SPECIAL

BULLETIN
MINISTRY OF HEALTH, ETHIOPIA
THE TWENTY-THIRD ANNUAL REVIEW MEETING OF THE HEALTH SECTOR

Responsive Health System in the New Beginnings!

SPECIAL
BULLETINMINISTRY OF HEALTH, ETHIOPIA
THE TWENTY-THIRD ANNUAL REVIEW MEETING OF THE HEALTH SECTOR

Responsive Health System in the New Beginnings!

SPECIAL BULLETIN MINISTRY OF HEALTH, ETHIOPIA

Contents
EDITORIAL BOARD AND REVIEWERS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . IV
FOREWORD . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . V
EDITORIAL. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . VI
SECTION ONE: RESEARCH ARTICLES. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . VII
Readiness of Primary Hospitals in Providing Neonatal Intensive Care Services in Ethiopia . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
Efficacy and Safety of Dihydroartemisinin-piperaquine versus Artemether-Lumefantrine for the Treatment of Uncomplicated
Plasmodium Falciparum Malaria in African Children: a Systematic Review and Meta-analysis of Randomized Control Trials . . . . . . 5
Assessment of Compassionate and Respectful Care Implementation Status in Model Healthcare Facilities: A Cross-Sectional Study.10
Patient Satisfaction with Health Care Services Provided in Ethiopian Health Institutions: Meta-Analysis. . . . . . . . . . . . . . . . . . 15
Effectiveness and Efficiency of Leadership, Management, and Governance Training in Ethiopia: A Cross-Sectional Facility-Based
Study. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
Time to Recovery and Predictors of Survival among Asphyxiated Neonates Admitted in Addis Ababa Public Hospitals, 2021 . . . . . 26
Maternal and Child Health Service Uptake amid COVID-19 in Public Health Facilities and Lessons Learned . . . . . . . . . . . . . . . . 30
Introduction of a Modified WHO Safe Childbirth Checklist in Health Centers of Ethiopia: A Pre-and-Post Introduction Study . . . . . 34
Contributing Barriers to Lost to Follow-up from Antenatal Care Services around Addis Ababa: A Qualitative Study. . . . . . . . . . . . 39
Treatment Outcome of Sick Newborns in Primary Hospitals in Ethiopia. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44
Effectiveness of Catchment-Based Mentorship Programs on Health Care Providers’ Competence: A Mixed-Method Study. . . . . . . 47
Evaluation of the National Safe Surgical Care Strategy and the Saving Lives through Safe Surgery (SaLTS) Program in Ethiopia: A
Nation-Wide Evaluation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51
Ethiopian Health Labor Market Analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55
Knowledge of Essential Newborn Care among Nurses and Midwives Working in Lideta Sub-city Public Health Centers. . . . . . . . . 61
Status of Histopathology Services in Ethiopia. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 64
Evaluation of the Effectiveness of Competency-based Training of Women Development Army Leaders in Improving the Uptake of
Health Care Services in Ethiopia. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 66
SECTION TWO: NEW INITIATIVES. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70
Clean and Timely Care in Hospital for Institutional Transformation (Catch-It) Project . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71
The National Health Promotion Strategic Plan: The Development Process and its Objectives . . . . . . . . . . . . . . . . . . . . . . . . . 73
Employees’ Performance Appraisal Problems and Lessons Learned at Ministry of Health. . . . . . . . . . . . . . . . . . . . . . . . . . . 75
Leadership in Action: How Ethiopia Embraced the Nurturing Care Agenda . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 78
SECTION THREE: BEST PRACTICES OR LESSONS FROM PROGRAM IMPLEMENTATIONS . . . . . . . . . . . . . . . . . . . . . . . . 82
Bridging the Gulf between the Academia and Social Sector; the Case of Capacity Building and Mentorship Program of the MOH of
Ethiopia. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 83
Implementation of Medical Devices Installation and Maintenance Campaign in Public Hospitals . . . . . . . . . . . . . . . . . . . . . . 87
Networking Patients with Health Extension Workers for Improved Care. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 91
Impact of the Innovation Phase of the Seqota Declaration: Promising Evidence for Expansion Across the Country . . . . . . . . . . . . 94
Community Lab: Seqota Declaration Innovation to Empower Communities to Identify Local Solutions for Local Problems . . . . . . 98
Implementation of Electronic Medical Record Project and Improvements in Service Quality at Yekatit 12 Hospital Medical College. 100
Ethiopia Digital Health Projects Inventory System . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .103
Web-Based Unified Nutrition Information System for Ethiopia for Multi-Sectoral Food and Nutrition Data Management System,
Seqota Declaration Woredas . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 105
The Role of the Health Sector in the Civil Registration and Vital Statistics Eco-system; Yesterday, Today and Tomorrow. . . . . . . . 108
The Health Sector’s Response to the COVID-19 Pandemic: Experience from the HRH perspective. . . . . . . . . . . . . . . . . . . . . . 113
Maternal and Newborn Health Quality of Care initiative in the 14 learning districts of Ethiopia: implementation status and results.116
Blended Learning- an Efficient Way to Build Knowledge and Skills of Community health workers. . . . . . . . . . . . . . . . . . . . . .119
Accelerating the Implementation of Auditable Pharmaceutical Transaction and Service in Public Health Facilities of Ethiopia. . . .121
The Outcome of A Short Course, Onsite Integrated Management of Newborn and Childhood Illness) Training in Four Regions of
Ethiopia. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 124

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EDITORIAL BOARD AND REVIEWERS

Editor-in-Chief
Naod Wendrad (BSc, MHA)

Director; Policy, Plan, Monitoring, and Evaluation Directorate

Editorial Board Coordinator

Bantalem Yeshanew (MSc), Senior HIS Advisor: Policy, Plan, Monitoring, and Evaluation Directorate

Editorial Board Members

Daniel Getachew (MPH), HIS consultant: Policy, Plan, Monitoring, and Evaluation Directorate

Kedir Seid (MD, MPH): Senior HIS Specialist: Policy, Plan, Monitoring, and Evaluation Directorate

Tamrat Awell (MPH): M&E officer: Policy, Plan, Monitoring, and Evaluation Directorate

Emebet Alemu (MSc): HIS and M&E Analyst: Policy, Plan, Monitoring, and Evaluation Directorate

Lemma Gutemma (MSc): HIS Specialist: Policy, Plan, Monitoring, and Evaluation Directorate

Reviewers
Prof. Wakgari Deressa (AAU), Prof. Mirkuze Wolde, Dr. Meseret Zelalem (MOH), Tariq Azim (JSI), Eleni Seyoum (WHO
Ethiopia), Yibeltal Tebekaw (Ph.D-JSI), Theodros Getachew (Ph.D-EPHI), Gizachew Tadele (Ph.D-JSI/L10K), Lemessa
Olijira (Ph.D-Haramaya University), Belete Getahun (Ph.D-MoH), Dr. Kassu Ketema (MD, Ph.D- WHO Ethiopia)

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FOREWORD
Dear participants of the 23rd Annual Review Meeting (ARM) and readers
of this edition of the bulletin, I would like to extend my warmest
welcome to this august event of the health sector. As you all know,
the health sector has made the information revolution one of the
priorities of the health sector both in the first and second health sector
transformation plans (HSTP). Being the lead directorate to spearhead
the information revolution agenda, the Policy, Plan, Monitoring, and
Evaluation Directorate (PPMED) of the Ministry of Health (MOH) has
been striving to enhance evidence generation and use to inform the
designing of health programs and improve health system performance.
To this end, the PPMED has been producing and distributing scientific
NAOD WENDRAD evidence with the special bulletin annually for the last nine years.

Director of Policy, Plan, Monitoring, Improving the culture of information use is pivotal to advancing the
and Evaluation Directorate Information Revolution agenda. As such, PPMED has been publishing
the bulletin with major objectives that would enhance the culture of
information use; enhancing capacities of the health system to generate
and synthesize scientific evidence; and dissemination of evidence
among participants of the ARM and to researchers, policymakers,
programmers, implementers and stakeholders of the health sector.

This Special Bulletin for this 23rd ARM is the 10th issue in a series published
for the last nine years as part of the publications distributed during
the ARM. This edition of the special bulletin contains three categories
of articles; research articles, new initiatives, and best practices.
The research articles bring scientific evidence to policymakers and
implementers on the effectiveness and efficiency of interventions
that have been implemented. The new initiatives section is essential
to shedding light on the new policy and strategic issues of the health
sector while the best practices bring experiences from the field for
possible replication and scale-up of practices at large. The evidence
organized in the three categories of this edition of the bulletin, I hope,
would inform our efforts to build a more responsive health system in
the New Beginnings the country has embarked.

I sincerely would like to extend my appreciation and thanks to all

MOH directorates, regional health bureaus, agencies, researchers,
programmers, and other health care cadres for their efforts and
contributions in publishing the articles. I am also grateful to the
editorial board members, PPMED staff, contributors, and reviewers
for their extraordinary efforts to realize the publication of this special
bulletin.

Have a good read!

Naod Wendrad

Director of Policy, Plan, Monitoring, and Evaluation Directorate

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EDITORIAL
Responsive Health System in the New Beginnings!
In Ethiopia, the health sector has made impressive Nonetheless, the responsiveness of the health system
gains in the last decade. Recently, it has been to non-health-related social goals becomes relevant
plagued by formidable challenges, particularly in the only after we make sure that the health system has the
past two fiscal years. Since March 2019, the health capacity to meet the other goals of a health system.
sector has been suffering from the effects of the To realize these goals in today’s ever-changing world,
COVID-19 pandemic that shocked the health system, the health system needs to be quick to respond or
disrupted essential health services provisions, and react appropriately with strategies tailored to fit the
has brought additional multifaceted challenges local contexts and desires of people. The ability of the
to the health system. Conflicts that resulted in health system to respond to changing health needs
internally displaced people in the country have also of populations, therefore, entails the capacity to
posed added dimensions to the hurdles the health respond to the prevailing health needs of the public.
system is currently grappling with. Emergencies that To meet its goal, the health system needs to have the
followed conflicts have strained the health system ability to respond to the health needs of the public
with additional human and material resource needs. through designing and implementing interventions
Responding to the arising health service needs of that are agile enough to accommodate the prevailing
the public in the face of an unpredictable and ever- contexts and desires of the public in the contemporary
changing world has been the key focus of the health period. This requires a huge investment in the health
system in the last two years to sustain the momentum system to make it nimble enough to accommodate
and build on the gains. any arising needs over time.
A well-functioning health system is pivotal for The response to the COVID-19 pandemic in low- and
delivering quality health services to every segment middle-income countries (LMICs) has been affected
of the population in all settings. The world health by fragile health systems, competing priorities, and
organization (WHO) has set three goals that poverty. The emergence of the pandemic proved that
require a health system to deliver high-quality and most LMICs were not operationally ready to prevent,
equitable health services; improving the health of detect or control this and similar health emergencies
the population, fairness in financial contribution, and and it illustrated the importance of developing public
improving the responsiveness of the health system. health response strategies for timely measures. Such
strategies should enable the health system to develop
According to WHO, health responsiveness is defined the capacity to deliver the same level of essential
as “the ability of the health system to meet the services during emergencies; the capacity to make
population’s legitimate expectations regarding organizational adaptations during emergencies, and
their interaction with the health system, apart from the capacity to transform its functions and structure
expectations for improvements in health or wealth” to respond to a changing environment, during shocks
These legitimate expectations were defined based and when exposed to long-term challenges.
on the international human rights norms and
professional ethics. Like any other social system such Ethiopia has developed a five-year plan (2020-2025) to
as education, justice, the health system is expected to improve the health status of the public by protecting
meet the common social goals expected of all social people from health emergencies, improving the
systems in addition to its goal of producing health health system responsiveness, and accelerating
in the population that is equitably distributed. As the progress towards universal health coverage.
such, the population expects the health system to To pursue its course and navigate through the right
treat people with dignity, autonomy, confidentiality, trajectory to realize the visions of the sector, the health
prompt attention, provision of social needs, basic system needs to be responsive enough to address any
amenities, choice of health care provider. emerging shocks and while keeping on delivering the
usual essential health services. To this end, the health
To improve responsiveness of the health system, system needs to espouse cutting-edge approaches
Ethiopia has recently made notable efforts. to ensure its agility to respond to the arising needs of
Cultivating compassionate, respectful and caring the public and make sure the health service delivery
(CRC) health workforce has been one of the four system is arranged in a way to meet the desires of
transformation agendas priotized during Health populations and their prevailing contexts and arising
Sector Transfromation Plan (HSTP-I), which is recoined needs. The generation of scientific evidence to inform
as motivated competetnt and compassionate the application of such adaptive management
professional (MCCP) during HSTP-II. In addition, approaches is critical to make sure the health system
improving responsiveness of the health system is one is agile enough to respond to any arising needs of the
of the four objectives of HSTP-II. health system and public health emergencies.

