## Abstract

Child Health Days (CHDs) are twice-annual campaign-style events designed to increase the coverage of vitamin A and one or more other child health services. Although more than two dozen countries have had a CHD, little has been published about them. This paper presents an activity-based costing study of Ethiopia's version of CHDs, the Enhanced Outreach Strategy (EOS).

The December 2006 round reached more than 10 million beneficiaries at an average cost per beneficiary of US$0.56. When measles is added, the cost of the package doubles. Given the way the distribution day delivery system and the service package are structured, there are economies of scope. Because most of the costs are determined by the number of delivery sites and are independent of the number of beneficiaries, other things equal, increasing the beneficiaries would reduce the average cost per beneficiary. Taking into account only the mortality impact of vitamin A, EOS saved 20 200 lives and averted 230 000 DALYs of children 6–59 months. The average cost per life saved was US$228 and the cost per DALY averted was equivalent to 6% of per capita GDP (US$9), making the EOS cost-effective, according to WHO criteria. While CHDs are generally construed as a temporary strategy for improving coverage of supply-constrained systems, inadequate attention has been paid to demand-side considerations that suggest CHDs have an important role to play in changing care-seeking behaviour, in increasing community organization and participation, and in promoting district autonomy and capacity. Recognition of these effects suggests the need for decisions about where and when to introduce, and when to end, a CHD to take into account more than ‘just’ health sector considerations: they are more broadly about community development. UNICEF played a key role in initiating the EOS and finances 68% of costs, raising concern about the programme's long-term sustainability. KEY MESSAGES • Child Health Days (CHDs) are increasingly common and are of growing importance. Although employed as a key strategy in more than 24 countries in 2005, and many since then, there has been only limited global recognition of their significance and few analyses of their costs. • In the last round of 2006, Ethiopia's CHD programme reached more than 10 million beneficiaries at an average cost per child per round of US$0.56. When measles are included in the package the average cost per child per round is US$1.04. • The Ethiopian EOS programme is cost-effective (by WHO criterion), benefits from economies of scope and can lower its cost per child by increasing coverage at its existing delivery system sites. ## Introduction Child Health Days (CHDs) are time-delimited, special efforts that are designed to increase the coverage of vitamin A and one or a few other high-priority child health services. They are generally large-scale, campaign-style events undertaken semi-annually, much like the national polio immunization days (NIDs) that were such a familiar part of the developing world's public health landscape over most of the past half century. The origins of CHDs can be traced to the integration of vitamin A supplementation with NIDS starting in 1998, and more recently, to the addition of multiple interventions in measles vaccination campaigns. Over the past decade, there has been steady growth in the number of especially African and South Asian countries that have come to provide these integrated packages of child health services. According to UNICEF (Rice 2008), 25 countries held at least one round of CHD in 2005, and the vast majority of them held more than one. While the size and composition of the service packages vary (as shown in Table 1), most include vitamin A, childhood immunizations and anti-helminths. Table 1 Types of health services delivered by countries during Child Health Days in 2005 Health service No. (%) of countriesa Vitamin A 25 (100%) Childhood immunizations (any type) 17 (68%) De-worming medication 18 (72%) Growth monitoring 10 (40%) Bed-net distribution 6 (24%) Otherb 9 (36%) Health service No. (%) of countriesa Vitamin A 25 (100%) Childhood immunizations (any type) 17 (68%) De-worming medication 18 (72%) Growth monitoring 10 (40%) Bed-net distribution 6 (24%) Otherb 9 (36%) Source: Adapted from Rice (2008). aCountries that included the intervention during one or both rounds of Child Health Days in 2005. Most, but not all, countries held two rounds. bOther includes: ORS distribution, health/nutrition education, birth registration, etc. CHDs have adopted two similar, in some cases related, yet distinct service delivery models. One consists of extraordinary, mass mobilizations, usually building upon what in many cases has been a tradition of annual national immunization campaigns—but provided twice each year. These efforts are implemented by special, often itinerant, teams of health workers together with volunteers, and in many countries employees of various local (community and district-level) government agencies, who set up special distribution sites where only the services included in the integrated package are provided for a few days. The other model is a less time-concentrated event that relies more upon routine, facility-based services. This model uses increased publicity and mobilization to promote the utilization of the priority services for 3 or 4 weeks and then wraps up the month-long campaign with an outreach effort of perhaps a week to ‘mop-up’ those who have not yet been reached in the course of that particular campaign. In some cases—Tanzania, for instance—the latter model has evolved from the former, and the last week of the month-long campaign is a vestige of the time when it was the only approach. The mop-up has been retained to ensure high coverage rates, as well as to reach the more isolated and poorly covered areas of the country, thereby also providing greater equity in coverage. While CHDs are increasingly common and are of growing importance, there are few published descriptive accounts and even fewer analyses of them. The first preliminary findings from a systematic review of CHDs were presented by UNICEF in 2007 at the 2nd Annual Global Immunization Meeting (UNICEF 2007a). There are a host of common issues and concerns that countries providing or considering CHDs address in the course of designing and implementing them. To date, these issues have been addressed country-by-country, and there has been no effort to distill general guidelines to help countries better understand options and alternatives and/or to improve the performance of CHDs. What types of considerations, for instance, should be taken into account in designing a CHD in terms of the number and mix of services included in the integrated package, the cost of the package and the frequency with which it is undertaken? Are countries offering ‘enough’ different types of services in their integrated packages, to take advantage of the high CHD participation rates to increase the coverage rates of other services? Are there countries at the other extreme—Uganda is sometimes mentioned—that have added so many services to their CHD that it has become administratively cumbersome and dampened would-be beneficiaries’ participation rates, because the attraction of being able to obtain several services during a single visit is undermined by the inefficiency with which the service delivery site is organized and functions? Are there tradeoffs in terms of the number of services and the number of beneficiaries that a CHD can be expected to reach? Are there insights from theory or country experiences that might aid countries in deciding how to balance lengthening the number of days of service provision and the amount of time and resources to devote to social mobilization efforts? Do countries know how much time and resources they are spending in mop-up activities? How can a country decide how much time and resources should go into mop-up activities? What is the ‘best’ balance between a fixed facility-based effort and outreach? Is there some type of general prototypical model or path of development that countries might be expected to follow as their health care delivery system grows and develops, as coverage expands and care-seeking behaviour patterns change? In many countries that are decentralizing, the implementation of CHDs is increasingly being led by districts that often have limited planning and administrative capabilities. What can be done to facilitate their management and the implementation of CHDs to make them more effective and to encourage their sustainability? How might their budgeting or their mobilization of the requisite manpower and in-kind contributions of vehicles and other inputs be better planned, made more routine and the CHD event made more effective? This paper is intended to contribute to our still nascent understanding of the structure, operations and cost of CHDs. It provides a case study of Ethiopia's version of CHDs, its Enhanced Outreach Strategy (EOS). ## The Ethiopian context Ethiopia is one of the poorest and most rural countries in the world. It has the second largest population among Africa's 54 countries, and some of its poorest general health indicators. Ethiopia's infant mortality rate is 110 per 1000 live births, its under-five mortality rate is 166 deaths per 1000 live births, its maternal mortality rate is 871 deaths per 100 000 live births, and life expectancy at birth is 42.5 years (World Bank 2007). The declines in child mortality and maternal mortality have been moderate over the past decades, and Ethiopia will need to intensify its efforts if it is to achieve its Millennium Development Goals. Ethiopia's poor health indicators are attributable to a constellation of factors. Per capita gross domestic product is only US$160, and 44% of the population lives below the poverty line (World Bank 2005b). The total adult literacy rate is 36%, and that of females is only 25%. Only 28% of Ethiopians have access to safe drinking water, and even fewer, 17%, have access to sanitation facilities (Central Statistical Agency 2000).

