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Submission Date: August 19, 2022
Revised Version: September 22, 2022
Final Version: November 1, 2022
Submitted to: 
USAID/Ethiopia 
Gebeyehu Abelti, COR
Submitted by: 
The Mitchell Group, Inc. (TMG)
Contract Number: OAA-I-15-00028 Task Order No.: AID-663-TO-17-00001
Transform: MELA Activity, Addis Ababa, Ethiopia
Michael Midling, PhD, Chief of Party/Principal Investigator
Email: mmidling@ethiopiatmela.com 
Phone: +251- 986356914
Principal Contact:
Abi Fasosin, Senior Advisor 
Email: abif@the-mitchellgroup.com
Phone: +001-202-557-9412 (Direct)
This document was produced for review by the United States Agency for International Development Ethiopia 
(USAID/Ethiopia). It was prepared by The Mitchell Group, Inc. (TMG) for USAID/Ethiopia for the Transform: Monitoring, 
Evaluation, Learning, and Adapting (Transform: MELA) Activity.
TRANSFORM MONITORING, EVALUATION, LEARNING 
AND ADAPTING (TRANSFORM MELA) ACTIVITY
FINAL PERFORMANCE EVALUATION OF
TRANSFORM HEALTH IN DEVELOPING REGIONS (HDR) ACTIVITY
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ACTIVITY INFORMATION
Activity Title TRANSFORM: MONITORING, EVALUATION, LEARNING 
AND ADAPTING (TRANSFORM: MELA): ACTIVITY
Contract/Task Order Numbers
Contract No.: OAA-I-15-00028
Task Order No.: AID-663-TO-17-00001
Name of Prime Implementing 
Partner
The Mitchell Group, Inc. (TMG)
1816 11th Street, NW, Washington, DC 20001
Tel: 202-745-1919
Activity Start Date March 7, 2017
Activity End Date August 31, 2022
Period of Planning and Conducting 
the Evaluations 
September 1, 2021 – August 31, 2022
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TABLE OF CONTENTS
ACRONYMS AND ABBREVIATIONS iv
Abstract 6
1) EXECUTIVE SUMMARY 6
2) BACKGROUND AND CONTEXT 13
3) EVALUATION PURPOSE AND EVALUATION QUESTIONS 15
Evaluation Purpose 15
Evaluation Questions 16
Audience and Intended Uses 16
4) EVALUATION METHODS, ETHICAL CONSIDERATIONS AND LIMITATIONS 16
4.1. Sampling of Woredas 17
4.2. Sampling of Households 17
4.3. Sampling for Health Facility Survey 18
4.4. Selection of Key Informants 18
4.5. Data Collection Methods 19
4.6. Data Analysis 20
4.7 Ethical considerations 21
4.8 Limitations 22
5) FINDINGS 23
5.1 How effective were the Transform HDR Activity approaches in contributing to 
improving MNCH/FP outcomes? 23
5.2 How and to what extent did transform program activities facilitate local 
ownership, sustainability, and coherence? 44
5.3 How did Transform Activities consider gender dynamics in activity design and 
implementation? What gender equity results did Transform Activity interventions 
achieve? 48
5.4 How and to what extent have the Transform IPs been able to adapt their 
interventions about learnings and new evidence? 50
6) Conclusions 54
7) Recommendations 56
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ANNEX 1: EVALUATION QUESTIONS AND DATA SOURCES 61
ANNEX 2: TRANSFORM HDR ACTIVITY RESULT FRAMEWORK 64
ANNEX 3: GLOSSARY 65
ANNEX 4: TRANSFORM HDR INTERVENTION ACHIEVEMENT AT ENDLINE COMPARED 
TO TARGETS 67
ANNEX 5: LIST OF PERSONS INTERVIEWED 69
ANNEX 6: BIBLIOGRAPHY OF DOCUMENTS REVIEWED 70
LIST OF FIGURES AND TABLES
Figure 1. Performance for family planning KPIs at baseline, endline and against LOA target (left) 
and Performance trend (right) in Transform HDR intervention areas 15
Figure 2. Performance for family planning KPIs at baseline and endline by Transform and non￾Transform intervention areas 16
Figure 3. Performance for maternal health KPIs at baseline, endline and against LOA target (left) 
and Performance trend (right) in Transform HDR intervention areas 17
Figure 4. Performance for maternal health KPIs at baseline and endline by Transform and non￾Transform intervention areas 18
Figure 5. Performance for newborn health KPIs at baseline, endline and against LOA target (left) 
and Performance trend (right) in Transform HDR intervention areas 19
Figure 6. Performance for newborn health KPIs at baseline and endline by Transform and non￾Transform intervention area 20
Figure 7. Performance for preventive child health KPIs at baseline, endline and against LOA target 
(left) and Performance trend (right) in Transform HDR intervention areas 22
Figure 8. Performance for preventive child health KPIs at baseline and endline by Transform and 
non-Transform intervention areas 23
Figure 9. Performance for preventive child health KPIs at baseline, endline and against LOA target 
(left) and Performance trend (right) in Transform HDR intervention areas 23
Figure 10. Performance for preventive child health KPIs at baseline and endline by Transform and 
non-Transform intervention areas 24
Figure 11. Performance trend for gender and women empowerment KPIs in Transform HDR 
intervention areas 26
Figure 12. Performance for gender and women empowerment KPIs at baseline and endline by 
Transform and non-Transform intervention areas 27
Figure 13. Post GBV service components provided at surveyed facilities in Transform and non￾Transform intervention areas 28
Figure 14. Adolescent and Youth Friendly service components provided at surveyed facilities in 
Transform and non-Transform intervention areas 28
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Figure 15. BEmONC signal functions provided at surveyed health facilities in Transform and non￾Transform intervention areas 29
Table 1. Coverage of Transform HDR Activity by Region...........................................................................14
Table 2. Distribution of Transform HDR sampled woredas .............................................................................17
Table 3. Distribution of households surveyed in Transform HDR and non-Transform intervention 
woredas......................................................................................................................................................................17
Table 4. Distribution of health facilities surveyed in Transform HDR and non-Transform 
intervention woredas ............................................................................................................................................18
Table 5. Distribution of KIIs..................................................................................................................................18
Table 6. Performance for family planning KPIs at baseline and endline in Transform HDR 
intervention areas by region .............................................................................................................................. 25
Table 7. Performance for maternal health KPIs at baseline and endline in Transform HDR 
intervention areas by region .............................................................................................................................. 27
Table 8. Performance for newborn health KPIs at baseline and endline in Transform HDR 
intervention areas by region .............................................................................................................................. 29
Table 9 Performance for preventive child health KPIs at baseline and endline in Transform HDR 
intervention areas by region .............................................................................................................................. 32
Table 10. Performance for preventive child health KPIs at baseline and endline in Transform HDR 
intervention areas by region .............................................................................................................................. 34
Table 11. Performance in MNCH/FP awareness creation at baseline and endline in Transform HDR 
intervention areas by region .............................................................................................................................. 35
Table 12. Performance for gender and women empowerment KPIs at baseline and endline in 
Transform HDR intervention areas................................................................................................................... 36
Table 13. Family planning method provided at surveyed health facilities in Transform and non￾Transform intervention areas ............................................................................................................................. 37
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ACRONYMS AND ABBREVIATIONS
ANC Antenatal Care
BEmONC Basic Emergency Obstetric and Neonatal Care
CBHI Community-based Health Insurance
COR Contracting Officer’s Representatives
DID Difference in Differences
DRS Developing the Regional States 
EQs Evaluation Questions
ESOG Ethiopian Society of Obstetricians and Gynecologists
GOE Government of Ethiopia
Gott Amharic: Neighborhood
HC Health Center
HDR Health in Developing Regions
HF Health Facility
HH Household
HLM High Level Monitoring
HMIS Health Management Information System
HP Health Post
HSTP Health Sector Transformation Plan 
KPIs Key Performance Indicators
IFA Iron and Folic Acid
IP Implementing Partner
ISS Integrated Supportive Supervision
Kebele Amharic: Ward
KI Key Informant
KII Key Informant Interview
LAFP Long-Acting Family Planning
LMG Leadership, Management, and Governance
LOA Life of Activity
MCPR Modern Contraceptive Prevalence Rate
MCVI Measles Containing Vaccine First Dose 
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MELA Monitoring, Evaluation, Learning, and Adapting
M&E Monitoring and Evaluation
MNCH/FP Maternal, Newborn, Child Health and Family Planning
MOH Federal Ministry of Health
PCMD Preventing Child and Maternal Deaths
PHCU Primary Health Care Unit
RH Reproductive Health
RHB Regional Health Bureau
RMNCH Reproductive, Maternal, Newborn, and Child Health 
SBCC Social and Behavior Change Communication
SNNP Southern Nations, Nationalities, and People 
TMG The Mitchell Group, Inc.
USAID United States Agency for International Development
USG United States Government
WHO World Health Organization
Woreda Amharic: District
WorHO Woreda Health Office
ZHD Zonal Health Department
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ABSTRACT 
This final performance evaluation of USAID/Ethiopia’s Health in Developing Regions (HDR) 
Activity was conducted by The Mitchell Group, Inc. as part of USAID/Ethiopia’s Transform 
Monitoring, Evaluation, Learning, and Adapting (Transform: MELA) Activity. Transform: MELA 
conducted this final performance evaluation to measure the progress made towards 
achievements of results by the activity towards improving maternal, newborn, child health, and 
family planning (MNCH/FP). Results are presented in terms of effectiveness in improving 
MNCH/FP outcomes; contributions to local ownership and sustainability and coherence with the 
existing health system; gender dynamics in design and implementation; and learning and use of 
evidence. Compared to the baseline, the evaluation confirmed that Transform HDR contributed 
to improvement in essential newborn care and early initiation of breastfeeding, measles 
coverage, Vitamin A supplementation and ARI and diarrhea treatment. However, performance 
on most MNCH/FP key performance indicators (KPI) declined by the endline, despite progress at 
the midterm. For almost three quarters of the KPIs, at endline performance in Transform HDR 
intervention areas descended below the respective baseline values. Despite these obstacles, 
Transform HDR intervention areas had better performance at endline compared to the non￾Transform intervention areas.
The evaluation also reviews the ways in which Transform HDR facilitated local ownership and 
sustainability, adopted a gender focus; and was coherent with Ministry of Health objectives. 
Findings were that Transform HDR: 1) adopted participatory approaches and worked in alignment 
with the existing health system to ensure ownership; 2) considered gender in most of its activities 
including supporting traditional women-only community structures; 3) was flexible and adaptive 
in addressing the changing needs of the health system and dynamic contexts. The report ends 
with recommendations for future programming in developing regions with specific 
recommendations for the Ministry of Health and USAID/Ethiopia.
1) EXECUTIVE SUMMARY
Background
In 2017, USAID/Ethiopia launched the Transform Program, a five-year integrated reproductive, 
maternal, newborn, and child health (RMNCH) program to reduce preventable maternal and child 
morbidity and mortality in Ethiopia. The Transform health in developing regions (HDR) is one of 
the three Activities implemented under the umbrella of the Transform program. Transform HDR 
targeted sixty woredas (districts) in four regions – Afar, Benishangul-Gumuz, Gambella, and 
Somali – that have had historically poorly performing health systems and high maternal, perinatal, 
and child mortality relative to other regions. USAID/Ethiopia awarded a contract to The Mitchell 
Group, Inc. to implement the Transform: MELA Activity, which was tasked to provide high quality 
monitoring and evaluation (M&E) information that guided programmatic decision making by 
USAID/Ethiopia, implementing partners, (IPs) and Ministry of Health (MOH) of Ethiopia. 
Transform: MELA conducted this final performance evaluation to measure the progress made by 
the Transform HDR towards improving MNCH/FP outcomes. This report, therefore, details the 
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evaluation questions, methods used, findings, conclusions, and recommendations for improving 
future MNCH/FP programming in Ethiopia. 
Evaluation objectives 
The final performance evaluation was intended to measure the effectiveness of Transform HDR 
interventions in contributing to improving MNCH/FP outcomes, in facilitating local ownership,
sustainability and coherence, in considering gender dynamics in its design and implementation, 
and in adapting interventions based on learning and available evidence. 
Methodology
The evaluation used a mixed methods pre-post cross-sectional design using quantitative and 
qualitative data from primary and secondary sources. The evaluation collected data in fifty-two 
woredas, from 3,210 households and 158 health facilities in both Transform HDR and non￾Transform intervention areas. Qualitative data were also obtained from twenty-two in-depth key 
informant interviews (KIIs) with USAID/Ethiopia staff, Transform implementing partners, and 
individuals at different levels of the health system. The evaluation also included a review of 
Transform HDR’s progress reports, annual work plans, MEL plans, assessments conducted by the 
IP, and other secondary documents. 
The evaluation used a three staged cluster sampling to select households from woredas in 
Transform HDR and non-Transform HDR intervention areas that met predefined inclusion and 
exclusion criteria. Health posts that were found within the selected kebeles and health centers 
and primary hospitals that had a reporting relationship respectively were considered for the 
health facility survey. The evaluation used Transform HDR’s results framework and associated key 
indicators to measure Activity performance. Analysis of quantitative data involved computation 
of values of the select set of key performance indicators, comparing values between/across 
periods, woreda categories (Transform HDR and non-Transform intervention), and regions. 
Thematic analysis was used to summarize and present the qualitative data. 
FINDINGS
Results are summarized below based on the following evaluation questions:
● How effective were the Transform HDR Activity approaches in contributing to improving 
MNCH/FP outcomes? What were the drivers of the observed changes? What constraints 
affected achievements?
● How and to what extent did the Transform HDR Activity facilitate local ownership, 
sustainability, and coherence?
● How did Transform HDR consider gender dynamics in activity design and implementation?
● How and to what extent has Transform IP been able to adapt its interventions in response 
to learnings and new evidence?
MNCH/FP Outcomes
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This section first provides a summary of MNCH/FP outcomes in the following thematic areas: 
family planning, maternal health, newborn health, and child health. Effectiveness of the 
approaches, as measured by triangulating quantitative and qualitative data, are briefly 
summarized below and describe in greater detail in the body of this report. 
Family Planning
● Performance for all family planning KPIs had positive progress at the midpoint of Activity 
implementation but dropped at the endline. Midterm performance exceeded the target 
set for 2020, but at the endline the Activity achieved only 37% of the life of activity (LOA)
target. 
● In Transform intervention areas, modern contraceptive prevalence rate (MCPR), and 
postpartum family planning (PPFP) counseling and use declined significantly (P<0.001). 
However long-acting family planning (LAFP) uptake remained the same. 
● Performance for family planning KPIs declined in both Transform HDR and non￾Transform intervention areas, except LAFP use in Transform HDR intervention areas. 
However, performance in Transform HDR areas was found to be higher in all cases. 
● At the endline, MCPR and LAFP use between Transform HDR, and non-Transform 
intervention areas were statistically different (p<0.05).
Maternal Health
● Maternal health outcomes declined in both Transform HDR and non-Transform 
intervention areas. At the baseline, non-Transform intervention areas had better 
performance on maternal health indicators. However, at the endline, the performance for 
all maternal health KPIs was better in Transform HDR intervention areas than in non￾Transform HDR areas.
● Although a steep decline was observed on performance of all the KPIs at endline, the 
performance trend for all maternal health KPIs was positive at midterm, apart from IFA 
which showed a steady decline over both periods.
● In Transform HDR intervention areas, maternal health indicators declined; these declines 
were statistically significant (p<0.001) except for early ANC and PNC. Iron and folic acid 
(IFA) supplementation and essential ANC coverages were the KPIs that underwent major 
declines. 
● At the endline, LOA targets set for ANC4+ and SBA were not achieved. 
Newborn Health
● Essential newborn care showed a sharp increase from its midterm status. However, 
performance for early PNC and early initiation of breastfeeding dropped despite the 
progress made at midterm.
● In Transform HDR intervention areas, essential newborn care and early initiation of 
breastfeeding significantly improved (p<0.001) when compared to baseline status. 
● At the endline, early PNC coverage showed a non-significant drop below its baseline. 
However, Transform achieved only 45% of its LOA target. 
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● Essential newborn care and early initiation of breastfeeding improved in both Transform 
HDR and non-Transform intervention areas, whereas early PNC declined in both. At the 
endline, Transform HDR intervention areas performed better than non-Transform HDR 
intervention areas. 
Preventive Child Health Service Components
● Performance trends for all preventive child health KPIs showed a decline despite gains at 
midterm. However, Transform HDR campaigns played a role in improvements in 
preventative child health. Measles coverage refers to MCV1 which is mainly provided as 
part of routine immunization service although some measles vaccine received through 
campaigns are also included. Vitamin A supplementation can be linked to services 
provided through campaigns as well as through routine modalities. In Transform HDR 
intervention areas, measles coverage among children who received the vaccine any time 
before the survey and vitamin A supplementation improved significantly (p<0.05). 
● Penta 3 and full immunization coverages declined significantly (p<0.001). 
● Transform HDR supported areas were only able to attain less than 30% of the LOA targets 
set for Penta 3 and full immunization. Conversely, the LOA target for Vitamin A 
supplementation was overachieved.
● Penta 3 and full immunization coverage and exclusive breastfeeding practices dropped 
in both Transform HDR and non-Transform intervention areas. At the endline, Transform 
HDR areas had higher performance for all KPIs than the non-Transform intervention 
areas. 
Curative Child Health Service Components
● Transform HDR areas outperformed non-Transform intervention areas for all key 
performance indicators (KPI) except deworming. At endline, diarrhea treatment showed 
an increase from its lowest point at midterm. ARI treatment and deworming declined 
sharply from their respective highest points at midterm. 
● Treatment of acute respiratory infection (ARI) and diarrhea increased from the baseline, 
although the difference is statistically significant only for ARI treatment (p=0.001). 
However, deworming and the practice of seeking treatment for children within 24 hours 
of onset of fever declined significantly (p<0.001).
● LOA targets for ARI, diarrhea and fever treatments were not met. 
Effectiveness in Increasing the Demand for High-Impact MNCH/FP Services
● Women who heard/saw specific messages on reproductive health and family planning 
declined from baseline in both Transform HDR and non-Transform intervention areas, 
whereas the proportion of women who were exposed to maternal, neonatal, and child 
health (MNCH) specific messages increased from baseline.
● Overall, women’s participation in health care decision making and men accompanying 
their spouses during antenatal care (ANC) and delivery declined significantly (p<0.001).
More Effective and Less Effective Approaches
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Key informants (KI) were asked to describe what they considered to be the most effective 
approaches that should be sustained or scaled up. The approaches most often cited as effective 
included: provision of the mobile ultrasound devices, and capacity building including training, 
clinical mentoring, coaching and post training follow-ups. In terms of less effective approaches, 
some KIs identified provision of youth friendly services, community level intervention, male 
engagement in family planning, and woreda transformation as interventions that were not 
adequately implemented. As an example, although the Activity provided training to health 
education workers and associated structures in the community, there was a lack of follow-up. KIs 
also mentioned the mismatch between the scope of Transform HDR and the resources available 
to implement the associated activities as a limiting factor. KIs also provided input on the Activity’s 
work to promote local ownership and sustainability, its coherence with the health system, gender 
dynamics in design and implementation, and learning and the use of evidence. These are detailed 
below.
Local Ownership, Sustainability, and Coherence
This section applies to approaches that were introduced by Transform HDR and those that were 
government-driven and strengthened because of support from Transform HDR. It therefore 
describes the strategies that were implemented by THDR to ensure institutionalization of 
interventions introduced by the Activity and to strengthen the existing health system 
interventions.