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 SECTION ONE

RESEARCH ARTICLES

SECTION ONE: RESEARCH ARTICLES

 Readiness of Primary Hospitals in Providing Neonatal Intensive Care
Services in Ethiopia

Hailemariam Segni Abawollo1*, Zergu Tafesse Tsegaye1, Binyam Fekadu Desta1, Ismael Ali Beshir1
1
John Snow Incorporate, USAID Transform Primary Health Care, Addis Ababa, Ethiopia;
*
Correspondence: [email protected]

ABSTRACT

Background: Ethiopia’s neonatal mortality rate has not significantly dropped over the years. Considering this,
the country has introduced various interventions such as the utilization of newborn corners and neonatal intensive
care units to avert preventable neonatal deaths. This study was conducted to assess the readiness of primary hospitals
in providing neonatal intensive care services.

Methods: A health facility-based cross-sectional study design was employed where data were collected using
both prospective and retrospective techniques using a format adapted from national documents. SPSS version 25 was
used for data entry and descriptive analysis. Data were collected from 107 of 113 (94.7%) primary hospitals within the
USAID Transform: Primary Health Care Activity’s intervention areas.

Results: The minimum national standard requirement of a level one neonatal intensive care unit for
infrastructure was met by 63% of the 107 primary hospitals while 44% had fulfilled the requirements for kangaroo
mother care units. The average number of neonatal intensive care unit trained personnel per primary hospital was 2.6
for nurses, 0.8 for general practitioners, and 2.9 for support staff; all of which are less than the minimum recommended
national standard. The minimum national requirement for medical equipment and renewable for primary hospital
level was fulfilled by 24% of the hospitals, whereas 65% and 87% of the hospitals fulfilled minimum national standards
for essential laboratory tests and clinical services and procedures respectively. The average number of admissions
during the six months before the data collection was 87.2 sick newborns per facility with a ‘discharged improved’
rate of 71.5%, referral out rate of 18.4%, and level one neonatal intensive care unit death rate of 6.6%. The remaining
newborns had either left against medical advice or were still undergoing treatment during data collection.

Conclusions: The overall readiness of primary hospitals to deliver neonatal intensive care services in terms
of infrastructure, human resources, and medical equipment was found to be low. There is a need to fill gaps in
infrastructure, medical equipment, renewables, and human resources of neonatal intensive care units of primary
hospitals to provide a better quality of service.

Keywords: Neonatal intensive care, NICU, Newborn care, Neonatal care, Primary hospital.

could be avoided with existing simple low-cost tools

Background (1).

Globally, 2.7 million newborns die every year during Ethiopia’s neonatal mortality rate has not shown a
the first month of life because of birth asphyxia, significant decline over the years. As indicated by the
complications of preterm birth, and infections. Most 2019 Ethiopian mini-Demographic Health Survey,
of the neonatal deaths and stillbirths (99%) occur in even a slight increment was observed from 29 deaths
Low and Lower-Middle-Income Countries with half per 1000 live births (LB) in 2016 to 33 deaths per 1,000
of the deaths happening at home (1). In Africa, about LBs in 2019 (3).
1.16 million babies die every year in their first month
of life, and half of them, on the first day of their life. Most neonatal deaths can be prevented through the
Another 3.3 million children will die before they reach utilization of quality essential newborn care (ENC)
their fifth birthday (2). About 75% of neonatal deaths services immediately after delivery along with quality

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obstetric care. However, the ENC services provision 2021. Within the Activity’s intervention areas, the
is limited in Ethiopia. The proportion of health existing 113 primary hospitals are expected to have
facilities in the country delivering hygienic cord care, level one NICUs. The assessment was conducted
immediate and exclusive breastfeeding, and thermal from January 1st , to March 31st, 2020. A facility-based
care were 52%, 53%, and 52% respectively, with a prospective and retrospective cross-sectional study
mean availability of newborn signal functions of design were used.
38% (4). The neonatal mortality rate of the country is
disproportionally high accounting for 44% of under- Data collection: The assessment was conducted
five deaths (5). To reduce the stagnating neonatal at all the intervention primary hospitals of the
mortality rate, the country has put in place various Activity. A national NICU status assessment tool
interventions which include but are not limited to was adapted and used by incorporating additional
the establishment of newborn corners to provide minimum requirements for level one NICUs from
ENC services in health facilities that are mandated respective national documents (6, 13). The Activity’s
to conduct skilled delivery and establishment of cluster staff were data collectors at their respective
different levels of neonatal intensive care units catchment primary hospitals. The number of project
(NICU) with kangaroo mother care (KMC) centers in staff involved in data collection per cluster varies
hospitals. NICUs are set up to provide advanced care from three to five, based on the size of the catchment
for sick newborns that require more specialized care area of a specific cluster. The staff were given an
and attention (6). A NICU or an Intensive Care Nursery orientation on the assessment protocols including
(ICN), is an intensive care unit (ICU) specializing in the the tools by the investigators before the actual data
care of sick or premature newborn infants who are collection. Data quality was checked by regional
likely to die as a result of simple conditions that can maternal and newborn health (MNH) officers who
be easily prevented (7). possess a master’s degree in public health and with
backgrounds in midwifery daily to identify gaps and
A cross-sectional study conducted in Debre address them immediately at the field level. The data
Berhan hospital indicated that the availability of were collected electronically and were sent to the
all the required infrastructure, equipment, trained country office after finalizing the data collection.
manpower, and supplies is key to providing quality
neonatal health services in hospitals. Additionally, Data analysis: Data were cleaned by investigators
the proper utilization of available resources was also and data entry was carried out by a data entry clerk.
found to be essential (8). There is no local evidence Data analysis was conducted at the country office
specifically on level one NICUs found in primary level by the investigators using statistical software
hospitals of the country and this study was conducted SPSS version 25.0. Descriptive statistics were used to
to fill this paucity of information. analyze the data.

Objectives Ethics: Ethical clearance for the assessment was

obtained from John Snow Incorporated (JSI)
The objective of this study was to assess primary institutional review board (IRB), with reference
hospitals’ readiness to provide NICU services by number IRB #20-17E. Each of the 113 primary hospital
assessing the status and availability of human leaders and responsible heads of the NICUs was
resources, infrastructure, and medical equipment in handed an information sheet and copy of the ethical
hospitals. clearance letter from the IRB of JSI and was asked
for verbal consent to go ahead with the assessment
Materials and Methods of their respective primary hospital NICUs. The NICU
professionals who gave information were also asked
Study setting, period, and design: The study was for verbal consent.
conducted in four regions of the country, namely,
Amhara, Oromia, South Nations Nationalities and
Peoples, and Tigray, where USAID Transform: Primary
Health Care Activity has been operating since January

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Results and Discussion Clinical services and procedures: The national

minimum standard clinical services and procedures
Data from 107 of the 113 primary hospitals (94.7%) expected to be available at level one NICUs were
were collected, and the findings of the assessment present in 87% of the 107 NICUs. The availability of
are categorized into five major pillars for NICU these clinical services and procedures ranged from
service delivery. Six of the primary hospitals were not 18% for ‘lumbar puncture (LP)’ to 99% for ‘insertion of
accessible during data collection time. nasogastric tube’.

Infrastructure: Based on the national minimum The average number of admissions to the 107 level
infrastructure standard expected at level one one NICUs during six months prior to data collection
NICUs, 63% of the 107 NICUs fulfilled the minimum was 87.2 sick newborns per NICU. The average
requirements (table 1). Similar findings were reported improvement and discharge rate was 71.5%, the
in other local studies and studies conducted in other referral out rate was 18.4%, and the rate for deaths in
countries within Africa (9, 10). KMC service is available NICUs was 6.6%. The remaining had either left against
in 85% of the 107 NICUs whereas 44% of them had medical advice or were still undergoing treatment
KMC service delivery units fulfilling the minimum during the data collection. The average number of
national standard for KMC of level one NICUs. days of service interruption during the same period
was 0.2 days per NICU.
Human resource: The nationally recommended
number of NICU trained nurses per 12 bedded level Conclusion and Recommendations
one NICUs is at least four, one to two for GPs, and
four for support staff (6). The average number of NICU Based on this assessment, we conclude that the
trained nurses per NICU at the assessed sites was 2.6, majority (87%) of the NICUs are delivering the
0.8 GPs, and 2.9 support staff - all of which are less than minimum services expected to be delivered at the
the minimum national standard recommendations. level; less than two-thirds (63%) of the Activity’s
Other studies also have shown nationwide shortages intervention NICUs have the minimum recommended
of adequate and well-trained health professionals infrastructure for the level; less than half (44%) of
contributing to low-quality services (8, 9, 10, 11). KMCs of the NICUs have the minimum recommended
KMC infrastructure; the available necessary human
Essential medical equipment and renewables: The resource per NICU is far less than the minimum
national minimum standards for essential medical recommended for the level; less than a quarter (24%)
equipment and renewables in level one NICUs are of the NICUs have the minimum recommended
available in 24% of the NICUs. Other studies reported medical equipment and renewables available for
shortages of medical supplies, equipment, and service delivery.
essential medications as widespread problems in
health facilities of the country, stating them as often Based on the gaps this assessment has shown, there
unavailable, broken, or inappropriate for use (8, 9). is a need for investment to improve the infrastructure,
Another study finding reported that less than half of human resources, medical equipment renewables,
the facilities had most of the supplies and equipment and drugs for a better quality NICU service delivery at
needed for newborns (12). the primary hospital level.

Laboratory tests: The national minimum standard-

essential laboratory tests for level one NICUs were
available in 65% (70/107) of the NICUs. The availability
of these tests ranged from 12% (13/107) for ‘culture
and sensitivity of anybody fluid’ to 99% (106/107) for
‘blood group and Rh’ status determination. Other
studies also have reported similar problems with the
availability of necessary laboratory services to render
quality NICU services (8).

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Annex 1: Table 1: Status of infrastructure at NICUs of primary hospitals, USAID Transform: Primary Health Care Activity, January-
March 2020.

Number
Variables Percent
(n=107)
Infrastructure (average) 68 63%
Location adjacent to the delivery room 94 88%
The NICU has direct access to the hospital’s transport receiving area 80 75%
Service units are connected to allow the transport of newborns without being exposed to outside
83 78%
cold weather
Room size: 8-12 square meters 89 83%
Gowning area at the entrance 72 67%
Hand washing stations 62 58%
Examination area 66 62%
Clean area for mixing iv fluids and medications 80 75%
Mothers’ area for expression of breast milk, bf, and learning mother crafts 43 40%
Boiling and autoclaving 41 38%
General support area 56 52%
Procedure room 49 46%

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 Efficacy and Safety of Dihydroartemisinin-piperaquine versus Artemether-
Lumefantrine for the Treatment of Uncomplicated Plasmodium Falciparum
Malaria in African Children: a Systematic Review and Meta-analysis of
Randomized Control Trials

Dawit Getachew Assefa*1,2, Gizachew Yesmaw1, Eyasu Makonnen1,3

1
Center for Innovative Drug Development and Therapeutic Trials for Africa (CDT-Africa), College of Health
Sciences, Addis Ababa University, Addis Ababa, Ethiopia
2
Department of Nursing, College of Health Science and Medicine, Dilla University, Dilla, Ethiopia
3
Department of Pharmacology and Clinical Pharmacy, College of Health Sciences, Addis Ababa
University, Addis Ababa, Ethiopia
*Correspondence: [email protected]

ABSTRACT
Background: The emergence of Plasmodium falciparum resistance to artemisinin and its derivatives poses a
threat to the global effort in controlling malaria.

