benefiting from
sunk costs of existing
infrastructure/cost sharing
Unit cost of mentors; unit
costs of personnel,
administration unit costs for
service provider;
Efficiency
No. women per MWH; degree of
spare capacity in community
groups;
Targeting efficiency – no.
error rates – no. youths
targeted as a % of total
targets; efficiency of use of
products, as measured by
discontinuation rates; no. new
users in sample;
Degree of spare capacity in
community groups;
attendance rates to groups
Effectiveness
No. women using facilities, no.
complications in births in MWH
against that in control group
ANC rate
PNC rate
SBA rate
Demographics of population
targets – in terms of income
group (equity measures),
ethnic groups, marital status,
age, and so forth;
Verification of targets are new
adopters or switchers
Baseline CPR rate
Ex post CPR rate
NPV, Cost per DALY,
collected at ex post
implementation phase, to
verify (or not) initial CBA
findings in business case
Baseline and end line CYPs
score card ranking based on
trend analysis of numbers or
% of people attributing
changes in attitudes and
behaviours to girls as a result
of social
communications/costs of
social communications.
Cost per CYP
Cost per DALY
Cost per unintended
Scoring based on analysis of
trends of ‘actuals’ as well as
performance versus targets
for: ratio of programme to
Cost
effectiveness
Cost per SBA; cost per MWH;
52
Equity –scoring of qualitative
case study analysis of trends
in costs and benefits of trying
to reach most vulnerable 40%
pregnancy averted
management costs; £ per
person reached by social
communications; £ per
person engaging in M&E;
cost per £ scale partner
investments in girls
In general, activities of the RIF will cease to provide good VfM when administrative overheads exceed 20%.
For family planning supply, this activity would not represent good VfM if the cost per DALY exceeded the GNI
per capita of £250. Also, if the targeted beneficiaries were not vulnerable groups, but those that are already
served by service providers, this would suggest that the benefits would not be additional, as the service
provider may be serving them in the counterfactual scenario.
E. Summary Value for Money statement
Table39:Summary VfM comparisons of the two options.
Particulars
Maternal
Waiting Homes
Intervention Activities
Youth friendly Girls
FP services
empowerment
programmes
Evidence
Generation
Option Overall
3.25
3.25
3.0
2.5
3
3
Average Score (out
of 5) on the four E’s
NAO Framework
 Option 2
 Option 3
2.5
2.5
2.94
2.81
Cost effectiveness
 Option 2
 Option 3
Cost per Birth Cost per DALY Cost per direct
of £4.46
of £31
girl of £218
Cost per CYP Cost
per
of £10.22
indirect benefit
of £55
Cost per Birth Cost per DALY Cost per direct
of £ 4.69
of £34.5
girl of £229
Cost per CYP
of £10.76
Cost
per
indirect benefit
of £58
Cost Benefit results
Total
Health
benefits
 Option 2
 Option 3
Health care cost
savings from youth
friendly
family
planning services
 Option 2
 Option 3
Efficiency gain from
system
strengthening
 Option 2
 Option 3
£4.4m
£4.1m
£0.83m
£0.78m
£8.3m
0
53
Summary
Cost
Benefit results
 Option 2
NPV=£40.9 m
BCR=4.4
NPV=£30.4 m
BCR=3.6
 Option 3
As revealed above, Option 2 – RIF managed by the FMOH is the preferred option as it has greater health
benefits in terms of DALYs averted and higher health cost savings compared to option 3. In addition, since
this option works through the government routes and would help build institutional capacity, there would be
certain efficiency gains by ‘learning by doing’ of government staff.
Option 2 appeared to be the preferred in terms of cost effectiveness indicators: cost per birth, cost per CYP,
cost per DALYs averted, cost per girls reached and cost per beneficiaries reached by the empowerment
programme. We found it relatively better from a VfM perspective as it generates £4.4 benefits to Ethiopia for
every £1 spent on interventions aimed at reducing barriers to RMNH services. Accounting for sensitivities
associated with the assumed parameters, option 2 was found to be better in terms of cost effectiveness and
cost benefit analysis as summarized above.
Within option 2, investment on youth friendly family planning services appears to be the most preferred from
VfM perspective. But, we believe that it would be great if all the four strategic focus areas (MWHs, youth
friendly family planning services, empowerment and research) are implemented in an integrated way to make
the option of RIF managed by the FMOH to be more cost effective.
54
3. Commercial Case
A. Procurement/commercial requirements for the intervention
Procurement Routes:
This intervention will require multiple routes in the use of its funding. The greatest amount of funding will
be delivered through indirect routes supported by two arrangements of direct spend; one for technical
assistance and the other for M&E.
Indirect Spend
The majority of the programme will be indirect spend: DFID will transfer the money to the FMOH who will
then provide grants to RHBs and implementing partners such as CSOs and FBOs to provide services.
Regions will develop and submit proposals to the FMOH which will then be scrutinised and selected by
the Ministry’s MCHTWG. The FMOH will then issue a contract and disburse grants to the successful
applicants. The grants will be subject to a monitoring and accountability process in line with the FMOH’s
and DFID’s requirements. The section below on indirect spend provides greater detail on this.
Direct Spend
To assist the successful implementation and financial management of the programme DFID will channel
a proportion of the programme as direct spend by procuring the following:
1. Technical Assistance (TA) to work with the FMOH and regions to:
i)
Support the RHB/CSOs/FBOs to identify the barriers and bottlenecks preventing RMNH service
utilisation in their region and develop proposals to address them.
ii) Develop an operational manual that lays out the procedures for proposal selection, issuing of
grants, financial management at the federal and regional level and procurement procedures.
iii) Assist the FMOH to manage the grant application process;
iv) Assist the FMOH to manage the contracting of the grantees, grant disbursement and
accountability processes;
v) Assist the FMOH by assessing the financial management capacity of the grantees and assisting
them to establish rigorous accounting and procurement systems;
vi) Assist the FMOH to monitor the use of the grants and provide the appropriate financial and
programmatic accountability to DFID in a timely manner ;
vii) Assist the FMOH to monitor and report on progress and document lessons learnt; and
viii) Support the FMOH to build their long term capacity to manage the RIF.