● A majority of KIs indicated that the approach of Transform HDR was highly participatory, and 
the activity worked in full alignment with the existing health system ensuring ownership at all 
levels. As an example, the activity participated in review meetings with health officials and 
other development actors to foster partnership and harmonize activities. The Activity worked 
jointly with decentralized MOH agencies, through joint planning, alignment, performance 
review exercises, integrated supportive supervision (ISS), post-training follow up, clinical 
mentoring, and coaching. 
● KIs acknowledged Transform HDR’s effort in creating a pool of certified master trainers at 
regional level. They viewed this as a valuable contribution in ensuring continuity of capacity
building activities for sustainability. 
● Transform HDR supported community engagement initiatives implemented by the 
government to improve health seeking behavior and ensure social accountability. These 
included supported a government-driven community score card initiative including capacity 
building for client councils and community awareness raising; support for traditional 
community structures to improve health seeking behavior (create demand) and ensure social 
accountability; training for women's development groups, social mobilization committee, 
clan, and religious leaders to increase demand; and support for pregnant mothers' 
conferences, forums where pregnant women gather regularly to discuss health and health 
related issues during pregnancy.
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● According to some KIs, factors such as conflict, staff turnover, a lack of commitment at some 
local levels, and the need for more financial resources for some of the interventions may limit 
sustainability of interventions supported by Transform HDR. 
Gender Dynamics in Activity Design and Implementation
● Transform HDR considered gender in most of its activities, such as health worker training, 
social and behavior change communication (SBCC), leadership training, and school 
programs. 
● The Activity supported traditional women-only community structures in the Somali region 
called Umulgargar, whose work was complemented by Abugargar groups for men. These 
were identified as potential models for scale-up for addressing gender issues in pastoralist 
communities with distinct traditions and cultures. 
● The one-stop GBV service center established in the Afar Region was successful in pulling 
together different resources in the community to support GBV survivors. 
Adaptation of Transform HDR interventions based on Learning and Generated Evidence 
● Transform HDR was flexible and adaptive to address the changing needs in the health system 
and dynamic contexts. As one example, based on evidence generated by the activity, it
supported the establishment of one-stop center for GBV survivors. 
● In response to gaps identified in Transform: MELA’s midterm evaluation and high-level 
monitoring (HLM), Transform HDR focused more of its development interventions in twenty 
“learning woredas.” Based on findings from these reports, the Activity also revitalized relevant 
interventions in antenatal care, strengthening of woreda coordination mechanisms, and 
improvement of data quality and information use practices in these twenty woredas. 
Moreover, the decision to use traditional birth attendants to strengthen different community 
health components such as disease surveillance and linkage to health facilities was stirred by 
findings from operational research conducted by Transform HDR and the HLM. 
CONCLUSIONS
● Performance on most MNCH/FP KPIs in Transform HDR intervention areas declined by the 
endline, despite progress at the midterm. For almost three quarters of the KPIs, performance 
at endline descended below the respective baseline values. 
● The performance declines are likely attributable to the recurrent security problems, 
protracted drought, flooding, and the massive internal displacement that followed these 
shocks which affected the demand for or access to healthcare. In addition, disease outbreaks 
(the COVID-19 pandemic, measles, cholera) affected the supply and demand side of the 
health service. 
● Despite these obstacles, at endline, Transform HDR intervention areas had better 
performance in terms of exhibiting lesser declines compared to the non-Transform 
intervention areas, clearly showing the contributions of Transform HDR Activity in preventing 
deterioration in most of the MNCH/FP outcome measures. 
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● Transform HDR capacity building interventions, integration to the health system, and efforts 
made to engage regional, zonal and woreda level experts to share experiences in health 
system planning, capacity building, and monitoring activities is believed to enable 
sustainability of MNCH/FP services and results achieved. 
● Transform HDR integrated gender in the design and implementation of most of its 
interventions. It also enabled accessibility of post-GBV services in many health facilities.
● There were good practices in the use of evidence generated from Transform HDR-led 
studies/assessments and those that were conducted by Transform MELA, to inform activity 
planning, the design of new initiatives and implementation.
RECOMMENDATIONS
The report includes recommendations for the Ministry of Health and for USAID/Ethiopia for 
future interventions in developing regions. These are briefly summarized below.
Recommendations to the Ministry of Health
● Develop and implement context specific MNCH/FP intervention strategies for each of the 
developing regions.
● Develop and implement innovative, tailored and context appropriate facility and 
community based SBCC approaches for sustained behavioral change in MNCH/FP 
practices.
● Strengthen male engagement in adolescent and youth services and in family planning.
● Reinforce coordination of development partners to effectively implement HSTP II.
● Commit earmarked resources in the future as part of co-design exercise with USAID 
investments to ensure sustainability of promising interventions.
● Develop and implement health performance-based standards and budgeting for 
woredas.
● Continue the support of quality improvement initiatives.
● Improve use of monitoring data for decision making at health facilities. 
● Strengthen and standardize mobile health service delivery to expand access to MNCH/FP 
services for pastoralist communities.
● Institute mobile services policy and guidelines for developing regions.
● Implement innovative health approaches when designing programs to pastoralist 
communities. 
● Assign more female providers, especially for childbirth services.
● Integrate FP counseling across all contacts in the continuum of care.
● Ensure availability of family planning services at health posts.
● Develop a national HR database to track participation in continuous education programs 
funded by donors, and support context specific MNCH/FP health workforce and 
leadership development and retention strategies.
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Recommendations to USAID
● The design of future activities should be performance-based and include a revised target 
setting and monitoring methodology and assumptions.
● The design of future activities should also have a plan to mitigate potential crisis/shocks 
in the developing regions.
● The design of future activities should consider selection of intervention sites that have a 
mix of performance levels – high, moderate, and low.
● The design of future activities should employ performance-based support that can also 
be complemented with allocation of a matching fund from government.
● Develop and implement context specific MNCH/FP intervention strategies for each of the 
developing regions. 
● Develop and implement innovative, tailored and context appropriate facility and 
community based SBCC approaches for sustained behavioral change in MNCH/FP 
practices. 
● Strengthen male engagement in adolescent and youth services and in family planning. 
● Support operational research agendas that identify causes of service bottlenecks and 
explore the underlying factors contributing to the decline in performance of selected KPIs. 
● Support ethnographic and health studies on pastoralist lifestyles for activity planning.
● Investment in developing regions should focus on anchoring capacity-building and SBCC 
to primary health care institutions. 
● Investment in developing regions should integrate essential health systems strengthening 
(HSS) interventions. 
2) BACKGROUND AND CONTEXT
Background to the Evaluation
In 2017, USAID/Ethiopia launched the Transform Program, a five-year (2017–2021) integrated 
reproductive, maternal, newborn, and child health (RMNCH) and water, sanitation, and hygiene 
(WASH) program to reduce preventable maternal and child morbidity and mortality in Ethiopia. 
The Transform Program operates across ten1
regions in Ethiopia and comprises three Activities: 
primary health care (PHC), health in developing regions (HDR), and water, sanitation, and hygiene 
(WASH). 
USAID/Ethiopia awarded a contract to The Mitchell Group, Inc. (TMG) to implement the 
Transform: MELA Activity. Overall, Transform: MELA provides and synthesizes high-quality M&E 
data for USAID/Ethiopia and guides the United States Government (USG) and the Government 
of Ethiopia (GOE)/ Ministry of Health (MOH) in learning and adaptive health system management. 
As part of its contract, USAID/Ethiopia and the MOH have commissioned Transform: MELA to 
conduct the final performance evaluation of the Transform: PHC and Transform HDR Activities, 
1 Beginning from September 2021, the Transform program is being implemented in ten regions. This 
evaluation, however, will not include a separate analysis for the newly formed South-West Ethiopia region. 
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the Transform Program Impact Evaluation in 2022. The performance reports also include short 
vignettes of selected case studies to document important lessons learned that highlight the 
contribution of the Transform program. The WASH activity was not included in these evaluations. 
This final performance evaluation of the Transform HDR Activity presents a brief background and 
details the evaluation objectives, methodology, findings, conclusions, and recommendations.
Activity Background
Transform Health in Developing Regions (Transform HDR) is one of USAID’s flagship investments.
The activity was implemented by Amref Health Africa with consortium partners Project Hope, 
IntraHealth, and General Electric. Transform HDR aimed to contribute to preventing child and 
maternal deaths (PCMD) through supporting the implementation of the GOE’s Health Sector 
Transformation Plan (HSTP) at different levels of the health system in Ethiopia’s developing 
regions. Through supporting the GOE’s strategic initiatives, Transform HDR aimed to achieve four 
high-level intermediate results (IR):
● IR1: Increased access to integrated, quality high-impact maternal, neo-natal, and child 
health/family planning (MNCH/FP) services at health facility and community levels
● IR2: Strengthened health systems to provide quality MNCH/FP services
● IR3: Increased demand for high-impact MNCH/FP services
● IR4: Improved strategic information for evidence-based decision making and program 
learning
Transform HDR targeted four developing regions – Afar, Benishangul-Gumuz, Gambella, and 
Somali – that have had historically poorly performing health systems and health outcomes such 
as high maternal, perinatal and child mortality, relative to other regions. Some of these regions, 
such as Somali, contain large pastoralist communities that are scattered over a large landmass. 
People living in developing regions are faced with underdeveloped infrastructure, recurrent 
manmade and natural disasters, and weak health systems. In focusing on these pastoralist regions 
and hard-to-reach communities, the Activity aimed to address geographic inequity observed in 
maternal and child health outcomes in the country. Over a five-year Activity lifespan, Transform 
HDR supported a total of 60 woredas2 which functioned at lower performance levels compared 
to the other woredas in each of the targeted regions. Table 1 presents the coverage of the Activity 
in each of the targeted regions. 
Table 1. Coverage of Transform HDR Activity by Region
2 Districts, or woreda (Amharic: ወረዳ), are the third-level administrative divisions of Ethiopia. Districts are 
further subdivided into wards (kebele), or neighborhood associations, which are the smallest unit of local 
government in Ethiopia. As a result of Transform: MELA findings and recommendations at mid-term, the 
Activity placed a stronger focus of 20 of these 60 woredas, which were termed “learning woredas.”
Regions Intervention 
Woredas
Total Woredas in 
Region
Percent covered by 
Transform HDR
Afar 17 39 44%
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Transform: HDR implements interventions through strategic approaches which include the 
provision of medical equipment, building capacities of the health workforce, supporting woreda 
health offices (WorHO) with the organization of comprehensive mobile outreach services, 
strengthening the provision of one-stop service to victims of gender-based violence (GBV), use 
of performance improvement interventions, and strengthening implementation of health 
management information systems (HMIS). 
3) EVALUATION PURPOSE AND EVALUATION QUESTIONS
EVALUATION PURPOSE 
The final performance evaluation of the Transform HDR Activity was to assess performance of 
Transform HDR with the intention of informing USAID/Ethiopia’s decisions related to future 
investment in supporting MNCH/FP interventions in developing regions. The purpose of the 
evaluation was to measure achievements of Transform HDR in terms its Activity-level results 
framework (see Results Framework in Annex 2), and to explore associated underlying reasons for 
achievement and/or non-achievement of anticipated results as well as reviewing intervention 
approaches used by the implementing partner (IP). The evaluation also assessed the degree to 
which the IP proactively adapted to contextual changes during the intervention period. In 
addition, the evaluation documents lessons learned and best practices—incorporating illustrative 
vignettes on selected case studies based on field visits—to inform the future programming of 
similar program activities by USAID/Ethiopia. 
This final performance evaluation assessed factors that contributed to the observed results and 
those which may have inhibited achievement. To do so, it examined the following key areas:
● Effectiveness, which is defined as the extent to which the interventions achieved their 
objectives and activity results.
● Gender equity, which is defined as fairness of treatment for women and men, according 
to their respective needs.
● Adaptive management, which is defined as an intentional approach to making decisions 
and adjustments in response to new information and changes in context; and
● Sustainability, which is defined as the extent to which interventions and their benefits will 
continue beyond the life of the program.
Regions Intervention 
Woredas
Total Woredas in 
Region
Percent covered by 
Transform HDR
Benishangul-Gumuz 10 23 43%
Gambella 6 12 50%
Somali 27 99 27%
Total 60 173 35%
16
EVALUATION QUESTIONS
The performance evaluation answered the following evaluation questions (EQs) related to Activity 
performance: 
1) How effective were the Transform HDR Activity approaches in contributing to improving 
MNCH/FP outcomes? What were the drivers of the observed changes? What constraints 
affected the achievements?
2) How and to what extent did the Transform HDR Activity facilitate local ownership, 
sustainability, and coherence? 
3) How did Transform HDR consider gender dynamics in activity design and 
implementation?
4) How and to what extent has Transform IP been able to adapt its interventions in response 
to learnings and new evidence?
Sub-questions were identified under each key evaluation question (EQ) as presented in Annex I. 
AUDIENCE AND INTENDED USES
The audiences of the final evaluation report are USAID/Ethiopia, specifically its Health Office; 
MOH authorities and its regional health bureaus (RHB); public healthcare providers at the 
regional, zonal, and woreda levels; and other country-level IPs. In this report, the evaluators also 
documented evidence of the lessons learned and best practices that can inform new policies and 
MNCH/FP programs. 
4) EVALUATION METHODS, ETHICAL CONSIDERATIONS AND LIMITATIONS
The final performance evaluation covers all regions where the Transform HDR Activity operates. 
Site visits and/or face-to-face interviews were not conducted in conflict-affected areas or areas 
with active conflict. The performance evaluation of Transform HDR employed a cross-sectional 
evaluation design in the intervention areas to measure effective achievement of HDR IRs in 
comparison to baseline and midline achievements, and life of project targets. Data from non￾intervention areas were collected and analyzed separately as part of the Transform Program 
Impact Evaluation. A mixed-methods approach, with both quantitative and qualitative methods, 
was used to gather and analyze data to answer the performance EQs.
17
4.1. Sampling of Woredas 
Simple random sampling was used to 
select woredas in the Transform HDR 
targeted regions with five or fewer 
interventions by other development 
partners. Woredas with security 
problems and no development partner 
information were excluded. A total of
36 and 16 woredas were selected for 
the performance evaluation from 
Transform HDR and non-Transform 
intervention areas respectively. 
Regional distribution of woredas 
sampled from Transform HDR intervention areas are shown in Table 2.
4.2. Sampling of Households 
A household (HH) survey employed a three-stage cluster sampling technique. At the first stage, 
the evaluation team drew a random selection of kebeles (wards) in the Transform intervention 
woredas as primary sampling units, drawing from the list of kebeles in the respective regions 
stratified by administrative zones and performance before 2017. In this manner, woredas, in which 
the randomly selected kebeles were located, were automatically included in the evaluation. The 
second stage of the sampling entailed the random selection of Gotts (neighborhoods) from the 
selected kebeles. Because of the difficulties and time-consuming exercise of developing a fresh 
list of households in a kebele, 2-3 Gotts were selected randomly from each kebele, to generate 
an average list of 150 households from those selected Gotts. 
The third stage of the sampling 
was a selection of HHs from the 
randomly selected Gotts. A list 
of households from each 
selected Gott served as a frame 
from which to select 30 HHs per 
kebele. The key eligibility 
criterion for selecting the HHs 
was the availability of a woman 
aged 15-49 in the HH, 
regardless of marital status, who had residential status there for at least 6 months prior to the 
data collection. When more than one such eligible respondent was found in a selected 
household, the enumerator randomly selected one respondent from among the eligible women. 
A total of 2,548 and 662 households were selected from Transform HDR and non-Transform 
intervention woredas, respectively (Table 3). 
Region Eligible 
Woredas
Sampled 
Woredas
Afar 12 9
Benishangul-Gumuz 2 2
Gambella 6 4
Somali 25 21
Total 45 36
Woreda Category
Number of 
woredas 
surveyed
Total HHs 
surveyed
Transform HDR intervention 36 2548
Non-Transform intervention 16 662
Table 2. Distribution of Transform HDR sampled 
woredas
Table 3. Distribution of households surveyed in Transform 
HDR and non-Transform intervention woredas
18
4.3. Sampling for Health Facility Survey
All the primary health care facilities designated to serve the population of the sampled kebeles -
health posts (HPs), health centers (HCs), and primary hospitals - were identified and included in 
the final performance evaluations. That is, the health post serving the population in the sampled 
kebele was automatically included in the study, and the catchment HC to which the selected 
health post was linked was also included. Similarly, if a primary hospital was attached to the 
selected HC, it too was included. Health posts were part of the health facility (HF) survey in 
sampled kebeles if they did not exist or were not functional.
As a result, 52 HCs and 65 
HPs from Transform 
intervention woredas were 
selected. The impact 
evaluation also included 17 
HC and 19 HPs from non￾Transform intervention 
woredas. Moreover, 
primary hospitals were 
included whenever such 
facilities existed in the selected woredas (Table 4).
4.4. Selection of Key Informants 
Interviewees for key informant interviews (KIIs) were selected using purposive sampling. Gender 
balance was considered in the selection process, as was representation of various stakeholder 
groups: USAID, central and regional IPs, relevant directorates at MOH, Regional Health Bureaus 
(RHBs), and selected WorHOs. A total of 22 KIIs were conducted as part of the performance 
evaluation (Table 5).
Table 5. Distribution of KIIs
Stakeholders 
USAID/Ethiopia Interview with USAID AOR 
Ministry of Health Interview with MOH Directorates 
Health System Special Support
Health Extension Program and Primary Health Care
Policy, Planning, Monitoring and Evaluation 
IPs central office KIs Transform HDR management and technical team (2)
IP’s regional offices Interview with Transform HDR four regional project coordination 
team
Regional Health Bureaus – MCH 
unit
KIIs (1 KII per region) MNCH Department 
Woreda health offices Transform Intervention woredas (4): 7 KIs – Heads of Woreda Health 
Offices and/or MNCH officers 
Woreda 
Category
Health 
posts
Health centers Primary 
Hospitals
Transform HDR 
intervention 65 52 5
Non-Transform 
intervention 19 17 0
Table 4: Table 4. Distribution of health facilities surveyed in 
Transform HDR and non-Transform intervention woredas
19
Stakeholders 
Non-Transform Intervention woredas (2): 2 KIs – Heads of Woreda 
Health Offices or MNCH officers
Total 22 KIIs
4.5. Data Collection Methods
4.5.1. Data Sources
This final performance evaluation used two main sources of qualitative data – document review 
and KIIs. Quantitative data came from several sources: HH and HF surveys as well as monitoring 
data as reported by Transform HDR. A wide range of documents were reviewed, including IP 
performance reports, IP-led research, MOH annual reports, the HSTP midterm review, Mini￾Demographic and Health Survey reports, Transform baseline and midterm evaluation reports, 
and other relevant documents. The primary data collection involved HH and HF surveys, along 
with KIIs from USAID/Ethiopia, MOH, RHBs, IP, and WorHOs in all regions. 
4.5.2. Data Collection Tools
The desk review was conducted on a list of documents. A data extraction spreadsheet was 
developed to gather the most significant findings. The findings from the desk review were then 
coded and triangulated with data from KIIs and HF and HH surveys. 
The KIIs followed a guide to gather the views and experience of the interviewee in relation to the 
performance of the Transform HDR Activity. The questions were broad and open-ended to 
gather unbiased responses and were accompanied by probing questions to gather more detail 
under each EQ. Trained bilingual interviewers conducted the KII in the interviewee’s language of 
preference and took notes in English. The KIIs were recorded to facilitate note taking. The KII 
notes were emailed daily to the focal person for review and quality control. 
Household and HF surveys were conducted using pre-tested structured questionnaires that were 
uploaded to smartphones, generating electronically collected HH and HF data. Moreover, some 
open-ended questions were used to collect relevant data from KIs at health facilities. In addition, 
Gott listing, HH listing,3
enumerator assignment and follow-up tools were used to guide the 
sampling and the data collection process.