Method: A computerized systematic search method was used to search for articles from online databases PubMed,
MEDLINE, Embase, and Cochrane Center for Clinical Trial database for retrieving randomized control trials. Using Rev-
Man software (V5.4) and R-studio, the extracted data from eligible studies were pooled as risk ratio (RR) with a 95%
confidence interval (CI).

Result: In this review, 25 studies which involved a total of 13,198 participants were included. PCR unadjusted
treatment failure in children aged between 6 months and 15 years was significantly lower in dihydroartemisinin-
piperaquine (DHA-PQ) treatment arm on day 28 than that of Arthemeter Lumefantine (AL) (RR 0.14, 95% CI 0.08 to 0.26;
participants = 1302; studies = 4; I2 = 0%, high quality of evidence). Consistently, the PCR adjusted treatment failure was
significantly lower with DHA-PQ treatment group on day 28 (RR 0.45, 95% CI 0.29 to 0.68; participants = 8508; studies =
16; I2 = 51%, high quality of evidence) and on day 42 (RR 0.60, 95% CI 0.47 to 0.78; participants = 5959; studies = 17; I2 =
0%, high quality of evidence). On days 28 and 42, a significant increase in serum hemoglobin level from the baseline was
also observed in DHA-PQ treatment arm (SMD 0.15, 95% CI 0.05 to 0.26; participants = 2715; studies = 4; I2 = 32%, high
quality of evidence) and (MD 0.35, 95% CI 0.12 to 0.59; participants = 1434; studies = 3; I2 = 35%, high quality of evidence),
respectively. Compared to AL, DHA-PQ was associated with a slightly higher frequency of early vomiting (RR 2.26, 95%
CI 1.46 to 3.50; participants = 7796; studies = 10; I2 = 0%, high quality of evidence), cough (RR 1.06, 95% CI 1.01 to 1.11;
participants = 8013; studies = 13; I2 = 0%, high quality of evidence), and diarrhea (RR 1.16, 95% CI 1.03 to 1.31; participants
= 6841; studies = 11; I2 = 8%, high quality of evidence) were more frequent in DHA-PQ treatment arm.

Conclusion and recommendation: From this review, it can be concluded that DHA-PQ reduces new infection and
recrudescence with a significant impact on hemoglobin recovery more than AL does, and both drugs are well tolerated.
This may trigger DHA–PQ to become the first-line treatment option. Continuous studies that measure the efficacy of
DHA–PQ and AL with 42 and 63 days follow-up are needed.

Keywords: Uncomplicated Plasmodium falciparum, children, Randomized control trial, Artemisinin combination
therapies, Dihydroartemisinin-piperaquine, Artemether-lumefantrine, Systematic review, and meta-analysis, Africa

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Background malaria in children, written in English, and published

between 2004 to April 2021 were included. The PICOS
Malaria is the cause of two-third of deaths among format was used to identify eligible studies. The
children under the age of five though it is a preventable WHO Methods and techniques for clinical trials on
and treatable disease (1-3). All African counties, where antimalarial drug efficacy classification of genotyping
malaria due to plasmodium falciparum is endemic, to identify parasite populations were used to
have introduced the currently recommended determine treatment outcome (20).
Artemisinin-Based Combination Therapy (ACT) for
the confirmed cases of plasmodium falciparum A computerized systematic search method was used
malaria since 2004 (1). The efficacies of ACT have been to search for articles from online databases PubMed/
effective in Africa (4, 5), numerous trials have reported MEDLINE, Embase, and Cochrane Center for Clinical
that dihydroartemisinin-piperaquine (DHA-PQ) is Trial database (CENTRAL). The search was limited
highly effective in the treatment of uncomplicated to human trials, randomized control trials, and
p. falciparum malaria (6-10). However, a review published between 2004 and April 2021. Using Rev-
reported that prolongation of the QTc interval from Man software (V5.4), R-studio, and Comprehensive
Electrocardiogram (ECG); pyrexia, early vomiting, and Meta-analysis software, the extracted data from
diarrhea were common in patients treated with DHA- eligible studies were pooled as risk ratio (RR) with a
PQ (11). The emergence of P. falciparum resistance 95% confidence interval (CI).
to artemisinin and its derivatives poses a threat to
global efforts in controlling malaria. Resistance to Result
most antimalarial drugs in common use has already
In this review, 25 studies that involved a total of
been reported (12-15). Although several studies were
13,198 participants were included. PCR unadjusted
conducted to assess the efficacy of ACT in adults
treatment failure in children aged between 6 months
yielding different success rates in Africa (16-18) and
and 15 years was significantly lower in DHA-PQ
most of the previous studies have compared the
treatment arm on day 28 than that of AL (RR 0.14, 95%
efficacies of Arthemeter Lumefantrine (AL) and other
CI 0.08 to 0.26; participants = 1302; studies = 4; I2 = 0%,
artemisinin-based combinations, but little or no
high quality of evidence).
attention has been given to their safety. Given the
wide range of ACT availability for the treatment of Consistently, the PCR adjusted treatment failure was
malaria and their potential adverse effects (AEs), it is significantly lower with DHA-PQ treatment group on
vital to compare their safety profiles, there has been day 28 (RR 0.45, 95% CI 0.29 to 0.68; participants = 8508;
no systematic review or meta-analysis conducted to studies = 16; I2 = 51%, high quality of evidence) and
obtain strong evidence about the outcome of malaria on day 42 (RR 0.60, 95% CI 0.47 to 0.78; participants
treatment and artemisinin resistance in African = 5959; studies = 17; I2 = 0%, high quality of evidence).
Children. However, the efficacy was ≥95% in both treatment
groups on day 28.
Objective
On days 28 and 42, a significant increase in serum
The aim of this review was, therefore, to compare
hemoglobin level from the baseline was also observed
the efficacy and safety of DHA-PQ and AL for the
in DHA-PQ treatment arm (SMD 0.15, 95% CI 0.05 to
treatment of uncomplicated P. falciparum malaria in
0.26; participants = 2715; studies = 4; I2 = 32%, high
African children.
quality of evidence) and (MD 0.35, 95% CI 0.12 to 0.59;
Methods participants =1434; studies = 3; I2 = 35%, high quality
of
The Preferred Reporting Items for Systematic
Review and Meta-analysis (PRISMA 2020) guideline
was followed to select studies to be included (19).
Randomized controlled trials conducted in Africa
which compared the efficacy and safety of DHA-PQ
versus AL for treatment of uncomplicated falciparum

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Figure 1, Forest plot of comparison between dihydroartemisinin-piperaquine and artemether-lumefantrine for the treatment
of uncomplicated plasmodium falciparum malaria in African children on PCR adjusted treatment failure on day 28

Figure 2, Forest plot of comparison between dihydroartemisinin-piperaquine and artemether-lumefantrine for the treatment
of uncomplicated plasmodium falciparum malaria in African children on PCR adjusted treatment failure on day 42

evidence), respectively. Compared to AL, DHA-PQ was treatment failure on days 28 and 42 in the DHA-
associated with a slightly higher frequency of early PQ treatment arm was similar to that of former
vomiting (RR 2.26, 95% CI 1.46 to 3.50; participants = reviews from Africa (22, 23). This difference might
7796; studies = 10; I2 = 0%, high quality of evidence), be attributed to the evening doses of AL given at
vomiting (RR 1.02, 95% CI 0.87 to 1.19; participants = home unsupervised; to the administration of AL
8789; studies = 13; I2 = 20%, high quality of evidence), without fatty food for less than 10% of lumefantrine is
cough (RR 1.06, 95% CI 1.01 to 1.11; participants = absorbed in an empty stomach (24) and to the longer
8013; studies = 13; I2 = 0%, high quality of evidence), elimination half-life of piperaquine (23–28 days)
and diarrhea (RR 1.16, 95% CI 1.03 to 1.31; participants compared with that for lumefantrine (3.2 days), which
= 6841; studies = 11; I2 = 8%, high quality of evidence) provides long-lasting post-treatment prophylactic
were more frequent in DHA-PQ treatment arm. effect (25, 26). (25, 26)[25, 26][25, 26][25, 26][25, 26]For
patients who live in areas where malaria transmission
Discussion is higher and reinfection is likely, a longer post-
treatment prophylactic period might have a great
The therapeutic efficacy of antimalarial drugs should advantage (27), but due to the sub-therapeutic drug
be monitored regularly using the standard WHO levels, selection for resistant parasite may occur
protocol (21). The observed lower PCR unadjusted

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(28). For a patient who lives in an area where malaria 6. Agarwal A, McMorrow M, Onyango P, Otieno K, Odero
transmission intensity is low, the benefit of the drug’s C, Williamson J, et al. A randomized trial of artemether-
longer post-treatment prophylactic period is low and lumefantrine and dihydroartemisinin-piperaquine in the
the probability of developing drug resistance is higher treatment of uncomplicated malaria among children in
(29). In this study, both drugs were well tolerated by western Kenya. Malaria Journal. 2013;12:254.
children. As also seen in one study from Papua New 7. Ebenebe JC, Ntadom G, Ambe J, Wammanda R, Jiya N,
Guinea, the overall frequency of adverse events was Finomo F, et al. Efficacy of Artemisinin-Based Combination
slightly higher in the DHA-PQ treatment arm than Treatments of Uncomplicated Falciparum Malaria in Under-
that of AL (30). However, Cough was more frequent in Five-Year-Old Nigerian Children Ten Years Following Adoption
patients who were treated with AL, but headache and as First-Line Antimalarials. The American Journal of Tropical
runny nose were common in the DHA-PQ treatment Medicine and Hygiene. 2018;99(3):649-64.
group (30). Thailand-Myanmar border (31, 32) and 8. Gargano N, Madrid L, Valentini G, D‘Alessandro U, Halidou T,
elsewhere in Africa (33-36) have reported that DHA- Sirima S, et al. Efficacy and Tolerability Outcomes of a Phase II,
PQ causes drug-induced electrocardiographic QT Randomized, Open-Label, Multicenter Study of a New Water-
prolongation. Regardless of the treatment groups, Dispersible Pediatric Formulation of Dihydroartemisinin-
most of these adverse events are associated with age Piperaquine for the Treatment of Uncomplicated Plasmodium
(≤18 years) (37), efavirenz-based ART (37), efavirenz- falciparum Malaria in African Infants. Antimicrobial agents
based ART (38), and administration of DHA-PQ with and chemotherapy. 2018;62(1).
food could increase piperaquine exposure and it
9. Nambozi M, Van Geertruyden JP, Hachizovu S, Chaponda
needs to be administered in fasting state (32-34).
M, Mukwamataba D, Mulenga M, et al. Safety and efficacy

Conclusion and Recommendation of dihydroartemisinin-piperaquine versus artemether-

lumefantrine in the treatment of uncomplicated Plasmodium
This systematic review and meta-analysis show higher falciparum malaria in Zambian children. Malaria Journal.
efficacy of DHA-PQ on days 28 and 42 than that of AL 2011;10:50.
and tolerability of both treatments. This may trigger 10. Dama S, Niangaly H, Djimde M, Sagara I, Guindo CO,
DHA–PQ to become the first-line treatment option. Zeguime A, et al. A randomized trial of dihydroartemisinin–
Continuous studies that measure the efficacy of DHA– piperaquine versus artemether–lumefantrine for treatment
PQ and AL with 42 and 63 days follow-up are needed. of uncomplicated Plasmodium falciparum malaria in Mali.
Malaria Journal. 2018;17.
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falciparum malaria in three provinces in Angola, 2017. 2014;371(5):411-23.