2. A Monitoring and Evaluation (M&E) partner to :
i)
Verify that results have been delivered in accordance to the reports from implementing partners,
RHB and the FMOH;
ii) Assist the FMOH to collate lessons learnt from the grant programmes and disseminate them to
other regions, nationally and internationally as appropriate;
iii) Assist the FMOH , RHB and implementing partners to conduct operational research on removing
barriers and increasing utilisation of RMNH services; and
iv) Conduct the annual reviews and end of project review to meet DFID corporate compliance.
DFID’s Reproductive Health Procurement Framework will not be used to procure suppliers for this
programme as TAis needed to support the FMOH to manage and monitor the grant process rather than
55
directly provide RH services and commodities.
The estimated break down of costs between direct and indirect spend are stated below:
Table 40: Estimated breakdown of expenditure between programme elements
Total estimated
Direct or Indirect
expenditure
% share of budget
spend
Funds channelled
through FMOHfor the
RIF for programme
implementation
£ 21,250,000
85%
Indirect Spend
Technical Assistance
Fees
£ 2,500,000
10%
Direct Spend
Monitoring and
Evaluation Partner
Fee
£1,250,000
5%
Direct Spend
Total
£25 million
100%
B. How does the intervention design use competition to drive commercial advantage for DFID?
There are two aspects to the direct spend that need to be adopted. These are for the TA and the M&E
partner. These are dealt with below in the following sections. The combined value of these contracts is
£3.75 million.
The contracts for the TA and M&E partner will both be results based. The programme’s objectives and
expected results have been laid out in the Appraisal Case and the Impact and Outcome section. The log
frame sets out annual milestone that are expected to be achieved over the lifespan of the programme.
The TOR and the supplier contract will have clauses reflecting the consequences of not meeting the
milestones in time.
The nature of this work does not warrant alternative options to be considered in accessing the supply
chain as competitive bidding in each case is viewed as the most appropriate approach. As the TA role will
be to support and build the capacity of the FMOHand to establish and implement the RIF a single contract
was felt the most appropriate. Frameworks were considered for each requirement but only the M& partner
has a suitable framework available.
Due to the nature of these two contracts no opportunities for collaboration with other donors are yet
identified. There may be additional donor support in the future which can contribute but this has yet to be
established.
The issues of risk transfer between DFID and the supplier will be a core aspect of the contract terms and
conditions. We will work with DFID’s Procurement Group (PrG) to include sufficient clauses to transfer
risks as far as possible and take into account supplier accountability for programme delivery, reporting
requirements, staff capabilities and any possible fluctuations in costs.
The Ethiopian market is not currently ideal to include in the scope and nature of this work which is to
support and monitor the project. However, there may be opportunities to help develop this market and the
TORs will include a request for suppliers to indicate how they may use local resources to deliver VfM
through existing office accommodation and also provide knowledge transfer to help improve the market
capability for the future where such opportunities exist.
C. How do we expect the market place will respond to this opportunity?
Technical Assistance
56
We have consulted with 3 possible international suppliers currently working in Ethiopia to test how the
market would view this opportunity. They responded positively that they would have the capacity and the
appetite to bid for such a tender. The size of the contract and the opportunity of working closely with a
reliable partner such as the FMOH are seen as attractive. There is a competitive market for providing TA
on financial management, granting mechanisms and capacity building to government. Sufficient suppliers
with necessary skills and expertise will therefore be available to ensure meaningful competition.
The range of the TA’s scope of work is broad as it requires expertise in financial management; capacity
development and helping regions identify the barriers to RMNH service utilisation. This will require a skill
set out with the normal financial management companies’ expertise. It is therefore predicted that they
will sub contract this element of work to a RMNH organisation and form a consortium. We will be open to
this. Potential bidders may propose to subcontract one of more of the project activities. However, there
will be management and risks sharing implications of sub-contracting which will need to be considered
during contract negotiations between DFID and the TA.
The need for TA to work in and with the FMOH will provide greater opportunities for the local market to be
engaged. This will strengthen the in country market for these services over the programme’s life span and
enable greater competition in the future.
M&E Partner
We have consulted with 3 of the prequalified suppliers under the M&E Framework Agreement to test how
the market would view this opportunity. They responded positively that they would have the capacity and
the appetite to bid for such a tender. The size of the contract and the opportunity to work within Ethiopia’s
dynamic policy environment are seen as attractive. There is a competitive market for providing expertise
on monitoring and evaluation and there are sufficient suppliers with the necessary skills and expertise
available to ensure meaningful competition.
We do not envisage any particular constraints on capacity in the market however the supplier will need
conduct monitoring missions to insecure areas such as Afar and Somali region. The ability for the supplier
to work in difficult environments and provide duty of care to its staff will be criteria in the TOR. The recent
procurement process for DFID Ethiopia’s Peace and Development Programme and for the monitoring of
other DFID programmes in Somali have demonstrate a williness and capacity of suppliers to work there.
We will be open to the bidder forming a consortium should this be necessary. Potential bidders may
propose to subcontract one of more of the project activities. If a consortium bids for the work, they may
want to divide activities among their agencies. However, there will be management and risks sharing
implications of sub-contracting which will need to be considered during contract negotiations between
DFID and the M&E partner.
Once again there is not yet a strong local market for the provision of these services but it is hoped that
contractors will be able to expose the local market to these skills requirements and thus develop the
market. Potential suppliers will be asked if and how they will be able to pursue areas of knowledge
transfer as well as opening up opportunities within that sector.
D. What are the underlying key costs drivers affecting overall price? How is value added and how
will we measure and improve this?
DFID will need to contract TA and M&E Partners to carry out the roles elaborated in Section A. The cost
drivers behind these contracts will be fuel costs, transport, travel, security costs, staff costs and inflation.
The highest cost driver is staff costs, which are a function of the advisory role and monitoring firm unit
cost of staff time deployed. In addition, DFID may have to cover costs of additional services for the
advisory role (i.e. office accommodation) which will be identified during the bidding process.
