m.<i Oll'lf'ltC- 1\.-\-V-A-i MINISTRY OF HEALTH·ETHIOPIA r11,•H·· rn.'i h'/1c. •OM)·l•i! USAID @ §.filQ Gt HEALTHIER CrrtZENS FOR PROSPEROUS NATION! FROM THE AMERICAN PEOPLE ACTIVITY INFORMATION Activity Title Communication for Health [Contract/Agreement] Number AID-663-A-15-000011 Name of Prime Implementing Partner Johns Hopkins Center for Communication Programs Name(s) of Subcontractor(s)/Sub awardee(s) John Snow, Inc. Activity Start Date July 20, 2015 Activity End Date December 31, 2020 Reporting Period July 20, 2015– December 31, 2020 Budget $22,193,954.00 Communication for Health 2 CONTENTS ACTIVITY INFORMATION . 2 Contents . 3 Acronyms and Abbreviations . 4 EXECUTIVE SUMMARY . 5 PROJECT OVERVIEW . 6 Theoretical Approach . 6 Project Goal, Objectives and Strategies . 7 Project Timeline and Focus Areas . 9 Partners . 10 IR1: STRENGTHENED PUBLIC HEALTH SYSTEMS AND COORDINATION FOR SBC . .. .11 IR2: SBCC DESIGN AND IMPLEMENTATION STRENGTHENED . ..17 IR 3: IMPROVED DATA USE FOR DECISION-MAKING . .. .. .. 28 CROSS-CUTTING ISSUES . 31 Gender Equality and Women Empowerment . ..31 Stakeholder Collaboration . .33 Collaboration and Knowledge Sharing with Other USAID Activities . 33 Collaboration and Coordination with Other Key Stakeholders . 33 Project Monitoring and Evaluation . 36 SUMMARY OF RESULTS . 36 CHALLENGES AND LESSONS LEARNED . 37 Appendixes . 38 End of Project Report (2015-2020) 3 Acronyms and Abbreviations AWD Acute Watery Diarrhea CCP Johns Hopkins Center for Communication Programs COP Community of Practice COR/AOR Country Officer’s Representative / Agreement Officer’s Representative CSO Civic Society Organization EPHI Ethiopian Public Health Institute FBO Faith-Based Organization FHG Family Health Guide FMOH Ethiopia Federal Ministry of Health GHSM Global Health Supply Management HDA Health Development Army HEP Health Extension Program HEW Health Extension Worker HQ CCP Head Quarter HSTP Health Sector Transformation Plan IEC Information, Education, and Communication IPC Interpersonal Communication IR Intermediate Result JHU Johns Hopkins University JSI John Snow, Inc. LGD Listener Group Discussions LIP Local Implementing Partner LOP Life Of Project LQAS Lot Quality Assurance and Sampling LLIN Long-Lasting Insecticidal Net LSHC Leadership in Strategic Health Communication M&E Monitoring and Evaluation MCHV Maternal and Child Health Video MOU Memorandum of Understanding NOHSC National One Health Steering Committee OCA Organizational Capacity Assessment PHCU Primary Health Care Unit PMTCT Prevention of Mother-to-Child Transmission RHB Regional Health Bureau RMNCH Reproductive, Maternal, Newborn and Child Health SBCC Social and Behavior Change Communication SNNP Southern Nations, Nationalities, and Peoples TB Tuberculosis TOR Terms of Reference TOT Training of Trainers TWG Technical Working Group UHEW Urban Health Extension Worker USAID United States Agency for International Development WDA Women’s Development Army ZHD Zonal Health Department Communication for Health 4 EXECUTIVE SUMMARY The Johns Hopkins Center for Communication Programs is pleased to present the end-of-project report for the Communication for Health project. The flagship Social and Behavior Change Communication (SBCC) project was implemented in Ethiopia from June 2015 to December 2020, with funding and technical support provided by the U.S. Agency for International Development (USAID). CCP and subcontractor John Snow, Inc. (JSI) partnered with the Federal Ministry of Health (FMOH) and regional health bureaus (RHBs) to build the health system’s capacity in SBCC and implement innovative SBCC interventions to improve the health practices of individuals and communities. Communication for Health intervened in 160 woredas in four major regions—Amhara, Oromia, South Nations Nationals and Peoples (SNNP), and Tigray—across six health areas: reproductive, maternal, newborn and child health (RMNCH); prevention of mother-to-child transmission (PMTCT); malaria; nutrition; tuberculosis; and water, sanitation and hygiene (WASH). The project added Global Health Security Agenda (GHSA) activities in 2018, focusing on emerging infectious disease risk communication for the country’s priority zoonotic diseases: rabies, anthrax, brucellosis, and avian influenza. ommunication for Health used the socio-ecological model to ensure that SBCC interventions addressed multiple levels of influence on health behaviors and outcomes. The project designed and implemented a strategic mix of mass media, social mobilization, and capacity-strengthening activities to change behavior at the individual, household, community, and health systems levels. The project’s innovations in behavioral data analysis led to the discovery of gender as a cross-cutting determinant for 10 of the 16 