The low coverage of health services is the outcome of a set of factors. On the supply side, there are three contributing factors. First, the health infrastructure is small. Including health posts and health stations, there is one facility for every 17 500 Ethiopians, and only 40% of Ethiopians live within 10 km of a health service—the benchmark the Government of Ethiopia uses to define ‘adequate access’ (Welfare Monitoring Survey 2004). Second, Ethiopia has severe human resources constraints. It has one-fifth the number of physicians and just over half the nurses that the World Health Organization (WHO) recommends for a country with its population (FMOH 2005). Third, over the 1990–98 era Ethiopia's annual average per capita health expenditure was US$4, only one-tenth the overall Sub-Saharan African average of US$42 (FMOH 2003).

Although the relatively limited health infrastructure constrains physical access to services, a significant portion of the low level of use of health services is attributable to behavioural and cultural factors which dampen demand. Annually, only 34% of Ethiopians access the health sector—either Ministry of Health (MOH) or private providers (Gebremariam et al. 2005). This is part of the reason why, as the health expenditures and the number of health facilities have grown in the past few years, the use of services has not expanded at a commensurate pace.

In 2004, the Federal Ministry of Health of Ethiopia (FMOH) endorsed the National Strategy for Child Survival and identified a number of priority, high impact interventions for which it intends to increase access and use. The longer-term strategy of the FMOH is guided by the vision of what it refers to as the Health Services Extension Program (HSEP). The concept of the HSEP is a comprehensive health system emphasizing preventive care, with ready access to a variety of facilities and providers. When the HSEP is fully in place, there will be one health post in every rural kebele,1 two Health Extension Workers at every health post, and one trained community volunteer for every 50 households or five for each Health Extension Worker in rural areas. The HSEP will take a substantial amount of time to fully design and implement. In the meantime, there is a need for an interim or ‘bridging’ strategy to increase coverage and use of services as rapidly as possible, while at the same time ensuring that the ground work for the HSEP is laid and a course is charted through the long transition from now until the time when the infrastructure, human resources and care-seeking behaviour changes are in place and the HSEP becomes fully operational. This transitional or ‘bridging’ strategy is the EOS.

## The Enhanced Outreach Strategy

When the EOS was introduced in April 2004, with massive support from UNICEF and the World Food Programme (WFP), it consisted of twice annual, mass mobilizations to provide vitamin A supplementation, de-worming, nutrition screening and, in some woredas, vaccinations to children from 6 to 59 months old and to pregnant and lactating women in the 325 districts that had been hit hardest by the drought and famine of 2002–03. Starting in 2005, a very similar programme, the Extended EOS (EEOS) has been introduced in all of the 305 non-EOS districts. The only difference in the two packages of services is that nutrition screening is a component of the EOS, but not the EEOS.2 The EEOS—and not the full EOS—is being introduced in these 305 districts for two reasons: (1) because they were less affected by the 2002–03 drought and are generally more food secure and less in need of the screening, and (2) because of management and financial constraints, according to UNICEF officials.

The phasing-in of the EOS/EEOS was completed in the last half of 2006 when nearly 10 million children 6–59 months old received vitamin A supplements, nearly 8.7 million children 12–59 months old received de-worming medicine, and 5.3 million children 6–59 months old and 900 000 pregnant and lactating women were nutritionally screened (see Figure 1). These are impressive accomplishments and testify to the massive social mobilization that organizing the delivery system—the supply side of the programme—has entailed. It also provides evidence—on the demand side—that the programme is providing services that are needed and valued by mothers, the community (kebele) and district (woreda) officials.

Figure 1

Evolution of EOS and EEOS services provision by round, 2004–2006

Source: Author's calculations based on tally sheet data maintained in the EOS Results database.

Figure 1

Evolution of EOS and EEOS services provision by round, 2004–2006

Source: Author's calculations based on tally sheet data maintained in the EOS Results database.

Both the EOS and the EEOS programmes operate on an annual cycle. Each level of the MOH structure (see Figure 2) participates in some aspect of the EOS/EEOS, though their levels of participation vary markedly. The role of the FMOH, the Regional Health Bureaux and the Zonal Health Departments in the EOS/EEOS are concentrated early-on in the programme cycle and in the review and reporting activities. The woredas and kebeles are the key organizing and implementing levels, while the FMOH, Regional Health Bureaux, Zonal Health Departments and UNICEF provide general programme direction, conduct a training of trainers session that is held at each Zonal Health Department, assist in coordinating and delivering supplies, supervise the campaign and compile results.