Invariably in some areas contractors will have little control over some aspects and so our TOR will ask
how they will manage such instances to ensure that DFID Ethiopia is not subjected to rising cost. We will
look for contractors who propose to utilise the most cost effective approaches to travel and
accommodation as well as those who offer guarantees to ensure that inflation impacts will not be passed
57
to ourselves or other methods that can be employed to ensure these risks are kept to a minimum. Once
in place we will regularly meet with and monitor the programme with contractors initially on a 2 weekly
basis moving to a monthly then on to a quarterly basis to assess programmatic progress, value for money
and management of the cost drivers. Value for money and management of the cost drivers will be
considered at each contract ‘break point’ with the FMOH, TA and M&E partner and to determine whether
the programme is still viable.
To manage the costs and mitigate the risks incurred by the contractors but not met out of their funds (i.e.
which are met by DFID directly and indicated above) we will, where possible, require suppliers to set out
such costs in their tender. We will include such costs within the selection criteria and put in place
governance arrangements which provide DFID with the ability to scrutinise, challenge and take the final
decision on key spending issues. Further, we will explore the opportunities to include incentives within the
contracts which encourage cost-effective delivery (the incentives offered will be discussed with the
commercial advisor prior to TOR being set out).
Value from each of these contracts will come from the efficient advisory role being given by the TA which
will help with the effective distribution of funds through the FMOH. The M&E value will be in providing
evidence that taxpayer’s money is being used effectively and provide flagging opportunities where areas
may be weak so remedial action can be taken. Aspects of the VfM will be under control of the programme
and will be tracked through indicators in the log frame. To enable DFID to manage this process
effectively, we will draw on the resources of a multi-disciplinary DFID virtual team, bringing together
commercial, finance and results expertise. We will also draw on the input of external representatives from
the FMOH where suitable.
The aspects of the VfM for this programme not directly under control are those of the cost drivers.
However, DFID Ethiopia will monitor these extensively and from the evaluation of tender bids will consider
how contractors propose to keep these costs down and insulate DFID from their possible impact.
E. Intended Procurement Process to support contract award
Two approaches will be used to acquire the contractors for each of the work streams. DFID’s
Procurement Group (PrG) will issue a tender for the Technical Assistance partner under OJEU and the
DFID M&E Framework Agreement respectively.
Technical Assistance
Firstly the TA will be acquired through the OJEU using a restricted procedure rather than using TA
provided through a UN agency or INGO. Frameworks held by PrG have been considered but at present
these are not available for the services required otherwise these would have been used. Through OJEU
we will utilise competition to help supportour goal to achieve the best value for money. As stated
engaging TA to support and build the capacity of the FMOH and the regions we will transfer and mitigate
risk of programme delivery and accountability. We will work with PrG to include sufficient clauses in the
contract to transfer risk as far as possible.
The indicative timescales for this work stream are illustrated below:
Activity
Date
1
Approval of BC
December 2012
2
Procurement plan agreed with PrG
January 2013
3
OJEU Notice Published
February 2013
4
Pre-Qualification Questionnaire Response Received
March 2013
5
Issuing Invitation to Tender to qualified bidders
March 2013
6
Bids Submitted
May 2013
58
7
Bid Evaluation complete
June 2013
8
Post Tender Clarification
June/July 2013
9
Contract Awarded
August/September
2013
10
End of Inception Phase and first payment milestone
(operational manual and design of granting mechanism
finalised, logframe finalised)
December 2013
Any procurement done by the TA will be required to follow DFID’s procurement procedures. As some of
the programme will be implemented in unstable environments special consideration will be given to
suppliers that are able to work in fragile environments and can provide a duty of care for their staff.
The selection criteria for the restricted process are shown below but these are indicative and will be
further discussed with PrG once the BC has been approved.
Initial high level selection criteria




Key Personnel-15%
Evidence of Management, advisory roles and quality assurance – 25%
Methodology (including environmental compliance)– 35%
Cost - 25%
M&E partner
The M&E partner will be acquired through a mini-competition using an existing framework held by PrG.
The advantages of the framework are that pre-qualified suppliers are available which will reduce our time
to market, as well as reduce the resources required within PrG, thus helping to support our VfM goals.
The indicative time frame to implement this work is shown as follows. The procurement of the M&E
partner will occur later to allow the procurement of the TA through OJUE and coincide with programme
implementation:
Activity
Date
1
Approval of BC
December 2012
2
Procurement plan agreed with PrG
January 2013
3
Approval of TORs
March 2013
4
Mini tender conducted within the relevant framework
March 2013
5
Bids submitted
April 2013
6
Bids Evaluation started
May 2013
7
Bid Evaluation complete
June 2013
8
Post Tender Clarification
July 2013
9
Contract Awarded
August/September2013
10
Inception phase ended and first milestones completed
(i.e. logframe finalised, M&E framework developed)
December 2013
Initial high level award criteria
 Technical ability to implement the contract-65%
59
 Cost - 35%
These criteria will be more fully developed within the TORs and will be discussed with the commercial
advisor/PrG to ensure that they are in line with the legislative requirements as well as for assessing the
outcome requirements required of the contractor. For now the generic award criteria being considered are
shown below along with the method of evaluation.
The evaluation of all proposals will be undertaken by a multi-disciplinary DFID team and the FMOH
against the following (indicative) criteria:

The quality of the team proposed, including expertise in and experience of:
o working in developing countries, preferably in Ethiopia itself or sub-Saharan Africa;
o working in the relevant area of intervention (advisory, health and monitoring as
appropriate), using the relevant tools;
o delivering DFID’s priority objectives;
o advisory/monitoring capability and capacity





The quality of the implementation proposals, which will be assessed for
o Understanding of TOR and deliverables;
o Development of a clear, evidence based approach clearly linking to results
o Credibility of plans to deliver superior programme outputs
Cost
Terms for payment – potentially including proposals to manage performance on an outcome rather
than output basis;
innovation – methodology set out for delivering the desired outputs and outcomes;
Approach to financial and performance monitoring and evaluation – including methodologies for
supplying data will be supplied to DFID in a clear and transparent way
The approach to procurement will be developed in parallel to the business case approval process, so as
to commence immediately after business case approval and PrG’s approval of the TORs.