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16. Mandara CI, Kavishe RA, Gesase S, Mghamba J, Ngadaya E, Mathematical model with implications for ACT drug policies.
Mmbuji P, et al. High efficacy of artemether-lumefantrine Malaria Journal. 2008;7(1):229.
and dihydroartemisinin-piperaquine for the treatment of 30. Tavul L, Hetzel MW, Teliki A, Walsh D, Kiniboro B, Rare L, et al.
uncomplicated falciparum malaria in Muheza and Kigoma Efficacy of artemether-lumefantrine and dihydroartemisinin-
Districts, Tanzania. Malaria Journal. 2018;17(1):261. piperaquine for the treatment of uncomplicated malaria in
17. Four Artemisinin-Based Combinations Study G. A head-to- Papua New Guinea. Malaria Journal. 2018;17(1):350.
head comparison of four artemisinin-based combinations 31. Saito M, Yotyingaphiram W, Cargill Z, Gilder ME, Min AM, Phyo
for treating uncomplicated malaria in African children: a AP, et al. Electrocardiographic effects of four antimalarials
randomized trial. PLoS Medicine. 2011;8(11):e1001119. for pregnant women with uncomplicated malaria on the
18. Uwimana A, Penkunas MJ, Nisingizwe MP, Warsame M, Umulisa Thailand-Myanmar border: a randomized controlled trial.
N, Uyizeye D, et al. Efficacy of artemether-lumefantrine Antimicrobial agents and chemotherapy. 2021.
versus dihydroartemisinin-piperaquine for the treatment of 32. Manning J, Vanachayangkul P, Lon C, Spring M, So M, Sea
uncomplicated malaria among children in Rwanda: an open- D, et al. Randomized, double-blind, placebo-controlled
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Society of Tropical Medicine and Hygiene. 2019;113(6):312-9. piperaquine for malaria prevention halted for concern over
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23. Sinclair D, Zani B, Donegan S, Olliaro P, Garner P. Artemisinin- BR, Oduro A, et al. Multi-country evaluation of the safety of
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2009;2009(3):Cd007483. 2016;11(10).

24. COARTEM®(artemether and lumefantrine) tablets fouNPC. 36. Mhamilawa LE, Wikström S, Mmbando BP, Ngasala B,
Mårtensson A. Electrocardiographic safety evaluation of
25. Ezzet F, van Vugt M, Nosten F, Looareesuwan S, White NJ.
extended artemether-lumefantrine treatment in patients with
Pharmacokinetics and pharmacodynamics of lumefantrine
uncomplicated Plasmodium falciparum malaria in Bagamoyo
(benflumetol) in acute falciparum malaria. Antimicrob Agents
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37. Creek D, Bigira V, Arinaitwe E, Wanzira H, Kakuru A, Tappero
26. Hung TY, Davis TM, Ilett KF, Karunajeewa H, Hewitt S, Denis MB,
J, et al. Increased risk of early vomiting among infants and
et al. Population pharmacokinetics of piperaquine in adults
young children treated with dihydroartemisinin-piperaquine
and children with uncomplicated falciparum or vivax malaria.
compared with artemether-lumefantrine for uncomplicated
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malaria. The American Journal of Tropical Medicine and
27. Price RN, Douglas NM. Artemisinin Combination Therapy for
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Malaria: Beyond Good Efficacy. Clinical Infectious Diseases.
38. Sevene E, Banda CG, Mukaka M, Maculuve S, Macuacua S, Vala
2009;49(11):1638-40.
A, et al. Efficacy and safety of dihydroartemisinin-piperaquine
28. Stepniewska K, White NJ. Pharmacokinetic determinants
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Malawi and Mozambique: an open-label non-randomized
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Day NPJ, White NJ. Spread of anti-malarial drug resistance:

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 Assessment of Compassionate and Respectful Care Implementation Status in
Model Healthcare Facilities: A Cross-Sectional Study

Kemal Jemal1*, Assegid Samuel2, Abiyu Geta2, Fantanesh Desalegn2, Lidia Gebru2, Tezera
Tadele2, Ewnetu Genet2, and Mulugeta Abate3, Nebiyou Tafesse4
1
Department of Nursing, College of Health Sciences, Salale University, Fitche, Ethiopia
2
Ministry of health Ethiopia, Human Resource Development Directorate Director, Addis Ababa, Ethiopia
3
Ethiopian public health Association, Addis Ababa, Ethiopia
4
Department of Public Health, College of Health Sciences, Kotebe Metropolitan University, Addis
Ababa, Ethiopia
*Correspondence: [email protected]

ABSTRACT

Introduction: Compassionate and respectful care (CRC), as an important component for the health care worker
(HCW), fosters a pleasant environment for healthcare professionals, clients, and families. The Ethiopian Ministry of
Health (MoH) implemented a compassionate, respectful, and caring strategy for the last five years to improve person-
centered care.

Objective: This study aimed to assess the prevalence of CRC and associated factors in the 16 health facilities in
Ethiopia, 2021.

Methods: A facility-based cross-sectional study was employed from February to April 2021. A structured and pre-
tested standard self-administered questionnaire that was translated to regional languages (Amharic, Oromifa, and
Somali) was used. Four hundred and twenty-nine respondents participated in self-administered. Data entered into Epi-
data version 4.32 and analyzed using SPSS version 26. Binary and multivariate logistic regression analysis was employed
and significance was determined at the odds ratio with a 95% confidence interval and P-value <0.05

Results: The prevalence of compassionate and respectful care among the respondents were 60.4% and 64%
respectively. Nurses, midwives, having training on CRC, leaders promoting CRC, having a conducive working environment,
and burnout management for HCW were significantly associated with compassionate care practices. Leaders promoting
CRC, having a conducive working environment, and burnout management for HCW were associated with respectful care
practice.

Conclusion: The findings identified distinct issues related to CRC implementation. Addressing HCW skill gaps on
CRC, a conducive working environment, and burnout management encouraged continuity of CRC practices. Incorporating
CRC in pre-service education, health system strengthening interventions, and motivating HCW are important for CRC
strategic implementation.

Keywords: Compassionate, Respectful care, Health workforce, Ethiopia

Introduction: The compassionate, respectful, and conducted in the Tigray region, 44% of healthcare
caring (CRC) health workers are more passionate about workers (HCWs) had an unfavorable attitude about
their profession and enjoy assisting others, being CRC (2). In addition, a survey conducted in the North
ethical, and being a model for young professionals and Shewa zone of the Oromia region found that 38.8%
students (1, 2). Compassion serves as a foundation of HCW had provided good compassionate care and
for medical ethics, a source of flexibility, useful in 46.2% had practiced respectful treatment (1). Also,
forming connections, and critical in today’s world for studies conducted in Ethiopia indicated that out of
dealing with human rights (3). According to research the 60 complaints reviewed by Health Professionals

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Ethics Committee, 39 complaints were concerning training on CRC, types of health facilities, facilities
the patient’s death, 15 complaints were about auditing were employed to observe and check the
impairment, one-fifth of the complaints were related CRC implementation guideline and practices. The CRC
to breach ethics (4). A similar study found that 57.6% were measured using 12 items for compassionate care
of complaints were connected to mortality, and and 21 items for respectful care, the mean was used
21.6% were related to errors involving physical injury, as cut off point. The tool was validated in Amharic
ethical violation, and carelessness (5). One-fourth of language (8). Data were coded, edited, cleaned, and
physicians were unaware of the code of ethics, and entered into Epi-data version 4.2 and transported
39% of medical practitioners had an unfavorable to SPSS version 24. The outcome variables were
attitude about the code (6). dichotomized based on the cut-off point of the
mean for binary logistic regression. Variables with
Many professionals in Ethiopia are sympathetic P-value ≤ 0.2 in the binary analysis were included
and aware of the attributes that are required for in a multivariable logistic regression analysis to
CRC practices. However, HCWs do not provide CRC control the confounding effect among the variables.
services to clients or their families (7). To reduce Statistical significance was declared if P-value < 0.05.
the knowledge of CRC gaps, Ethiopia’s government Ethical clearance was obtained from the Ethiopian
has been implementing the CRC program during Public Health Association. Informed written consent
Health Sector Transformation Plan (HSTP I) (2016- was obtained from each respondent.
2020), and efforts were made in the last five years to
improve person-centered care. Respect for clients’ Results
human rights, autonomy, dignity, sentiments, desires,
and choice of friendship wherever feasible must be A total of 429 HCW participated with a response rate of
maintained. 98.6%. A little more than half of the study participants
were women (51.7%), 39.9% were aged between 25
Objective to 29 years old. More than three-fifth (61.1%) had
a bachelor, nurses’ account for 37.5% and 40.1%
The study intended to assess the prevalence of of them have 5 to 10 years of working experience.
compassionate and respectful health care practices, Although 87.5% of the facilities have an independent
and associated factors in the 16 CRC model health plan on CRC, only 18.8% of the facilities allocated
facilities in Ethiopia, 2021. finance for CRC implementation.

Methods and Materials The prevalence of compassionate care among HCW

in 16 MHFs was 60.4%. More than half (51.5%) of
This nationwide cross-sectional study was conducted health professionals introduce themselves to their
in 16 model health facilities (MHFs) from February to clients, 66% called their clients by their names, and
April 2021. The 16 MHFs were previously randomly 73.9% engaged themselves in conversation with
selected as CRC incubation centers starting from 2015 clients. About 82.5% were actively listening, 80% had
from the nine regions and two city administrations. love and tolerance, 83.9% understood client needs,
The sample size was determined using single and 76.5% understood their clients’ emotions. The
population proportion formula with the assumptions prevalence of respectful care in 16 MHFs among the
of a 95% confidence level, and a 5% precision, taking HCW was 64%, which 77.6% greet client with respect
50% proportion due to the lack of the previous study. and 71.8% of HCW were properly addressed clients’
The sample size of 435 was obtained after adding a concerns by considering their age and social status.
13% none response rate for the reason of COVID-19
impact. Proportional allocation was used based on Factors associated with compassionate and
the number of the health workforce per each 16 MHF. respectful care practice
Health workforces who have been working for more
than six months in 16 MHFs in Ethiopia were included In multivariable logistic regression analysis, nurse
in the study. Data were collected using a standardized professionals [AOR=4.16; 95% CI= (2.21.9.38)], midwifes
and pre-tested questionnaire. The questionnaire [AOR=3.31; 85% CI=(1.60,8.62)], having training on CRC
contains socio-demographic characteristics, previous [AOR=2.75; 95% CI=(1.67,4.53)], leader promoting CRC

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in the health facilities [AOR=2.34; 95% CI=(1.42,3.87)], to inspire with genuine team collaboration across
having conducive working environment in the health professional boundaries.
care facilities [AOR=1.70; 95% CI=(1.05,2.74)], and
burnout management for HCW [AOR=6.92; 95% Having a conducive working environment is
CI=(3.31,14.44)] were significantly associated with associated with compassionate and respectful care.
compassionate care among HCW at 16 CRC model The health care facilities must meet the needs of
health care facilities in Ethiopia (Table 1). Regarding their employees by providing a stimulating working
respectful care, leaders who promoting CRC in the environment to promote efficiency, effectiveness,
health care facilities [AOR=2.55; 95% CI=(1.52,4.29)], productivity, luxury, and job dedication (15).
having a conducive working environment in health Conversely, an inadequate working environment
care facilities [AOR=6.94; 95% CI=(2.24,9.38)] and affects the performance of health care professionals,
burnout management for HCW [AOR=4.29; 95% quality of health care delivery, and reduces client-
CI=(2.18,8.44)] were significantly associated with centered and compassionate care practice (16). The
respectful care (Table 2). Ministry of Health plays a critical role in HCW retention
by establishing a conducive healthcare environment,
Discussion and motivating health care workers that create high-
quality care.
We found that the prevalence of compassionate and
respectful care was 60.4% and 63.9%, respectively. Burnout management for HCW is very important
This result was higher than the previous study finding that furthermore associated with compassionate
in non CRC model health facilities indicated that 38.8% and respectful care practice. A study done in Kenya
for compassionate care and 46.2% for respectful care reported similar findings that sufficient career training,
practice (1). The discrepancy may be in the 16 MHF, job security, supervisor support, and manageable
all health workforce have been trained the CRC and workload, and terminal benefits were identified as
high focuses was given. Several studies have found motivation and reward of HCW burnout management
that the CRC is vital for better adherence to medical mechanisms (17). Due to a lack of trained human
advice and treatment plans, faster healing processes, resource, HCW in Ethiopia often reported taking on
better clinical outcome, improve health care system additional a responsibility that adds to duties for
and reduce malpractice (9-11). which they lack the necessary skills and training.