The household survey tool included sections on: 
• Household and women’s demographics, household living conditions 
• Enrollment in community-based health insurance plans 
• Household decision-making practices 
• Health service uptake including family planning, antenatal care, delivery and postnatal 
care, and newborn health child immunization and child health services 
3 Lists were prepared by using already available HH records at a health post or kebele, which were validated and updated 
with information sought from kebele guides. In some instances, when enumerators could not locate available records, HH 
lists were prepared afresh with the help of kebele guides. 
20
The health facility survey tool enabled collection of data on: 
• Availability of MNCH/FP services and water and sanitation facilities 
• Access to communication and power supply
• Health facility management and performance, human resources
• Gender responsiveness 
• Provision of selected family planning, antenatal care, delivery and postnatal care, 
immunization services, and adolescent and youth health services
4.5.3. Data Collectors’ Training and Quality Assurance
To ensure high-quality data, a day-and-a-half training was conducted for qualitative data 
collectors and a three-day training took place for all survey coordinators and supervisors in Addis 
Ababa. Enumerators who administered HH surveys had at least a BA/BSc degree and were fluent 
in the local languages. Importantly, all data collectors had prior experience collecting similar data 
and understanding the culture and traditions of the communities they were visiting. Supervisors 
had an MA/MSc in health or social science fields and previous experience in similar activities. The 
respondents were mothers of reproductive age, and to ensure that they felt comfortable 
speaking with interviewers, the survey team took gender balance into account. Qualitative data 
collectors had a minimum of an MA/MSc in health or social science fields and extensive 
experience in qualitative data collection, transcription, and analysis. 
The training covered topics such as research ethics, the rights of human subjects during research, 
sampling procedures, informed consent, data collection tools, interviewing techniques, data 
handling, confidentiality, and quality, and gender considerations during data collection. The 
structure of the training included presentation of and detailed discussions on survey instruments 
followed by a role-play. Data collectors received training on both the paper-based and electronic 
versions of the data collection tools. The survey tools were pre-tested by data collectors in the 
field in all languages at the end of the training, before the commencement of the actual data 
collection, to ensure consistency with the baseline and midline evaluation. 
Before traveling to each of the selected woreda, supervisors and coordinators communicated 
with regional and local leaders about the evaluation. To ensure the quality of collected data, 
supervisors conducted spot-checks and reinterviewing, especially at the beginning (the first 3 
days) of data collection. Moreover, supervisors reviewed a sampling of completed questionnaires 
daily before uploading them to the server. All KIIs were audio-recorded and transcribed and 
translated into English. Five percent of the transcriptions were checked against the audio file for 
accuracy. In addition to the KIIs, Transform: MELA conducted limited interviews for nested case 
study vignettes on topics relevant to program goals of reducing preventable maternal and child 
morbidity and mortality.
4.6. Data Analysis
All HH and HF survey data were cleaned, checked, and validated to immediately identify and 
address any issues during data collection, a process that occurred between supervisors and data 
collectors. Once data collection was complete, an intensive cleaning was conducted that included 
coding and recoding, consistency checks, addressing refusals and non-responses, and validating 
contents.
21
4.6.1. Quantitative Data Analysis: 
Descriptive (frequency and percentage calculations) analysis was conducted to describe the 
characteristics of a select set of MNCH/FP key performance indicators (KPIs). The analysis of HH 
data compared KPI values between periods (baseline vs endline), across regions, and against LOA 
targets for Transform intervention areas. It also assessed the difference in endline KPI values 
between Transform HDR and non-Transform intervention areas. Data management and analysis 
were done using STATA 14 (StataCorp LLC, USA).
4.6.2. Outcome Measures
The evaluation used the results framework of Transform HDR and its KPIs to measure 
performance. A result-indicator matrix (Annex 2) linked the KPIs to measures for the IRs identified 
in the results frameworks of Transform HDR. Some of the KPIs considered in this analysis were: 
family planning indicators (modern contraceptive prevalence rate (MCPR), long-acting family 
planning (LAFP) use, postpartum family planning (PPFP) counseling and use), maternal health 
indicators (antenatal care (ANC), skilled birth attendance (SBA), early postnatal care (PNC), iron￾folic acid (IFA) supplementation, neonatal health indicators (early PNC, essential newborn care 
and early initiation of breastfeeding), child health indicators (Penta3 coverage, measles coverage 
(MCV1), exclusive breastfeeding, vitamin A supplementation, deworming, ARI treatment with 
antibiotics, diarrhea treatment with ORS and Zinc, and fever treatment within 24 hours of onset) 
and cross cutting indicators (access to basic sanitation, spouse accompany to ANC, spouse 
accompany to delivery, and women participation in decisions regarding their health). These KPIs 
were used in the measurement of achievement of intermediate results of the Transform HDR 
Activity. 
4.6.3. Qualitative Data Analysis
Coding: A codebook was developed based on evaluation questions. In addition, part of the 
interview transcripts was reviewed, and the codebook was further refined as specific themes 
emerged. Then, the transcripts were coded using the codebook. Development of the coding 
framework was an iterative process based on an initial list of the codes developed by the analysis 
team as identified from the evaluation questions. Through a series of meetings with technical 
specialists, preliminary codes were further refined by adding emergent codes and modifying the 
preliminary codes after careful reviews of a sample of field notes based on KIIs.
Analysis: Thematic analysis was conducted using ATLAS.ti, a qualitative data analysis software. 
Selection of themes and the analysis of the data were framed by the EQs and key thematic areas 
related to MNCH/FP. The synthesis of various qualitative information was used to understand 
factors facilitating or hindering implementation as well as achievement of results. 
4.7 Ethical Considerations
The evaluation received institutional review board (IRB) approval from the Ethiopian Public Health 
Institute (EPHI) at the outset of research, and all data collectors and supervisors were trained in 
research ethics. Key informants (KIs) were asked for their consent to be interviewed and for the 
interview to be recorded, and interview notes and recordings were coded to protect respondent 
confidentiality. Survey respondents were also asked for their informed consent; during that 
22
process, they were informed about choices regarding participation, responding or not to specific 
questions, and their right to request termination of the survey at any time. Informed consent also 
covered the privacy and confidentiality of participants—respondent names were not captured; 
instead, coding was used to conceal their identity. All interviews were conducted privately, 
ensuring that information collected remained confidential. For women under the age of 18, 
additional parental permission and participant assent was obtained before data collection. 
4.8 Limitations 
Methodological Limitations. Non-Transform intervention areas selected to serve as the 
comparison areas should not be regarded as true controls due to complex factors. One of the 
principal ways that the design sought to control for “contamination” effects was to ensure that 
Transform intervention woredas were not contiguous with non-Transform intervention woredas. 
Such a design does mitigate contamination to some degree. Although these design issues pose 
methodological challenges, from a methodological standpoint the spillover would likely 
attenuate differences between the intervention and non-intervention areas, thus leading to 
conservative findings rather than overstated ones. Furthermore, because Transform program 
interventions are designed to support nationwide health-system building for improved MNCH/FP 
outcomes, the design did not control for the effect of this type of spillover. Moreover, from a 
“real-world” implementation perspective such “spillover” effects can be viewed as positive 
outcomes for the program. 
Resource availability was an important factor that was considered when determining sample size 
and the decision to use a ratio of 4:1 households for THDR intervention areas and non-Transform 
intervention areas respectively. This ratio provides adequate statistical power at the Transform 
program level but is not adequate for determining statistical significance for regional level 
comparisons. The design also allows for approximation of the effects of other MNCH/FP-focused 
development partners intervening in the non-intervention areas. However, there are limited data 
available on the level of financial investments that these other development partners made in 
both Transform-intervention woredas and non-Transform intervention woredas. Thus, measuring 
the actual effects of other partner investments remains a challenge. 
In terms of triangulation with other data sources such as IP monitoring data, the evaluation 
recognizes that there can be methodological difference with these sources. For this reason, 
comparisons of these data sources with the Transform evaluation data, particularly with the 
quantitative data obtained through household and facility surveys, may demonstrate divergent 
results. Furthermore, because the qualitative data depends on the views and comments of those 
persons that made themselves available to be interviewed, selection and desirability bias can 
result. However, the careful selection and training of highly qualified qualitative data collectors 
and analysts helped to mitigate data quality bias to a large extent. Data from various sources 
were carefully triangulated to confirm the evidence and to mitigate recall bias as well as potential 
social desirability bias, whereby respondents give favorable or positive answers to please the 
interviewer.
Security and logistics. Security issues in Benishangul-Gumuz and Gambella limited access to 
many woredas. For this reason, results from these regions should be interpreted with caution as 
they may over- or under-estimate the outcome of interest in the entirety of those regions. 
Moreover, survey data collection took longer than initially anticipated because of security and 
logistical issues, which required adjustments to the survey and interview schedules in all regions. 
23
In addition to impacting schedules, this also had important cost implications in regions such as 
Somali, due to the need for changed itineraries and the unavailability of gasoline at fixed market 
prices. Despite these challenges, security and logistical issues were mitigated; evaluators were 
able to interview selected informants, visit facilities, and collect sampled data.
5) FINDINGS
This section presents overall performance findings by evaluation question and sub-question, and 
where appropriate, by region and technical area: maternal health, newborn health, child health, 
family planning, and gender.
5.1 HOW EFFECTIVE WERE THE TRANSFORM HDR ACTIVITY APPROACHES IN CONTRIBUTING 
TO IMPROVING MNCH/FP OUTCOMES? 
Were Transform activities implemented as planned? If not, why not?
Transform HDR was implemented with the objectives of increasing the number of healthy 
mothers with successful birth outcomes, expanding access and uptake of family planning, 
increasing numbers of healthy newborns, and sustaining gains in preventing child and maternal 
deaths. According to key informants, most Activity implementation in targeted regions went as 
planned, with some exceptions in areas where implementation was interrupted or ceased 
because of security problems.
Conflict interrupted Transform HDR activities in some regions such as Benishangul-Gumuz. 
Respondents there reported that although the program had been implemented as planned for 
the first three years, interventions were largely interrupted over the last two years due to the 
security problem in the area. When explaining how security problems affected the program 
activities, a Transform regional manager in Benishangul region described the challenges: 
“Transform HDR was able to implement its activities in ten targeted woredas only during the first 
two and a half years. Later, due to the local security problem, the project couldn’t continue to 
operate in eight woredas and was obliged to withdraw its support totally. It has therefore restricted 
itself to supporting only the remaining two woredas over the last two years.” 
In addition, key informants (KIs) described several challenges in implementing the T-HDR 
program. Developing regions have fragile health systems, where the number of trained and 
capable health professionals are limited. In addition to that, the turnover of trained individuals 
during the intervention period was common. As one example, a scarcity of midwives in the 
Gambella region was a challenge in promoting maternal health service. In addition, there was
high turnover and gaps in levels of commitment of regional and woreda health sector leaders 
and local government. In sum, the activity met targets set for more than half of the key 
performance indicators. However, it did not meet 16 of the 34 performance indicators in the MEL 
plan in the Activity 2021 Annual Report.
4
4 USAID Transform Health in Developing Regions, FY 2021 Annual Progress Report. 
24
To what extent did the activity improve MNCH/FP outcomes and reduce inequities in different 
groups and intervention areas?
Family planning outcomes 
As shown in Figure 1, in Transform HDR intervention areas, 
MCPR among currently married women, PPFP counseling 
and PPFP use declined significantly (p<0.001) compared to 
their baseline values, except for LAFP, which remained the 
same. Although at midterm the Activity was close to 
meeting targets for MPCR, the Activity achieved only 37% 
of the LOA target at the endline. Performance for all family 
planning KPIs had positive progress at the midpoint of 
Activity implementation, although dropped at endline 
(Figure 1). Frequently mentioned reasons by the surveyed 
women for not ever or not currently using family planning methods included in rank order: 
religious restrictions, the need for children, having no partner, partner/spouse refusal, and fear 
of side effects or infertility.
Figure 1. Performance for family planning KPIs at baseline, endline and against LOA target (left) and 
Performance trend (right) in Transform HDR intervention areas
Most family planning KPIs declined in all regions except LAFP use in Afar, Benishangul-Gumuz 
and Gambella, and PPFP use in Benishangul-Gumuz. Somali region had the lowest performance 
for all family planning indicators (Table 6). Family planning commodity stockout was a problem 
in 60% of the surveyed facilities, where at least one type of FP commodity was reported as being 
out of stock in the last three months. Family planning commodities that were out of stock in one 
out of five of the facilities included: combined oral contraceptives, condoms, progesterone-only 
injectables (Depo-Provera), and Jadelle. Moreover, findings of the health facility survey showed 
that nearly half of the health posts (50.8%) in Transform HDR intervention areas were not 
providing modern family planning methods, which is higher than non-Transform intervention 
areas (42.1%).
Baseline Midterm Endline
MCPR
LAFP use
PPFP use
18.9
3.6
14.5
12.2
8.8
3.6
5.2
4.4
23.6
M C P R L A F P P P F P 
c o u n s e l l i n g
P P F P U s e 
Baseline (%) Endline (%) LOA Target (%)
Performance for all family planning 
KPIs had positive progress at the 
midpoint of Activity implementation 
but dropped at the endline. At 
midterm, the Activity close to 
meeting targets for MCPR but at the 
endline, the Activity achieved only 
37% of the LOA target. 
25
Table 6. Performance for family planning KPIs at baseline and endline in 
Transform HDR intervention areas by region
Indicator Period Afar B/Gumuz Gambella Somali
MCPR 
Baseline 5.1 41.7 21.6 6.2
Endline 4.2 41.9 14.0 1.5
LAFP
Baseline 0.2 12.2 0.8 0.9
Endline 0.9 20.2 2.3 0.6
PPFP counselling
Baseline 11.8 25.8 11.7 8.4
Endline 6.9 22.9 8.7 0.5
PPFP Use
Baseline 6.4 30.5 9.6 3.1
Endline 1.5 35.7 2.2 0.3
Performance for all family planning KPIs declined in both Transform HDR and non-Transform 
intervention areas, apart from LAFP use which remained the same in Transform HDR intervention 
areas (Figure 2). Although both areas have shown declines in performance for all the indicators
at the endline, performance in Transform HDR areas was higher than non-Transform areas.
However, statistically significant differences were detected on performance between Transform 
HDR and non-Transform intervention areas only for MCPR and LAFP use (p<0.05).
Figure 2. Performance for family planning KPIs at baseline and endline by Transform and non-Transform 
intervention areas
Maternal Health Outcomes
As shown in Figure 3, 
Maternal health outcomes 
declined in both Transform 
HDR and non-Transform 
intervention areas. At the 
baseline, non-Transform 
intervention areas had better 
performance on maternal 18.926.0 3.6
6.8
14.5
23.4
12.2
21.2
8.8
4.0
3.6
1.2
5.2
4.6
4.4
2.0
Transform Non
Transform
Transform Non
Transform
Transform Non
Transform
Transform Non
Transform
MCPR LAFP PPFP counselling PPFP Use
Baseline (%) Endline (%)
Maternal health outcomes declined in both Transform HDR and 
non-Transform intervention areas. At the baseline, non-Transform 
intervention areas had better performance on maternal health 
indicators. However, at the endline, the performance for all 
maternal health KPIs was better in Transform HDR intervention 
areas than in non-Transform HDR areas. Although a steep decline 
was observed on performance of all the KPIs at endline, the 
performance trend for all maternal health KPIs was positive at 
midterm, apart from IFA which showed a steady decline over both 
periods.
26
health indicators. However, at the endline, the performance for all maternal health KPIs was better 
in Transform HDR intervention areas than in non-Transform HDR areas. For Transform HDR areas, 
these declines were statistically significant (p<0.001) except for early ANC and PNC. The most 
affected outcomes are IFA supplementation and essential ANC components which declined by 
71.2% and 44.5%, respectively. At the endline, the Activity has achieved 53.4% and 60.6% of the 
LOA targets set for ANC4+ and SBA, respectively. 
Figure 3. Performance for maternal health KPIs at baseline, endline and against LOA target (left) and 
Performance trend (right) in Transform HDR intervention areas
Although a steep decline was observed on performance of all the KPIs at endline, the 
performance trend for all maternal health KPIs was positive at midterm, apart from IFA which 
showed a steady decline over these periods. Despite significant declines in the reported essential 
components of ANC and IFA use, more than 84% of the surveyed facilities in Transform HDR 
intervention areas provided essential components of ANC and all provided IFA supplementation.5
Conversely, essential components of ANC were available in fewer facilities in non-Transform 
intervention areas. For example, syphilis testing was available in 47% of the surveyed facilities. 
The most frequently mentioned reasons for not having any ANC contact (in rank order) include 
long distance to a facility, no observed problems during pregnancy, the unavailability of 
transportation, perceived poor service quality, not knowing where to get the service, absence of 
female service providers, and partner refusal. The Activity implemented targeted SBCC 
interventions using existing community structures. Supporting the organization of pregnant 
women conferences and use of mothers group that facilitated education and referral of women 
for ANC, delivery, and other maternal and child health services, were identified as mechanisms 
used address the knowledge and attitudinal issues. Similarly, the quality improvement 
interventions at facilities were used to address service delivery gaps. 
Similarly, long distance to a facility, not thinking it as necessary, the service being not customary 
in the community, lack of transportation, perceived poor service quality, facility closure at the 
time and absence of female service provider at the facility were the most frequently mentioned 
reasons for not having the last birth at a health facility. Generally, geographic, behavioral, and 
5 The evaluation did not assess reasons for the declines in utilization of the specific services despite the observed availability 
in the surveyed facilities. This is noted as an area for future research in the recommendations. 24.7 27.4 23.3 26.0 28.1 23.2 22.9 15.2 6.7 15.423.8 20.128.8 39.3
Baseline (%) Endline (%) LOA Target (%)
Baseline Midterm Endline
IFA
ANC4+
SBA
Early PNC
27
organizational (health facility) factors played a substantial role in limiting the access of women to 
ANC and SBA services. Despite the intervention, this problem continues to persist. 
As shown in Table 7, performance for maternal health KPIs varied by region. Between baseline 
and endline, all regions had improved performance for early ANC and PNC, except Somali, 
exacerbating inequalities in that region compared with other THDR regions. All maternal health 
KPIs improved in B/Gumuz, except IFA intake. IFA intake for at least 90 days declined in all 
regions. In Gambella, there was an increase in ANC4+ uptake despite a slight decrease in SBA. 
In contrast, in Afar, SBA service uptake improved by close to 50% from baseline value, unlike 
ANC4+ uptake, which dropped by more than a quarter. 
Table 7. Performance for maternal health KPIs at baseline and endline in Transform HDR 
intervention areas by region
Indicator Period Afar B/Gumuz Gambella Somali
Early ANC
Baseline 15.8 30.2 34.5 24.6
Endline 21.6 71.4 54.4 11.1
Essential components of ANC 
Baseline 40.7 22.7 21.7 16.9
Endline 15.7 55.7 15.2 7.3
IFA supplement for at least 90 
days
Baseline 17.7 36.5 11.8 5.9
Endline 7.4 30.0 10.9 1.4
ANC 4+ 
Baseline 16.5 49.7 23.7 16.9
Endline 11.8 78.6 26.1 4.1
SBA
Baseline 17.7 31.8 50.9 21.4
Endline 26.0 81.4 47.8 8.7
Early PNC for mothers
Baseline 10.5 37.1 34.2 17.6
Endline 20.1 78.6 34.8 7.3
Maternal health outcomes generally declined in both Transform HDR and non-Transform 
intervention areas. However, at the endline, Transform HDR intervention performance for all 
maternal health KPIs was better than non-Transform HDR areas (Figure 4), although the 
28
performance difference between them was observed to be statistically significant only for ANC4+ 
(p<0.05). 
