The Last Ten Kilometers: What it Takes to Improve Health Outcomes in Rural Ethiopia

Dates: 2007-2015

Country: Ethiopia

Client(s): Bill & Melinda Gates Foundation

Services: Technical Assistance, Monitoring, Evaluation, and Research, Training, Capacity Development

Technical Expertise: Maternal, Newborn & Child Health, Immunization, Infectious Diseases, Research, Monitoring, and Evaluation


Ethiopia is the second most-populous country in sub-Saharan Africa, with an estimated population of 96 million, 85% of whom live in rural areas. In 2013, Ethiopia achieved the Millennium Development Goal 4 by reducing under five child mortality to 68/1000 live births. Ethiopia, with 673 deaths per every 100,000 live births, has the sixth-highest maternal mortality ratio in the world and the second-highest in Africa. Because approximately 85% of births occur in the home, a community-based approach is essential.

The Last Ten Kilometers: What it Takes to Improve Health Outcomes in Rural Ethiopia Project (L10K) strengthened the delivery of health services by mobilizing families and communities to take charge of their own health. The project supported and complemented the Government of Ethiopia's Health Extension Program (HEP) and at the same time tested and promoted community-based models that aim to improve community health norms by engaging families and kebeles (i.e. villages) in health initiatives.

L10K strengthened the bridge between Ethiopian families, communities, the HEP, and the formal health care system to achieve sustainable reproductive, maternal, neonatal and child health improvements at scale, in order to contribute to the Government of Ethiopia's achievement of the Millennium Development Goals 4 and 5.

L10K assisted in the implementation of the following community-based health strategies:

Platform strategies (the basis for all other community-based initiatives):

  • Community Based Data for Decision Making (CBDDM)
  • Family conversation for improved care seeking

Additional community-based health strategies:
  • Participatory Community Quality Improvement (PCQI)
  • Referral solutions
  • Integrated Case Management of Childhood Illness (iCCM)
  • Basic Emergency Obstetric and Newborn Care (BEmONC)
  • Community Based Newborn Care (CBNC)

As a "learning project," L10K's robust monitoring and evaluation (M&E) system: 1) improved program performance by promoting data-based decision-making; 2) improved the M&E capacity of its grantees; and 3) documented and disseminated evidence on what works and what does not work so that effective community solutions could be adapted by local and regional stakeholders to achieve maternal and child mortality reduction at scale.

L10K was implemented in 215 woredas in the four most populated regions of Ethiopia - Amhara, Oromia, Tigray, and the Southern Nations, Nationalities and People’s (SNNP) regions. It covered a population of about 25 million people, nearly 26% of the total Ethiopian population.

L10K was implemented by JSI Research & Training Institute, Inc., with grants primarily from the Bill & Melinda Gates Foundation and with additional funding from UNICEF and USAID. L10K worked closely with the Ethiopian Government, and other development partners, and provided technical and financial support to 12 civil society organizations.

Read related blog posts by Bailey Herrington on Working Towards a Greater Good: One Health Worker’s Journey and by Melaku Muleta on How to Improve Respectful Maternity Care through Community Engagement.

Learn more about L10K 2020, a project that builds upon the successful work of L10K.


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