F. How contract & supplier performance will be managed through the life of the intervention
Two different contracts will be managed for this work. Clear TORswith clear deliverables will be used to
support the contracts. Each contract will contain clear roles and responsibilities which will be adopted to
manage the contracting partners. Contracts will reflect the needs of the programme along with the quality
of its outputs to be assessed as part of on-going management of the programme (including periodic
fiduciary risk assessment monitoring processes).
Each contract will be developed so that the contracting partners will be required to take ownership of key
performance indicators (KPI), targets and baselines which will form the basis for performance-based
management of the supplier by DFID.
Technical Assistance
As stated above the performance of the TA will be monitored with the FMOH through quarterly meetings
and annual reviews. To incentivise good performance payments will be made on meeting specific KPI and
milestones. Initial KPI will be outlined in the TORs and then further developed during the post tender
contract negotiations. KPIs will include establishing and operating of the granting mechanisms,
developing the programme’s operational manual, programmatic and financial reporting, and management
of the cost drivers.
DFID will consult with the FMOH, suppliers in the regions and the RHB to assess whether KPI and
milestones have been met before payment is made. Invoice payments will only be made on the
satisfactory approval of the programme manager and the budget holder using Aries to provide an audit
trail of the process. The M&E partner will also verify results on the ground and provide periodic
60
evaluations. Awards for exceeding expectations may be considered in consultation with PrG colleagues
and incentives to avoid delivery failure (withholding a % of payment until milestone or output successfully
delivered) will be articulated in the contract between DFID and TA. The contracts will be for the length of
the programme and include annual reviews with break clauses for failure or non-compliance with an
escalating mechanism to ensure compliance with the contract is maintained through an agreed channel.
Annual supplier appraisals will be conducted and changes made to the contract as appropriate. Variations
to the contracts will be made as necessary and conducted in cooperation with DFID’sPrG. Any price
changes will need to be approved through a formal process and facilitated through a variation of contract.
Such variations will also be used during the life of the contract to make adjustments that may be required
during its life, such adjustments being identified and agreed though regular meetings with the supplier.
M&E partner
This contract will follow much of the same pattern. The charging model will be dictated by the contract
and the framework agreement and linked to successful achievements of the KPI. DFID will monitor
progress against their work plan on a quarterly basis and assess performance through the annual review
process. DFID will consult with the FMOH, suppliers in the regions and RHB to assess whether KPI and
milestones have been met before payment is made. We will also draw on the expertise of DFID Ethiopia’s
results adviser to quality assure their reports. Due to the nature of the work we do not foresee any
opportunities for using incentives in the contract but this will be reviewed annually. The contracts will be
for the length of the programme and include annual reviews with break clauses for failure or noncompliance. Annual supplier appraisals will be conducted and changes made to the contract as
appropriate. Variations to the contracts will be made as necessary and conducted in cooperation with
DFID’sPrG.
For both contracts appropriate resources will be allocated from DFID Ethiopia’s Human Development
Team for the life of the contract. Members of the Human Development Team will attend contract
management training to ensure they have the skills and understanding to manage the contract. DFID
Ethiopia’s Commercial Adviser and DFID’sPrG will support the Human Development Team to monitor
supplier’s performance and be involved in the quarterly monitoring meetings.
Annual, mid-term and end of project reviews will be conducted by the M&E Partner to monitor and
address the performance of the programme and the TA.The FMOH will be consulted through the contract
management process.
Indirect Spend
A. Why is the proposed funding mechanism/form of arrangement the right one for this
intervention, with this development partner?
The Strategic and Appraisal cases explain why we have chosen to channel the majority of this
programme’s spend through the FMOH. This will enable the government to have ownership and
leadership over the programme and build up contractual arrangements with RHB/CSO/FBO that will
increase coordination and accountability of RMNH service providers in the country. It will also help build
up the sustainability of demand side funding for RMNH services as funds will become part of the
government’s overall health budget. This indirect spend will be governed by a MoU with the FMOH and
DFID Ethiopia.
The FMOH oversees Ethiopia’s Regional Health Bureaus which in turn oversees the woreda or district
health authorities. CSO/FBOs working on health in a region and woreda are required to register with the
authorities thus creating a network of service implementers across the country. This network will facilitate
the programme’s implementation, and by placing the FMOH in charge of the RIF, will ensure any activities
are complementary to the overall health plans of the region/country. Building on this existing network
rather than creating a new one will help speed the programme’s implementation and deliver better value
for money.
61
The FMOH has both the technical and commercial capacity to offer sustainable quality which represents
VfM though out the life of the programme. The FMOH has a proven track record of using DFID funds in
the MDG PF to procure goods and services in line with government guidelines. External Audits 59 have
demonstrated FMOH’s capacity to spend our resources correctly, procure goods on time and at good cost
and to provide satisfactory accounts and reports. The EDHS has shown significant progress in reducing
child mortality which is attributable to the FMOH’s leadership and provision of services through the RHB
and woredas. FMOH also has a proven track record of providing grants to CSOs to deliver immunisation
services with GAVI funding. The FMOH has recently established a Grant Management Unit to ensure
they have sufficient human capacity and expertise to manage donor grants. The provision of TA by this
programme will help strengthen this capacity further at the federal, regional and implementation level.
DFID participation in the sub -committee of the MCHTWG will enable us to monitor the programme on a
regular basis and be involved in key decision making. This will give us the opportunity to interrogate a
range of issues such as costs, grantee selection, performance and accountability. The M&E partner will
undertake verification missions to ascertain the validity of grantee’s reports and monitor value for money.
Key decision points in the programme’s life will be the agreement of the operational manual that will lay
out the grantee process, financial management procedures, accountability and monitoring processes; the
selection and issuing of grants on an annual or semi-annual basis; the receipt of accountability and
progress reports and the annual audits and reviews.
B. Value for money through procurement
Any goods or services procured with the indirect spend will be in line with the FMOH’s procurement
procedures. The FMOH follows theGOE procurement guidelines which have been approved by the World
Bank. As stated above the FMOH have demonstrated their ability to use DFID’s funds correctly in line
with these guidelines and deliver value for money. The FMOH’s procurement capacity was assessed in
the independent Financial Management Assessment (FMA) in November 2011 and in a procurement
audit of 2010. The studies identified some weaknesses that have since been acted upon such as
developing national procurement guidelines for pharmaceuticals, strengthening the capacity of internal
audit, sharing of external audit reports by the GFATM and others. A report in September 2012 reported
significant action has been taken on the FMA’s recommendations and that the FMOH commercial
capability is improving. We continue to monitor the implementation of the FMA’s recommendations and
the FMOH’s annual procurement audits.