Figure 2

Organization structure of the Ministry of Health, Ethiopia

Figure 2

Organization structure of the Ministry of Health, Ethiopia

Each year there are two multiple-day distributions, each of which is preceded by two, cascading training sessions. The first session is a Training of Trainers (TOT) and the second is a Training of Service Providers. A TOT session is held in each zone and UNICEF, Regional Health Bureaux and Zonal Health Department officials train two representatives from each woreda in the zone. The annual planning cycle starts with the development of the Micro-Plan. UNICEF/Ethiopia has developed a set of standardized, simple, but powerful algorithms to aid the districts in preparing these plans, and has translated them into an Excel-based planning tool that is referred to as the Micro-Planning Tool (MPT). During the first TOT of the year, the MPT is used to develop an EOS implementation plan for each district.

The primary driver of the MPT's algorithm-based calculations is the district's population and its number of kebeles. The MPT is used to quantify all of the inputs required by a district to achieve 100% coverage of its target population (children 6–59 months old and pregnant and lactating women), including: the numbers of EOS/EEOS distribution sites, the numbers and composition of teams, the number of supervisors, per diems for all personnel, and the quantities of the various supplies; vitamin A capsules, albendazole, nutrition screening tapes, scissors for cutting the vitamin A capsules and the various reporting forms. Generally, there is one EOS team per kebele and each team is comprised of five members, with one supervisor for every five teams. The average district in Oromiya and Amhara has a population of 160 000, a target population of 25 000, is comprised of 32 kebeles and has 26 EOS teams, 125 team members and 5 supervisors. These numbers vary, however, and sometimes substantially. The variations in these general benchmark figures, together with various potential extenuating circumstances—such as a relatively more dispersed population, or a particularly poorly developed transportation system—give rise to the need to adjust the MPT's parameters for some districts. From the inception of the programme, UNICEF has provided the per diem and all of the supplies of the programme. It has technically led the Micro-Planning process and has directly undertaken or managed all logistics related to the EOS in a vertical, stand-alone manner. With UNICEF husbanding its resources, the final Micro-Plan parameters of any district are the outcome of discussions and negotiations between the district representatives participating in the TOT session and the Zonal Health Department, Regional Health Bureaux and UNICEF officials.

The MPT is indispensable for organizing, planning, coordinating and managing the EOS/EEOS distribution. Still, a substantial proportion of the preparatory work that is essential to ensuring a successful EOS/EEOS distribution is left in the hands of the woredas. The Micro-Planning process stops short of getting involved in, or providing anything more than general guidance about, the recruitment, organization and preparation of the actual programme implementers in each woreda. The programme is a partnership between UNICEF, the FMOH, the Regional Health Bureaux and the Zonal Health Departments on the one hand, and the Woreda Health Offices and other woreda-level government agencies, kebeles and communities on the other.

The trainees of the TOT session return to their woredas where they hold a sensitization meeting to inform their constituents of the upcoming EOS/EEOS round and to begin organizing and promoting community support and participation. These community organizing and general promotion activities include recruiting the EOS/EEOS service delivery team members for each of the kebeles in their woreda, and the recruiting of those persons who will serve as supervisors, coordinating and monitoring the delivery of services throughout the woreda during the round.

After the initial sensitization meeting, the woreda officials who have been trained in the TOT session convene a meeting of the kebele teams and supervisors in their woredas and train them. This is the Training of Service Providers, which is held in the woreda, usually in the woreda administration building. A few weeks after the Training of Service Providers, the EOS/EEOS distribution is held. On average, in any given woreda, a round will last 7 to 10 days, as long as is required to reach all of the kebeles. Following the distribution days, a report of activities and coverage is prepared and a review meeting is held to discuss distribution day accomplishments and problems.

## The study design and costing methodology

The present study is an economic analysis designed to estimate the total costs of the EOS/EEOS programme, including those that UNICEF incurs in providing supplies and the cash payments that UNICEF makes to pay for training, per diems and other aspects of EOS/EEOS operations. It also quantifies the value of the personnel time that employees at all levels of the MOH devote to planning, implementing and supervising the programme, and the value of the substantial amount of time and other inputs that are donated or provided in-kind by other (especially kebele and woreda level) agencies and individual members of the community. Some costs, however, were not included in the analysis: UNICEF staff costs, UNICEF and the FMOH's overhead costs, and the costs of the Targeted Supplementary Food programme (other than the nutrition screening) were excluded. Due to the time and resource constraints of the study, the geographic scope of the study was limited to two of Ethiopia's 10 regions, Amhara and Oromiya. These two regions account for a disproportionate share of the national population, 55%, and of the country's total land area, 57%.

The methodological approach uses a combination of activity-based costing (ABC) and the ‘ingredients approach’ (WHO 2006). ABC combined with an ingredients approach is a bottom-up methodology. Its application requires identifying the major activities of each organizational level of the programme and defining these as the cost centres of the study. Through a series of interviews with officials at all levels of the MOH and with UNICEF officials, together with data from a survey conducted specifically for this study, 11 activities were identified. For each of the 11 activities, a unit cost algorithm was defined. The algorithms identify the different types, quantities and costs of the inputs required to produce the activity. In the many instances in which activities are implemented by more than one level of the MOH, distinct algorithms were specified for each level (region, zone, district or kebele). To estimate the total cost of a particular activity, at a particular level, the level's unit cost algorithm for the activity was multiplied by the corresponding number of units at that level (i.e. the number of zones, woredas, kebeles and target beneficiaries). The total cost of the EOS at a particular level of the programme is the sum of all of the activities’ costs at that level, and the sum of the costs of all levels’ activities is the estimated total cost of the EOS.

### Data sources

Data sources used in the study included:

• Woreda level EOS and EEOS micro-planning tool data;

• Woreda tally sheet data of the number and types of EOS services provided in each round;

• A survey of Zonal Health Departments, Woreda Health Offices and Kebele/Health Facility levels (consisting of 133 interviews) which was conducted specifically for this study.

