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Abstract：
BACKGROUND: The Ethiopian government implemented a national community health program, the Health Extension Program (HEP), to provide community-based health services to address persisting access-related barriers to care using health extension workers (HEWs). We used implementation research to understand how Ethiopia leveraged the HEP to widely implement evidence-based interventions (EBIs) known to reduce under-5 mortality (U5M) and address health inequities.
METHODS: This study was part of a six-country case study series using implementation research to understand how countries implemented EBIs between 2000-2015. Our mixed-methods research was informed by a hybrid implementation science framework using desk review of published and gray literature, analysis of existing data sources, and 11 key informant interviews. We used implementation of pneumococcal conjugate vaccine (PCV-10) and integrated community case management (iCCM) to illustrate Ethiopia\'s ability to rapidly integrate interventions into existing systems at a national level through leveraging the HEP and other implementation strategies and contextual factors which influenced implementation outcomes.
RESULTS: Ethiopia implemented numerous EBIs known to address leading causes of U5M, leveraging the HEP as a platform for delivery to successfully introduce and scale new EBIs nationally. By 2014/15, estimated coverage of three doses of PCV-10 was at 76%, with high acceptability (nearly 100%) of vaccines in the community. Between 2000 and 2015, we found evidence of improved care-seeking; coverage of oral rehydration solution for treatment of diarrhea, a service included in iCCM, doubled over this period. HEWs made health services more accessible to rural and pastoralist communities, which account for over 80% of the population, with previously low access, a contextual factor that had been a barrier to high coverage of interventions.
CONCLUSIONS: Leveraging the HEP as a platform for service delivery allowed Ethiopia to successfully introduce and scale existing and new EBIs nationally, improving feasibility and reach of introduction and scale-up of interventions. Additional efforts are required to reduce the equity gap in coverage of EBIs including PCV-10 and iCCM among pastoralist and rural communities. As other countries continue to work towards reducing U5M, Ethiopia\'s experience provides important lessons in effectively delivering key EBIs in the presence of challenging contextual factors.
METHODS: This study was part of a six-country case study series using implementation research to understand how countries implemented EBIs between 2000-2015. Our mixed-methods research was informed by a hybrid implementation science framework using desk review of published and gray literature, analysis of existing data sources, and 11 key informant interviews. We used implementation of pneumococcal conjugate vaccine (PCV-10) and integrated community case management (iCCM) to illustrate Ethiopia\'s ability to rapidly integrate interventions into existing systems at a national level through leveraging the HEP and other implementation strategies and contextual factors which influenced implementation outcomes.
RESULTS: Ethiopia implemented numerous EBIs known to address leading causes of U5M, leveraging the HEP as a platform for delivery to successfully introduce and scale new EBIs nationally. By 2014/15, estimated coverage of three doses of PCV-10 was at 76%, with high acceptability (nearly 100%) of vaccines in the community. Between 2000 and 2015, we found evidence of improved care-seeking; coverage of oral rehydration solution for treatment of diarrhea, a service included in iCCM, doubled over this period. HEWs made health services more accessible to rural and pastoralist communities, which account for over 80% of the population, with previously low access, a contextual factor that had been a barrier to high coverage of interventions.
CONCLUSIONS: Leveraging the HEP as a platform for service delivery allowed Ethiopia to successfully introduce and scale existing and new EBIs nationally, improving feasibility and reach of introduction and scale-up of interventions. Additional efforts are required to reduce the equity gap in coverage of EBIs including PCV-10 and iCCM among pastoralist and rural communities. As other countries continue to work towards reducing U5M, Ethiopia\'s experience provides important lessons in effectively delivering key EBIs in the presence of challenging contextual factors.
摘要：
背景：埃塞俄比亚政府实施了一项国家社区卫生计划，健康扩展计划(HEP)提供以社区为基础的卫生服务，以解决使用卫生推广工作者（HEW）持续存在的与获得护理相关的障碍。我们使用实施研究来了解埃塞俄比亚如何利用HEP广泛实施已知可降低5岁以下儿童死亡率（U5M）和解决健康不平等的循证干预措施（EBIs）。
方法：本研究是六国案例研究系列的一部分，使用实施研究来了解各国在2000-2015年之间如何实施EBI。我们的混合方法研究是由一个混合实施科学框架，使用发表的和灰色文献的案头审查，分析现有数据源，和11个关键线人采访。我们使用肺炎球菌结合疫苗（PCV-10）和社区综合病例管理（iCCM）的实施来说明埃塞俄比亚通过利用HEP和其他实施策略以及影响实施结果的背景因素，在国家层面快速将干预措施纳入现有系统的能力。
结果：埃塞俄比亚实施了许多已知的EBI，以解决U5M的主要原因，利用HEP作为交付平台，在全国范围内成功引入和扩展新的EBIs。到2014/15年，三剂PCV-10的估计覆盖率为76%。在社区中疫苗的可接受性很高（近100％）。在2000年至2015年之间，我们发现了改善寻求护理的证据；口服补液溶液治疗腹泻的覆盖范围，iCCM中包含的服务，在此期间翻了一番。HEW使农村和牧民社区更容易获得医疗服务，占人口的80%以上，与以前的低访问，背景因素是干预措施高覆盖率的障碍。
结论：利用HEP作为提供服务的平台，使埃塞俄比亚能够在全国范围内成功引入和扩展现有和新的EBI，提高引入和扩大干预措施的可行性和覆盖面。需要做出更多努力，以减少牧民和农村社区之间包括PCV-10和iCCM在内的EBI覆盖范围的公平差距。随着其他国家继续努力减少U5M，埃塞俄比亚的经验为在存在具有挑战性的背景因素的情况下有效交付关键EBIs提供了重要的经验教训。
方法：本研究是六国案例研究系列的一部分，使用实施研究来了解各国在2000-2015年之间如何实施EBI。我们的混合方法研究是由一个混合实施科学框架，使用发表的和灰色文献的案头审查，分析现有数据源，和11个关键线人采访。我们使用肺炎球菌结合疫苗（PCV-10）和社区综合病例管理（iCCM）的实施来说明埃塞俄比亚通过利用HEP和其他实施策略以及影响实施结果的背景因素，在国家层面快速将干预措施纳入现有系统的能力。
结果：埃塞俄比亚实施了许多已知的EBI，以解决U5M的主要原因，利用HEP作为交付平台，在全国范围内成功引入和扩展新的EBIs。到2014/15年，三剂PCV-10的估计覆盖率为76%。在社区中疫苗的可接受性很高（近100％）。在2000年至2015年之间，我们发现了改善寻求护理的证据；口服补液溶液治疗腹泻的覆盖范围，iCCM中包含的服务，在此期间翻了一番。HEW使农村和牧民社区更容易获得医疗服务，占人口的80%以上，与以前的低访问，背景因素是干预措施高覆盖率的障碍。
结论：利用HEP作为提供服务的平台，使埃塞俄比亚能够在全国范围内成功引入和扩展现有和新的EBI，提高引入和扩大干预措施的可行性和覆盖面。需要做出更多努力，以减少牧民和农村社区之间包括PCV-10和iCCM在内的EBI覆盖范围的公平差距。随着其他国家继续努力减少U5M，埃塞俄比亚的经验为在存在具有挑战性的背景因素的情况下有效交付关键EBIs提供了重要的经验教训。