The study participants who have in service training on Conclusion and Recommendations
CRC have significantly associated with compassionate
care. Various studies confirmed that having training The assessment identified distinct issues related
can assist healthcare professionals to increase mental to CRC implementation in each MHF. Having in-
health resilience, improve patient care, and minimize service training on CRC, leaders who have promoted
burnout, and CRC training is an important first step CRC implementation, having a conducive working
toward further updating the caring, patient right, and environment, and burnout management for HCW
responsibility of HWF competency (12, 13). are important predictors of CRC practices by
HCWs. The study revealed that shortage of human
About 60.1% of the study participants indicated resources, health care facilities challenges, and
that they have leaders in the facility, which promote lack of compassionate leaders are challenges of
CRC implementation in the 16 MHFs. This result was CRC implementation in the health care facilities.
similar to a previous study report in non MHFs (1). Conversely, incorporating in education, advocacy
The components of good care (improved quality, and system strengthening, and motivating HCW
increased productivity, nurtured compassion, are strategies for improved CRC practices. The
ensured effectiveness, stimulated innovation, and Ministry of Health should incorporate CRC in pre-
maintained patient satisfaction) can only be achieved service education, health system strengthening and
when leaders are compassionate (14). As strategies motivating HCW are important for CRC strategic
to sustainable CRC in the health care facilities, implementation in collaboration with stakeholders,
health care system strengthening and developing and the Ministry of Education.
compassionate and innovative leader are important

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Reference 9. Goodrich J. What makes a compassionate relationship

between caregiver and patient? Findings from the
1. Jemal K, Hailu D, Mekonnen M, Tesfa B, Bekele K, Kinati T. The ‘anniversary’Schwartz Rounds. Journal of Compassionate
importance of compassion and respectful care for the health Health Care. 2016;3(1):1-8.
workforce: a mixed-methods study. Journal of Public Health.
10. Frezza E. Patient-Centered Healthcare: Transforming the
2021:1-12.
Relationship Between Physicians and Patients: CRC Press;
2. Berhe H, Berhe H, Bayray A, Godifay H, Beedemariam G. Status 2019.
of caring, respectful and compassionate health care practice
11. Dowell J, Williams B, Snadden D. Patient-centered prescribing:
in Tigrai regional state: patients’ perspective. Int J Caring Sci.
seeking concordance in practice: CRC Press; 2018.
2017;10(3):1119.
12. Scarlet J, Altmeyer N, Knier S, Harpin RE. The effects of
3. Mechili E-A, Angelaki A, Petelos E, Sifaki-Pistolla D, Chatzea
Compassion Cultivation Training (CCT) on health‐care
V-E, Dowrick C, et al. Compassionate care provision: an
workers. Clinical Psychologist. 2017;21(2):116-24.
immense need during the refugee crisis: lessons learned
from a European capacity-building project. Journal of 13. Sinclair S, Torres M-B, Raffin-Bouchal S, Hack TF, McClement
Compassionate Health Care. 2018;5(1):1-8. S, Hagen NA, et al. Compassion training in healthcare: what
are patients’ perspectives on training healthcare providers?
4. Wamisho BL, Abeje M, Feleke Y, Hiruy A, Getachew Y. Analysis
BMC Medical Education. 2016;16(1):1-10.
of medical malpractice clams and measures proposed
by the health professionals ethics federal committee of 14. West MA, Eckert R, Steward K, Pasmore WA. Developing
Ethiopia: review of the three years proceedings. Ethiop Med J. collective leadership for health care: King’s Fund London;
2015;53(Suppl 1):1-6. 2014.

5. Wamisho BL, Tiruneh MA, Teklemariam LE. Surgical and 15. Raziq A, Maulabakhsh R. Impact of working environment
medical error claims in Ethiopia: trends observed from 125 on job satisfaction. Procedia Economics and Finance.
decisions made by the Federal Ethics Committee For Health 2015;23:717-25.
Professionals Ethics Review. Medicolegal and Bioethics. 16. Oswald A. The effect of working environment on workers
2019;9:23-31. performance: The case of reproductive and child health care
6. Tiruneh MA, Ayele BT, Beyene KGM. Knowledge of, and providers in Tarime District: Muhimbili University of Health
attitudes toward, codes of ethics and associated factors and Allied Sciences; 2012.
among medical doctors in Addis Ababa, Ethiopia. Medicolegal 17. Ojakaa D, Olango S, Jarvis J. Factors affecting motivation and
and Bioethics. 2019;9:1-10. retention of primary health care workers in three disparate
7. Shea S, Wynyard R, Lionis C. Providing compassionate regions in Kenya. Human resources for health. 2014;12(1):1-13.
healthcare: challenges in policy and practice: Routledge; 2014.

8. Zeray M, Mariam DH, Sahile Z, Hailu A. Validity and reliability

of the Amharic version of the Schwartz Center Compassionate
Care Scale. PloS one. 2021;16(3):e0248848.

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Table 1:- Factors (crude and adjusted odds ratios, confidence intervals, and p-value) associated with compassionate care among
HCW at 16 MHFs in Ethiopia (n=429)

Compassion
Category Variables Adjusted OR (95% CI) p-value
Yes No
Male 109 98 1
Sex
Female 150 72 1.49(0.91,2.43) 0.110
Nurse 119 42 4.16(2.21.9.38) 0.001
Medical doctor 36 32 2.21(0.68,4.22) 0.190
Public health officer 20 21 1.98(0.80,4.93) 0.152
Profession Midwifes 30 13 3.31(1.60,8.62) 0.006
Anesthesia 19 17 2.07(0.80,4.93) 0.109
Pharmacy 26 26 1.76(0.98,3.38) 0.052
Others 9 19 1
Yes 173 61 2.75(1.67,4.53) 0.001
Training on CRC
No 86 109 1
Leader promoting Yes 186 72 2.34(1.42,3.87) 0.001
CRC No 73 98 1
Conducive working Yes 165 75 1.70(1.05,2.74) 0.031
environment No 94 95 1
Burnout manage- Very important 247 114 6.92(3.31,14.44) 0.001
ment for HCW is
important Less important 12 56 1

Table 2:- Factors (crude and adjusted odds ratios, confidence intervals, and p-value) associated with respectful care among HCW at
16 MHFs in Ethiopia (n=429)

Respectful care Adjusted OR (95%

Category Variables p-value
Yes No CI)
Male 115 92 1
Sex
Female 159 63 1.33(0.81,2.21) 0.261
Nurse 119 42 2.19(0.75,6.35) 0.151
Medical doctor 36 32 0.75(0.23,2.51) 0.644
Public health officer 26 15 1.41(0.44,3.19) 0.510
Profession Midwifes 31 12 1.96(0.56,5.82) 0.291
Anesthesia 21 15 1.19(0.37,4.50) 0.687
Pharmacy 26 26 0.84(0.29,2.03) 0.921
Others 15 13 1
Yes 159 75 0.77(0.45,1.31) 0.332
Training on CRC
No 115 80 1
Leader promoting Yes 193 65 2.55(1.52,4.29) 0.001
CRC No 81 90 1
Conducive working Yes 199 41 6.94(2.24,9.38) 0.001
environment No 75 114 1
Burnout manage- Very important 255 106 4.29(2.18,8.44) 0.001
ment for HCW Less important 19 49 1

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 Patient Satisfaction with Health Care Services Provided in Ethiopian Health
Institutions: Meta-Analysis

Henok Biresaw 1*, Henok Mulugeta2, Aklilu Endalamaw1, Nurhusien Nuru Yesuf3, Yibeltal
Alemu1
1
Bahir Dar University, Bahir Dar, Ethiopia
2
Markos University, Debre Markos, Ethiopia
3
University of Gondar, Gondar, Ethiopia
*Correspondence: [email protected]

ABSTRACT

Background: Patient satisfaction is the direct or indirect measure of the quality of services delivered in healthcare
institutions. Different primary studies in Ethiopia showed the proportion of satisfied patients towards health services.
Patient satisfaction reflects the wide gap between the current experience and the expected services. Inconsistent findings
of the proportion of patient satisfaction towards healthcare services in Ethiopia make generalization difficult at the
national level.

Methods: Studies were accessed through an electronic web-based search strategy from PubMed, Cochrane Library,
Google Scholar, Embase, and CINAHL by using a combination of search terms. The quality of each article included in
the study was assessed using a modified version of the Newcastle-Ottawa Scale for cross-sectional studies. All statistical
analyses were done using STATA version 14 software for windows.

Results: Of 188 records screened, 41 studies with 17,176 participants fulfilled the inclusion criteria and were included
for proportion estimation. The pooled proportion of satisfied patients was found to be 63.7 %. Those patients who were
attending health center (AOR = 2.68; 95% CI: 1.79, 2.85), being literate (AOR = 0.46; 95%CI: 0.28–0.64), with an age >34 years,
and divorced marital status (AOR = 0.58; 95% CI: CI; 0.38, 0.88) were identified associated factors.

Conclusion: The proportion of patient satisfaction in Ethiopia was high based on over 50% satisfaction scale. But
it remains low as compared with other countries. The Ministry of Health should give more emphasis to improve hospital
health care services to further improve patient satisfaction.

Keywords: patient satisfaction, systematic review, meta-analysis

Background health services given (Assefa & Mosse, 2011). Different

studies were conducted to assess patient satisfaction.
Patient satisfaction is the level of satisfaction A study conducted in India shows that 73% of the
that clients experience after using the service. It study participants were satisfied with nursing service
reflects the difference between the expected (Sharma, Kasar, & Sharma, 2014), 51.7% in Serbia
service and the experience of the service from (Milutinović, Simin, Brkić, & Brkić, 2012).
the patient`s point of view (Mathew & Beth, 2001).
Measuring patient satisfaction becomes an integral In Ethiopia, patient satisfaction reflects the wide gap
part of healthcare services strategies across the between the current experience and the expected
world; the quality assurance and accreditation services that push clients to go to more far health care
process in most countries consider the satisfaction facilities and even to more expensive private health
of patients as a basic criterion in evaluating patient facilities to find quality healthcare services (Miles &
satisfaction (Mathew & Beth, 2001). Patients need to Mezzich, 2011). Inconsistent findings of the proportion
be allowed to explain the services they received since of patient satisfaction towards healthcare services in
it is a good step in improving the standard of the Ethiopia make generalization difficult at the national

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level. Therefore, this systemic review and meta- (studies conducted at a health center, hospital, or
analysis will answer what is the estimated pooled institutional level in Ethiopia). Two independent
magnitude of patient satisfaction and predictors that reviewers extracted data using a structured data
affect patient satisfaction. The output of this review extraction format prepared in a Microsoft Excel
and meta-analysis will help the Ministry of Health, spreadsheet.
regional health offices, and other stakeholders to
fill the gap in this regard. Furthermore, it provides Results and discussion
evidence to clinicians who have direct contact with
patient care. The search strategy retrieved 188 articles. After the
removal of duplicated articles, 162 articles remained.
Objective About 57 full-text articles were accessed for eligibility,
12 articles excluded because of lack of reporting the
The study intended to assess the proportion of patient outcome of interest, and four due to lack of abstract
satisfaction towards healthcare services in Ethiopia and full text. Finally, 41 studies were screened for full-
and identify factors affecting patient satisfaction text review, prevalence, and/ or associated factors
towards healthcare services analysis with a total sample of 17,176 patients. The
overall proportion of patient satisfaction was 63.7 %
Methods (95% CI; 59.48, 67.91; I2 = 99.5%) (Fig. 1).