The RHB and implementing partners that receive grants will also be required to follow the GOE
procurement procedures. An operational manual will be developed by the programme that will outline
financial management and procurement procedures that the implementing partners will be required to
follow. Due to the wide range of possible implementing partners their capacity to spend resources on time
and procure goods and services is less known. Implementing partners will be required to provide
evidence of their capacity to utilise and account for funds in their proposals. To mitigate risk the
programme will employ TA to assess partners’ financial management capacity and to work with them to
ensure that any procurement follows the GOE guidelines.
The programme’s objectives and expected results have been laid out in the Appraisal Case and the
Impact and Outcome section. The logframe sets out annual milestone that are expected to be achieved.
These results will be laid out in the MoU between DFID and the FMOH. DFID will use the logframe and
annual milestones to monitor progress with the FMOH through annual reviews. Subsequent funding will
only be released to the FMOH upon satisfactory progress against the logframe milestones and
satisfactory reporting and accountability. The annual reviews will provide ‘break points’ in the programme
if it is believed that the programme is no longer viable. This will be reflected in the MoU between FMOH
and DFID.
59
Audit Services Corporation, The Health Sector Development Programme The Federal Ministry of
Health MDG Program Audit Findings and Recommendations on the accounts for the year ending 7
July 2011.
62
The FMOH will be procuring a range of services in the regions to improve RMNH outcomes. The key cost
drivers behind service delivery are salaries, fuel costs, price of assets (i.e. computers, vehicles), security
costs and inflation. Value for money will come from creating a competitive process between implementing
partners in the regions to provide services. Costs of proposals will be examined closely during the
application screening process and compared to drive down cost. Grants will be monitored and managed
by the FMOH, with the support of the TA, to drive down costs and achieve efficiency savings.
It is recognised that delivering services in insecure areas, such as Somali and Afar, is more expensive
than in more secure regions. However DFID’s Peace and Development Programme and other
programmes in Somali will provide us with comparisons so that we can judge whether proposals are
reasonable.
The mapping exercise identified a significant funding gap and numerous organisations working in RMNH
and social empowerment programmes in Ethiopia. It also demonstrated that there is significant interest
and capacity of these organisations to expand their activities to meet the objectives of this programme.
We have confirmed this through consultation with a range of partners in the sector. We are therefore
confident that the market will respond positively to the FMOH’s call for proposals and that there will be a
competitive market for providing the range of RMNH services and social empowerment activities required.
The presence of RDA, international and local NGOs in the regions means that there are sufficient
suppliers with the necessary skills and expertise to ensure a meaningful competition. The availability of
funding for RMNH and social empowerment activities is an opportunity to develop the local market and
economy further.
Working in Afar and Somali regions will require organisations to be able to work with pastoralist
communities in insecure settings. This may restrict the number of organisations able and willing to apply
for funding for activities in these regions. However the recent procurement of a supplier to implement
DFID’s Peace and Development Programme in Somali demonstrated that there are a range of NGOs who
do have the expertise and experience and that a competitive process is possible.
Due to the range of activities needed to increase service utilisation it is likely that NGOs and RDA will
form consortiums. We will be open to this but will also monitor the number of separate grant applications
coming from the regions to ensure the process remains competitive. Potential bidders may propose to
subcontract one of more of the project activities. If a consortium bids for the work, they may want to divide
activities among their agencies. However, there will be management and risks sharing implications of
sub-contracting which will need to be considered during contract negotiations between the FMOH and
implementing partners.
The FMOH will contract implementing partners in the regions to deliver services against agreed results.
Methods to incentivise performance will be explored although the scope of only paying on delivery may be
limited. Due to the funding constraints of CSOs/FBOs, not providing funding up front may deter many
local CSOs/FBPs from applying for grants. Awards for exceeding expectations or non-payments for failure
to deliver will be articulated in the programme’s operational manual. The provision of TA to the FMOH will
ensure that they have the capacity to manage the agreements with in the MoU with DFID and also
manage the contracts with the implementing partners in the regions.
We have discussed this programme with other donors. Whilst supportive of the initiative they are unable
to provide funding at this time. As laid out in the economic appraisal channelling the majority of the
programme’s funds through the FMOH rather than through the TA or another agency (i.e. UN or a
contractor) will reduce cost and drive value for money. By creating a fund that regions/implementing
partners have to apply for will create competition and drive commercial advantage for DFID and the
63
FMOH. DFID is transferring the risk of programme delivery and accountability by the grantees to the
FMOH. The provision of TA to the FMOH and regions will help support the FMOH in their role and
mitigate the risk of poor delivery.
Whilst this programme will not result in any policy development it is operationalizing a principle set out in
the HSDP to work with the non-governmental sector and increase accountability of implementing partners
to RHB and FMOH.
4. Financial Case
A. The costs, how they are profiled and how they will ensure accurate forecasting
DFID will provide up to £25 Million over four years: 2012/13-2015/16. The estimation is based on
experiences managing similar kind of programmes by DFID Ethiopia. The estimated breakdown of costs by
year is as follows:
Table 41: Estimated costs per year
UK FY60
Programme
Management
Evaluation
Total %
2012/13
20%
2.5%
1%
23.5%
2013/14
21.4%
2.5%
1%
24.9%
2014/15
22.1%
2.5%
1%
25.8%
2015/16
21.5%
2.5%
2%
26.3%
85%
10%
5%
100.00%
Total
£21,250,000
£2,500,000
£1,250,000
£25,000,000
Initial forecasting will be based on estimates of progress and past experience of managing similar
programmes. These will be revised once proposals have been received and approved. This will give an
indication of expected programme spend in the financial year.The rate of spend and ability of the
programme to meet its forecast will be monitored by DFID, the FMOH and TA each quarter and forecasts
altered accordingly.
B. How it will be funded
The programme will be funded from DFID Ethiopia’s programme resources allocation and has been
budgeted for in the DFID Ethiopia Operational Plan up to 2014/15. It is assumed that resources will be
available in 2015/16.