Figure 4. Performance for maternal health KPIs at baseline and endline by Transform and non- Transform 
intervention areas
Newborn Health Outcomes 
Essential newborn care and early initiation of breastfeeding 
significantly improved (p<0.001) compared to baseline 
status. At endline, early PNC coverage dropped below its 
baseline, although not statistically significant, and reached 
only 45% of its LOA target. Essential newborn care showed 
a sharp increase from its midterm status. However, 
performance for the remaining KPIs dropped despite the 
progress made at midterm (Figure 5). 24.730.1 27.4 41.7 23.3
24.1
26.0
38.4
28.1
43.8
22.9
35.6
23.2
18.7
15.2
12.6
6.7
4.6
15.4
8.1
23.8
21.7
20.1
19.7
Transform Non
Transform
Transform Non
Transform
Transform Non
Transform
Transform Non
Transform
Transform Non
Transform
Transform Non
Transform
Early ANC Essential ANC IFA ANC 4+ SBA Early PNC for
mothers
Box 1: Case Study Vignette: Maternal / Perinatal Death Surveillance and Response Baseline (%) Endline (%)
The MOH began surveillance of maternal deaths in 2013, later adding surveillance of perinatal deaths. 
However, expansion of the surveillance system and use of the information to prevent deaths has been 
slow. According to the 2016 Ethiopia Demographic and Health Survey (DHS), only 1,025 maternal deaths 
were recorded at the time of data collection, representing only approximately 8% of expected maternal 
deaths and 0.4% of expected perinatal deaths. To address the lack of MPDSR in the four developing 
regions in which it operated, Transform HDR facilitated MPDSR implementation beginning with the 
training of 198 healthcare workers on MPDSR use, following this up with training of an additional 161 
health workers. Importantly, the Activity performed follow-up visits assisted with the implementation of 
the system and with making decisions based on surveillance data to improve service delivery and 
address the last two of the three sources of delays that are generally associated with preventable 
maternal and perinatal deaths: 1) Delay in recognizing the complication, and subsequently seeking 
professional care; 2) Delay at the primary level in referring the patient for treatment at secondary level; 
3) Delay in providing appropriate treatment at the secondary level.
Interviewees in Karamara Hospital in Somali and Dupti Hospital in Afar reported monthly meetings on 
MPDSR, reporting marked reduction in maternal deaths and progress in reducing perinatal deaths. At 
Karamara Hospital, MPDSR teams worked closely with facility-based quality Improvement Teams to set 
up a neonatal intensive care unit. Respondents also pointed to related contributions of Transform, such 
as a mini blood bank that has enabled them to successfully treat maternal hemorrhage, a common 
cause of death. Transform-supported skills labs and CEmONC mentoring were also cited as contributing 
to improved emergency maternal health services. In Afar, recent improved performance at Dupti 
Hospital has motivated changes in other facilities in that region. However, in both regions, high staff 
turnover and fear of accountability issues following a death audit or review remain challenges to MPDSR 
sustainability. 
Transform HDR has successfully revitalized MPDSR in selected facilities. This intervention led to further 
quality improvements and linkages with other programs such as the hospital’s Quality Improvement 
Team, the CEmONC, Kangaroo Mother Care (KMC) program, the creation of Neonatal Intensive Care 
Units (NICU) and the installation of Mini Blood Banks.
Essential newborn care showed a 
sharp increase from its midterm 
status. However, performance for 
early PNC and early initiation of 
breastfeeding dropped despite the 
progress made at midterm.
29
Figure 5. Performance for newborn health KPIs at baseline, endline and against LOA target (left) and 
Performance trend (right) in Transform HDR intervention areas
Compared to the baseline, performance for essential newborn care improved in all regions. 
Similarly, early PNC uptake increased in all regions, except in Somali, where it dropped by 14.5 
percentage points and was the cause for the overall decline in Transform HDR regions. Unlike 
the marginal decline observed in Gambella, the practice of initiating breastfeeding within one 
hour of childbirth improved in all regions (Table 8). 
Table 8. Performance for newborn health KPIs at baseline and endline in Transform HDR 
intervention areas by region
Indicator Period Afar B/Gumuz Gambella Somali
Essential Newborn Care
Baseline 0.0 0.0 13.3 25.0
Endline 14.8 42.1 22.7 40.6
Early PNC for newborn (2 
days)
Baseline 12.3 30.5 36.8 22.1
Endline 20.1 70.0 37.0 7.6
Early initiation of breastfeeding 
Baseline 52.3 48.8 82.6 35.4
Endline 65.2 84.3 80.4 62.7
Essential newborn care and early initiation of breastfeeding improved from their baseline status 
in both Transform HDR and non-Transform intervention areas. On the other hand, Early PNC 
declined in both intervention categories, although the non-Transform areas suffered a 
considerable decline. At endline, Transform HDR intervention areas performed better than the 
non-Transform intervention areas, although differences were not statistically significant (Figure 
6). 
8.6
23.4
53.5
30.3
19.6
66.8
43.6
E s s e n t i a l c a r e E a r l y P N C E a r l y 
b r e a s t f e e d i n g
Baseline (%) Endline (%) LOA Target (%)
Baseline Midterm Endline
Early PNC
Essential care
Early breastfeeding
30
Figure 6. Performance for newborn health KPIs at baseline and endline by Transform and non-Transform 
intervention areas 8.6
7.8
23.4
37.0
53.5
55.9
30.3
18.6
19.6
17.7
66.8
64.1
Transform Non Transform Transform Non Transform Transform Non Transform
Essential Newborn Care Early PNC for newborn Early initiation of breastfeeding
Baseline (%) Endline (%)
Box 2: Case Study Vignette: Comprehensive Emergency Obstetric and Newborn Care
Transform HDR provided technical support for Ethiopian Association of Obstetricians and 
Gynecologists (ESOG) training on CEmONC in ten hospitals in the four HDR regions: five in Somali, 
three in Afar, one in Benishangul-Gumuz, and one in Gambella. The engagement of this 
professional association ensured that the quality of care provided and contributed to sustainability 
and potential scale-up further expansion. These activities were preceded by an assessment of 
16,808 deliveries that took place in 15 hospitals, and it was found that 1,942 (11.5%) had not received 
CEmONC. The most common causes of obstetric emergencies that led to 22 maternal deaths 
observed in 2018 in these 15 hospitals were: hemorrhage, preeclampsia, uterine rupture, sepsis, and 
abortion. The assessment also demonstrated that staff had limited clinical skills. About half of the 
hospitals failed to provide one of nine CEmONC services due to lack of trained staff and equipment. 
Eighty percent of those providing CEmONC services had not received basic (BEmONC) or 
emergency training, and three hospitals lacked anesthetists. After CEmONC orientation, each 
trained hospital staff received regular mentoring visits, and there were successful CEmONC 
graduates in all ten hospitals. Transform HDR also organized kangaroo mother care (KMC) rooms 
for mothers and premature babies. 
The Hospital CEO and Medical Services Director at the Karamara hospital in Somali reported that 
Transform interventions contributed to marked reductions in maternal deaths, increases in C￾sections from 9.8% to 19.9%, and a reduction in the number of maternal referrals from 72% to 25%. 
The quality of obstetric care improved due to ultrasound scans and timely transfusions. Hospital 
staff emphasized the need to continue having the support of Ethiopian Society of Obstetrics and 
Gynecology (ESOG) to continue improving maternal and neonatal care and to become accredited 
CEmONC training centers. However, challenges cited by hospital leaders were limited government 
budget allocation to implement improvements and lack of intra-sectoral collaboration between the 
MCH directorate in MOH and the public health emergency system.
31
Child Health Outcomes
Preventative child health service outcomes
Measles coverage among children 12-23 months of age 
who received the vaccine any time before the survey 
improved significantly (p=0.004). Likewise, a statistically 
significant increase in Vitamin A supplementation for 
children between the 6 to 59 months was noted 
(p<0.001). On the contrary, full immunization and Penta 
3 coverages significantly declined (p<0.001) (Figure 7). 
On examination of the practice of provision of vaccines 
at the appropriate age of a child (in the first year of life), 
13.8%, 30%, and 11.3% of the children had their Penta3, 
measles, and full immunizations, respectively, and 
Transform HDR-supported areas were only able to 
attain less than 30% of the LOA targets set for Penta 3 
and full immunization. Conversely, the LOA target for 
Vitamin A supplementation was overachieved. As 
evident in Figure 5, performance trends for all the KPIs, exclusive breastfeeding (BF), showed a 
decline despite the gains at midterm. 
Figure 7. Performance for preventive child health KPIs at baseline, endline and against LOA target (left) and 
Performance trend (right) in Transform HDR intervention areas
As displayed in Table 9, performance for preventive child health, KPIs vary by region. Measles 
coverage and Vitamin A supplementation increased in all regions, but Somali.6
Exclusive 
breastfeeding also improved in all regions except Afar, where the practice was observed to drop 
by 27 percentage points from the baseline. Except for exclusive breastfeeding, Afar region 
6 Measles coverage in this case refers to MCV1. Whenever immunization card is available data were taken from the card. 
However, when this was not the case mothers were asked about the first measles vaccination their children had. Therefore, 
in the latter case, the possibility of reporting measles vaccines received through such campaigns is higher, which may have 
accounted for the observed high measles coverage. 31.3 28.1 27.636.0
66.1
15.7
36.4
12.3
42.3
61.13
36.5
Baseline (%) Endline (%) Life of Project Target (%)
Baseline Midterm Endline
Full immunization Measles (MCV 1)
Penta 3 Vitamin A supp.
Exclusive BF
Performance trends for all preventive child 
health KPIs showed a decline despite gains at 
midterm. However, Transform HDR 
campaigns played a role in improvements in 
preventative child health. Although measles 
containing vaccine first dose (MCV1) is 
mainly provided as part of routine 
immunization service, vitamin A 
supplementation can be linked to services 
provided through campaigns as well as 
through routine modalities. In Transform 
HDR intervention areas, measles coverage 
among children who received the vaccine 
any time before the survey and vitamin A 
supplementation improved significantly. 
32
improved most for all KPIs, whereas Somali’s performance was the lowest between baseline and 
endline.
Table 9 Performance for preventive child health KPIs at baseline and endline in Transform 
HDR intervention areas by region
Indicators Period Afar B/Gumuz Gambella Somali
Penta 3
Baseline 8.7 65.0 39.9 27.1
Endline 23.7 63.4 26.3 4.9
Measles (MCV1)
Baseline 15.4 41.6 34.0 29.3
Endline 49.3 85.4 52.6 22.5
Full immunization
Baseline 9.9 61.4 30.4 20.4
Endline 20.4 46.3 23.7 3.0
Vitamin A supplementation
Baseline 37.2 46.4 29.9 30.8
Endline 62.9 90.7 58.7 23.9
 Exclusive breastfeeding
Baseline 74.1 75.7 77.4 27.7
Endline 46.8 81.8 93.8 60.4
As presented in Figure 8, comparing Transform HDR and non-Transform areas, Penta 3 and full 
immunization coverage and exclusive breastfeeding practices dropped in both Transform HDR 
and non-Transform intervention areas. In Transform HDR areas, measles coverage and Vitamin 
A supplementation increased in contrast to the performance in non-Transform intervention 
areas. At the endline, Transform HDR areas had higher performance for all KPIs than the non￾Transform intervention areas, although the difference was statistically significant only for Vitamin 
A supplementation (p<0.001). 
Figure 8. Performance for preventive child health KPIs at baseline and endline by Transform and non￾Transform intervention areas 31.338.0 28.1 29.7 27.634.8 36.0 33.6 66.171.7 15.7 12.5 36.4 28.3 12.3 9.9 42.3 21.1 61.1 53.7
Transform Non
Transform
Transform Non
Transform
Transform Non
Transform
Transform Non
Transform
Transform Non
Transform
Penta 3 coverage Measles Full immunization Vitamin A
supplementaion
Exclusively
breastfeeding
Baseline (%) Endline (%)
33
Curative child health service outcomes
As shown in Figure 9, treatments of ARI with antibiotics 
and diarrhea with ORS + Zinc increased from the 
baseline, although the difference was statistically 
significant only for ARI treatment (p=0.001), which may 
be due to increased COVID-19 cases and a resulting 
higher number of respiratory cases requiring 
treatment. On the other hand, deworming and the 
practice of seeking treatment/advice for children within 
24 hours of onset of fever declined significantly 
(p<0.001). Except for diarrhea treatment, which is 2.9 
percentage points below its LOA target, performances 
for ARI and fever treatment were very far from meeting 
their respective LOA targets. 
Figure 9. Performance for preventive child health KPIs at baseline, endline and against LOA target (left) 
and Performance trend (right) in Transform HDR intervention areas
At the endline, ARI treatment and deworming declined sharply from their respective highest 
points at midterm. On the contrary, diarrhea treatment showed an ascent picking up from its 
lowest point at midterm. Fever treatment within 24 hours of onset showed a steady decline. 
Despite the decline in treatment of the three childhood illnesses, 69.2% of health posts in 
Transform HDR intervention areas provided integrated community management of newborn and 
childhood illness (ICMNCI), which indicated an achievement of more than 85% of the LOA target. 
Compared to baseline status, deworming increased in all regions, although marginally in 
Gambella. Moreover, ARI treatment increased in all regions except Gambella, and ARI treatment 
nearly doubled in Afar and Benishangul Gumuz. Fever treatment within 24 hours of onset 
declined in all regions leading to the overall significant decline. The Gambella region had the 
largest decline followed by Benishangul Gumuz. 
Transform HDR areas 
outperformed non-Transform 
intervention areas for all key 
performance indicators (KPI) except 
deworming. At endline, diarrhea 
treatment showed an increase from 
its lowest point at midterm. 
ARI treatment and deworming 
declined sharply from their 
respective highest points at 
midterm. 
27.4
16.8
28.2
52.2
18.9
34.9
33.9
22.9
83.6
36.8
83.2
D e w o r m i n g A R I 
t r e a t m e n t 
w i t h 
a n t i b i o t i c s 
D i a r r h e a 
t r e a t m e n t 
( O R S + Z i n c )
F e v e r 
t r e a t m e n t 
w i t h i n 2 4 
h r s o f o n s e t
Baseline (%) Endline (%) LOA Target (%)
Baseline Midterm Endline
ARI treatment Diarrhea treatment
Deworming Fever tretment
34
Table 10. Performance for preventive child health KPIs at baseline and endline in 
Transform HDR intervention areas by region
Indicator Afar B/Gumuz Gambella Somali
Deworming
Baseline 20.7 58.1 31.1 3.5
Endline 24.0 84.0 31.2 7.8
ARI treatment with antibiotics 
Baseline 16.7 25.6 17.2 0.0
Endline 46.2 79.0 16.7 23.1
Diarrhea treatment with ORS and 
Zinc
Baseline 22.8 26.5 32.9 33.3
Endline 41.7 51.2 25.0 26.5
Advice/treatment sought within 
24 hours of onset of fever
Baseline 41.3 56.5 70.4 28.9
Endline 30.4 34.1 25.0 17.6
Comparisons between Transform HDR and non-Transform intervention areas revealed that, 
except deworming,7
Transform HDR areas’ performance for all KPIs was higher. ARI treatment 
with antibiotics improved in both Transform HDR and non-Transform HDR intervention areas, 
whereas diarrhea treatment improved only in Transform HDR areas. On the other hand, the 
practice of seeking treatment/advice for fever within 24 hours of onset declined in both areas 
(Figure 10). At the endline, Transform HDR and non-Transform intervention areas’ performance 
was identified to differ significantly (p<0.05) only for deworming.
Figure 10. Performance for preventive child health KPIs at baseline and endline by Transform and non￾Transform intervention areas
Demand for high-impact MNCH/FP services
7 Although Vitamin A supplementation and deworming activities are provided simultaneously through campaigns, the target 
groups for Vitamin A supplementation are wider than those for deworming and thus there are children who receive vitamin 
A but do not get the drug for deworming. Differences may also be attributed to the provision of Vitamin A supplementation 
in facilities along with MCV1 vaccines, which is not the case for deworming. 27.4 24.1 16.8 19.028.2
33.9
52.2
59.4
18.9
23.7
34.9
30.0
33.9
28.3
22.9
17.7
Transform Non
Transform
Transform Non
Transform
Transform Non
Transform
Transform Non
Transform
Deworming ARI treatment with
antibiotic
Diarrhea treatment with
ORS + Zinc
Fever treatment within 24
hrs of onset
Baseline (%) Endline (%)
35
Awareness of MNCH/FP
As shown in Table 11, women who heard/saw specific messages on RH/FP declined from baseline 
in both Transform HDR and non-Transform intervention areas, whereas the proportion of women 
who were exposed to MNCH-specific messages tended to improve from baseline. At the endline, 
although more women reported seeing/hearing RH or MNCH messages in non-Transform 
intervention areas, the differences with that of Transform intervention areas were not statistically 
significant.
Table 11. Performance in MNCH/FP awareness creation at baseline and endline in 
Transform HDR intervention areas by region
Indicators
Transform Non-Transform 
Baseline Endline Baseline Endline
Specific RH/FP messages 48.1 25.9 52.3 28.0
Specific MNCH messages 19.1 23.6 23.4 24.6
Despite the declines observed in the exposure women had to RH/FP and MNCH messages over 
the last three months from the survey data, KIs reported that the Transform HDR activities 
contributed to improved health-seeking behaviors of communities. Several activities were 
implemented using the existing community health structures. This involved strengthening the 
capacities of health extension workers and Women Development Army (WDA) members who 
conducted awareness raising and demand creation activities. On top of the face-to-face 
interaction Health Education Workers (HEWs) and WDAs had, the spread of tailored messages 
related to family planning and MNCH through print media, such as leaflets, were reported. These 
efforts were reported to have improved the knowledge of the community in FP and MNCH, and 
service utilization at health facilities and outreach/mobile sites. This according to the KI from 
Benishangul Gumuz is described as follows:
“Transform HDR has been providing capacity building support to HEWs, who in turn train WDAs. 
WDAs pass information about MNCH/FP services at the household level. As a result, communities’ 
awareness of the importance of utilizing MNCH/FP services increased especially on institutional 
delivery. Besides, the project supported the transfer of key MNCH/FP messages through distributing 
leaflets to the community. These demand creation approaches helped to change attitudes of 
mothers in favor of facility delivery since they came to realize the risks associated with home 
delivery.” 
Pregnant women conferences are community-based interventions designed to raise awareness 
of obstetric danger signs and the use of institutional skilled maternal health care services. These 
were mentioned by KIs as an effective strategy to mobilize the community to provide the 
necessary support to mothers to use ANC, delivery, PNC, and family planning services. Moreover, 
the efforts made to engage existing community structures, such as community/religious/clan 
leaders and elders in the behavior change communication activities, was also reported to improve 
the acceptability and effectiveness of the works of HEWs and uptake of family planning services. 
The changes observed in family planning uptake because of use of these structures was described 
by a KI from Benishangul Gumuz as follows:
36
“In Maokomo woreda, FP uptake was so low and Transform HDR trained community and religious 
leaders and they set a three-month plan of action to mobilize the community on FP. After the three 
months, uptake of both short and long-acting FP methods increased markedly. This was 
documented as a success story by Transform HDR.”
Insecurity in multiple areas of the intervention regions may have led to the decline in the 
proportion of women who reported hearing/seeing RH/FP and MNCH messages at the endline 
compared to the baseline. 
Gender norms and women’s empowerment
Women’s participation in health care decision-making declined in all regions except in B/Gumuz. 