The procedure for this systematic review and meta- The analysis estimation of this study was higher than
analysis was designed per the Preferred Reporting a study conducted in Mozambique (Newman, Gloyd,
Items for Systematic Reviews and Meta-Analyses Nyangezi, Machobo, & Muiser, 1998). The difference
(PRISMA) guidelines. We searched PubMed, Google might be attributed to the fact that, in our health care
Scholar, and web of science database for studies facilities, there is a relatively adequate number of
reporting the level of patient satisfaction with health health professionals and better diagnostic facilities.
care services from January 2000 to January 20, 2018.
End Note version X8 reference management software The subgroup analysis based on the region, service
for Windows was used to download, organize, review, area, and publication year was done. Based on this,
and cite the articles. The following types of studies the proportion of patient satisfaction was found to be
were included: quantitative studies, studies that 61.02% in Addis Ababa, 51.129% % in the inpatient
reported at least one associated factor of patient service, and 55.8% before the 2010 publication year
satisfaction without any restriction with regards to (Table 1).
publication status, study period, and study settings

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%
Authors ES (95% CI) Weight

Belaynew Wasie Taye et al 51.70 (50.47, 52.93) 2.39

EPHREM GEJA 44.10 (42.28, 45.92) 2.38
Mesfin Worku 91.70 (89.68, 93.72) 2.38
K.Srinivasan 76.20 (72.31, 80.09) 2.35
Molla Gedefaw et al 58.30 (56.40, 60.20) 2.38
FEKADU ASSEFA et al 77.00 (75.06, 78.94) 2.38
Mulatu Melese Derebe et al 39.30 (37.51, 41.09) 2.38
Tirsit Retta Woldeyohane 67.20 (64.34, 70.06) 2.37
Tahir Hasen 35.10 (33.33, 36.87) 2.38
rodas getachew Abera 59.70 (57.08, 62.32) 2.37
Zelalem Teklemariam 87.60 (85.64, 89.56) 2.38
Geletta Tadele 60.40 (58.51, 62.29) 2.38
Melal Teresa 63.30 (61.29, 65.31) 2.38
Addisu Gize Yeshanew 55.90 (53.26, 58.54) 2.37
Azmeraw Tayelgn 61.90 (59.99, 63.81) 2.38
Zeritu Dewana 90.20 (87.66, 92.74) 2.37
Mesafint Ewunetu Mekonnen 74.90 (73.27, 76.53) 2.39
Rahel Tesfaye 79.10 (77.17, 81.03) 2.38
Zeritu Dewana 90.20 (87.66, 92.74) 2.37
Kurabachew Bitew 81.70 (79.68, 83.72) 2.38
Taklu Marama 79.70 (77.75, 81.65) 2.38
Tayue Tateke 65.90 (64.33, 67.47) 2.39
Rahel Mezemir 57.70 (55.80, 59.60) 2.38
Birna Abdosh 54.10 (52.41, 55.79) 2.39
Anteneh Asefa 80.10 (78.21, 81.99) 2.38
lemesa oljira 57.10 (55.13, 59.07) 2.38
Getu Gamo Sagaro 54.20 (52.33, 56.07) 2.38
Zewdie Birhanu 62.60 (61.19, 64.01) 2.39
Mohammed Biset Ayalew 51.90 (49.65, 54.15) 2.38
Adane Teshome Kefale 52.60 (50.65, 54.55) 2.38
Abebaw Tegegn Damtie 75.80 (73.05, 78.55) 2.37
solomon Yimer 61.20 (59.35, 63.05) 2.38
Haftom Desta 72.00 (70.05, 73.95) 2.38
Teshome Mulisa 71.60 (69.35, 73.85) 2.38
Bekele chaka 67.00 (65.43, 68.57) 2.39
Solomon bekele 56.30 (54.45, 58.15) 2.38
Azanu Kibret N. et al 67.10 (65.06, 69.14) 2.38
Sharew NT. et al 49.20 (47.26, 51.14) 2.38
Mende M. et al 40.90 (38.84, 42.96) 2.38
Mehret TL. Et al 47.00 (45.13, 48.87) 2.38
Molla Teferi 50.30 (48.33, 52.27) 2.38
Tadese G. et al 55.90 (54.00, 57.80) 2.38
Overall (I-squared = 99.5%, p = 0.000) 63.70 (59.48, 67.91) 100.00
NOTE: Weights are from random effects analysis

0 25 50 75

Figure 1, patient satisfaction from articles reviewed.

Table 1, Pooled prevalence of patient satisfaction by region and service areas

Variables Characteristic Pooled prevalence (95% CI) I2 (p-value)

Oromia 59.815% (51.345 -68.285) 99.4% (<0.001)
Amhara 60.881% (54.026 -67.736) 99.4% (<0.001)
SNNPR 68.145% (57.146 -79.145) 99.7% (P<0.001)
Study regions
Tigray 67.334 % (50.133 -84.535) 99.6% (<0.001)
Addis Ababa 61.017 % (56.235- 65.800) 96.7% (<0.001)
Harari 70.846% (38.017 -103.676) 99.8% (<0.001)
Emergency service 62.493% (37.101-87.885) 99.9% (<0.001)
General health 62.669 % (44.374 -80.964) 99.7% (<0.001)
Inpatient service 51.129% (19.672 -82.587) 99.7% (<0.001)
Laboratory service 65.393% (53.649 - 77.138) 99.3% (<0.001)
labor and delivery 79.643% (72.795- 86.491) 98.8% (<0.001)
Service area
Outpatient service 61.672% (55.288 - 68.057) 99.0% (<0.001)
Pharmacy service 60.072% (46.233- 73.912) 99.1% (<0.001)
Psychiatry service 66.596% (56.012 - 77.180) 98.4% (<0.001)
Radiological service 71.600% (69.349- 73.851) .% (<0.001)
Nursing service 54.219% (47.704 - 60.734) 99.0% (<0.001)
Before 2010 55.779% (53.977 -57.580) 65.6% (0.055)
By publication year
After 2010 64.302% (59.783 - 68.820) 99.5% (<0.001)

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The proportion of patient satisfaction was high in study was in line with the study conducted in west
the labor and delivery service area compared to Amhara; the overall client satisfaction in the health
other service areas. The reason for higher patient centers was significantly higher (55%) than that of
satisfaction in labor and delivery service may be due hospital services (36%) users (Derebe et al., 2017) (fig
to the governments and private partners’ initiative 2).
to give priority to mothers, especially for pregnant
mothers; most of the services in this ward were free Conclusion and recommendation
of charge, all types of equipment were well prepared
and heath care professionals were well trained The proportion of patient satisfaction was high
based on over 50% satisfaction scale. But it remains
Literate individuals were 54% less likely satisfied with low as compared with other countries. Attending
the service compared to illiterate individuals (fig 2). health centers, educational status, age, and marital
This is also in agreement with the study conducted status were associated with patient satisfaction with
in Kuwait(Al-Doghaither, Abdelrhman, Saeed, Al- health care service. Therefore, hospital management,
Kamil, & Majzoub, 2001) in which patients with lower policymakers, and other responsible officials are
educational levels, illiterate and elementary school suggested to strengthen the satisfaction by improving
level patients showed a high level of satisfaction. the individual’s awareness of the importance of
According to a study, a study conducted in Rome attending health care services, give regular education
greater satisfaction was observed in individuals with on the importance of having a good family life.
lower educational status(Renzi et al., 2001). The odds Individuals are suggested to improve their awareness
of individuals who attended health centers were of the services given by health care institutions.
nearly three times more than the hospital users. This

%
Authors ES (95% CI) Weight

health center
abebe bekele 3.09 (2.02, 4.16) 6.90
Mulatu Melese Derebe et al 2.18 (0.98, 3.38) 6.06
Subtotal (I-squared = 18.7%, p = 0.267) 2.68 (1.79, 3.57) 12.96
.
litrate indiviuals
abebe bekele 0.57 (0.33, 0.81) 14.08
Haftom Desta 0.34 (-0.02, 0.70) 13.15
Teshome Mulisa 0.32 (-0.07, 0.70) 12.98
Subtotal (I-squared = 0.0%, p = 0.423) 0.46 (0.28, 0.64) 40.21
.
age >34
Adane Teshome Kefale 1.94 (1.13, 2.75) 8.99
Rahel Mezemir 3.35 (0.71, 5.99) 1.85
Subtotal (I-squared = 0.8%, p = 0.315) 2.07 (1.28, 2.85) 10.84
.
Provision of prescribed drugs
Rahel Mezemir 4.30 (-2.43, 11.04) 0.32
Tangut Dagnew 2.70 (0.45, 4.95) 2.43
Subtotal (I-squared = 0.0%, p = 0.658) 2.86 (0.73, 5.00) 2.75
.
Divorced clients
Mulatu Melese Derebe 4.26 (-3.31, 11.83) 0.25
abebe bekele 0.58 (0.33, 0.83) 14.04
Subtotal (I-squared = 0.0%, p = 0.341) 0.58 (0.33, 0.83) 14.29
.
excellent empathy
Zewdie Birhanu 0.18 (-0.01, 0.37) 14.42
Getu Gamo 2.39 (0.89, 3.89) 4.52
Subtotal (I-squared = 87.7%, p = 0.004) 1.15 (-1.00, 3.30) 18.94
.
Overall (I-squared = 83.4%, p = 0.000) 1.05 (0.67, 1.44) 100.00
NOTE: Weights are from random effects analysis

.01 10

Figure 2, patient satisfaction from articles reviewed by patient characteristics

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References

1. Mathew, S., & Beth, E. (2001). To assessing client 6. Newman, R. D., Gloyd, S., Nyangezi, J. M., Machobo, F., &
satisfaction: Durban, (South Africa). Health system Trust. Muiser, J. (1998). Satisfaction with outpatient health care
services in Manica Province, Mozambique. Health policy
2. Assefa, F., & Mosse, A. (2011). Assessment of clients’ and planning, 13(2), 174-180.
satisfaction with health service deliveries at Jimma
University specialized hospital. Ethiopian journal of 7. Al-Doghaither, A. H., Abdelrhman, B. M., Saeed,
health sciences, 21(2), 101-110. A. A., Al-Kamil, A. A., & Majzoub, M. M. (2001).
PATIENTS’SATISFACTION WITH PRIMARY HEALTH CARE
3. Milutinović, D., Simin, D., Brkić, N., & Brkić, S. (2012). CENTERS SERVICES IN KUWAIT CITY, KUWAIT. Journal of
The patient satisfaction with nursing care quality: family & community medicine, 8(3), 59.
the psychometric study of the Serbian version of
PSNCQ questionnaire. Scandinavian journal of caring 8. Derebe, M. M., Shiferaw, M. B., & Ayalew, M. A. (2017). Low
sciences, 26(3), 598-606. satisfaction of clients for the health service provision in
West Amhara region, Ethiopia. PloS one, 12(6), e0179909
4. Miles, A., & Mezzich, J. (2011). The care of the patient and
the soul of the clinic: person-centered medicine as an
emergent model of modern clinical practice. International
Journal of Person-Centered Medicine, 1(2), 207-222.

5. Sharma, A., Kasar, P. K., & Sharma, R. (2014). Patient

satisfaction about hospital services: a study from
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jabalpur, madhya pradesh, india. National J Community
Medicine, 5(2), 199-203.