There are no contingent or actual liabilities.
60FY
= UK financial year (1 April – 31 March)
64
C. How will funds be paid out
Funding will be channelled to3 recipients: the FMOH, the TA and the M&E partner. This funding will be
used to fund programme implementation. DFID will channel the funds to FMOH twice a year as non-budget
support financial aid. The amount of funding will be determined by the number and size of proposals
submitted and approved by the MCHTWG.FMOH will provide quarterly financial reports highlighting
progress and annual progress reports against the milestones in the log frame. Funds will flow from the
FMOH to implementing partners ( RHB, CSOs, FBOs, RDA) as grants and will be bound by contracts. The
grants will be managed by the Grant Management Unit in the FMOH with the support from the TA.
Payments to the TA and the M&E partner will be governed by the terms of the contracts between them and
DFID. Payments will be made based on the achievement of KPIs. Frequency of payment may vary but will
not be more frequent than quarterly.
D. Assessment of financial risk and fraud
DFID Ethiopia’s most recent Fiduciary Risk Assessment of the Federal Government of Ethiopia, completed
in April 2012, gave an overall assessment of fiduciary risk as moderate, with the risk of corruption also
assessed as moderate. The World Bank has issued a corruption report on the public financial system of
the FMOH. This report has provided information that the fraud and corruption rate in the public financial
system of the FMOH is relatively low61.We consider the risk of this programme as lower than that assessed
in our Fiduciary Risk Assessment as our funds will be managed in a separate account within the FMOH
and not co-mingled with other donor funding. In addition the funding will be released against specific
proposals that DFID and others have approved through the MCHTWG . Funds will be reported on against
the approved budgets and subject to external audits. The presence of TA working in the FMOH and the
new Grant management Unit will add another layer of assurance that funds are used for their intended
purpose.
The main fraud risks in the programme are in the expenditure by the implementing partners, some
examples of which are:

Theft of funds within the implementing partners;

Misuse of funds by implementing partners – expenditure on activities not part of the contract; and

Fraudulent claims by implementing partners for activities that have not taken place.
Project management and the monitoring and accounting of financial expenditure will be designed to
mitigate these risks. The FMOH and TA will submit quarterly financial reports and annual audited accounts
for each of the financial years covered by the project. The TA will be recruited through OJEU process with
TOR that will clearly require the suppliers to provide supporting evidence on their track record of financial
management capability.
The TA will be responsible in carrying out due diligence check of the implementing partners that will
receive the funds. In addition it will provide technical support to RHBsand implementing partners on
financial management and reporting to ensure spending and management is according to the operational
manual and DFID’s requirements. The TA will closely monitor and report on the rate of spend and the
progress of activities. Any delay of financial reports or unsatisfactory reporting will result in the delay of any
future payments to the FMOH.
In addition, FMOH will be required to open a separate bank account so that funds will not be mixed with
other resources. FMOH will be responsible for having the financial statement of the programme audited
annually and for submitting the audit report and management letterwithin six months of the end of financial
year.
61Diagnosing
Corruption in Ethiopia: Perception, Realities and the Way forward for key sectors, WB 2012
65
E. How expenditure will be monitored, reported, and accounted for
The FMOH with the assistance of the TA will provide quarterly financial reports on the disbursement and
rate of utilization of funds by the implementing partners. In addition to these quarter reports, the FMOH will
submit annual independent audit statement and the management letter to DFID.
Primary accountability for funds will rest with the DFID Ethiopia and FMOH, however DFID will hold project
partners accountable through agreed formal reporting processes. Progress reports will be provided by the
TA in collaboration with the FMOH against agreed annual and six monthly milestones.
Monitoring and evaluation costs have been factored into the costs of the project.
66
5. Management Case
A. Management Arrangements for implementing the intervention
The RIF will be managed by the FMOH with the support of TA (see below):








The RIF will be governed by the MCH TWG in the FMOH. Membership of this committee includes
Directors of the FMOH, technical partners ( UN and International NGOS) and development partners
including DFID.
A sub committee of the MCH TWG will be formed to manage the operations and functioning of the
RIF. This will be supported by the TA and will : developing the RIF operations manual, issue the
call for proposals, select proposals and make recommendations to the MCH TWG; managing grant
disbursement, and collating expenditure and programme reports for submission to the MCH TWG.
The sub committee of the MCH TWG and the TA will collaborate with health sector authorities at
national and sub-national levels on the implementation and monitoring of activities.
The TAwill report to an identified Director in the FMOH and to the Senior Health Adviser in DFID’s
Human Development Team.
Funds will be disbursed to implementing partners in the form of accountable grants, the terms of
which will be formalised in a contract. Mechanisms for grant disbursement will be designed to be
transparent, efficient and cost-effective and based on effective management of fiduciary risk.
Government departments, RHBs, and other public sector institutions such as RDAs, UN agencies,
CSOs/FBOs and private sector organisations that have demonstrated adequate financial
management and implementation capacity will be eligible to receive funding from the RIF on a notfor-profit basis.
Proposals will be invited from organisations on an annual basis and will be submitted to the RIF as
follows:
▬
Stage 1: Submission of a project concept note which must meet the thematic and technical
criteria of the RIF and be consistent with HSDP IV. These willbe appraised by a Technical
Advisory Group (TAG) comprising technical RMNH experts from a range of organizations to be
selected by the MCHTWG subcommittee and approved by the FMOH. If successful the
applicants will be invited to develop a full proposal.
▬
Stage 2: Submission of a full proposal (that includes a technical narrative, workplan and
budget) to be evaluated against a set of published criteria. Those bidding for resources will
need to demonstrate the evidence-base, how the intervention will add value and deliver
specified results, and demonstrate non-duplicationof existing programmes.
Design of the RIF and participation in the MCH TWG and sub committee
guidelines to prevent conflict of interest.
will include clear
The primary stakeholders are those who will benefit from increased RMNH information and services to
enable them to make informed choice on their reproductive health. This includes girls and young women,
youth and their communities in rural areas. Secondary stakeholders include health workers and
implementing providers who will benefit from support.
