The Fifth Child Project

The value and unexpected by-product of a community engagement strategy aimed at addressing the immunisation gap in north-west Ethiopia

A formative qualitative evaluation project conducted by Tracey Chantler, Emilie Karafillakis, Samuel Wodajo, and Heidi Larson

Increased attention is being paid to the role of community engagement strategies to address low and stagnating vaccination rates. The International Rescue Committee (IRC) developed a multi-pronged community engagement strategy (‘The Fifth Child Project’) to close the immunisation gap in Benishangul Gumuz Regional State in north-west Ethiopia. The project introduced a defaulter tracing system, and a colour-coded health calendar for mothers (Enat Mastawesha); involved existing health infrastructures (Health Extension Programme and the Health Development Army) and fostered community co-management of vaccination activities. The following video, produced by IRC, provides an overview of the ‘Fifth Child Project’:

LSHTM led the formative evaluation of the ‘Fifth Child Project’ together with colleagues at the IRC, focusing on the project integration into the health system, utilisation and acceptability, community co-management, and contribution to improving routine immunisation system performance. Routine immunisation data from two districts was analysed; and a series of interviews, focus groups and observations of project activities were conducted in three kebeles within these districts from May-July 2016.

Caregivers waiting with their children at the health post (Photo by Anna Kim, IRC)


The formative evaluation found that the ‘Fifth Child Project’ introduced new ways of working which helped health workers identify and connect with hard to reach families. Project tools decreased health workers workload and the calendar enabled mothers to maintain better control over their children’s health. It also operated as a catalyst for health-related discussions within families and enabled more personalised interactions with health workers. Varying levels of support from kebele leaders were reported and there was a lack of clarity about their role in defaulter tracing. We also found evidence of community-agreed sanctions (monetary fines and cautions by local court) for non-compliance with the infant vaccination schedule. Interviewees wanted the project to expand but highlighted the need for infrastructural investment to improve the performance of the immunisation programme. Increased immunisation coverage was observed but cannot be attributed solely to the project.

A Health Development Army member explaining the calendar to a caregiver (Photo by Anna Kim, IRC)


The project was well integrated within the Health Extension Programme and successful at engaging community members at household and kebele command post level. Whilst community co-management activities merited strengthening, the establishment of community-agreed sanctions were evidence of community ownership, even though they constituted an ethical conundrum.

Community engagement activities in BGRS (Photo by Anna Kim, IRC)


This formative evaluation was made possible by funding received by the IRC from the International Initiative for Impact Evaluation (3ie).

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Literature Literature archive

Biswal . 2019 NEJM DOI: 10.1056/NEJMoa1903869
Piot P, Larson HJ, O'Brian KL, et al 2019 NATURE Vol. 575, pages119–129.
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The Vaccine Knowledge Project at the Oxford Vaccine Group