Given the importance of the role of personnel in implementing the EOS, quantifying all personnel time input—even that of volunteers—was deemed essential for purposes of understanding how the programme was planned, implemented and what it cost. Since many of the volunteers are employees of government agencies other than the MOH and normally working in some unrelated capacity, this analysis enables estimating the opportunity cost to the government of ‘releasing’ them to participate in the EOS. It also enables a better understanding of the issue about whether or not volunteers should be paid, and if so, how much, and what would be the cost of doing so.

The only systematic information available on EOS personnel was that produced about the distribution day teams and supervisors as part of the Micro-Plan. No analysis had ever been done to assess how closely the actual implementation adhered to this plan. Nor was there any information about the composition of these teams. This and other information was obtained through a survey.

### The survey and sample

Three questionnaires—one each for the Zonal Health Department, the Woreda Health Office and the Kebele/Health Facility level—were developed and administered as part of the study. The survey was used to corroborate and complement the Micro-Planning Tool data and to quantify the number and types of personnel and all other resources used to implement activities at each of these three levels. The survey also obtained more detailed information about how the woredas and kebeles implemented the programme and their perceptions of the programme, the adequacy and timeliness of supplies and, more generally, the programme's strengths and weaknesses.

The sample was not statistically representative: it was purposive. It was developed using the three criteria: (1) EOS/EEOS status of the zone and woreda; (2) population size; and (3) number of kebeles and/or number of EOS/EEOS teams. In each region, the sample included six zones; two zones in which only the EOS programme is being implemented, two zones in which only the EEOS is being implemented, and two zones in which both the EOS and the EEOS are being implemented.

• In each of the two zones in which only the EOS is being implemented, three woredas were selected: six woredas total.

• In each of the two zones in which only the EEOS is being implemented, three woredas were selected: six woredas total.

• In each of the two zones in which both the EOS and the EEOS are being implemented, two woredas were selected that are implementing only the EOS and two woredas were selected that are implementing only the EEOS: eight woredas total.

Thus, in each region the sample consisted of six zones and 20 woredas (63 and 11%, respectively, of the combined, two-region totals). In each of the 20 woredas, two health facilities/kebeles were visited, for a total 40 health facilities/kebeles (1% of the combined two-region total). The total number of interviews per region was 66. The study design and sampling criteria were vetted in a formal meeting with officials of the MOH and UNICEF, and were subsequently distributed among the health services research community of Ethiopia soliciting input and comments. The field work was conducted over a two-month period by four interviewers.

## Results

### Unit cost algorithms and total cost estimates

Table 2 contains the unit cost estimates of each of 11 activities by level and region. For five of the 11 activities, neither the content of the activities nor the quantity, type or cost of resources used to produce them varies systematically by type of programme (EOS versus EEOS). For the other six activities in which they do vary, four different algorithms were specified for each level: (1) EOS with measles, (2) EOS without measles, (3) EEOS with measles and (4) EEOS without measles. Thus, there are two sets of 63 algorithms, one set for each region, for a total of 126.

Table 2

The unit cost algorithms of EOS/EEOS activities by level in Amhara and Oromiya, Ethiopia (US$per EOS/EEOS round) Activity Level/unit Amhara Oromiya Amhara as % of Oromiya 1. TOT RHB 1267 1267 100 ZHD 33 33 100 Woreda 74 74 100 2. TOSP Woreda 2946 1601 184 Kebele 26 11 235 ZHD 135 135 100 3. Sensitization Woreda 1336 285 468 meeting Kebele 127 127 100 4. Other organizational or promotional meetings Woreda 28 113 24 5. Other promotion Woreda 135 100 134 and mobilization Kebele 100 6. Repacking supplies Woreda 100 7. Supply transport Woreda 119 119 100 from: Kebele 373 All kebeles/W 114 31 373 ZHD 165 165 100 8. Supplies Woreda EOS–without measles 1157 764 151 EOS–with measles 5547 8467 66 EEOS–without measles 701 396 177 EEOS–with measles 8421 4511 187 9. Implementation/ distribution day Woreda (and Kebele) EOS–without measles 7413 4808 154 EOS–with measles 11 653 5768 202 EEOS–without measles 7751 3867 200 EEOS–with measles 10 284 3080 334 ZHD 964 964 100 RHB 1712 1712 100 10. Review meeting Woreda 414 414 100 ZHD 985 985 100 RHB 266 266 100 11. Other RHB ZHD 90 90 100 and ZHD RHB 66 66 100 Activity Level/unit Amhara Oromiya Amhara as % of Oromiya 1. TOT RHB 1267 1267 100 ZHD 33 33 100 Woreda 74 74 100 2. TOSP Woreda 2946 1601 184 Kebele 26 11 235 ZHD 135 135 100 3. Sensitization Woreda 1336 285 468 meeting Kebele 127 127 100 4. Other organizational or promotional meetings Woreda 28 113 24 5. Other promotion Woreda 135 100 134 and mobilization Kebele 100 6. Repacking supplies Woreda 100 7. Supply transport Woreda 119 119 100 from: Kebele 373 All kebeles/W 114 31 373 ZHD 165 165 100 8. Supplies Woreda EOS–without measles 1157 764 151 EOS–with measles 5547 8467 66 EEOS–without measles 701 396 177 EEOS–with measles 8421 4511 187 9. Implementation/ distribution day Woreda (and Kebele) EOS–without measles 7413 4808 154 EOS–with measles 11 653 5768 202 EEOS–without measles 7751 3867 200 EEOS–with measles 10 284 3080 334 ZHD 964 964 100 RHB 1712 1712 100 10. Review meeting Woreda 414 414 100 ZHD 985 985 100 RHB 266 266 100 11. Other RHB ZHD 90 90 100 and ZHD RHB 66 66 100 ZHD = Zonal Health Department. RHB = Regional Health Bureaux. TOT = Training of Trainers. TOSP = Training of Service Providers As may be seen in Table 2, about half of the activities’ unit costs are not the same in the two regions. These variations reflect differences in the ways in which the regions implement the programme. This is one of the two sources of variation in the region's total cost of the EOS/EEOS. The second is due to differences in the number of units of each type—i.e. in the number of kebeles, woredas and zones—in the two regions. Table 3 presents the total cost per region, per district and per beneficiary by programme and service package. Table 3 EOS AND EEOS costs per round in Amhara and Oromiya, Ethiopia (in US$)