More men accompanied their spouses during ANC in B/Gumuz and Gambella. More men 
accompanied their spouses during the birth of their last child born in Gambella and Somali. 
Overall, women’s participation in health care decision-making and men accompanying their 
spouses during ANC and delivery declined significantly (p<0.001) (Table 12). As presented in 
Figure 11, a consistent decline was observed in performances for two KPIs: women’s participation 
in decisions concerning their own health and women accompanied by their spouses at least on 
one ANC visit. Performance on women being accompanied by their spouses during birth declined 
at endline despite some progress witnessed at midterm.
Table 12. Performance for gender and women empowerment KPIs at baseline and 
endline in Transform HDR intervention areas
Indicator Time Afar B/Gumuz Gambella Somali Overall
Participation in own 
health care 
decisions
Baseline 85.1 79.0 71.0 93.4 82.3
Endline 73.6 89.4 61.2 78.3 77.7
Accompanied by 
spouse during at 
least one ANC visit
Baseline 53.3 52.8 42.4 12.3 44.4
Endline 23.0 65.7 43.5 9.5 21.5
Accompanied by 
spouse during last 
delivery
Baseline 87.8 90.3 66.7 61.1 78.2
Endline 60.7 87.9 77.3 73.5 74.7
Figure 11. Performance trend for gender and women empowerment KPIs in Transform HDR intervention 
areas
As can be seen from Figure 12, all three gender and women’s empowerment KPIs declined both 
in Transform HDR and non-Transform intervention areas from baseline; a substantial decline was 
Baseline Midterm Endline
Participation in own healthcare decisions
Accompanied during ANC
Accompanied during birth
37
observed for women who were accompanied by their spouse during at least one ANC visit. At 
the endline, Transform HDR intervention areas happened to have higher performance for all the 
KPIs than non-Transform areas, although the performance difference between the two areas was 
found statistically significant for only women’s participation in health care decisions (p<0.001).
Figure 12. Performance for gender and women empowerment KPIs at baseline and endline by Transform 
and non-Transform intervention areas
Health system performance 
Availability of family planning service in surveyed facilities
Family planning service was provided in 93% and 76.5% of surveyed health facilities in Transform 
HDR and non-Transform intervention areas, respectively, demonstrating an improvement in 
Transform HDR intervention areas. The LOA target (70%) set by the Transform HDR activity for 
availability of family planning services was exceeded as well. Results on availability of family 
planning methods also revealed a higher proportion of facilities in Transform HDR intervention 
areas provided each of the modern family planning methods than facilities in non-Transform 
intervention areas (Table 13). On the contrary, family planning service availability was very low at 
surveyed health posts in both intervention and non-intervention areas; 50.8% and 42.1% of 
surveyed health posts did not provide modern family planning methods in Transform HDR and 
non-Transform intervention areas, respectively. 
Table 13. Family planning method provided at surveyed health facilities 
in Transform and non-Transform intervention areas
Contraceptive methods Transform (%) Non -Transform (%)
Combined oral contraceptive 
pills 87.7 82.4
Progestin-only contraceptive 
pills 75.4 41.2
Progestin-only injectable 79.0 58.8
Male condom 73.7 52.9
Implants (Implanon or Jadelle) 75.4 41.2
Emergency contraceptive pills 66.7 52.9
IUCD 54.4 47.1 82.3 80.1 44.452.3 78.2 72.9 77.7 70.0 21.5 18.7 74.7 67.3
Transform Non Transform Transform Non Transform Transform Non Transform
Participation in own health care
decisions
Accompanied during at tleast one
ANC visit
Accompanied during last dellivery
Baseline (%) Endline (%)
38
Availability of post GBV services in surveyed facilities 
As is evident in Figure 13, a generally higher proportion of health facilities in Transform HDR 
intervention areas provided the different components of post GBV services than facilities in non￾Transform intervention areas. On average, about three times as many health facilities in 
Transform HDR intervention areas provided the different components of post GBV services as 
those in non-Transform intervention areas.
Figure 13. Post GBV service components provided at surveyed facilities in Transform and non-Transform 
intervention areas
Availability of adolescent and youth friendly services in surveyed facilities
Adolescent and youth friendly (AYF) services were provided in 22.8% of surveyed health facilities 
in Transform HDR intervention areas, whereas more facilities (35.3%) in non-Transform 
intervention areas were identified as providing the services. As can be seen in Figure 14, out of 
the facilities that provided AYF services in Transform intervention areas, all AYF service 
components were provided in more than half of them. STI treatment and HIV testing were 
available in all facilities where AYF services were found to be provided. Each of the remaining 
eight AYF components were available in a higher proportion of health facilities in Transform HDR 
than non-Transform intervention areas. 
Figure 14. Adolescent and Youth Friendly service components provided at surveyed facilities in Transform 
and non-Transform intervention areas
33.3
43.9 42.1
36.8
42.1 38.6
17.7
23.5
17.7
23.5
11.8
17.7
GBV screening
services
Emergency
contraceptives
Post exposure
prophylaxis
Psychosocial
counseling
Referal for
psychosocial
services
Referal for legal
services
Transform Non Transform
76.9
92.3
92.3
76.9
92.3
100
100
100
84.6
69.2
53.9
83.3
83.3
83.3
83.3
66.7
83.3
100
100
66.7
83.3
50
Counselling through peer educators
Counselling through YFS trained health…
Provision of modern contraceptives
Youth-friendly post-abortion care
Youth-friendly post-abortion contraceptives
Pregnancy testing
Treatment of sexually transmitted infections
HIV testing
Link to ART clinics
Life skill training
All components
Non-Transform Transform
39
Availability of Basic Emergency Obstetric and Neonatal Care in surveyed facilities
Nearly four out of ten facilities surveyed in Transform HDR intervention areas reported providing 
all Basic Emergency Obstetric and Neonatal Care (BEmONC) signal functions, which is slightly 
lower than what was identified in the non-Transform intervention areas. Compared to non￾Transform HDR intervention areas, a higher proportion of facilities in Transform HDR intervention 
areas provided each of the signal functions except for assisted vaginal delivery (Figure 15).
Figure 15. BEmONC signal functions provided at surveyed health facilities in Transform and non-Transform 
intervention areas
Health facility performance assessments
All surveyed primary hospitals and 78.9% of the health centers in Transform HDR intervention 
areas reported conducting monitoring/self-assessments of performance using the Ethiopian 
Hospital Service Transformation Guideline (EHSTG) and Ethiopian Health Center Reform 
Implementation Guidelines (EHCRIG). In a majority of the facilities (79.5%), the monitoring was 
reported to have taken place in the second and third quarter of the current Ethiopian fiscal year 
(EFY 2014). Results demonstrated that a majority of the facilities (80%) had not analyzed their 
monitoring data, and from those that had, 27.8% had an overall performance score of more than 
80%. Regarding monitoring of implementation status of health information system, 43.9% of 
facilities reported conducting the exercise regularly, and in 68.2% of the facilities, the practice 
was identified as taking place in the second and third quarter of EFY 2014. Results showed that 
60% of the facilities did not analyze their monitoring data, and among those that did, very few 
facilities (16.7%) reported an overall score of more than 85%. These findings demonstrate that 
not many facilities are processing and using the monitoring data they have collected related to 
health facility performance to inform the decisions they are supposed to make in improving 
performance. 
From all surveyed health facilities in Transform HDR intervention areas, 78.9% of the facilities had 
annual quality improvement plans in place. Out of those facilities that had a quality improvement 
94.4
89.1
94.4
87.3
54.6
83.3
38.9
60.0
36.8
70.6
75.0
88.2
76.5
47.1
70.6
35.3
64.7
41.2
Administration of parenteral oxytocin
Administration of parenteral anticonvulsants
Administration of parenteral antibiotics
Manual removal of placenta
Removal of retained products of conception
Newborn resuscitation using bag and mask
Administration of corticosteroids
Assisted vaginal deliveries
All signal functions
Non-Transform Transform
40
plan, only half reported implementing them. In addition, facilities that received support from 
Transform HDR for implementation of quality improvement initiatives (22.8% of surveyed 
facilities), 84.6% had quality improvement (QI) plans. Of the facilities with QI plans, 72.7% 
reported implementation.
Health workforce capacity development
Health workforce capacity building on various thematic areas was one of the core activities of the 
Transform HDR activity. By the time of its completion, Transform HDR had supported the training 
of 18,728 health workers on MNCH/FP and related areas. Over the same period, the activity also 
supported post-training follow-up, onsite mentoring and coaching on BEmONC and family 
planning for 151 health workers from 79 health facilities, 421 health workers from 301 health 
facilities, and 60 health workers from 44 health facilities on BEmONC, modern family planning 
methods (long acting and postpartum), and traditional (standard days) family planning methods. 
To strengthen the community health system, it also enabled training of 1,503 HEWs and their 
supervisors on integrated management of childhood illness and community-based newborn 
care. 
According to the KIs, training, post-training follow-ups, mentoring, and coaching activities that 
were supported by the Transform HDR activity enhanced the competency of health workers and 
ultimately contributed to improving quality and uptake of services. The need-based nature of the 
trainings and the follow-up activities implemented afterward were recognized by KIs as the most 
important drivers of service improvement. These capacity building efforts were reported to 
specifically improve diagnosis and management of childhood illnesses, provision of long-acting 
family planning methods, uptake of antenatal care and delivery service, and the early detection 
and management of complications during labor and delivery. Describing the changes that 
resulted from the capacity building work by Transform HDR, a KI from Benishangul Gumuz had 
this to say:
“Transform HDR provided MNCH/FP trainings to many staff and checked the application of 
trainings through the post-training follow-ups. As a result of these efforts, we saw many changes. 
For example, utilization of LAFP is increasing from time to time because of the capacity building 
works coupled with the many FP promotion works especially targeting native Ethnic Groups who 
used to associate FP with religion and tradition.” 
How effective are the Transform activity strategies and approaches?
Key informants described what they considered to be the most effective approaches that should 
be sustained or scaled up. Some of the interventions such as community awareness creation and 
capacity building efforts, including both onsite and offsite trainings, were mentioned as effective 
approaches in terms of improving service uptake and quality. The most frequently mentioned 
effective intervention approaches noted by KIs included the provision of mobile ultrasound, 
capacity building trainings on different topics and material support. Awareness creation, 
furnishing maternity waiting homes, Leadership Management and Governance (LMG) trainings 
and mentoring/coaching were also mentioned as effective interventions by KIs. In addition, the 
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establishment of NICU and mini-blood banks were cited as effective interventions in reducing 
maternal and infant mortality. 
Views expressed by key informants on the effectiveness of some Transform HDR interventions 
reflecting subjective experiences and were sometimes at variance with performance on key 
indicators. Performance on KPIs reflected MNCH/FP outcomes in a period that was markedly 
affected by recurrent/prolonged conflicts, natural disasters, outbreaks, and resulting massive 
internal displacements. Although the interventions were appreciated, the scale of the intervention 
compared to needs in developing regions was small, a relatively late start on demand creation 
for MNCH/FP activities, and external shocks had serious repercussions on improving service 
quality at health facilities, community awareness on various aspects of MNCH/FP utilization of 
services.
Most effective interventions 
The changes in MNCH/FP services observed because of the support received from Transform 
HDR were described by the KI from Gambella as effective and the result of providing essential 
equipment and medical technology, and capacity building to facility staff: “the introduction of 
portable ultrasound increased the possibility of outreach services. As a result of that, access to 
maternal health services and the demand for health services increased. Moreover, the clinical 
coaching and mentoring played a significant role in building the capacities of professionals at 
health centers leading to a reduction in the number of cases referred to hospitals. These implied 
improved competencies of the professionals to manage non-complicated maternal and child health 
problems independently at the health centers.”
A KI from Benishangul-Gumuz also indicated improvement in neonatal care owing to the material 
and capacity building support provided by Transform HDR. “The supplies provided to facilities had 
the greatest role for the improvement of MNCH/FP services, for example, the NICU in Assosa 
general hospital has substantially improved, because of the training provided to staff on neonatal 
care and treatment and some medical equipment donated. This support has therefore contributed 
to the sharp drop in neonatal mortality observed in the hospital.”
Regional variations in effectiveness of gender-related interventions
Targeting of men to increase FP uptake had mixed results. KIs underlined the need for much 
more work on family planning awareness creation targeting men, because many of the 
developing regions are highly patriarchal societies and women still have no right to 
independently decide to use family planning methods. As discussed in a later section, targeting 
men was reported to have contributed to FP uptake in some regions, such as Benishangul-Gumuz 
and Somali. In Gambella, although engaging religious and community leaders was difficult, some 
progress was made in terms of women’s empowerment through organizing “coffee ceremonies” 
was reported.
Least effective interventions 
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When asked to mention the least effective interventions, only a few mentioned least effective 
approaches. And in most cases, those mentioned by KIs as least effective were not because of 
their problem in terms of the theory of change but rather because the interventions were not 
adequately implemented. KIs mentioned that the scope of the Transform HDR was wide which 
stretched its resources. The KI from Benishangul-Gumuz reported this constraint in resources and 
the impact as:
“The scope of Transform HDR was so wide from the beginning and its goal was to transform or 
nearly transform targeted woredas. However, we haven't achieved the anticipated transformation 
in all woredas since such a goal is too big to be achieved by one development partner. To the worst, 
health facilities that were making progress on the way to being models were destroyed by the 
conflict that has been affecting the region over the last two years. Activity implementation was also 
highly limited by the small number of staff Transform HDR has; there was a mismatch between 
number of Transform HDR staffs and the area of intervention.”—KII, Benishangul-Gumuz.
Community level interventions, the provision of reproductive health services to young people, 
and the work done so far to promote male engagement in FP were identified as less effective by 
KIs from Somali and Gambella, respectively. Lack of follow-up after training of community level 
health workers and volunteers was the reason mentioned by KIs regarding the limited extent of 
community level behavioral changes that would have been realized because of the intervention. 
The lack of a separate room dedicated to providing youth reproductive services was also pointed 
out to have limited the tendency of young people to use the services. This gap in youth-friendly 
services was described as: 
“The least effective approaches were FP services for adolescent and youth because the MNCH/FP 
service provision at a single compound for all people of different ages challenged the service needed 
by the adolescent-youth. Access to family planning and other sexual health care services in the 
same location with their families was difficult for adolescents or youth. This means that due to 
privacy issues and cultural taboo, adolescents and young people did not feel comfortable visiting 
the health care center on sexual health-related issues, particularly pregnancy and the management 
of sexually transmitted infection. As a result, the area of adolescent-youth sexual and reproductive 
health was not effectively worked on. –KII, Gambella.
What interventions are replicable or can be scaled up in different settings? 
Mobile health and outreach services have the potential for greater scale up, particularly in heavily 
pastoralist communities in the Somali and Afar regions. The success of these measures was 
reported to be linked to further engaging regional bureaus, coordinating, and harmonizing these 
efforts with zonal health bureaus and WorHO, and with other IPs that offer outreach and mobile 
health services. Mobile health is an important innovation that was reported to be particularly well 
suited for regions such as Somali and Afar and that can be further scaled up. However, important 
challenges remain to ensure institutionalization of mobile services:
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● Woredas do not have transportation budgets to support mobile services, and longer￾term sustainability is uncertain due to a dearth of vehicles and fuel.
● Poor road infrastructure and weak “last mile” distribution exacerbates stockouts of 
medicines and the lack of laboratory services. 
● In areas where Transform was working, other NGOs also came and provided partial 
MNCH servicers, especially nutrition services, requiring harmonization of mobile services 
across partner interventions.
● Mobile teams are only able to conduct ultrasound investigations for a few women in the 
field because of the device’s short battery life and lack of a backup battery.
● Mobile teams are also unable to provide food supplements for children and mothers as 
other partners do; such offerings attract more women to those services.
● Health workers are demotivated because of differences in payment schemes from partner 
to partner.
Social and behavior change communication (SBCC) was reported as another potential domain 
for scaling up, but to operate effectively these efforts will require adjustments. As an early 
comprehensive MNCH/FP partner in developing regions, the Activity faced strong headwinds, 
and required time to adequately address social messaging. Future scaling of services was 
reported to require even more intensive community outreach through women’s groups, 
community and religious leaders, and other influential local structures to gradually break down 
resistance in areas such as professional antenatal care and modern family planning adoption. 
Although women’s and men’s groups such as Umulgargar and Abulgargar are promising 
practices, scaling these types of interventions more widely in pastoralist communities would 
require more intensive support in every activity-supported pastoral community.
What is the effect of context (conflict, COVID-19 pandemic, internal displacement) on the 
Transform interventions and achievements?
Several factors affected program implementation. The most frequently mentioned factors 
reported by KIs in in-depth interviews included: war/conflict, political instability, COVID-19; and 
leadership turnover within the public health system.
The pandemic caused a decline in reproductive, maternal, and child health services. The Activity’s 
response was swift, as IPs activated their emergency rapid response funds, mitigation strategies 
were enacted rapidly, and health systems disruptions were averted. One of the respondents said, 
“there was a minor decline in service use in the first month, but we installed strategies 
immediately and were able to reverse the course.” 
The impact of conflict, insecurity, internal displacement, drought, floods, and other natural and 
manmade health system disruptions affected outcomes in Transform HDR regions. 
The first two years of Transform HDR’s implementation in the Somali region were challenged by 
security concerns. More recently, during the last two years since 2020, security problems in Afar 
and Benishangul-Gumuz regions affected health systems in those regions. Disease outbreaks 
such as the COVID-19 pandemic, acute watery diarrhea (AWD), measles, malaria, yellow fever, 
dengue fever, and the Chikungunya virus, which is spread to people by infected mosquitos, 
affected Activity implementation. 
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Key informants noted that during 2020 and 2021, war, public unrest, drought, and flooding 
disrupted the health system. A key informant from Afar RHB stated that most Transform 
intervention woredas were affected by the war in Northern Ethiopia. A key RHB informant 
interviewed in the Somali region said that despite the investment from Transform HDR, the 
performance was affected by manmade and natural catastrophes during these years, including 
drought, conflict, flooding, and locust infestation. He phrased it as follows: 
“Our health system has been tested this year, which has been challenging. Despite 
these challenges, we did a lot of activities in collaboration with the Transform 
program. . . and tried to maintain the achievements in the previous years. We tried 
to prevent from reversing our achievements. We are encouraged by this because our 
health system becomes resilient. It keeps performing despite those shocks.” 
Transform HDR utilized crisis modifier funds to respond to the effects of these shocks. The 
Activities supported RHBs in their response to the COVID-19 pandemic to ensure continuity of 
essential MNCH/FP services. Similarly, the crisis modifier funding was used to support emergency 
health service needs of internally displaced persons (IDP) in Afar and Benishangul-Gumuz. The 
crisis modifier was also used to counter a measles outbreak in Somali and flood response support 
in Afar. 
Frequent changes of leadership within the health system also negatively affected the momentum 
of promising interventions supported by Transform HDR in almost all regions. Key informants 
across all regional and woreda health bureaus revealed that there was frequent change in 
leadership at all levels of the health system. According to one respondent: “The leader you met 
this month and discussed the implementation challenges you experienced may not be occupying 
the position after a month or two,” explaining the challenges the program faced because of 
increased leadership reshuffles and turnover (KI, Transform HDR Afar office). In some woredas, 
district health leaders left the position after receiving LMG training, one of the key interventions 
the Transform program implemented to strengthen the health system. Whereas commitment 
among some of the woreda leadership contributed to notable coverage for key MNCH/FP 
interventions, progress was stalled by the war that affected the area in 2021.
5.2 HOW AND TO WHAT EXTENT DID TRANSFORM PROGRAM ACTIVITIES FACILITATE LOCAL 
OWNERSHIP, SUSTAINABILITY, AND COHERENCE?
