You’ve been with JSI since 2003. Have you been working on anything exciting recently?
While I’ve been working on the Ethiopia Last 10 Kilometers project for nine years, the focus is changing a bit. The Bill & Melinda Gates Foundation [which funds the project] is realigning their programs in Ethiopia, and it’s really interesting to help think about how to implement these changes.
I’m also very excited to work on a behavioral economics intervention funded by the Hewlett Foundation. We are working in partnership with Ideas42 to use behavioral economics to address the discontinuation rate of women using injectable contraceptives in Ethiopia.
What does ‘behavioral economics’ mean?
Behavioral economics uses psychology and economic theories to design interventions that encourage people to change their behaviors. How you frame things is important. People respond differently when asked the same question in different ways.* Behavioral economics uses this kind of psychology to help people change their behavior.
At JSI, we’re analyzing certain behaviors, looking at issues related to decision-making, and with that information, determining messages that motivate people to change their behavior.
What sorts of behaviors are you trying to change?
Family planning is an example. In Ethiopia, we’re looking at why the rate of women who use injectable contraceptives is declining, so we talked to service providers and women who used injectables. Based on their responses, we developed hypotheses about the reasons for discontinuation. Maybe because of lack of proper information? Maybe people forgot? Didn’t like the side effects? Maybe due to lack of prospective follow-up?
We analyzed these issues and found that service providers have a mechanism for tracking defaulters, but they were tracking defaulters after they dropped out, which is not useful. So we developed strategies to modify the problems associated with discontinuation—we came up with interventions to track clients and send reminders before their appointment dates. Thus far, program monitoring indicates that the interventions are going well. The final evaluation of the intervention will take place in November 2017.
You used to work for BRAC, the largest NGO in the world, in Bangladesh. What were you doing there?
I began as a medical officer implementing women’s health and development programs—managing maternal and child health and TB control interventions. Then I shifted and was the management information system specialist for a USAID-funded rural family health program. (You may recall that JSI had the urban component to this program!). Through BRAC, I was able to come to Harvard in 1994 and get an MS in population and international health. Joel Lamstein was one of my professors; I took his MIS course.
When did you start at JSI?
I was hired as the DELIVER Project analysis and research advisor in October 2003. Before that, when I was working on a Ph.D. at Tulane, I conducted operations research for the HORIZONS, FOCUS, and (JSI-managed) MEASURE projects.
And what did you think?
When I started, I was skeptical because my background ranged from implementing public health programs to monitoring and evaluating them. DELIVER had such a specific health systems focus that, frankly, I wasn’t sure how interesting it would be. I quickly realized that public health logistics systems have a wide spectrum of activities and there were many different ways to apply my skills. I assessed the performance of global and country-level logistics systems, measured the contribution of logistics system on overall program performance, conducted market segmentation analysis to assess public health commodity security. Later, as a project performance manager, I developed and implemented the quality assurance surveillance plan for the project.
What made you decide to move to Ethiopia in 2010?
When the Gates Foundation awarded JSI the Last 10 Kilometers (L10K) project, it was an exciting “learning project,” and there was a monitoring and evaluation position based in Addis Ababa. The position offered intimacy with program implementation and exposure to another culture for my family.
L10K is the Gates Foundation’s flagship program on community solutions for maternal and newborn health. It has continued and expanded JSI’s work to strengthen the Ethiopian health system, first through the ESHE project, and since then quite a few others. The Last 10 Kilometers is so named because previously the average family in rural Ethiopia lived 10 kilometers from a health facility. L10K is improving demand and quality of services in addition to closing that distance.
What are some results from the first nine years of the L10K project? What are you looking forward to in the second phase of the project?
Early on, L10K introduced the community-based data for decision-making approach—a simple and effective community-based information system to help frontline workers of the Ethiopia Health Extension Program ensure use of MNCH services. This has been adopted as the national strategy, and other program interventions—family conversations, birth notifications, and active detection of newborn sepsis, to name a few—have also been incorporated into the national health extension program.
The Federal Ministry of Health has been using JSI survey data for planning, monitoring, and evaluating MNCH interventions; and frequently calls on us to conduct operations research to inform program policies.
Today, JSI is recognized as one of the critical partners for shaping the national quality improvement strategy for community- and facility-based health MNCH services. Our evaluations have shown that when women delay coming to a health center for delivery, it is often related to concerns about the skills of the health providers. That’s a quality issue that we can help improve.
*An example that’s often cited is the way forms were designed by the U.S. Department of Motor Vehicles. When getting a driver’s license, people were asked a ‘yes/no’ question: ‘Will you donate your organs if you’re in a fatal accident?” That didn’t garner a high rate of the desired response (of ‘yes’), so they changed it to “If you want to opt out of donating your organs, check here.” Suddenly, more people were signing up to be organ donors.