Region–Programme Total cost per region Cost per district Average cost per beneficiary
Amhara EOS–without measles 1 003 975 18 592 0.7
Amhara EOS–with measles 1 470 028 27 223 1.3
Amhara EEOS–without measles 1 098 005 17 710 0.6
Amhara EEOS–with measles 1 733 755 27 964 0.9
Oromiya EOS–without measles 1 481 365 11 757 0.5
Oromiya EOS–with measles 2 572 949 20 420 1.1
Oromiya EEOS–without measles 1 375 676 10 664 0.5
Oromiya EEOS–with measles 1 805 004 13 992 0.9
Amhara + Oromiya EOS– without measles 2 485 340 30 349 0.6
Amhara + Oromiya EOS– with measles 4 042 976 47 643 1.2
Amhara + Oromiya EEOS–without measles 2 473 681 28 374 0.5
Amhara + Oromiya EEOS– with measles 3 538 759 41 956 0.9
Both EOS/EEOS without measles 4 959 020 58 723 0.6
Both EOS/EEOS with measles 7 581 735 89 599 1.0
Region–Programme Total cost per region Cost per district Average cost per beneficiary
Amhara EOS–without measles 1 003 975 18 592 0.7
Amhara EOS–with measles 1 470 028 27 223 1.3
Amhara EEOS–without measles 1 098 005 17 710 0.6
Amhara EEOS–with measles 1 733 755 27 964 0.9
Oromiya EOS–without measles 1 481 365 11 757 0.5
Oromiya EOS–with measles 2 572 949 20 420 1.1
Oromiya EEOS–without measles 1 375 676 10 664 0.5
Oromiya EEOS–with measles 1 805 004 13 992 0.9
Amhara + Oromiya EOS– without measles 2 485 340 30 349 0.6
Amhara + Oromiya EOS– with measles 4 042 976 47 643 1.2
Amhara + Oromiya EEOS–without measles 2 473 681 28 374 0.5
Amhara + Oromiya EEOS– with measles 3 538 759 41 956 0.9
Both EOS/EEOS without measles 4 959 020 58 723 0.6
Both EOS/EEOS with measles 7 581 735 89 599 1.0

### The total recurrent cost of one round of the EOS/EEOS in Amhara and Oromiya

The total cost of one round of the EOS/EEOS in Amhara and Oromiya—considered together—is 44.7 million Birr or US$5 million. Adding measles vaccinations to the basic services packages increases the cost of a round by 53% to 78.4 million Birr (US$8.7 million). The average cost per woreda of the combined programme is 120 527 Birr (USS$13 367) per round without measles and 184 271 Birr (US$20 435) with measles.

The total recurrent costs vary by programme, by region (Amhara vs. Oromiya) and by service package (with and without measles). The total cost of one round of EOS/EEOS is roughly 30% more in Oromiya than in Amhara. Oromiya, however, has more than twice as many woredas as Amhara, and when the average total cost per woreda is calculated, Amhara has the higher costs. The average cost of an Amharan woreda is 61% higher than in Oromiya. Amhara's higher costs are due to: (1) its having larger distribution teams (a median of six, relative to Oromiya's five), (2) Amhara's more expensive teams (due not only to their larger size, but also because their members have higher average salaries and per diems), (3) Amhara's Training of Service Provider sessions which are longer and more costly than Oromiya's, at both the woreda and kebele levels, and (4) the larger numbers of participants at Amhara's woreda-level organizing and promotional meetings.

The EOS's average cost per woreda per round is 7% higher than the average cost per woreda of the EEOS, 124 500 and 116 800 Birr, respectively (US$13 807 and US$12 953, respectively).

### Total cost by service component and economies of scope

Figure 3 shows the total cost of the EOS/EEOS in Amhara and Oromiya by activity. Figure 4 disaggregates the EOS/EEOS costs by their five service components. The major difference between the EOS and EEOS programmes is nutritional screening, which is included in the EOS, but not the EEOS. Screening accounts for most of the difference between the two programmes’ cost structures by service component; accounting for 29% of total EOS costs and just 2% of total EEOS costs.3

Figure 3

Cost of EOS and EEOS programmes in Amhara and Oromiya by activity

Figure 3

Cost of EOS and EEOS programmes in Amhara and Oromiya by activity

Figure 4

Service composition of the total cost of one round of EOS/EEOS in Amhara and Oromiya, Ethiopia (without measles vaccinations)

Figure 4

Service composition of the total cost of one round of EOS/EEOS in Amhara and Oromiya, Ethiopia (without measles vaccinations)

Figure 5

Total cost of EOS/EEOS by programme and service component per round (without measles) in Amhara and Oromiya, Ethiopia

Figure 5

Total cost of EOS/EEOS by programme and service component per round (without measles) in Amhara and Oromiya, Ethiopia

### Average cost per beneficiary and the economies of expanding coverage

The average cost per child of the EOS/EEOS in Amhara and Oromiya is 5.1 Birr (US$0.57) per round without measles vaccinations and 9.4 (US$1.04) with them. The greatest amount of variation in the average cost per child is dependent upon whether or not measles vaccinations are provided. That difference far exceeds the amount of variation due to regional or programmatic differences.