Most MOH stakeholders had a positive view and a sense of ownership of the interventions 
supported or introduced by the Activity. KIs from three HDR regions—Afar, Benishangul-Gumuz, 
and Gambelia—indicated that the approach of Transform HDR was highly participatory, and the 
activity worked in full alignment with the existing health system. 
In terms of coherence, the majority of KIs indicated that the Activity worked jointly with regional, 
zonal and woreda health bureaus/offices from its design and inception stages, through joint 
planning, alignment, and review exercises. For instance, Transform HDR involved RHB and zonal 
experts in all activities such as integrated supportive supervision (ISS), post-training follow up, 
clinical mentoring, and coaching. At regional levels, health workers were certified as master 
trainers. These experts can be used to train, mentor and coach health workers in the absence of 
the program. Through these interventions, the Activity contributed to building the skills of local 
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health professionals working on issues related to MNCH/FP. To the extent that these 
professionals remain in their posts, this capacity is likely to be sustained. 
What mechanisms are in place to ensure government ownership of Transform health system 
interventions? 
Key informants agreed that most Transform HDR strategies and interventions were aimed at 
strengthening the existing health system rather than implementing new or parallel activities. KIs 
indicated that the role of the program was to facilitate the achievement of the government’s 
strategic plan on RMNCH/FP through system strengthening, service integration and service 
reconfiguration. 
According to a KI respondent from the Gambella RHB, Transform HDR activities were fully 
integrated within the Ethiopian health system in contrast with other development partner 
interventions in the Gambella region: 
"[Transform] was a model of working in full effort and in line with national health care protocol or
standards, supporting the health system. Transform HDR interventions follow Ethiopian health care 
system protocols, and nothing was divergent. 
Although most KIs supported this view of full integration into the health system, one respondent 
from Somali reported gaps in the integration of the program activities and noted that the voice 
of the regional bureau was less than anticipated:
“The project can’t be said to be well integrated, but [it is] somehow integrated. This is because the 
RHB has no control or mandate to lead the project, AMREF is the lead and there are other partners. 
[Key decisions are made] in Addis, so we don’t even know what the collaboration looks like. When 
I say aligned, I mean it is the nature of the design which is strengthening existing services and 
system. The project also lacks transparency; we don’t know the budget and what is assigned for 
activities. Unlike Transform PHC, which builds the capacity of the government through direct 
funding, here it is the partners having the sole decision making on the project resources, led by the 
head offices in Addis. The ownership in TPHC targeted regions is much better because of the support 
of funding to have direct supervision as well.”
To what extent did government staff/community perceive that the approaches established by 
the project will be maintained by the government and continue to sustain MNCH/FP 
improvements in the next 3 and 5 years?
According to KIs, health system staff now have capacity to take over the implementation of most 
MNCH/FP activities because of the training they received. Certain elements of program activities 
such as ultrasound services are expected to be fully sustainable. However, most respondents 
expressed doubts that activities that required substantial financial support were likely to be 
owned and sustained by the government. Although key informants expressed a strong sense of 
ownership of the program activities, KIs are concerned that budget and financial constraints could 
hamper the continuation or sustainability of some program activities, for the following reasons: 
● Political instability and conflict affected the implementation of the program and is also a 
risk factor for sustainability of the activities and observed benefits. Because of conflict, 
some target woredas have not been accessible for years. 
● Staff shortages and staff turnover are also mentioned as risk factors for sustainability. 
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● Program ownership appears to be weaker in Somali compared to other regions. 
Government stakeholders are not pleased that the program focused on management 
and health worker capacity building, whereas greater emphasis should be on providing 
equipment. Moreover, according to this interviewee, the program has weak engagement 
with the RHB and weak community engagement in the Somali region. 
● The majority of KIs understand that the program will end soon and some of them 
indicated that they have already had discussions with Transform staff on exit strategies 
to ensure proper handover of the activities. Some KIs expressed concern that an exit 
strategy is not well enough planned to ensure sustainability. However, because the 
Activity was still operational in most regions at the time of interviews, formal closing 
meetings and workshops had not yet taken place. 
To what extent did the project improve community involvement and its role in accountability, 
transparency in decision-making, and advocacy for community health needs?
Transform HDR supported community engagement initiatives implemented by the 
government to improve health seeking behavior and ensure social accountability. For instance, 
the Activity supported a government initiative called community score card (CSC) and 
implemented activities to strengthen and sustain the CSC approach. The activities included 
capacity building of client councils and community awareness creation. In addition, Activity 
experts participated in quarterly discussions to rate the performance of the health facilities. 
Other interventions cited by KIs to involve communities included:
● Support for traditional community structures (e.g., community elders and influential 
leaders called ‘Boto’ in Somali region) to improve health seeking behavior (create 
demand) and ensure social accountability. 
● Training for women’s development groups, social mobilization committee, clan, and 
religious leaders to increase demand. 
● Support for “pregnant mothers’ conferences,” a forum where pregnant women can 
gather regularly to discuss health and health related issues during pregnancy.
To what extent did the project improve community engagement for advocacy and health service 
oversight? What capacity for community engagement did Transform build? 
Key informants pointed to improved awareness of women’s health rights because of the 
program. KIs noted improvements in engaging communities in evaluating health facilities. During 
the Activity intervention period, women’s development groups, traditional birth attendants, and 
religious and clan leaders were provided with training on community health demand creation 
and community-based surveillance. Community members also participated in the 
implementation of the project. For instance, clan leaders in Afar region were engaged in 
providing support for survivors of gender-based violence. Business associations were involved in 
detecting and reporting measles cases and outbreaks to health workers/HEWs. According to 
respondents from the regional health bureau in Afar:
“The project built the capacity of women development groups and social mobilization committees 
through training. Mobile outreach teams mobilized the community about the availability of quality 
maternal health and family planning services. The project actively engaged the community through 
the process from planning and implementation through the monitoring process. In general, the 
47
community was informed about the benefits of the outreach mobile clinic services. In particular, 
clan and religious leaders, women’s development groups program, in selecting outreach sites and 
organizing the program, in mobilizing community members for which they were part of the 
outreach mobile team. They were actively engaged in planning and scheduling of the outreach 
services, in reviewing and monitoring quality of health care services, and in providing feedback.” 
How do Transform HDR coordinate with other development partners and their activities?
KIs reported that Transform HDR employed different strategies to foster partnership and 
harmonize activities with MOH activities and the activities of other partners. Because Transform 
program activities were aligned with government plans and protocol, KIs indicated that this 
generally facilitated natural partnerships between the program and government. Transform HDR 
was regarded as having been active in terms collaborating with other development partners 
operating in all the targeted regions. As an example, RHB key informants cited Transform HDR 
as a model partner in the Gambella region in terms of creating and sustaining partnerships with 
other development partners:
“And that I may say, Transform HDR is a model on this area. What makes Transform HDR unique 
was its initiative to establish cooperation and coordination among other partners through its review 
meeting approach. The HDR effort and tendency to work collaboratively was impressive.”
Transform HDR respondents similarly acknowledged MOH’s key role in facilitation coordination 
inter-partner dialogue. This was particularly important, as regional health bureaus, often through 
their NGO coordination offices as well as zonal health departments, assigned partners in different 
areas based on the existing need to avoid duplication of efforts. Transform HDR regional staff in 
Benishangul-Gumuz, for example, acknowledged the key RHB role in coordinating efforts:
“The RHB assigns its development partners during woreda base planning each year and each 
partner supports its target woredas to make the planning sessions successful, Besides, RHB 
facilitates experience sharing among partners, i.e., by organizing a partners’ forum annually or 
biannually. In the forum, Transform HDR presents its performances from which others can learn 
and vice-versa.”
Participatory approaches, such as joint planning, and joint program implementation were most 
often cited by key informants as effective mechanisms to strengthen the partnership among 
development partners. Transform HDR was an active participant in partnership forums, which 
were established at national, regional zonal and woreda levels to facilitate coordination among 
partners, harmonize activities, and avoid duplication of efforts. In this regard, KIs reported that 
the program was successful in creating strong partnerships with actors, particularly at the regional 
level, and somewhat less so at zonal and woreda levels, which had fewer functional partnership 
forums. As one example, through sharing in regional and other forums, the cluster based clinical 
mentorship approach which was a key Transform HDR strategy was adopted by other partners 
in the Benishangul region.
Although Transform HDR was acknowledged as an active partner in partnership forums and 
regular review meetings, some KIs referred to challenges that were external to THDR. Partnership 
challenges were sometimes hampered by the fact that some other development partners were 
reported as being non-transparent in terms of disclosing their budgets. In such cases, plan 
48
alignment and coordination were challenging. In other cases, KIs cited a reluctance among some 
of these other development partners to attend partnership forum meetings, to cooperate and 
work together. In other cases, particularly at lower levels, partnership forums were not strong, 
and some were not active or held no regular meetings. Moreover, several respondents indicated 
that there is no shared partner database on management or health workers that have received 
training on specific topics, and that in some cases, these individuals attended repeated trainings 
offered by multiple partners on the same topic. Still others pointed to conflicts of interest and 
competition among partners for funding, which can also be a barrier to partnerships.
5.3 HOW DID TRANSFORM ACTIVITIES CONSIDER GENDER DYNAMICS IN ACTIVITY DESIGN 
AND IMPLEMENTATION? WHAT GENDER EQUITY RESULTS DID TRANSFORM ACTIVITY 
INTERVENTIONS ACHIEVE?
Transform HDR considered gender in the activities, such as conducting training on the issue of 
gender streamlining and integrating gender in SBCC activities. According to KIs, the Activity 
increased women’s leadership through its leadership training and training of female 
schoolteachers on gender issues and establishment of gender clubs in schools. Awareness and 
advocacy of gender issues was conducted through Motherhood Day and Women’s days and 
other community activities, such as coffee ceremonies and sending invitation cards to involve 
men in ANCs, delivery, and FP conversations. HDR also strengthened mother’s waiting homes by 
supplying equipment and other supplies and training new graduate midwives. 
According to one respondent, although changing attitudes in patriarchal societies such as those 
found in Gambella is difficult, some progress was made in terms of women’s empowerment and 
male engagement in that region:
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“Coffee ceremonies enable advocacy activity to promote women empowerment. The understanding 
level of the male partners increased, and the resistance from the male partner on the females’ 
decision making to have family planning minimized. Therefore, the inclusiveness approach of "have 
coffee" and mothers’ conferences showed fruitful progress. –Gambella RHB
The activity also supported women’s groups such as pregnant women conferences and a 
traditional women-only community structures in the Somali region called Umulgargar, whose 
work was complemented by Abulgargar groups for men. These groups worked to engage 
influential community elders and religious leaders to discuss male dominance, GBV and early 
marriage. 
One demonstration GBV center was established successfully in Afar Region. According to an Afar 
RHB respondent the Dubti Hospital One-Stop GBV center was successful in uniting various 
elements of the community to support GBV survivors:
“…Through the support provided by Transform HDR, a one-stop center in Dubti Hospital was 
established and strengthened in response to effort to provide comprehensive services including 
medical treatment, law, and psycho-social counseling for sexual and gender-based violence 
survivors.” 
Box 3: Case Study Vignette: Umulgargar Implementation in Awbare Health Center 
“Umulgargar” a Somali word translated as “save mothers at risk group.” It was established seven years 
ago by staff from maternity unit in Awbare health center. The establishment of the group was inspired 
by an incident that involved a mother who was fighting for her life after losing a large amount of blood 
following childbirth, which the maternity unit staff have witnessed firsthand. Staff were able to mobilize 
resources from the facility and the community to refer the mother to a public hospital in Jigjiga, which 
allowed the mother to continue accessing service to this day. That incident and the positive outcome 
that followed it motivated staff to organize a group of mothers who make monthly contributions to 
financially support fellow mothers from poor families to get necessary health care during pregnancy 
and childbirth. 
Mulo Abdi was one of the founders of the group. She is currently working at the woreda health office 
as a CBHI coordinator as well as serving as a focal person for Umulgargar. She noted that there are 
190 Umulgargar members in Awbare woreda, out of which 50 are in the Awbare town. Each woman in 
the group is responsible for five more households and the member responsible for her group provides 
a written referral card printed by Transform HDR to the nearest health center. Members also facilitate 
mother-to-mother support groups sessions, which promote linkages of pregnant mothers to health 
centers for antenatal care and delivery services. They keep track of the referrals made by using the 
referral cards shown in the picture below. 
Umulgargar also played a part in the launch of the Fredo (“good woman”) initiative, which promotes 
uptake of modern and traditional (standard days method) family planning methods. The uptake of 
modern family planning methods, specifically IUCD, Implanon and oral contraceptive pills has 
increased as a result. Umulgargar members are also engaged in notification of maternal and neonatal 
deaths that occurred in their community and also provide food and sanitary materials to mothers 
staying at the maternity home located in the health center premises. Umulgargar is supported by 
UNFPA in addition to Transform HDR. If these implementing partners pull out, interviewees expressed 
concerns that support for review meetings and associated transportation costs may be difficult to 
cover.
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What gaps exist in the current USAID/Transform intervention design or programming in terms 
of addressing the key gender issues in the targeted regions of Ethiopia?
At the start of the activity, a gender and socio-cultural assessment was conducted to identify 
gaps and what services were available. The assessment also identified what factors hinder or 
facilitate health service providers in the delivery of gender-based violence services. HDR 
developed several gender interventions to address selected service delivery gaps, which are at 
the demonstration stage. These interventions were implemented in selected woredas and some, 
such as the Mothers’ Group, Umulgargar, and youth friendly services—according to KIs—
demonstrated their effectiveness in selected woredas only. However, according to KIs, scaling of 
these interventions so they become an integral part of the MNCH/FP routine services had not 
started yet, and therefore, it is possible to demonstrate only limited measurable social change 
and results.
IPs discussed examples of how the T-HDR changed its activities to include the establishment of 
one-stop centers for GBV survivors. According to KIs, this intervention was not included in the 
initial plan but was added after conducting context analysis. The program also often amended 
its budgets according to the context and stakeholders’ needs. These budget amendments and 
shifts were possible within activities under the RMNCH/FP umbrella. A program staffer in Afar 
described the Activity’s flexibility under changing contexts as follows:
“Since the Transform program is flexible, the program activities adapted to the changing context. 
First context analysis is done to ensure the continued relevance of the program activities and 
planned activities are amended on the basis of the results of the analysis. So, budgeting and 
spending is aligned within the amended program activities. For example, some of interventions 
(e.g., the one-stop center for GBV survivors) which were not included in the plan are added during 
the course of the implementation, and these interventions produced positive results.” 
5.4 HOW AND TO WHAT EXTENT HAVE THE TRANSFORM IPS BEEN ABLE TO ADAPT THEIR 
INTERVENTIONS ABOUT LEARNINGS AND NEW EVIDENCE? 
This question was primarily raised with regional IP respondents, who noted that from their 
perspectives, the Activity was flexible and adaptive to address the changing needs of stakeholders 
and dynamic contexts. Regional managers appreciated the flexibility of the Activity and indicated 
that if there was a need and stakeholders requested support, the program amended its plan and 
acted accordingly. In this regard the program staff worked with national and local stakeholders 
to identify the changing needs and modify the program approach accordingly. Joint planning, 
joint supervision, and joint review meetings further helped the program to align its activities with 
government priorities. 
To what extent did key informant respondents perceive that the project established processes 
are functional to track and address gender and inequitable health outcomes?
Gender related findings discussed Transform HDR had three RMNCH officers who were tasked 
to support all MNCH/FP activities. However, it was reported it had one SBCC and gender officer 
to support 10 woredas in the Benishangul Gumuz region during the first two years of 
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implementation. These respondents indicated that gender issues did not receive adequate 
support and that social communication requires more attention in future programming: 
“Decision making at the household level regarding reproductive and sexual health is made by males 
in our region, which is a huge challenge for us, to change this we organized discussions with 
community leaders and men. Both themes (gender and SBCC) are vast and how can they be 
managed by one person? As a result, it wasn’t possible to reach all woredas.”
Despite the challenges, a woreda health office head midwife in the Somali region indicated some 
improvement in male engagement: 
“There is some improvement, they tried to engage men on SRH issues, the project helped mother 
to mother groups, and outreach services also targeted women beneficiaries, delivery service 
improvement, furnishing maternity waiting room, etc., are all good actions to make sure that 
women benefit from the intervention."
To what extent did the project make adaptive changes? Based on what evidence? 
KIs reported that the Activity used evidence from the mid-term evaluation to improve 
implementation approaches and introduce new activities. For instance, KIs mentioned that based 
on evidence from the mid-term evaluation, the Activity revisited its plan, identified good practices 
for scale up and facilitated sharing of experiences among facilities and woredas. Also informed 
by findings of the midterm evaluation, the Activity supported the implementation of DHIS2 in 
health facilities with the intention to improve the collection of quality data, and information use 
practices in the learning woredas. Moreover, the Activity gave feedback to health facilities to help 
them better address gaps identified during the midterm. 
Strengthening woreda coordination mechanisms was also another activity that was implemented 
in using evidence. The findings of the midterm evaluation enabled design of the "ANC 
revitalization initiative" that repackaged relevant interventions and was implemented in the 20 
learning woredas. Also, based on evidence generated from Transform MELA’s high level 
monitoring and operational research conducted by Transform HDR, new traditional birth 
attendant structures were established, and existing structures were strengthened with the 
purpose of strengthening service linkage with health facilities, particularly disease surveillance 
systems. Gambela-based IP respondents pointed to the fact that evidence generated from 
evaluation, monitoring, and research output was helpful for revisiting and re-exercising the 
planning, to identify strengths and weaknesses, to observe good practices and scale up, to get 
input, to share experiences and to reduce resource wastage, and to replicate something good 
practices implemented in other areas. Afar respondents discussed how the use of evidence 
generated from Transform MELA’s midterm evaluation, high-level monitoring (HLM) and from 
operation research gave them direction for improving quality service delivery. For instance, these 
key informants reported that the Activity helped to strengthen woreda coordination mechanisms 
by filling the gaps through training. 
Moreover, Transform HDR made use of evidence it generated from the annual random follow￾up visits conducted it inform interventions, activities and KPI targets. However, these visits did 
not reveal declines in performance for most of the indicators that would have helped in making 
timely adjustments to associated targets
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How did respondents perceive innovative or best practices that contributed to MNCH/FP 
outcomes? 
KIs were asked to mention innovative/best practices implemented by the T-HDR related to 
MNCH/FP outcomes. KIs discussed the provision of ultrasound machines to health centers; the 
provision of laboratory equipment, reagents, mini-blood banks, and neonatal intensive care units 
(NICU); and solar energy systems as key material contributions. KIs also pointed to facility linkages 
and experience sharing, joint planning exercises, LMG training, review meetings and supportive 
supervision, training for data quality improvement, and post-training follow-up and mentoring 
and coaching activities as key technical assistance contributions. In terms of gender-related 
activities, KIs mentioned advocacy to strengthen mothers’ conferences and the use of community 
structures to decrease child marriage and GBV. In terms of coordinating with partners, some KIs 
found that partnership mechanisms contributed to avoiding duplication of efforts. A KI in the 
Somali region described the importance of material support:
“The innovative good example is bringing ultrasound, V-scan, lab equipment, and solar (energy) 
systems as well as the data quality improvement component of the project. Most projects 
implemented in this region mostly lack this data quality component, T-HDR is very good at that, I 
worked in the area ten years, and I can prove that.” 
A KI from Gambella described the importance of LMG, essential lab testing, and quality assurance:
“The training offered by Transform HDR on leadership, management, and governance also enabled 
them to understand the role of leadership in the health system. Furthermore, support of the 
essential lab test mechanism and quality assurance in review form, mobile ultrasound: catchment￾based service, and transfer of skills and knowledge, such as clinical mentorship and coaching, were 
best practices.” 
