Exemplars in Under-5 Mortality: Ethiopia Case Study Dr. Lisa Hirschhorn1,2, Agnes Binagwaho1, Alula M. Teklu3, Laura Drown1, Kelechi Udoh1, Miriam Frisch1, Jovial Thomas Ntawukuriryayo1 1 University of Global Health Equity 2 Feinberg School of Medicine, Northwestern University 3 MERQ Consultancy PLC 28 February 2020 Exemplars in U5M: Ethiopia Case Study 1 Table of Contents LIST OF TABLES ............................................................................................................................................................................ 4 LIST OF FIGURES........................................................................................................................................................................... 6 ACKNOWLEDGEMENTS ............................................................................................................................................................... 7 ABBREVIATIONS .......................................................................................................................................................................... 8 1 EXECUTIVE SUMMARY .................................................................................................................................................... 12 1.1 Background on Ethiopia .......................................................................................................................................................... 12 1.2 Causes of Under-5 and Neonatal Mortality ........................................................................................................................... 13 1.3 Dropping U5M in Ethiopia ...................................................................................................................................................... 13 1.4 Evidence-Based Intervention Implementation: Successes and Challenges ......................................................................... 14 1.5 EBI Implementation Strategies ............................................................................................................................................... 16 1.6 Contextual Factors Including Other Health Interventions .................................................................................................... 17 1.7 Transferrable Lessons ............................................................................................................................................................. 20 2 INTRODUCTION .............................................................................................................................................................. 21 2.1 Exemplars in Global Health ..................................................................................................................................................... 21 2.2 Exemplars in Under-5 Mortality ............................................................................................................................................. 21 2.3 Ethiopia .................................................................................................................................................................................... 22 3 METHODS FOR CASE STUDY ............................................................................................................................................ 39 3.1 Project Framework .................................................................................................................................................................. 39 3.2 Desk Review ............................................................................................................................................................................. 39 3.3 Primary Research ..................................................................................................................................................................... 40 3.4 Analysis and Synthesis ............................................................................................................................................................. 41 3.5 Human Subjects Review .......................................................................................................................................................... 41 4 SPECIFIC CAUSES OF DEATH AND EVIDENCE-BASED INTERVENTIONS ............................................................................. 42 4.1 Pneumonia, Diarrhea, and Malaria ........................................................................................................................................ 43 4.1.1 Facility-Based Integrated Management of Childhood Illness ....................................................................................... 43 4.1.2 Integrated Community Case Management ................................................................................................................... 49 4.1.3 Other Diarrhea Interventions ......................................................................................................................................... 56 4.1.4 Other Pneumonia Interventions ..................................................................................................................................... 66 4.1.5 Other Malaria Interventions ........................................................................................................................................... 76 4.2 Other Vaccine-Preventable Diseases ..................................................................................................................................... 83 4.2.1 Measles Vaccination........................................................................................................................................................ 84 4.2.2 Meningococcal Vaccination ............................................................................................................................................ 88 4.3 HIV ............................................................................................................................................................................................ 91 4.3.1 Prevention of Mother-To-Child Transmission of HIV .................................................................................................... 91 4.3.2 Early Infant Diagnosis and Treatment of HIV ................................................................................................................. 97 4.5 Nutrition ................................................................................................................................................................................ 102 4.5.1 Management of Severe Acute Malnutrition ............................................................................................................... 102 4.5.2 Vitamin A ...................................................................................................................................................................... 106 4.6 Neonatal Interventions ........................................................................................................................................................ 109 4.6.1 Improving Antenatal Care Services, Access, and Uptake ........................................................................................... 109 4.6.2 Improving Childbirth Delivery Services, Access, and Uptake ..................................................................................... 119 4.6.3 Improving Post-Partum Care ....................................................................................................................................... 141 4.7 Regional variability and equity gaps for Disease Rates and EBI Coverage ........................................................................ 155 4.8 Common Implementation Strategies .................................................................................................................................. 156 Exemplars in U5M: Ethiopia Case Study 2 5 CROSS-CUTTING CONTEXTUAL FACTORS (FACILITATORS AND BARRIERS) ..................................................................... 158 5.1 Effective National Leadership and Control: Setting Clear Goals and Priorities (facilitator) ............................................. 158 5.2 Donor and Implementing Partner Resources (facilitator) .................................................................................................. 159 5.3 Economic Growth (facilitator) ............................................................................................................................................. 160 5.4 Investment in Health (facilitator) ........................................................................................................................................ 160 5.5 Strong Community Health System (facilitator) ................................................................................................................... 161 5.6 Ongoing Health Systems Strengthening Efforts.................................................................................................................. 161 5.7 Data Availability and Use (facilitator) .................................................................................................................................. 162 5.8 Rising Private Health Sector (facilitator) ............................................................................................................................