At a given distribution site, there are economies to increasing the number of beneficiaries in the provision of EOS and EEOS, i.e. as the number of beneficiaries increases within a region, or within a woreda or at a particular kebele distribution site, the average cost per beneficiary falls. This is because most of the costs of the programme are personnel and personnel-related costs that are determined by the structure of the programme. Eighty-nine per cent of the total implementation/distribution day costs are comprised of personnel (i.e. salary), per diem and fuel, which are determined by the number and location of distribution sites and team members. Although the number of team members and the number of teams were initially determined by the number of beneficiaries and their distribution/location, once the distribution sites were identified, they have generally not been changed from one round to the next. Thus the number and size of teams has become fixed (assuming the same service package), and the only element of cost that changes as the number of beneficiaries changes is the relatively minor cost of supplies (11% of the total distribution day costs).

Distribution day costs constitute 40.5% of the total cost of the EOS/EEOS in Amhara and Oromiya. That means that supply costs account for 4.46% of those total costs. In other words, slightly more than 95% of the costs of EOS/EEOS remain fixed when the number of beneficiaries increases. When the relatively much more expensive measles vaccinations are provided, the financial significance of the economies of increasing numbers of beneficiaries that are realized is reduced, but this fundamental relationship still exists.

The existence of these economies of increasing numbers of beneficiaries means that expanding coverage within the current delivery system will add little to total costs and will reduce the overall EOS/EEOS cost per beneficiary. Also, with economies of scale, it is likely to be cost-effective (as measured by average cost per beneficiary reached) to undertake additional efforts and incur additional costs in attempting to increase participation rates, even though rates are already very high. How much more it might be cost-effective to spend on such efforts depends upon on how effective are the alternative methods that might be considered.

## Estimating the minimal, lower bound impact of the EOS/EEOS

It is not possible to conduct anything that might be regarded as a rigorous evaluation of the impact of the EOS/EEOS because there is no control group and no baseline data. Rather than to disregard this line of inquiry altogether, we chose to make use of a simple model for estimating the impact of vitamin A supplementation developed by Johns Hopkins University and UNICEF (2001) that is based on data from the Beaton et al. (1993) meta-analysis of randomized control trials of vitamin A supplementation programmes in other countries. For the other interventions, however, there is no such similar model. Thus this estimate is based on the effect of only vitamin A, underestimating the full impact of the EOS/EEOS.

The Hopkins/UNICEF model estimates the number of children who would have died had they not received vitamin A. The annual number of lives saved by vitamin A supplementation is calculated as a proportion of the children 6–59 months old who receive two doses of vitamin A in a year multiplied by the annual number of deaths of children 6–59 months old. The impact of a single round of EOS/EEOS is calculated as one-half the annual number of lives saved. Two alternative scenarios are examined. Scenario #1 assumes that the reduction in the mortality rate due to vitamin A dosing is 20% among 6–59 month olds. This is an African region-wide estimate developed by Johns Hopkins University. Ethiopia, however, has the fifth highest prevalence of vitamin A deficiency in the world (West et al.2005). Given that the prevalence and severity of vitamin A deficiency in Ethiopia is more similar to Asia—where the Johns Hopkins University team has estimated the mortality rate reduction to be 30%—Scenario #2 adopts an alternative, higher rate of 30%.

The estimated number of lives saved by each round of the EOS/EEOS in Amhara and Oromiya is 13 469 using Scenario #1 and 20 203 using Scenario #2. Recognizing that the analysis here includes only the mortality impact of only vitamin A, and that there are no measures of the morbidity impacts of any of the services in the intervention, these estimates should be regarded as the minimum or lower bound of the impact of the EOS/EEOS.

## An approximation of the cost-effectiveness of the EOS/EEOS

In light of the fact that only the minimum or lower bound of the impact of the EOS/EEOS could be estimated, this analysis of the cost-effectiveness of the programme will be a conservative one—one that underestimates its cost-effectiveness. Using Scenario #2′s estimated number of lives saved, Table 4 presents the cost per life saved in Birr, US dollars and as a percentage of per capita gross domestic product (GDP).

Table 4

Cost-effectiveness analysis of the EOS/EEOS, based exclusively on the estimated mortality impact of vitamin A assuming a 30% mortality reduction

In Ethiopian Birr In US$As a percentage of GDP Indicator/programme site Including only the costs of vitamin A Including total EOS/EEOS costs Including only the costs of vitamin A Including total EOS/EEOS costs Including only the costs of vitamin A Including total EOS/EEOS costs Estimated costs per life saved Amhara EOS/EEOS 582 2362 65 262 40% 164% Oromiya EOS/EEOS 521 2126 58 236 36% 147% Amhara + Oromiya EOS/EEOS 545 2220 60 246 38% 154% Estimated cost per DALY averted Amhara EOS/EEOS 20.3 82.5 2.3 9.1 1.4% 5.7% Oromiya EOS/EEOS 19.9 81.0 2.2 9.0 1.4% 5.6% Amhara + Oromiya EOS/EEOS 20.1 81.6 2.2 9.1 1.4% 5.7% In Ethiopian Birr In US$ As a percentage of GDP
Indicator/programme site Including only the costs of vitamin A Including total EOS/EEOS costs Including only the costs of vitamin A Including total EOS/EEOS costs Including only the costs of vitamin A Including total EOS/EEOS costs
Estimated costs per life saved
Amhara EOS/EEOS 582 2362 65 262 40% 164%
Oromiya EOS/EEOS 521 2126 58 236 36% 147%
Amhara + Oromiya EOS/EEOS 545 2220 60 246 38% 154%
Estimated cost per DALY averted
Amhara EOS/EEOS 20.3 82.5 2.3 9.1 1.4% 5.7%
Oromiya EOS/EEOS 19.9 81.0 2.2 9.0 1.4% 5.6%
Amhara + Oromiya EOS/EEOS 20.1 81.6 2.2 9.1 1.4% 5.7%

The EOS/EEOS average total cost per life saved is 2057 Birr (US$228), the equivalent of 143% of per capita GDP. Based on the criteria established by WHO (2006), the EOS/EEOS is a cost-effective programme. If the cost per life saved is recalculated limiting the cost to only the vitamin A service component of the programme, the cost per life saved falls to a quarter of this level, to 505 Birr (US$56), the equivalent of 35% of per capita GDP.