A KI in Afar described the importance of partnership mechanisms, participatory annual planning, 
and post-training follow-up and mentorship in enhancing coordination and skills:
“The partnership mechanism is an important platform to avoid duplication of efforts. Participatory 
detailed annual plan exercises are key to addressing the needs of the region. Post training follow 
up and mentoring are effective tools in enhancing the skills and knowledge of health workers. Using 
the existing structure (religious and clan leaders) is effective in overcoming (the) GBV issue.” 
What lessons were learned for project future design, management, and monitoring? 
Most KIs, when asked to give recommendations for future programming, focused on sustaining 
what they perceived as the most effective interventions. Most KIs suggested that best practices 
need to be strengthened and scaled up in future programming. KI recommendations included 
the following:
• Mentorship and coaching activities should be sustained in the future as these activities 
are effective in improving service quality.
• The number of experts was insufficient in certain technical areas, especially for gender. The
number of personnel should more appropriately match the scope of required work for 
future activities.
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• Holistic approaches are required to address development challenges in the developing 
regions: agriculture, schools, and health facility infrastructure; that is, roads, water, 
electricity, internet access, etc. 
• Adequate consultation with local stakeholders (religious leaders, traditional leaders, etc.) 
is key during the design of future programs. For example, the problem of FP use in 
pastoralist regions could not be addressed by interventions that work in other areas, but 
potential effective approaches are understood by local stakeholders.
• The HDR activity was planned, managed, and led from Addis Ababa, which is not 
advisable for the future. Planning and management control should be more 
decentralized. This might contribute to greater flexibility and responsiveness to emerging 
local needs. 
• More emphasis should be given to sustainability at the outset. For example, Transform 
HDR expects the government to allocate resources for maintaining activity-provided 
equipment, but some local facilities indicated that they do not have budgeted resources 
for maintaining ultrasounds and solar energy systems when activity funding ends.
• Woreda health offices are critical to implementation and should be fully engaged in 
implementing program activities in the future, so interventions are part of their work plans 
and budgets to build sustainability from the start.
• The Activity’s primary focus has been on training, but a greater supply of equipment, 
materials, and health facility infrastructure (NICU, mini blood banks, waiting homes, etc.) 
would be highly appreciated by health facilities in the future.
• Training alone does not bring change, but follow-up, coaching, and monitoring are 
crucial for better performance. Therefore, all these activities should be sustained and 
made part of the routine activities in every woreda’s workplan and budget. 
• Community dialogue is effective and community dialogue structures such as mother’s 
groups should be sustained.
• Involving community leaders in the implementation of MNCH/FP promotes sustainability. 
Use of the community score card is an effective approach for improving health seeking 
behavior and community utilization of public health services.
According to KIs in the Somali region, because there are limited numbers of other implementing 
partners there, complementary multi-sectoral programs are key to meeting different critical 
needs of the community. KIs viewed Transform HDR as an important opportunity to improve the 
health system, but in that region, they indicated that a more holistic approach which integrates 
elements of health, education, agriculture, and access to water is preferable. KIs indicated that 
some health facilities lack WASH infrastructure, for instance, making it more difficult to achieve 
health goals than it would be otherwise. Somali RHB respondents also felt that the activity 
structure was not appropriate given the scale and scope of needs in the region. According to a 
Somali RHB respondent:
“The program was planned, managed, and led from Addis Ababa, which is not advisable for the 
future. We have other partners, to whom we give office space here at the RHB, they sit and work 
with us, and we can equally talk about their work and consider it as it is our own. Transform HDR 
rather rented its own office, has the vehicles going in their own direction, and resources are wasted 
here. Rather than putting one seconded staff at RHB, and putting many staff in their office, they 
54
could come here with a lower number of staff and cost as we can work effectively together. Having 
seconded staff of course is very good but having a full team here would help more.” 
6) CONCLUSIONS 
Performance on almost all MNCH/FP KPIs in Transform HDR intervention areas declined by the 
endline, despite progress at the midterm. For almost three quarters of the KPIs, performance at 
the endline descended below the respective baseline values. These performance declines are 
likely attributable to the recurrent security problems, primarily in Afar and Benishangul Gumuz; 
the protracted drought in Somali, flooding in Afar and the massive internal displacement that 
followed these shocks. In addition, disease outbreaks (the COVID-19 pandemic, measles, cholera) 
shadowed the period after the midterm evaluation and substantially affected the supply and 
demand side of the services. However, for most of the outcome indicators, Transform HDR 
intervention areas had better performance at the endline compared to the non-Transform 
intervention areas, which were generally higher at the baseline. This would indicate that the 
Transform HDR Activity contributed to preventing deterioration in most MNCH/FP outcome 
measures. 
KIs and the IP had the general perspective that the Transform HDR activity made important 
contributions to improving the access to and quality of MNCH and FP services. However, many 
of the outcome data cited in this endline study do not support the view of improved outcomes, 
and indeed, the continuity of MNCH/FP services (e.g., ANC1 to ANC4+ dropout) remains a 
challenge. 
Family Planning Outcomes
The Activity faced strong headwinds in terms of FP, and its strategies were not adequate to break 
the deeply entrenched attitudes about FP in some cultures in which the Activity operated. The 
evaluation found that effectiveness in improving FP coverage was mixed. FP KPI performance 
(MCPR and PPFP) declined, whereas LAFP use remained unchanged. The decline in MCPR 
appears to have resulted from a decrease in the use of short-acting methods, largely because of 
weak performance of health posts and stockouts of commodities. 
Newborn, immunization, and Child Health Outcomes
KIs noted that maternal, neonatal, and child mortalities have declined over the period of the 
program implementation. Indeed, this evaluation confirmed that Transform HDR did contribute 
to improvement in several newborn, immunization, and child health KPIs, including: 
● Essential newborn care and early initiation of breastfeeding
● Measles coverage
● Vitamin A supplementation
● ARI and diarrhea treatment
Measles vaccination increased due to campaigns. However, full vaccination and Penta 3 coverage 
remained low. 
55
IFA intake showed a steady decline from baseline to endline. There was also variation in 
performance among regions as measured by KPIs. The decline in KPIs at endline is more 
pronounced in Somali followed by Gambella, where community health services were weak.
Sustainability
Transform HDR capacity building interventions, integrated systemic interventions and efforts 
made to engage experts at different levels of the health system in the planning, capacity building, 
and monitoring activities is believed to have enabled the sustainability of MNCH/FP services and 
results achieved. However, the impact of recent shocks show that future interventions need to 
be designed within existing social and community structures so they can work during and despite 
these shocks. 
The program’s capacity building and quality improvement activities, community sensitization 
activities, and the introduction of portable ultrasound equipment were responsible for the 
observed positive changes. Specifically, some potentially sustainable activities that contributed 
to improved MNCH/FP service access and quality include:
● Establishment and functioning of maternal waiting homes and training on respectful and 
compassionate care and BEmONC seemed to improve care quality. 
● Implementation of CEmONC and MPDSR to reduce maternal and neonatal mortality.
● Quality improvement initiatives, clinical mentoring and coaching, and clinical skill-labs 
established by the program were recognized by KIs as effective interventions that 
improved maternal health service quality.
● Distribution of safe birth checklists 
● Community level awareness activities, such as engaging traditional community structures 
(elders, religious and clan leaders) and pregnant women conferences appear to increase 
health seeking behavior and skilled delivery coverage. 
● Introduction of ultrasound equipment to health centers appears to increase ANC 
attendance and continuum of care.
● Achievement of greater equity through outreach mobile clinic service to address 
marginalized communities in hard-to reach areas. 
However, the recurrent conflict in some areas, staff turnover, lack of ownership at some levels of 
the health system, and the nature of certain activities requiring more investment were reported 
to potentially undermine the sustainability of some interventions and results achieved. 
Gender 
In terms of gender related activities, the evaluation found that advocacy to strengthen mothers’ 
conferences and the use of community structures to decrease child marriage and GBV were 
important interventions from the perspective of KIs. Post-GBV service availability increased in 
health facilities supported by Transform HDR. Transform HDR also considered gender in activities 
such as conducting training on the issue of gender streamlining and integrating gender in SBCC 
activities. The Activity increased women’s leadership through its leadership training and training 
of female school teachers on gender issues and the establishment of gender clubs in schools. 
The activity also supported local women’s groups through activities such as pregnant women 
56
conferences and women-only community structures and worked with influential community 
elders and religious leaders to discuss male dominance, GBV, and early marriage. One 
demonstration GBV center was established successfully in Afar Region. According to an Afar RHB 
respondent the Dubti Hospital One-Stop GBV Center was successful in uniting various elements 
of the community to support GBV survivors. Despite these achievements, respondents indicated 
that much more effort is needed to fully engage women in decisions relating to maternal, child, 
and neonatal health-seeking behavior and family planning.
Adaptation and Learning
There were good practices in the use of evidence generated from Transform HDR led 
studies/assessments and those that were conducted by Transform MELA, to inform activity 
planning, design of new initiatives and implementation. Joint planning, joint supervision and joint 
review meetings further helped the program to align its activities with government priorities. 
Through such use of evidence and adaptive planning, for example, the Activity actively supported 
initiatives such as the Afar One-Stop Center for GBV survivors. In terms of community-based 
communications efforts, the Activity initially faced challenges in tailoring messaging designed for 
agrarian regions to pastoralist regions. Traditional cultures and practices in the pastoralists 
regions also made it difficult for messaging and promotion of behavioral change on MNCH/FP 
issues to have the desired level of impact.
7) RECOMMENDATIONS
Activity-Level Recommendation 
As the Transform HDR is slated to close in early 2023, it will be essential for the activity to 
consolidate the improvements made and plan and implement a smooth transfer and handover 
of lessons, tools, and know-how to RHB, zonal, and woreda counterparts, and, as applicable, to 
successor programs. Therefore, it is recommended that an overlap of the existing activity with 
the new one be facilitated to ensure the regions, zones, and supported woredas integrate 
previous and new interventions into their next year’s work plans and budgets and thus sustain 
the previous investment.
Recommendations for MOH
▪ Reinforce coordination of development partners to effectively implement HSTP II. HSTP II 
set goals for woreda transformation in the context of multisectoral development and a set 
of targets. It is essential that MOH, USAID, and other development actors work together to 
demonstrate an effective model that can be implemented in a pre-determined number of 
models woredas in each of the developing regions. 
▪ Continue support for quality improvement initiatives: Transform HDR supported a range of 
quality improvement activities. However, there are still considerable gaps in the quality of 
MNCH/FP interventions along the continuum of care. This is demonstrated by low coverage 
of essential components of ANC, a high ANC 1 to ANC 4 dropout rate, and unavailability 
of essential supplies. MOH, with support from development partners, should take the lead 
in implementation of measurable quality improvement activities in a pre-determined
57
number of woredas that can serve as learning sites. Quality improvement should be 
institutionalized as a continuous process and show measurable progress in the quality of 
care at all levels. Implementation of quality improvement activities should be rigorously 
monitored and evaluated, and course correction actions should be undertaken in a timely 
fashion.
▪ Improve use of monitoring data for decision making at health facilities. Evaluation findings 
demonstrated that most facilities are not processing and using the monitoring data they 
have collected related to health facility performance to inform decisions for improving 
performance. MOH and partners should provide technical support for use of data for 
decision-making through regular post-training follow-up.
▪ Strengthen and standardize mobile health service delivery to expand access to MNCH/FP 
services for pastoralist communities: Future GOE and donor budget support to pastoralist 
regions should prioritize mobile health approaches to reach underserved communities. 
Mobile health service approaches should be considered as a key service delivery 
mechanism. Developing a well-functioning mobile health system will require adequate 
human, logistical and financial resources, coupled with a strong monitoring system and the 
attention of health system leadership at different levels. A mobile health system is 
particularly important for services that require repeated visits (e.g., immunizations and 
antenatal care) and are designed to reduce discontinuation rates. 
▪ Implement mobile services policy and guidelines for developing regions. The lack of a 
standardized federal mobile services policies and guidelines has led to variation across 
partners which poses a challenge to institutionalizing mobile health approaches. Some 
partners provide certain services and not others; some provide incentives, and some do 
not; and per diems vary in ways that creates disincentives for health workers. As a result, 
there is a need for standardization of approaches across the GOE. Mobile health program 
standardization, particularly in Afar and Somali regions, is required to ensure the 
institutionalization and sustainability of access to key MNCH services to hard-to-reach 
pastoralist populations.
▪ Implement innovative health approaches when designing programs to pastoralist 
communities. Services to pastoralist communities should be designed in coordination with 
livestock health outreach programs that consider not only human health but also livestock 
health, which is highly valued by pastoralist communities. 
▪ Assign more female providers, especially for childbirth services: The lack of female 
providers was reported to be a barrier to improving MNCH intervention coverage. Regional 
health bureaus should give priority to female applicants for enrollment and encourage 
donors to provide scholarships in midwifery training programs.
▪ Integrate FP counseling across all contacts in the continuum of care: Contraceptive use is 
low in developing regions. Counseling for postpartum family planning was also rare and 
has not been integrated into programming. There is need for standard integrated FP 
guidelines and service delivery checklists to ensure that every woman and man that comes 
58
to a facility gets counseled. Therefore, integrating family planning counseling during all 
contacts in the continuum of care (ANC, childbirth, postnatal care, immunization) should 
be demonstrated and achieved in the follow-on project. 
▪ Ensure availability of family planning services at health posts: Family planning is one of the 
packages of the health extension program in Ethiopia. Nonetheless, this evaluation found 
that more than half of surveyed health posts did not provide family planning services. 
MOH/RHB-supported activities programs should ensure full availability of family planning 
services in all health posts and work with partners to ensure sustainable “last mile” 
distribution of FP commodities and to help mitigate for distance and transport related 
problems.
▪ Develop a national HR database and keep track of participation in continuous education 
programs funded by donors, and support context specific MNCH/FP health workforce and 
leadership development and retention strategies. High turnover of trained personnel and 
leaders at woreda health offices and regional health bureaus was one of the key challenges 
to improving service delivery. The evaluation found that some health workers attended the 
same training multiple times in part because there is no database that would allow RHBs 
to track who has been trained and to plan accordingly. High turnover of trained personnel 
and leaders at woreda health offices and regional health bureaus was one of the key 
challenges to improving service delivery. This problem is particularly acute in developing 
regions. Therefore, MOH should develop minimum retention standards for health workers 
and health system leaders. In conjunction with implementation of a national training 
database and staff development, this will better allow MOH and foreign assistance 
providers to efficiently address capacity gaps and reduce duplication of effort. 
Recommendations for USAID
To ensure careful planning and execution that meets desired targets for future interventions, 
several key tasks will be required at the outset, such as a careful mapping of tailored strategies 
for pastoralist regions, and, with guidance and collaboration from regional structures, support 
for strengthening and expanding mobile outreach to pastoralist communities. In addition, it will 
be important to support community structures or groups in developing community-based 
strategies and service delivery programs. In tandem with SBCC activities, it will be important for 
future activities to build on and continue strengthening male engagement in family planning and 
assist MOH through RHBs and ZHB to ensure the availability of family planning services and 
commodities in remote areas. As part of baseline and continuing research, ethnographic studies 
of pastoralist communities are recommended.
▪ The design of future activities should be performance-based and include a revised target 
setting assumptions and monitoring methodology. Targets against performance should be 
monitored periodically by a third party for course correction and adjustment of targets. 
Most Transform HDR Life of Activity targets were not satisfactorily achieved, which should 
have been detected and corrected sooner through periodic outcome monitoring and 
timely adjustment. This may have increased the likelihood of achieving targets.
59
▪ The design of future activities should continue have a plan to mitigate potential 
crisis/shocks in the developing regions. Given the increased vulnerability of the developing 
regions to natural or manmade crisis/shocks, USAID should strengthen it crisis modifier
funding mechanism to support timely response to potential crisis and protect development 
results obtained because of USAID’s investment in health programming. 
▪ The design of future activities should consider selection of intervention sites that have a 
mix of performance levels – high, moderate, and low. This will facilitate cross learning 
through instituting twinning partnerships for improvement and using high performers as 
demonstration sites. 
▪ The design of future activities should employ performance-based support that can also be 
complemented with allocation of a matching fund from government. This approach will 
better ensure continuity of interventions and results achieved.
▪ Develop and implement context specific MNCH/FP intervention strategies for each of the 
developing regions: Developing regions are contextually different and require different 
strategies and performance targets. For example, the context in Benishangul-Gumuz and 
Gambella is different from the context in Somali and Afar, which, because of the 
predominance of pastoralist societies, should be a priority for future programming. Future 
programs should be designed in line with the context in each region and have measurable 
targets e.g., number of woredas that will be able to provide quality MNCH/FP services in 
all their facilities and implement regular outreach and mobile services.
▪ Develop and implement innovative, tailored and context appropriate facility and 
community based SBCC approaches for sustained behavioral change in MNCH/FP 
practices. Despite some progress, coverage for key MNCH/FP indicators in Transform HDR 
regions is low and has declined in the last two years. As examples, many women noted that 
they did not visit health facilities during pregnancy and childbirth because of the belief that 
these services are not needed unless some disorder is observed. Similarly, MCPR is low. 
Therefore, context specific SBCC approaches should be further designed and implemented 
to help change such perceptions and promote demand for facility and community based 
MNCH/FP services. Moreover, traditional community structures should be further 
strengthened, institutionalized, and expanded to promote MNCH/FP-related behavioral 
changes. The use of successful approaches, such as Umulgargar (women’s groups), are 
effective in mobilizing communities, but the current reach of these initiatives is limited. 
Replicating such structures may accelerate MNCH/FP coverage.
▪ Strengthen male engagement in adolescent and youth services and in family planning: 
Many women in developing regions reported that they are not currently using modern 
contraceptives because of partner refusal. Such challenges may be mitigated by increasing 
male involvement in awareness raising, FP counseling, and other MNCH service provision.
▪ Develop an operational research agenda to identify causes of service bottlenecks and 
explore the underlying factors contributing to the decline in performance of selected KPIs. 
Determining the root causes for the decline in performance for selected KPI requires further 
60
research. For example, few health posts in Transform HDR intervention areas provided
modern family planning methods and although there were declines in the reported 
essential components of ANC, essential newborn care and early initiation of breastfeeding 
indicators improved. Also, the number of facilities that have IFA and can provide lab tests 
and vaccines but are not providing them to clients is not known. In some instances, regional 
discrepancies have been exacerbated, with Somali performing lower on several indicators 
compared to other developing regions. The outcome of operational research on these and 
other subjects could inform future design and programming and contribute to the design 
of more effective and efficient SOPs to improve operational productivity and coverage of 
supported health facilities and woredas.
▪ Support ethnographic health research focused on pastoralist lifestyles for activity planning.
Future activities should determine the best ways to reach pastoralists. Ethnographic 
research that provides more understanding of pastoralist lifestyles, belief systems and their 
relation to their livestock can help inform programming that better fits with sociocultural 
dynamics.
▪ Establish institutionalized mechanisms for field-level sharing of information between 
primary health interventions and interventions targeting pastoralist regions and 
communities. USAID cooperative agreements with successor primary health interventions 
in developing regions should include specific clauses for formal mentoring and capacity 
development. As one example, USAID primary health care implementing partners possess 
a wealth of experience in operations and implementation research, SBCC, and technical 
support for training and quality improvement. Future programming should formally 
leverage this capacity to ensure that lessons learned over the past decades in agrarian 
regions can be successfully adapted to developing regions.