A separate contract will be let to aM&E partner to perform annual evaluations and document and share
lessons learned and increase the knowledge base for the country. Evaluation will help standardise how
results are measure.
In addition to participating in the MCHTWG DFID will meet the FMOH, TA and M&E partner each quarter
to assess progress against their work plans and resolve any bottlenecks.
67
Figure 2 Management of the Reproductive Maternal and Neonatal Health Innovation Fund
Maternal and Child
Health Technical
Working Group
DFID Ethiopia
RIF sub
committee&
TAG
M&E partner
Technical
Assistance
Regional
Health Bureau
led by
RMNHRIF
Innovation
FMOH
Fund within the
Federal Ministry of
Health
External
Audit
Woreda Health
Office
District level
Media
NGOs,
CBOs
FBOs
Academia
Communities, community organisations, schools, HEWs, HDAs
68
B. Perceived risks and how these will be managed
The overall risk rating for this programme is medium. The anticipated interventions are based on good
evidence and complement existing programmes. Management arrangements will ensure relatively tight
control. However adolescent sexual and reproductive health and family planning and entrenched cultural
practices are sensitive areas to address. The programme will use innovative approaches with the aim of
producing new evidence: these are, by their nature, at higher risk of not producing all the predicted
benefits.
Table 42: Risk mitigation matrix
Risks
Probability
Impact
(3 high, 1 low) (3 high,1 low)
Mitigation strategies
1. Community opposition from
traditional/religious leaders to
RMNH
2
2
Advocacy at community and woreda levels to
engage key opinion leaders (including faith
groups). Evidence from existing programmes
suggests communities are receptive.
2. Lack of government support for the
programme,
1
3
The programme has been designed with full
consultation and is fully aligned to HDSP IV
and strategies to achieve MDG 4 and 5.
3. The RIF does not lead to proposals
of satisfactory quality
1
3
There are many RMNH stakeholders who
have expressed interest in expanding their
reach and who have implemented effective
interventions.
4. Demand creation creates a parallel
system to national effort through
HAD
2
2
Ensure all contractors follow national
guidelines e.g. the standard packages of the
health extension programme
2
Increased support to the MDG PF provides an
option for FMOH to supplement supplies of
commodities. Planned investment will increase
supply of skilled health workers and health
facilities
2
The RIF will be managed as a separate bank
account within the FMOH and not pooled with
other funding. The use and accountability of
the funds will be clearly laid out in an
operational manual developed by the TA and
approved by the FMOH’s senior management
and DFID. Quarterly financial reports and
annual programmatic reports will be submitted
to DFID as well as annual audited statements.
DFID will monitor the use and accountability of
funds closely in accordance to corporate
requirements. DFID and the M&E partner will
verify that activities have taken place through
regular programme monitoring and annual
reviews and programme evaluations.
3
Existing programmes to make maternity
services more women friendly have been well
received by trainees. Close monitoring of
changes in practice and enhanced
accountability through provider-community
dialogue.
3
The programme will look at demand and
behavioural issues in adolescents and address
some of the cultural barriers affecting women
of all ages.
5. Increased demand for RMNH
services is not matched by
increased supply
6. Financial risk and fraud
7. Health workers are resistant to
adapt birthing practice to meet
needs of women
8. Interventions to make services
more accessible and culturally
appropriate do not lead to
increased demand
2
1
2
1
69
9. Operational research and other
evidence is not taken up into
practice
2
2
70
The programme will work within national
guidelines and be overseen by a national
body. Coordination and information sharing
amongst academics and policy makers will be
strengthened. There will be a strong emphasis
put on the quality of research and evaluation.
C. What conditions apply(for financial aid only)
Ahead of disbursements of funds to the FMOH, DFID will assess performance against the UK’s four
partnership principles:
i.
ii.
iii.
iv.
Poverty reduction and the Millennium Development Goals;
Respecting human rights and other international obligations;
Improving public financial management, promoting good governance and transparency and fighting
corruption; and
Strenghtened domestic accountability.
D. How progress and results will be monitored, measured and evaluated
The logframe for this programme can be found on Quest 3745986. This contains preliminary
output targets that will need to be finalised during the programme’s inception period.
While there is extensive evidence of the most effective approaches to improve RMNH there is less
evidence of effective context specific solutions in Ethiopia. This intervention is a major part of DFID
Ethiopia’s programme for improving reproductive health outcomes which itself will contribute significantly
to DFID’s global results in this area. Over recent years there have been improvements in availability and
quality of health information from both survey and administrative sources but more can be done
particularly to improve the frequency and level of detail of the data.
Reflecting this broader context DFID will invest in a dedicated monitoring and evaluation component for
this programme to supplement existing FMOH systems.
DFID will contract an independent M&Epartner to support the FMOH in the following areas to:
 Provide feedback and make recommendations for improvement to the overall monitoring and
evaluation framework;
 Make recommendations for any supplementary data collection requirements arising from the
finalised framework;
 Undertake any recommended additional data collection where it is not feasible to utilise FMOH
systems including, potentially, beneficiary feedback and results verification;
 Collate lessons learnt, document best practices and disseminate among implementing agencies;
 Undertaking DFID Annual Reviews and Project Completion Report; and
 Conducting a full mid-term and end-term evaluation
The Terms of Reference for the contract for M&E provider will be agreed within one month of approval of
this business case with a view to the framework being developed in parallel with the inception period of
the programme itself. The M&E partner will be expected to collaborate with the FMOH and the TA in the
design of any additional monitoring requirements.
We anticipate that the overall costs associated with M&E will be around 5% of the overall programme
budget. The contract will be tendered via DFID’s Global Evaluation Framework Agreement.
Monitoring
The programme log frame will be the primary tool for on-going monitoring of programme milestones and
outputs. The logframe has a small number of gaps of milestones and regional targets. Regional targets
are set on annual basis and will be available and incorporated into the logframe on a yearly basis.
71
Theprincipal users of the monitoring information will be DFID and the FMOH who will use it to ensure
effective management of the overall programme but we would envisage a wider range of interest from all
key RMNHstakeholders.
At the impact and outcome level the log frame sets out indicators and associated milestones and targets
based on national RMNH targets and indicators taken from the HSDP and Ethiopia’s Growth and
Transformation Programme. The logframe also identifies baselines for these indicators in each of the
suggested focal regions. Once the regional focus is agreed we will work with the FMOH to develop
baselines and expected trajectories for these indicators. We expect that these will be agreed within the
inception period.