A second cost-effectiveness indicator is the cost per disability-adjusted life-year (DALY) averted. The DALY captures both morbidity and mortality, although, as already noted, we have only mortality impact estimates. Thus our estimates of DALYs averted will be underestimated not only because we have impact measures only for vitamin A, but also because we do not have any measures of the impact on morbidity associated with the reduction in vitamin A deficiency. The DALYs are calculated from the Scenario #2 estimated number of lives saved of 20 203 children aged 6–59 months who would otherwise have died, and further assumes: (1) that they will live to the current average Ethiopian life expectancy at birth, 49 years, and (2) that they would have died, on average, at age 2. Thus each life saved is assumed to have saved 47 life-years. The number of lives saved was discounted using a 3% discount rate. The discounted number of DALYs averted was 229 730 in Amhara, 318 039 in Oromiya; a total of 547 769 for the two regions. The EOS/EEOS average total cost per DALY averted is 82 Birr, or US$9, the equivalent of 6% of per capita GDP. When the calculations include the cost of only the vitamin A service component, the cost per DALY averted drops to 20 Birr, or US$2, the equivalent of 1.4% of per capita GDP.

The World Health Organization (2005) classifies all health interventions that have a cost per DALY averted that is equivalent to less than per capita GDP as cost-effective. The EOS/EEOS is a cost-effective programme and a good investment for Ethiopia.

## Discussion

The costs of the EOS/EEOS are low for several reasons. First, the services in the EOS package are interventions with relatively few and relatively inexpensive supplies and materials. Second, wage levels in Ethiopia are among the lowest in the world (see Table 5). The average health worker salary, for example, is less than US$3.00 per day. As a result, even though the EOS/EEOS entails a massive mobilization—with nearly 27 000 persons participating in one or more of the organizing and implementing activities during a single round of the programme in Amhara and Oromiya, alone—total personnel costs are relatively modest. Implementing an EOS/EEOS-like intervention in another country, where salaries and opportunity costs are likely to be three times or more higher, will cost considerably more. Table 5 Regional average salaries of health workers as a percentage of the average Ethiopian health worker salary Geographic domain (World Bank defined Regions) Annual salary (US$ 2007) As % of Ethiopia's average
Ethiopia 660 100
Sub-Saharan Africa 2722 412
Middle East and North Africa 8532 1293
East Asia and Pacific 2209 335
Eastern Europe and Central Asia 2671 405
South Asia 1969 298
Latin America and the Caribbean 5250 795
Geographic domain (World Bank defined Regions) Annual salary (US\$ 2007) As % of Ethiopia's average
Ethiopia 660 100
Sub-Saharan Africa 2722 412
Middle East and North Africa 8532 1293
East Asia and Pacific 2209 335
Eastern Europe and Central Asia 2671 405
South Asia 1969 298
Latin America and the Caribbean 5250 795

Source: Author's adjustments of 'best point' estimates presented in Mulligan et al. (2005). Based on WHO-CHOICE Level 2 positions (of 5) which require an (upper) secondary education. As a reference point, Registered Nurses are Level 3 and require a post-secondary, non-tertiary education.

The low wage levels of Ethiopia also contribute to making the UNICEF contribution to the programme a relatively high proportion of the total cost of the intervention, roughly 68%. The per diems that UNICEF pays are the equivalent of twice the average daily salary, which has contributed to making the programme popular for people to participate in as team members and supervisors. The EOS constitutes an opportunity for many government employees to substantially augment their income. For volunteers the attraction is even greater because there are so few similar opportunities in rural Ethiopia to earn cash.

For example, to implement one round woreda-level health officials usually spend an average of 2 days travelling to/from the TOT, 2 days in the TOT, 2 days in the Training of Service Providers, 1 or more days in sensitization and organizational planning meetings, and 5–7 days in the distribution rounds. Over the course of a year, there are two rounds, resulting in a doubling of these figures, and another 4 days are spent travelling to and from and attending the annual review session, making a total of 30 days. The total annual per diem is the equivalent of more than 3 months’ salary. There is no doubt but that some of the success of the programme must be attributable to the powerful incentives these per diems provide. Will the Government of Ethiopia be willing and able to finance these per diems when UNICEF ‘moves on’? If not, what will happen to the effectiveness, efficiency and cost of the EOS/EEOS?

Another important supply-side related factor that contributes to the programme's relatively high level of effectiveness is its logistics system. The MOH's logistics system is notoriously deficient. From its inception, EOS/EEOS's logistics needs have been managed and financed by UNICEF using a vertical approach. In Amhara and Oromiya, UNICEF delivers or contracts the delivery of EOS/EEOS supplies not just to the Regional Health Bureaux, but down to the 19 zonal warehouses. Even with this level of close oversight by UNICEF, supply-related problems are quite common. The survey conducted for this study found that 58% of the zones reported that EOS/EEOS supplies did not arrive on time at the Zonal Health Departments, and two-thirds of them reported that there were some supply shortages. This dependency and the 2008 launch of UNICEF's new five-year programme—which calls for reducing its support to the nation-wide implementation of EOS/EEOS—raises concerns about what that will mean for the EOS/EEOS supply system, the payment of per diems, and by implication, the effectiveness and sustainability of the programme.4

Returning to the discussion of the cost of the EOS/EEOS, it should be noted that there are some factors that suggest that the costs of implementing this programme are probably higher in Ethiopia than they would be in many other countries. The major cost driver of the EOS is the structure of the programme—foremost the number of teams and the number of service delivery sites. The factors influencing the number of service delivery sites include the absolute size of the target population, the degree of dispersion of the population and the quality of the infrastructure. The EOS is a large-scale programme. In the second distribution round of 2006, 11 million persons—14% of the national population—received EOS services. With 84% of Ethiopia's 78 million people living in rural areas, coupled with a poor road system and a poor public transportation system, Ethiopia needs relatively more teams and/or relatively more service delivery sites, and/or its teams must provide EOS services for longer periods of time, resulting in relatively higher costs than would likely be the case in other countries.5

The finding that there are economies of scope—which may not yet be exhausted—means that if additional services were added to the EOS, the average cost per person served may fall. This study does not provide any direct guidance in terms of what might be or should be added to the EOS service package, or about when ‘too many’ have been added. Ultimately there is a trade-off between adding additional services and slowing down the provision of services. In light of the locale-specific nature of the determinants of the number of teams and delivery sites, the decision of what to add, beyond a basic core set of services, might best be left to district-level officials, with the federal authorities identifying the core interventions that are provided countrywide.