▪ Future MNCH/FP investment in developing regions should anchor capacity-building and 
SBCC to primary health care institutions. Technical assistance for quality improvement 
initiatives should be anchored to health facility level interventions. Health facilities can serve 
as demonstration centers for replicating best practices, accountability, and generation of 
valid and reliable data on outcomes, as well as serve as a nexus for community-based health 
interventions and social and behavior change communication for their respective 
catchment populations. 
▪ Future USAID investments should integrate essential health systems strengthening (HSS) 
interventions in developing regions. Transform HDR had most components of HSS 
embedded in its scope, but resources and coordination with other USAID/Ethiopia HSS 
mechanisms was limited. Greater integration of these essential health systems 
strengthening approaches should begin with intentional geographic convergence with 
other key HSS mechanisms in developing regions to ensure complementarity. Starting from 
planning through execution phases, designs for community and health facility level 
interventions should integrate human resource development, health financing and health 
insurance, supply chain management (last-mile delivery), and health information systems. 
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ANNEX 1: EVALUATION QUESTIONS AND DATA SOURCES
Key Evaluation 
Questions
Specific and Probing Questions Design Data Source
1. How effective were 
the Transform Program 
Activities’ approaches in 
contributing to 
improving MNCH/FP 
outcomes? 
1.1. Were Transform activities 
implemented as planned? If not, why 
not?
1.2. To what extent did the Transform 
improve MNCH/FP outcomes and 
reduce outcome inequities in different 
groups in intervention areas compared 
to control areas?8
● To what extent did activities achieve 
their targets? 
● Which targets were met or exceeded? 
● Which targets were not met? 
1.3. How effective are the Transform 
Activities strategies and approaches? 
1.4. In your opinion which of the Transform 
Activity interventions are replicable or 
can be scaled up/applied to a different 
setting?
1.5. What is the effect of context (Conflict, 
Covid 19 pandemic, internal 
displacement) on Transform Activity 
interventions and achievement of 
intended results?
Mixed 
methods 
- HH respondents
- HF respondents 
and observation
- KIs from USAID, 
MOH, IPs, RHBs
- Transform IP 
reports and 
documents from 
MOH
2. How did Transform 
Program Activities 
facilitate local 
ownership, 
sustainability, and 
coherence? 
2.1. What mechanisms are in place to ensure 
government ownership of Transform 
health system interventions? 
2.2. To what extent did government 
staff/community perceive that the 
approaches established by the project 
will be maintained by the government 
and continue to sustain MNCH/FP 
improvements in the next 3 and 5 years?
2.3. To what extent did the project improve 
community involvement and its role in 
accountability, transparency in decision￾making, and advocacy for community 
health needs?
Qualitativ
e 
- KIs from USAID, 
MOH, IPs, RHBs
- Transform IP 
reports and 
documents from 
MOH
8 Note: We intend to measure inequities in terms of geographic variations among regions, residential 
locations (urban/rural), age, educational status, and others.
62
Key Evaluation 
Questions
Specific and Probing Questions Design Data Source
2.4. To what extent did the project improve 
community engagement for advocacy 
and health service oversight? 
● What capacity for community 
engagement did Transform build? 
2.5. How do Transform Activities coordinate 
with other development partners and 
their activities?
3. How did Transform 
Activities consider 
Gender dynamics in 
activity 
implementations? 
3.1. To what extent did the government 
staff/people perceive that the project 
established processes are functional to 
track and address gender and 
inequitable health outcomes? 
● Provide examples to substantiate 
perceptions. 
3.2. What gender equity results did 
Transform Program Activities’ 
interventions achieve?
3.3. What gaps exist in the current USAID/ 
Transform intervention 
design/programming in terms of 
addressing the key gender issues in the 
targeted regions of Ethiopia?
Qualitativ
e 
- KIs from USAID, 
MOH, IPs, RHBs
- Transform IP 
reports and 
documents from 
MOH
4. How and to what 
extent have the 
Transform IPs been 
able to adapt 
implementation 
approaches based 
on learnings and 
new evidence? 
4.1. To what extent did the project make 
adaptive changes? 
● Based on what evidence? (e.g., responses 
to Transform midterm recommendations 
and IP-led studies)
4.2. How did respondents perceive that these 
adaptations contributed to MNCH/FP 
outcomes? 
4.3. What lessons were learned for project 
future design, management, and 
monitoring? 
Qualitativ
e 
- KIs from IPs, 
- Transform IP 
reports 
5. To what extent did 
the Transform 
program improve 
MNCH/FP outcomes 
5.1. To what extent did the Transform 
program ensure improvement in 
MNCH/FP outcomes? 
- HH respondents
- HF respondents 
and observation
63
Key Evaluation 
Questions
Specific and Probing Questions Design Data Source
in Transform 
intervention 
woredas compared 
to non-Transform 
intervention 
woredas?
5.2. Are there any unintended results 
(positive or negative) specific to 
Transform program interventions?
- KIs from USAID, 
MOH, IPs, RHBs
- Transform IP 
reports and 
documents 
from MOH
64
CDCS GOAL: Ethiopia’s Transformation to a Prosperous and resilient country Accelerated
Mission’s DO2: Increased Utilization of Quality Health Services
Activity Strategic Objective: Increased utilization of quality high-impact MNCH/FP services in Afar, Benishangul-Gumuz, Gambella and Ethiopian Somali regions by 2021
Indicator 1: MCPR, Indicator 2: % of children received Penta 3 by 12 Mths, Indicator 3: % children fully immunized, Indicator 4: % births attended by SBAs, Indicator 5: % pregnant women receiving ANC 4+
IR1: Increased access to integrated, quality high-impact MNCH/FP 
services at health facility and community levels
Indicators 1.1. Contraceptive acceptance rate; 1.2. Skilled Birth 
attendance rate; 1.3. ANC 4+, 1.4. Penta 3 coverage, 1.5. Full 
immunization coverage, 1.6. % PW treated for malaria, 1.7 # of children 
treated for malaria, 1.8. % of newborns with asphyxia resuscitated & 
IR2: Strengthened health systems to provide quality 
MNCH/FP services
Indicator 2.1: % of HFs who received technical support 
or supervision in the past 6 months by district health 
care managers
IR3: Increased demand for high-impact MNCH/FP 
services
Indicator 3.1. Number of community members reached 
with culture sensitive and region-specific awareness 
IR4: Improved strategic information for evidence based 
decision-making and program learning
Sub IR 1.1. Increased availability CEmONC services at selected primary 
hospitals and health centers
Indicator 1.1.1. % of health facilities providing CEmONC services
Sub IR 1.2. Increased availability of culturally appropriate and acceptable 
MNCH/FP service packages including BEmONC at health centers
Indicators 1.2.1 % of health facilities providing BEmONC services
1.2.2 % of USG-assisted service delivery sites providing family planning 
(FP) counseling and/or services 
Sub IR 2.1. Strengthened capacity of human resources 
for health focusing on MNCH/FP services provision
Indicator 2.1.1. # of Health Care Providers trained on 
MNCH/FP program areas
Indicator 2.1.1. # of people trained with USG funds in 
Sub IR 2.2. Leadership and coordination capacity of 
regional, district and facility level MNCH/FP structures 
strengthened
Indicator 2.2.1. # of people trained with project support 
on LMG
Sub IR 3.1. Increased community’s knowledge and 
awareness on MNCH/FP services
Indicator 3.1.1. % of audience who recall hearing or 
seeing a specific USG-supported FP/RH message
Indicator 3.1.2. % of audience who recall hearing or 
Sub IR 3.2. Improved SBCC services to address gender 
norms and women empowerment
Indicator 3.2.1. % of men who accompany their spouse 
or partner to at least one ANC visit
Indicator 3.2.2. % of men who were at the health facility 
during the birth of their last child, either in the room 
Sub IR 4.1. Strengthened HMIS system to capture 
MNCH/FP data
Indicator 4.1.1: % of health facilities (Primary 
Hospitals, HCs) submitting complete HMIS report on 
time for the recent reporting period
Sub IR 4.2. Strengthened community health 
information system to capture MNCH/FP data
Indicator 4.2.1. % of HPs submitting complete HMIS 
report on time for the recent reporting period
Sub IR1.3: Improved community-based outreach MNCH/FP services 
through Mobile Health Team
Indicators 1.3.1. # of women aged 15-49 served by a mobile health team 
Sub IR1.5: Strengthened Bi-direction referral system between 
health facility & community
Indicator 1.5.1. # of referral review meetings conducted 
Sub IR2.3: QA/QI approaches implemented to ensure 
high-impact MNCH/FP interventions
Indicator 2.3.1. % of health facilities that have annual 
quality improvement plans in place
Sub IR2.4: Strengthened supply chain management 
capacity and resource mobilization
Indicator 2.4.1. % of USG supported service delivery 
points experiencing stock out of tracer drugs
Sub IR1.4: Increased deployment of women MNCH/FP service providers
Indicator 1.4.1. % of female midwives deployed in the activity 
implementation woredas
Sub IR3.3: Women and girls empowered to obtain 
MNCH/FP services
Indicator 3.3.1. % of women who participate in decisions 
regarding their own healthcare
Sub IR4.3: Improved operational studies and 
evaluations to track activity performance and inform 
decision-making
Indicator 4.3.1. Number of operational research 
conducted for MNCH/FP for health system 
improvements
Sub IR4.4: DRS focused MNCH/FP knowledge 
management and information sharing platform 
established
Indicator 4.4.1. Number of districts documenting and 
sharing best practices and lessons learned
Transform HDR Inputs: Training curricula & materials; Equipment & supplies; Coordination meetings; Staff time; Printing; Assessment checklist; Blood bank equipment & supplies; Space for storage; Obstetrician volunteers. Transform HDR 
Activities: Sensitization & review meetings; Training to health workers; Mentorship and quality/performance improvement, Establish Newborn Corners; Distribute guidelines, job aids & training materials; Support the referral system; Formative 
assessment; In-service training; Establish & strengthen blood banks & transfusion centers
ANNEX 2: TRANSFORM HDR ACTIVITY RESULT FRAMEWORK
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ANNEX 3: GLOSSARY
Terms Definition
Adaptive management An intentional approach to making decisions and adjustments in response to new 
information and changes in context. 
Adaptive management integrates approaches throughout the Program Cycle as the 
second of four core principles. (Program Cycle Operational Policy. ADS 201.6; 
09/21/2021).
Case Study For the Transform Program evaluation, we defined a case study as the study of public 
health problem-solution situation and the process to implement it, evaluate it and 
learn from it. All the interventions selected to solve the problems identified by the 
PHC and HDR activities have demonstrated their efficacy elsewhere to prevent or 
treat disease, death, or disability. They had just not been adapted to be implemented 
in the Primary Health Setting in Ethiopia and are therefore considered innovations. 
Coherence The compatibility of the intervention with other interventions in a country, sector, or 
institution. 
Collaboration with the 
Ministry of Health 
Collaboration is a practice whereby individuals, communities and organizations work 
together for a common purpose to achieve a shared benefit. For the purposes of this 
evaluation, collaboration between MOH and the Transform program encompasses 
working relations between central bureaus, regional, zonal and woreda health offices. 
Effectiveness The extent to which the intervention achieved its objectives and results, including any 
differential results across groups.
Gender equity Fairness of treatment for women and men, according to their respective needs. 
In the development context, a gender equity goal often requires built-in measures to 
compensate for the historical and social disadvantages of women including measures 
are taken to compensate for historical and social disadvantages. (USAID Gender 
Terminology)
Health care quality The degree to which health care services for individuals and populations increase the 
likelihood of desired health outcomes and are consistent with current professional 
knowledge. (Institute of Medicine: Crossing the Quality Chasm, 2001)
Health workforce capacity 
building
Actions intended to improve human resources for health, contributing to healthy 
lives and well-being, effective universal health coverage, resilience and strengthened 
health systems at all levels. 
WHO (2016:4). Global strategy on human resources for health: Workforce 2030
Impact The extent to which the intervention has generated or is expected to generate 
significant positive or negative, intended or unintended, higher-level effects.
Intervention A process developed with the objective of improving a health outcome. Interventions 
can be classified as preventive interventions such as vaccines, or curative, such as an 
improved diagnostic or treatment protocol or a more effective and efficiently 
streamlined service delivery, or both preventive and curative interventions such as 
CEmONC that timely detects and treats complications, thus preventing morbidity 
and mortality. 
66
Terms Definition
Medical equipment and 
supplies provision
Medical equipment is defined as a capital equipment and durable items that last for 
several years; Medical supplies are items that need replacing on a routine basis, 
including disposables, single use items. 
Provision encompasses procurement, delivery and management of equipment and 
supplies based on requirements for preventive care, diagnostic tests, and treatment. 
Non-Transform intervention 
woredas 
Woredas which do not receive USAID investment through the Transform Program.
Ownership The extent to which national partners have a stake in the implementation of 
programs and activities. 
Performance improvement The goal or benefit of focusing on individual and organizational change and business 
results. 
Caiola and Sullivan for USAID, Paper #9, page 2 (2000). Performance Improvement: 
Developing a Strategy for Reproductive Health Services.
Performance monitoring 
indicators 
Measures intended to detect progress towards the results included in a Results 
Framework. (USAID: Performance monitoring indicators)
Performance standards for 
public health 
Organizational or system standards, targets, and goals to improve public health 
practices. (Public Health Foundation: Performance Standards)
In the Ethiopian context this refers to performance standards at different levels of the 
health system. These are included in references such as the Ethiopian Hospital 
Services Transformation Guidelines (EHSTG).
Public financial 
management
The set of laws, rules, systems, and processes used by sovereign nations (and sub￾national governments), to mobilize revenue, allocate public funds, undertake public 
spending, account for funds and audit results. 
Lawson (2015). Public Financial Management
Relevance The extent to which the intervention objectives and design respond to beneficiaries, 
global, country, and partner/institution needs, policies, and priorities, and continue
to do so if circumstances change. 
Solution A solution is a set of interventions that health managers have selected to solve a 
healthcare delivery, or public health program problem. Solutions are usually 
implemented by development projects with donor support to improve the quality of 
healthcare and expand utilization and access to services and thus improve health 
outcomes. In the case of The Transform Program, both activities have implemented 
numerous solutions that have demonstrated improved outcomes and impact on the 
health of mothers and children in Ethiopia.
Sustainability The extent to which interventions and their benefits will continue beyond the life of 
the program. 
Transform intervention 
woredas
Woredas in which the USAID Transform Program implemented through Transform 
PHC and HDR Activities. 
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ANNEX 4: TRANSFORM HDR INTERVENTION ACHIEVEMENT AT ENDLINE COMPARED TO 
TARGETS 
No. Key performance indicators LOA 
target9
Endline 
value
Family planning
1. Modern method contraceptive prevalence rate among currently married women 23.6 8.8
Maternal and newborn heath
2. Percentage of women who had at least 4 ANC visits pregnancy (for the last birth over 
the last 12 months prior to the survey) 28.8 15.4
3. Percentage of deliveries attended by a skilled birth attendant such as Doctor, Nurse, or 
Midwife (for the last birth over the last 12 months prior to the survey) 39.3 23.8
4.
Percentage of women who received Iron folate supplements for at least 6 months during 
pregnancy of their last birth over the last 12 months prior to the survey 51.110 0
Percentage of women who received Iron folate supplements for at least 3 months during 
pregnancy of their last birth over the last 12 months prior to the survey - 6.7
5. Percentage of women who received postnatal care at least once within two days of 
childbirth (for the last birth over the last 12 months prior to the survey) NA 20.1
6. Percentage of newborns who received postnatal care within two days after birth (for the 
last birth over the last 12 months prior to the survey) 43.6 19.6
Child health
7.
Percentage of children aged 12-23 months who received DPT3/Penta3 vaccine by 12 
months of age 50.5 13.8
Percentage of children aged 12-23 months who received DPT3/Penta3 vaccine at any 
time before the survey - 15.7
8.
Percentage of children aged 12-23 months who received their first dose of measles￾containing vaccine (MCV1) by 12 months of age NA11 30.0
Percentage of children 12 to 23 months of age who received their first dose of measles￾containing vaccine (MCV1) at any time before the survey - 36.4
9.
Percentage of children aged 12-23 months who are fully immunized at the age of one 
year
37.0 11.3
Percentage of children aged 12-23 months who are fully immunized at any time before 
the survey - 12.3
10. Children under 5 who had a fever in the past two weeks for whom advice/treatment was 
sought within 24 hours of the onset of fever 83.2 22.9
11. Percentage of under-five children with ARI who received antibiotics (in the last two weeks 
prior to the survey) 83.6 34.9
9
Source for Life of Activity targets: Transform HDR FY 2022 work plan.
10 Target set for 2022 was taken. Source is Transform HDR Source MEL plan revised October 2021
11 Target set in count/number not percentage
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No. Key performance indicators LOA 
target9
Endline 
value
12. Percentage of under-five children with diarrhea received ORT & Zinc (in the last two 
weeks prior to the survey) 36.8 33.9
13. Percentage of children aged 6-59 months who received Vitamin A supplementation in 
the last six months prior to the survey 36.5 42.3
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ANNEX 5: LIST OF PERSONS INTERVIEWED
1. USAID/Ethiopia Transform HDR Activity Agreement Officer's Representatives 
2. MOH, health systems strengthening and special support director
3. Transform HDR chief of party and management team
4. Amref Health Africa Afar regional office, regional manager
5. Amref Health Africa Benishangul Gumuz regional office, regional manager
6. Amref Health Africa Benishangul Gumuz regional office, M&E officer
7. Amref Health Africa Gambella regional office, regional manager and RMNCH officer
8. Amref Health Africa Somali regional office, regional manager
9. Afar RHB M&E coordinator
10. Benishangul Gumuz RHB EPI officer 
11. Gambella RHB MCH director 
12. Gambella RHB MCH officer
13. Somali RHB Planning, resource mobilization and NGO coordination director
14. Assaita WoHO MCH coordinator (non-Transform HDR intervention woreda in Afar)
15. Telalak WorHO head (Transform HDR intervention woreda in Afar)
16. Telalak WorHO EPI coordinator (Transform HDR intervention woreda in Afar)
17. Assosa WoHO MCH coordinator (Transform HDR intervention woreda)
18. Itang WorHO MCH director 
19. Itang WorHO MCH case team leader
20. Babile WorHO head (Transform HDR intervention woreda in Somali)
21. Babile WorHO, Albahr HC MCH focal (Transform HDR intervention woreda in Somali)
22. Arores WorHO deputy head (non-Transform intervention woreda in Somali)
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ANNEX 6: BIBLIOGRAPHY OF DOCUMENTS REVIEWED
1. Transform HDR annual progress reports
2. CEmONC assessment report
3. Afar and Somali Region: GPS Mobility Mapping
4. 2021 and 2022 Transform HDR annual workplans and MEL plans
5. Assessment of gender and other sociocultural barriers to RMNCH service utilization in Afar, 
Benishangul-Gumuz, Gambella, and Somali Regional States of Ethiopia (2019)
6. Quality RMNCH service assessment in Developing regions of Ethiopia (2019)
7. Health care quality improvement assessment in four developing regions of Ethiopia (2018)
8. Reduction of neonatal death through quality improvement intervention in Dubti general 
hospital of Afar region (2018)
9. Quality of Antenatal Care (ANC) through improving the essential laboratory services for ANC 
in Developing Regional States (DRS), Ethiopia
10. Amref Health Africa’s Response to Equity: Transform Health in Developing Regions (T-HDR), 
Ethiopia
11. Mid-term performance evaluation of USAID Transform HDR Activity.
12. Transform Midline Evaluation Report 2020
13. Health Sector Transformation Plan (HSTP) II 2020/21-2024/25
14. Ethiopia Mini Demographic and Health Survey 2019
15. Ethiopia National Health Accounts Report 2019/20
16. Essential Health Services Package of Ethiopia