key health behaviors; and three gateway behaviors that informed program strategy: early initiation of antenatal care (<12 weeks), having the Family Health Guide at home and having a proper handwashing station – all of which lead to the adoption of multiple other health behaviors. The project focused on three overarching intermediate results (IRs): 1) Public sector health systems and coordination for SBCC strengthened, 2) SBCC design and implementation strengthened, and 3) Improved data use for decision making. Key highlights of each IR follow: Highlights of IR1: Public sector health systems and coordination for SBCC strengthened Communication for Health strengthened public health sector systems, and coordination for SBCC, by providing technical and organizational capacity strengthening support to the FMOH, RHBs, and technical working groups (TWGs). The project created and sustained strong public health leadership and structure for SBCC work through extensive training and the establishment of technical working groups at the national and regional levels. The project provided strategy development expertise to nearly every major health strategy and implementation guideline developed by the FMOH during the project period. The establishment of the National One Health Steering Committee and its TWGs under the GHSA activity improved the coordination of interventions to control zoonotic diseases in the country. Highlights of IR2: SBCC design and implementation strengthened Communication for Health developed an integrated campaign platform that promoted specific health behaviors as well as gender equitable norms and other cross-cutting issues. The project’s media and social mobilization activities innovated message integration by using a life cycle approach to phase messaging according to the pressing needs of each life stage. SBCC activities included a long-running radio program in five languages and radio listeners group discussions, a series of videos on maternal and child health, the Hulu Betiena mobile app, and social mobilization activities. Communication for Health also undertook specific health area campaigns; the “Malaria Roadshows” are an example of a focused intervention that has been extensively used and widely replicated by the health system. The project used a gender transformative End of Project Report (2015-2020) 5 approach to challenge underlying inequitable norms within the community. These tools changed the narratives of women and promoted couple communication and the constructive involvement of men in household responsibilities and family health. The program significantly shifted gender equitable norms in women of reproductive age, demonstrating the impact of an SBC intervention that prioritized gender equity at multiple levels. Highlights of IR3: Improved data use for decision-making In close collaboration with partners, the project made extensive use of data for the effective design and implementation of the project, which contributed significa tly to the current understanding of how to leverage key facilitators and mitigate barriers to sustained behavior change across multiple health areas. The project’s research led to the discovery of three gateway behaviors and identified gender as a c oss- cutting determinant for health behaviors. These findings framed the focus of the SBCC intervention. The project also trained federal and regional government entities on monitoring and evaluation and qualitative and quantitative research. Results Communication for Health’s 2019 midterm evaluation (MTE) showed high exposure to the project’s SBCC activities. About 63% of respondents reported being exposed to at least 1 intervention, 38% were exposed to 1-2 interventions, and 25% were exposed to 3+ interventions. The MTE indicated significa t improvement in gateway behaviors and gender equitable norms, as well as key indicators for the six specific health areas. Significant differences were found over the 3-year period between the 2016 baseline survey and the 2019 midterm survey and, in the MTE, between groups with different levels of exposure to the SBCC interventions. The project’s revision, promotion, and distribution of the Family Health Guide led to the adoption of multiple health behaviors. Following this intervention, household availability of the FHG improved from 9.5% at baseline to 20.5% at midterm. The regression analysis depicted that women who had the FHG at their house were more likely to test for HIV, deliver in a health facility, and attend postnatal care services. The project promoted knowledge about and practice of ANC visits. At midterm, 34% of women reported early initiation of ANC (<12 weeks), compared with 30% at baseline. The project’s SBCC interventions to encourage proper handwashing facilities,