The cost-effective way to expand the contents of the service package depends on the incremental costs and the incremental impacts of the interventions being considered. It should not simply be assumed that because economies of scope have resulted in falling average costs for services currently being provided that the addition of any intervention will necessarily result in further reductions in average costs. Indeed, anecdotal evidence suggests that the 2005 one-time incorporation of insecticide-treated bed-nets into the EOS in one zone of Oromiya so disrupted the normal supply system and the organization of the service delivery site that it was responsible for reducing coverage of all services, resulting in an increase in the average cost of all services.

The Micro-Planning Tool could easily be adopted in other countries with CHDs. The MPT is a remarkably effective way of standardizing a CHD in terms of inputs and structure, but at the same time allowing for local participation in the planning and implementation-related decision-making processes, and providing flexibility in how to do so. The way in which the orientation, training and financing of the EOS/EEOS have been structured invites districts to participate in the programme, and provides them with a detailed but flexible blueprint for what needs to be done, what resources are required and what it will cost. At the same time, however, it requires the districts to make their own decisions and to mobilize their own resources (most often providing them in-kind) if the programme is going to be effective. This partnership approach is an effective means of building local administrative capacity and promoting district-level inter-sectoral communication and action. It balances the provision of essential inputs, leadership, direction and structure, with the need for local commitment and active participation in mobilizing the community, the local government and the resources that are essential to transform the inputs that are provided into a successful programme. Fifty-eight per cent of the 40 woredas surveyed as part of this study reported that they have added additional services to the EOS/EEOS package at their own discretion, demonstrating that they regard it as their own programme.

A more telling and surprising finding from the survey was that local woreda health officials report that they use EOS/EEOS as a tool for increasing immunization coverage, which many of them have periodically added to the core intervention package. In numerous interviews held during the design phase of this study, woreda officials noted that the primary EOS/EEOS service that draws mothers and caretakers is de-worming. The mothers see what it does for their children. They understand it. They value it. In contrast, the woreda officials further noted that the significance of vitamin A is not well understood and it is not as highly valued, in and of itself. While this is anecdotal evidence, it is striking how often one hears this comment from team members participating in the EOS/EEOS in Ethiopia, as well as from local health officials implementing CHDs in other countries. This is an insight that should be considered in identifying the content of the CHD package of services and in promoting participation in CHDs. Consideration should be given to including de-worming in every CHD, not only because of the value of treating worm infestation, but also because of its value in increasing participation rates.

Another demand-side consideration about CHDs is that they economize on the direct and indirect costs that mothers and other caretakers must incur to obtain services: with a single visit, they are able to obtain a package of services for all of their under-five children. In light of the finding that there are economies to increasing the number of beneficiaries per site, keeping demand high is another way of making the programme more efficient and more cost-effective, other things being equal.

An often heard, unsolicited comment of woreda health officials—some of whom confided that they regard the additional work that the EOS/EEOS entails as onerous—was that the EOS/EEOS has become such a popular programme among mothers that they believe the community would not ‘allow’ them to discontinue it. In other words, these officials feel that the EOS/EEOS has become a community-driven programme. In a country with a highly underdeveloped health infrastructure and where a lack of tradition and understanding of the potential of modern preventive health care services contribute to a low care-seeking pattern and constitute an obstacle to improving health status, this is an important strategic insight.

While one must be cautious not to infer too much from these various pieces of anecdotal evidence—that the EOS/EEOS is used to increase immunization coverage rates and that vitamin A coverage rates are improved by being tied to de-worming—they suggest that Ethiopian health officials regard the disruption to their routine service delivery caused by EOS/EEOS to be worth the increased coverage rates that the CHD has spawned. It is likely, however, that the terms of this trade-off, and Ethiopian health workers’ perception of the acceptability of the balance it currently constitutes, will change as the health system of Ethiopia becomes more developed and as care-seeking behaviour changes, giving rise to higher routine utilization rates. How quickly that occurs and what indicators may be monitored to determine when the EOS/EEOS—and more generally CHDs—have outlived their usefulness as a ‘temporary-bridging strategy’ is one of the more important of the many still unanswered questions about Child Health Days.

## ACKNOWLEDGEMENTS

This work was undertaken for the Micronutrient Initiative, with supplementary support provided by the World Bank, A2Z: The USAID Micronutrient Project and UNICEF/Ethiopia. The authors thank Dr Zewdie Wolde-Gabriel, Edna Berhane and Carol Marshall (all of the Micronutrient Initiative) for their suggestions and support in the design and implementation of the study, and Amy Rice (of SSDS) and Amy Conlee (of the A2Z Project) for reviewing the paper. The views expressed are those of the authors and do not necessarily reflect those of the study's sponsoring agencies.

## Endnotes

1
A kebele is the smallest administrative unit in Ethiopia, with an average population of about 5000 people.
2
Those identified in the EOS screening as malnourished are referred to the Targeted Supplementary Feeding Program in which they receive quarterly take-home rations.
3
In the EEOS, the 2% is the value of the time and resources devoted to discussing screening in the TOT and Training of Service Providers sessions (which, according to the survey respondents, is discussed even in the EEOS woreda Training of Service Providers sessions).
4
That the programme is often plagued by supply shortages means that some beneficiaries did not receive care that they had sought. This, in turn, means that coverage rates would have been even higher than the levels reported had all the programme not been supply constrained.
5
The population density of Amhara and Oromiya is 89 persons per square kilometre, slightly less than the nationwide Ethiopian average of 92. Other things equal, it is likely that countries with lower population densities will have higher costs per person served due to higher transportation costs and the increased costs associated with the need for more service delivery sites to ensure adequate access.

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