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 Effectiveness and Efficiency of Leadership, Management, and Governance
Training in Ethiopia: A Cross-Sectional Facility-Based Study

Sualiha Abdulkader Muktar1, Binyam Fekadu Desta1, Wondwosen Shiferaw Abera1, Heran
Demissie1, Mesele Damte Argaw1*
1
USAID Transform: Primary Health Care, JSI Research & Training Institute, Inc., Addis Ababa, Ethiopia
*Correspondence: [email protected]; [email protected]

ABSTRACT

Background: Leadership, management, and governance (LMG) training are implemented to capacitate
managers and clinical healthcare providers in several countries. However, there is a shortage of evidence gathered
on the effectiveness and efficiency of LMG training in low-income countries. Hence, this study aims to assess the
effectiveness and efficiency of basic LMG training implemented in Ethiopia.

Methods: This study employed a facility-based cross-sectional survey design. The study was conducted in 24
purposively selected districts of Amhara, Oromia, Southern Nations, Nationalities, and People regions in September
2018. The data was collected through self-administered questionnaires from 293 participants. Secondary data were
extracted on the achievements of 136 leadership projects. In addition, financial documents were reviewed from the
training database.

Results: In the study, 100% of participants have responded. They were recruited from 10 blocks, 8 segmented I
and 6 Segmented II implemented basic LMG training approach. The mean pretest score with SD was 44.9% ± 15.50%,
and the post-test score was 78.1% ± 14.2%, which showed a significant gain in knowledge at post-test with t=-35.9,
df=292, p<0.001. After implementing leadership projects for nine months, the average net health service coverage gain
by each entity was 16.5% (95% CI: 12.2%, 20.8%). The project invested 19.20 $ , 24.77$, and 34.60$ to increase one unit
of health service coverage in a block, segmented I and Segmented II training approaches, respectively.

Conclusions and recommendations: Both the block and segmented LMG training were each found to be
effective in imparting knowledge and skills for staff to lead, manage and govern primary health entities. However,
the block LMG training approach was much more effective and efficient than the segmented training approaches
with regards to time, communication, and resources utilized during the sessions. Therefore, scaling up of block LMG
training to reach more primary health care units is recommended.

Keywords: Effectiveness and Efficiency; Leadership, Management, and Governance; Performance Improvement;
Training Evaluation; Ethiopia.

Background
Training is the act of enriching the knowledge and
The health system of any country must transform skills of employees in a particular job, to improve
itself to promote health, prevent and control current organizational performance in general and healthcare
challenges and be prepared to face emerging global services effectiveness in particular (3). This leadership,
public health concerns. However, the challenges to management, and governance training is a result-
be addressed are very complex and needs leadership oriented, participatory leadership development
at all levels. Building the LMG competencies of program that enables healthcare professionals who
healthcare workers is the most proven solution in play a hybrid of clinical and management roles to
creating a resilient health system (1, 2). overcome self-identified challenges and achieve

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more results (3). Following the training, the trainees response rate, and 555 LMG trained staff of source
are expected to apply all leadership, management, population. The final sample size was 293.
and governance practices through developing and
implementing leadership projects for six to nine Data collection and analysis: The first tool
months [5] [6]. In Ethiopia, USAID Transform: primary used in the study consists of 19 items dedicated
health care Project implemented three different LMG to capturing the independent variables, namely,
training approaches, namely, (1) block course: A six- time, communication, and resources, and 11 items
day classroom LMG training and six to nine months long were focused on the effectiveness and efficiency of
leadership project with coaches for training institutes LMG training were dependent variables. The tools
(2) Segmented one: Two workshops of three-day were developed based on a 5-point Likert scale
classroom LMG training and six to nine months-long ranging from strongly disagree to strongly agree. In
leadership project with coaches assigned from the addition, secondary data were extracted on training
zone health department and (3) Segmented two: investment, pre-test, post-test, and leadership
Two workshops of three-day classroom LMG training, project scores from training records. Sixteen data
and six to nine months-long leadership project with collectors and four supervisors each with clinical,
coaches assigned from USAID Transform: PHC project health management, social science, or public health
field staff. training were recruited and trained on the ethical
principles, and data collection tools. Before the
Effectiveness is focused on the usefulness of training actual data collection started, all tools were piloted
content to the employees’ work. Efficiency is the and amended accordingly. The data were analyzed
often measurable ability to avoid wasting materials, using SPSS IBM version 20.
energy, efforts, money, and time in doing something
or producing the desired result (7). Conducting LMG Operational definitions
training effectiveness and efficiency evaluation is
helpful for policymakers, program managers, and Effectiveness: was determined using LMG knowledge
health professionals to maximize the gains of such and competencies scores and average score
interventions and improve the training materials and measurements using a five Liker scale question that
processes. estimates the perception of trainees on positive
impact, performance improvements, use of tools,
Objectives and recommendation of similar training for other co-
workers
The objective of this study was to assess the effectiveness
and efficiency of LMG training implemented in Ethiopia. Efficiency: was measured using six Likert scale
questions that measured trainees’ perception of
Methods session organization; trainer preparedness; and
trainees’ ability to understand the materials and
Study area and design: This study employed a complete sessions.
facility-based cross-sectional survey design and was
conducted in the Amhara, Oromia, Southern, Nations, Time: trainees were asked to rate the adequacy of
Nationalities, and People regions of Ethiopia in time spent on each training topic and activity.
September 2018. The regions are the USAID Transform:
Primary Health Care project implementation area and Communication: trainees were asked to rate the
were purposively selected based on the information on various levels of communication, including the
LMG training and interventions. invitation to participate in the training, the purpose of
the training, and post-training communication with
Sample size and sampling procedure: The sample trainers and program managers.
size was calculated using a single population formula.
The assumptions followed were the prevalence of Resources: trainees were asked to rate the resources
effectiveness of LMG training (p) is 50% (where, p=0.5, including training materials, tools, and any additional
q=0.5), allowing 5% for expected margin of error materials used to assist trainees during the training
(d), 95% confidence level (Z α/2=1.96), 25% for non- sessions

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Result Effectiveness and efficiency of LMG trainings

Socio-demographic characteristics: Out of two- The mean pretest score with SD was 44.9% ± 15.5%.
hundred ninety-three participants, 35.1% were from The post-test score was 78.1% ± 14.2%, which showed
SNNP, 28.0% were from Oromia, 26.3% were from a significant gain in knowledge at post-test with t=-
Amhara, and 10.6% were from Tigray regions were 35.9, df=292, p<0.001. In this study, 80.9% (237) of
enrolled. The majority, 75.8% of the participants were trainees scored greater or equal to 70.0% on post-
male. The mean age of participants with standard tests. The majority, 252 (86.0%) of trainees achieved
deviation (SD) was 29.9 ± 6.9 years. Among LMG 80.0% or more on their leadership projects. As a
trainees, 60.8% had attended the segmented LMG result of these projects, 2,290.6 units of heath service
training approach, while the rest, 39.2% had attended coverage was gained. The average net gain by each
the block LMG training approach. entity was 16.5 (95% CI: 12.2, 20.8) with SD (± 17.5)
units. The result gained, with paired sample t-test t=
LMG trainee evaluations: The figure1 illustrates -12.28, df= 292, p<0.001, was statistically significant.
the results of the LMG trainee evaluations using three Table 1 presents the beta (β) coefficient from the
independent and two dependent variables. The general linear models for LMG training effectiveness,
lowest average score was 3.8 ± 0.8 for time assessment unadjusted score with 95% confidence interval (CI)
variables. While the highest average score was 4.3 ± for communication was β 0.127(0.048, 0.175), and
0.6 for effectiveness assessment variables. resources was β 0.473 (0.419, 0.527), p <0.05. The
following (1) & (2) final models of effectiveness and
efficiency were developed.

Efficiency 4.27 • Effectiveness = 1.845 + 0.127*, Communication +

0.473*, Resources (1)
Effectiveness 4.30
• Efficiency = 1.507 + 0.351*, Resources + 0.214*,
Resource 4.12 Communication + 0.123* Time (2)

Communication 3.96 Return on investments

Time 3.82 Of the 136 projects implemented, 52 (38.5%) were

dedicated to improving skilled delivery services. The
3.00 3.50 4.00 4.50 projects invested $52,719.99 to gain an additional
2,290.6 health services coverage. The least investment-
Mean
per-unit-gained health service coverage was $19.20
for block LMG training approach; and the highest
Figure 1. Bar chart showing the average score of both depen- recorded investment was $34.60 for a segmented II
dent and dependent variables, September 2018
training approach (Table 2).

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Table 1: Linear regression coefficients, September 2018

Standardized
Model Unstandardized coefficients
coefficients T Sig.
B
Std. error Beta
(Constant) 1.848 .206 8.982 0.001
Time -.003 .040 -.003 -.064 0.949
Effectiveness (1)
Communication .128 .050 .152 2.554 0.011
Resources .474 .056 .497 8.537 0.000
(Constant) 1.845 .200 9.247 0.000
Effectiveness (2) Communication .127 .048 .151 2.652 0.008
Resources .473 .054 .496 8.733 0.001
(Constant) 2.010 .193 10.404 0.001
Efficiency (3)
Resources .549 .046 .571 11.857 0.001
(Constant) 1.656 .195 8.478 0.001
Efficiency (4) Resources .387 .053 .403 7.297 0.001
Communication .258 .047 .302 5.480 0.001
(Constant) 1.507 .198 7.610 0.001
Resources .351 .053 .366 6.578 0.001
Efficiency (5)
Communication .214 .048 .251 4.417 0.001
Time .123 .039 .164 3.173 0.002

Table 2, Return on investment of LMG training, September 20

Unit cost Unit cost /

Ser Number of Gains in Total cost /gained gained
Theme
no. projects coverages in USD coverages coverages
(ETB) (USD)
1 Program area
1.1 Delivery: maternal and neonatal health 53 714.7 23,524.70 905.18 32.92
1.2 Antenatal care: maternal and neonatal health 20 372.6 60,38.37 445.67 16.21
1.3 Postnatal care: maternal and neonatal health 2 24 358.71 411.02 14.95
1.4 Family planning 25 466.6 9,649.89 568.74 20.68
1.5 Health systems 25 355.7 8,856.66 684.73 24.90
1.6 Child health and immunization 5 97 1,486.83 421.52 15.33
1.7 Community-based health insurance 4 178 1,681.87 259.84 9.45
1.8 Other (malaria and tuberculosis prevention/control) 2 82 1,122.96 166.93 13.69
1.9 Overall leadership projects 136 2,290.6 52,719.99 632.93 23.02
2 Regions
2.1 Amhara 37 607.3 13,480.22 610.42 22.20
2.2 Oromia 34 564.9 17,836.56 868.30 31.57
2.3 SNNP 43 830.0 15,541.05 514.91 18.72
2.4 Tigray 21 288.4 5,862.15 558.98 20.33
3 Training approaches
3.1 6-day block basic LMG training 58 1,045.3 20,074.00 528.11 19.20
3.2 Segmented I: two 3-day basic LMG trainings 60 1,062.7 26,328.14 681.31 24.77
3.3 Segmented II: two 3-day basic LMG trainings 17 182.6 6,317.85 951.48 34.60

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Discussion The Strength and limitations of the study

In 2007, the world health organization (WHO) The study has demonstrated the need to evaluate
recommended a framework for strengthening health training for evidence-based decision-making. In
systems and improving health outcomes through addition, it used various data sources which can help
synergetic interventions [8]. This study documented to triangulate generated information. As a cross-
the results of 293 LMG trainees who developed and sectional study, the study has limitations to claim
implemented 136 leadership projects in Ethiopia [9]. causal relationships. Since the data collection was
The evidence generated on the effectiveness and made after completing the training and practical
efficiency of the LMG training evaluations enables exercises on leadership projects, there might be
policymakers, program managers, and health recall bias. The study was conducted only in USAID
professionals to decide on training approaches and Transform: Primary Health Care project targeted sites,
contents based on evidence. which signifies the need interpreted based on the
context.
In this study, the effectiveness of the basic LMG
training was assessed by measuring the knowledge, Conclusions and recommendations
skills, and behavioral patterns of trainees within
primary healthcare facilities [10]. The trainees have Both the block and segmented LMG training were
completed the LMG training successfully. This result found to be effective in imparting knowledge and
was also attributed to the implementation of multi- skills for staff to lead, manage and govern primary
faceted interventions, which ranged from classroom health entities. However, the block LMG training
training to leadership-project implementation, and approach was much more effective and efficient than
onsite coaching by experts (11). The findings also the segmented training approaches regarding time,
concur with La Rue et al. (2012), who compared communication, and resources utilized during the
leadership exposed and non-exposed groups and sessions. Therefore, scaling up of block LMG training
revealed higher and statistically significant differences to reach more health workers and primary health care
in health service coverage in the first group (12). units is recommended.