Data for tracking progress at impact and outcome level will be drawn primarily from EDHS which is
regarded as robust and of international standard. Ethiopia now has 3 DHS ( 2000, 2005, 2011) and will
conduct a mini DHS on maternal health in 2014. A full DHS will then be conducted again in 2015. This will
generate national level and regional level data for most of the indicators. Some will also be disaggregated
for age and economic quintile.
Administrative data from the government’s Health Management Information System (HMIS) is weak and
covers80% of the country. Efforts are underway to strengthen the HMIS and improvements are likely to
be seen over the programme’s time frame. DFID, as well as other donors are supporting the
strengthening of data collection in the health sector through our investments in the Protection of Basic
Services Programme and MDG PF.
Progress against the output level indicators identified in the logframe will rely more heavily on data
emerging from HMIS and, potentially, bespoke data collection systems to be assessed as part of the
initial work of the M&E partner.
The implementing partners will also be required to collect and submit data as part of their grant reporting
and accountability responsibilities. They will need to show how they propose to systematically collect data
and monitor progress against milestones and targets in the intervention level log frame. Where possible
this should be done in a way that reinforces and strengthens the government’s own management
information system, although additional data collection systems may be required. The M&Epartner will be
responsible for assessing the robustness of implementing organisations’ data reporting and for verifying
results.
Annual reviews and the final project completion report will be conducted according to DFID procedures in
collaboration with the FMOH, the TA, RHBs and implementation partners to provide assurance to DFID
that the programme is achieving good value for money and making consistent progress towards achieving
targets.
The M&E partner will involve beneficiaries in annual reviews to capture their voices and experiences. This
will help to test assumptions and measure progress against set results, milestones and indicators.
Evaluation
DFID Ethiopia’s evaluation strategy sets out a range of criteria which it will use to assess evaluation
priority across its programme. The programme is of major strategic importance being a key component of
DFID Ethiopia’s overall RMNH programme which makes up a significant contribution of DFID’s overall
global expected results in this area. The programme also scores heavily in terms of coherence with
government’s own evaluation agenda. On the other hand the programme is relatively small in value and
while there are some innovative elements, particularly in a local context, the overall evidence base is
reasonably robust; overall risk is assessed as medium. Together these factors suggest that the
programme is given medium priority within the evaluation strategy.
This programme is one of range of government and donor funded interventions across Ethiopia aimed at
accelerating development results across all areas of RMNH. As such it may be difficult to isolate the
72
particular contribution of any single intervention to these results. DFID is considering how it may develop
a thematic evaluation to measure the combined impact of all of its programming in this area.
This particular evaluation will focus primarily on determining the effectiveness of the programme in
delivering the identified outputs and, where possible, the extent to which any progress against the
expected outcomes can be attributed to the programmes interventions. The evaluation will also assess
the overall value for money for the programme by testing the cost benefit assumptions set out in this
business case and measuring progress against the identified VFM metrics.
A full evaluation framework will be developed by the M&E partner working alongside the FMOH and TA
to establish baselines and any additional data requirements including proposed methodology and tools
The RIF will consider supporting proposals that include an operational research component and could
contribute to increasing the evidence base on what works in the Ethiopian context. The
MCHTWGsubcommittee will refer to the overarching evaluation framework when considering support to
operational research to ensure it is in line with priorities. They will liaise with the M&E partner to assess
the relevance and quality of operational research proposals. The M&E partner will then work with the
implementing partner to ensure robust data collection and analysis and assist the programme to collate
the lessons learnt.
Indicative evaluation questions based on the DAC criteria for evaluation (relevance, effectiveness,
efficiency, impact and sustainability) are set out below. As noted previously the exact questions will be
agreed during the early stages of programme implementation.
Relevance:
 To what extent is the design of the programme appropriate and relevant in view of the existing
RMNH policy environment?
 Is the programme complementary to existing government and development partner programming
in this area or is it creating conflict with existing programmes?
Effectiveness: To what extent does the programme…
 …empower young women and girls to make healthy reproductive health choices?
 … improve community attitudes to RH needs of youth?
 …increase knowledge and evidence of innovative new RH approaches?
 … reduce disparities in use of RH services between states?
 …increase supply of culturally acceptable and appropriate RH services?
 … enhance accountability of service providers to communities and women?
Efficiency:
 Which of the programme interventions are showing the strongest results? How can the
programme build on or expand these successes?
 What efficiencies are resulting from the combination of interventions? To what extent are they
mutually reinforcing?
 Do the emerging results justify costs? Could the same results be achieved more cost effectively?
 How is value for money considered in the overall governance of the programme?
Impact:
 Has there been any change in the use of RMNH services by the poor and other socially excluded
groups? How does this vary across regions? To what extent can this be attributed to the
programme?
 Has there been any change in the level of unwanted pregnancy and/or safe pregnancy and
childbirth by the poor and other socially excluded groups? How does this vary across regions? To
what extent can this be attributed to the programme?
Sustainability:
 How replicable and scalable is the programme design, delivery and partnership model?
73

Is the intervention supported by local institutions and well integrated with local social and cultural
conditions?
In addition to addressing the above questions the mid-term evaluation at the end of year two will provide
an overall assessment of progress in delivering the stated outputs andthe extent to which the expected
outcomes are on-track outlining any lessons learned and recommendations for corrective action.
The end of programme evaluation will seek comprehensive evidence on the answer to each of the agreed
evaluation questions with a view in particular to identifying positive change attributable to the programme
and the extent to which these can be replicated elsewhere.
The RIF monitoring andevaluation will be conducted by an independent evaluation partner. This partner
will be selected through a competitive tender and contracted/managed directly by DFID Ethiopia. The
evaluation partner will share their work plans and reports with the MCHTWG that includes government,
NGO and donor representatives, including DFID. As the performance of the TA partner and FMOH who
is primarily managing the grant is itself subject to evaluation, the TA partner will facilitate (e.g. logistical
support) the evaluation but will play no direct management role in the evaluation to reduce any conflicts of
interest.
74