Effectiveness and efficiency were computed against

time, communication, and resources dedicated to
the training. The results of this study revealed that
resources and communication had a statistically
significant positive impact on the effectiveness of
the LMG training. Moreover, an increase of health
services coverage by one unit or percent required an
investment of 23.02 USD from the project. This study
indicates that block basic LMG training was more
effective and efficient than the segmented training
approaches.

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References

1. UN General Assembly, Transforming our world: the 2030 8. World Health Organization. Everybody’s business--
Agenda for Sustainable Development, 21 October 2015, A/ strengthening health systems to improve health outcomes:
RES/70/1 WHO’s framework for action. World Health Organization;
2007.
2. Rauscher M, Walkowiak H, Djara MB. Leadership,
Management, and Governance Evidence Compendium. 9. USAID Transform Primary Health Care Project . Theory of
Management Sciences for Health, 2018. Change in Practice 2017. USAID TPHC: Addis Ababa 2017.

3. Armstrong M. Armstrong’s handbook of performance 10. Tetui M. Participatory approaches to strengthening

management: An evidence-based guide to delivering high district health managers’ capacity: Ugandan and global
performance. Kogan Page Publishers; 2009 Sep 3. experiences (Doctoral dissertation, Umeå universitet):
2018.
4. Bayou B, Hailu T, Jenberie A, Minalu Y, Tesfamichael T.
Transforming primary health care unit service delivery 11. Desta BF, Abitew A, Beshir IA, Argaw MD, Abdlkader S.
through leadership, management and governance (LMG) Leadership, governance and management for improving
training: a field action report from Ethiopia. Ethiopian district capacity and performance: the case of USAID
Journal of Health Development. 2020;34(2). transform: primary health care. BMC family practice. 2020
Dec;21(1):1-7.
5. Federal Ministry of Health (FMOH). Leadership,
Management and Governance In-Service Training Manual 12. La Rue KS, Alegre JC, Murei L, Bragar J, Thatte N, Kibunga
for Health Managers at Hospitals and Health Centers. P, Cheburet S. Strengthening management and leadership
FMOH: Addis Ababa. 2017. practices to increase health-service delivery in Kenya: an
evidence-based approach. Human resources for health.
6. Galer JB, Vriesendorp S, Ellis A. Managers Who Lead: a
2012 Dec;10(1):1-7.
handbook for improving health services. Cambridge:
Management Sciences for Health (Firm); 2005.

7. Kirkpatrick JD, Kirkpatrick WK. Kirkpatrick’s four levels of

training evaluation. Association for Talent Development;
2016 Oct 1.

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 Time to Recovery and Predictors of Survival among Asphyxiated Neonates
Admitted in Addis Ababa Public Hospitals, 2021

Fekadeselassie Belege1*, Girum Sebsbie1, Mekonen Adimasu1, Natnael Moges2, Zebenay

Workneh3, Dessalegne Abebaw3, Dires Birhanu4, Shiferaw Abeway5
1
Addis Ababa University, College of Health Sciences, Addis Ababa, Ethiopia.
2
Debre Tabor University, College of Health Sciences, Debre Tabor, Ethiopia.
3
St. Paul’s Hospital Millennium Medical College, Addis Ababa, Ethiopia.
4
Dilla University, College of Health Sciences, Dilla, Ethiopia.
5
Wollo University, College of Medicine and Health Sciences, Dessie, Ethiopia.
*Correspondence: [email protected],

ABSTRACT

Background: Globally, perinatal asphyxia (PNA) is a major cause of morbidity and mortality among newborns. It is
a major concern in resource-constrained countries like Ethiopia. Thus, researches on survival status and determinants of
perinatal asphyxia are critical to tackling the effect of PNA. Therefore, this study is intended to determine survival status
and predictors of asphyxia among neonates admitted to public hospitals in Addis Ababa, Ethiopia.

Methods: Hospital-based retrospective follow-up study was conducted in four selected public hospitals of Addis
Ababa. Kaplan-Meier survival curve, log-rank test, and median time were computed. The cox-proportional hazards
regression model was fitted to identify predictors.

Result: Four hundred eleven babies admitted asphyxiated babies followed for 3062 neonate-days. Overall
incidence rate of survival was 10 (95% CI: 0.08-0.11) per 100 neonate-days with a median recovery time of 8 days (95%
CI: 7.527- 8.473). Low-birth weight (AHR: 0.67, 95% CI: 0.47- 0.96), stage II Hypoxic-ischemic encephalopathy (AHR: 0.70,
95% CI: 0.51 - 0.97), stage III Hypoxic-ischemic encephalopathy (AHR: 0.44, 95% CI: 0.27 - 0.71), seizure (AHR: 0.61, 95% CI:
0.38 - 0.97), thrombocytopenia (AHR: 0.44, 95% CI: 0.24 - 0.80) and not administering calcium-gluconate (AHR: 0.75, 95%
CI: 0.58 - 0.99) were found independent predictors of recovery time of asphyxiated neonates.

Conclusion: In the current findings, the recovery time was prolonged compared to other findings. This implies
early prevention, strict monitoring, and taking appropriate measures timely is mandatory before babies are transferred
to the highest stage of HIE and managing complications are recommended to hasten recovery time and increase survival
of neonates.

Keywords: Perinatal-asphyxia, Predictors, Survival-status

Background
much less common, particularly in developed
Perinatal Asphyxia occurs during the perinatal period countries, and became a rare diagnosis in the average
due to a lack of oxygen flow to the fetus or infant, which nephropathology laboratory. However, APSGN still
may lead to ischemia of the brain or other organs (1) remains a frequent form of glomerulonephritis in
APSGN has been extensively studied, and we learned third-world countries, particularly in areas where
a tremendous amount of information about the the disease occurs in epidemics. In this chapter,
pathogenesis of immune complex glomerulonephritis we review the pathogenesis, clinical presentation,
through these studies. In recent decades, after renal biopsy findings, morphologic differential
the widespread use of antibiotics, APSGN became diagnosis, and clinicopathologic correlations of

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APSGN.”,”author”:[{“dropping-particle”:””,”family”:”R. random sugar, AST, ALT, and creatinine level within

KLIEGMAN, J. ST. GEME, B. stanton”,”given”:”N. schor the first day of postnatal age.
(eds. Although global infant mortality has been
progressively reducing for the past two decades, Of the total participants, 305 (74.2%) asphyxiated
progress in Sub-Saharan Africa has been slow. neonates have recovered or been discharged alive
Perinatal asphyxia is a major cause of newborn from NICUs and 106 (25.8%) were censored. Among
deaths in the Sub-Saharan Africa region (2). In censored neonates, 99 (24.09%) died, 6(1.5%) have
developing countries, only 23% of asphyxiated babies left against medical advice and one (0.24%) was lost
have a chance of survival (3). However PNA is highly follow-up. The estimated cumulative probability of
prevalent in Ethiopia, studies on recovery rate and survival was 99 %, 96 %, 63 %, 20 %, 6 % and 4 % at
predictors are scant. Therefore, this study aimed to 1,3,7,14,21 and 28 days, respectively.
determine survival status and predictors of recovery
time of asphyxiated neonates. Findings from the multi-variable analysis showed
that LBW, HIE stages, thrombocytopenia, seizure,
Methods and calcium gluconate were identified predictors
for recovery time from asphyxia (table 1). Low birth
A hospital-based retrospective follow-up study was weight neonates were found 33% less likely to recover
conducted in four randomly selected public hospitals faster from asphyxia compared to those with normal
of Addis Ababa, Ethiopia. Data were collected from birth weight (AHR: 0.67, 95% CI: 0.47- 0.96).
February 15 to March 15, 2021, by reviewing 435
medical charts of asphyxiated neonates who were The time of recovery was slower or prolonged when
registered from January 2016 to December 2020. the stage of HIE stages increase. Neonates diagnosed
The proportional allocation formula was used to with HIE stage II had 30% decrement and HIE stage III
select study participants from each hospital and had 56% decrement in survival compared to Stage I
each year. Epi-data version 4.6 and STATA Version 16 HIE babies (AHR: 0.70, 95% CI: 0.51 - 0.97) and (AHR:
were used for data entry and analysis. Bi-variable and 0.44, 95% CI: 0.27 - 0.71), respectively. Neonates who
multivariable cox-regression hazards models were developed thrombocytopenia were 56% less likely to
fitted to identify predictors of time to recovery. recover earlier than those who had normal platelet
count (AHR: 0.44, 95% CI: 0.24 - 0.80). Similarly,
Result and discussion neonatal seizures that appear within 24 hours of
postnatal age were 39% and neonatal seizures that
Four hundred thirty-five charts of asphyxiated appear after 24 hours of postnatal age were 31%
neonates were reviewed of which; 411(94.48%) were lower probability to recover faster compared to
eligible in this study. Out of the total cohort, 411 neonates who had not experienced a seizure (AHR:
(60.58%) were males. Most of the newborns (70%) 0.61, 95% CI: 0.38 - 0.97) and (AHR: 0.69, 95% CI: 0.49
had normal birth weight and 25.6% had low birth - 0.97), respectively. Neonates who received calcium
weight with a mean weight of 2.82 ± 0.65 kg. Nearly gluconate through the intravenous fluid within 1st day
(15.3%) were preterm and 37(9%) were post-term. of life were hastened recovery time by 25% (AHR: 0.75,
The most frequently identified additional medical 95% CI: 0.58 - 0.99).
complications at admission among asphyxiated
newborns and during their hospital stays were Proportional hazard assumption was checked by
hypothermia (86.13%), followed by respiratory distress using Schoenfeld’s residuals global test. The findings
(51.82%), MAS (64.96%), hypoglycemia (4.62%), sepsis indicated that all individual variables included in the
(36.9%) and seizure disorders (23.1%). The mean WBC model were satisfied PH assumptions (p-value > 0.05)
count and HCT level were high in censored babies and (Global test for Cox proportional hazard P-Value
than survived (21.74 ± 1.7 Vs 19.37 ± 0.58) and (55 ± 1.4 = 0.393 > 0.05).
vs 53.74 ± 0.6), respectively. On the contrary, the mean
platelet count was lower in censored babies (171.62
± 12 vs 196.76 ± 4.9) than survived babies. The mean
serum sodium and calcium level in censored babies
were lower than survived but higher in Potassium,

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Table 1, Bivariate and Multivariate Cox regression analysis results of Asphyxiated babies who were admitted at NICUs of Addis Ababa
public hospitals, Ethiopia, 2021 [n=411]

Covariates CHR (95% CI) P-value AHR (95% CI) P- value

Maternal Age
20 – 34 years 1 1
<20 years 0.94(0.58 – 1.52) 0.812 1.22(0.73 - 2.04) 0.455
>34 years 1.34(0.92 – 1.94) 0.120 1.28(0.85 - 1.95) 0.241
Place of residency
Addis Ababa 1 1
Out of Addis Ababa 0.78(0.58 – 1.05) 0.105 0.89(0.64- 1.23) 0.479
Mode of delivery
SVD 1 1
Assisted delivery 0.92(0.66 – 1.27) 0.621 0.89(0.62 - 1.26) 0.506
C/S delivery 0.81(0.62 – 1.04) 0.107 0.89(0.66 - 1.19) 0.418
Prolonged labor
No 1 1
Yes 1.26(0.92 – 0.74) 0.142 1.21(0.85 -1.71) 0.292
Birth weight
Normal 1 1
Big baby 1.16(0.71 – 1.91) 0.554 1.24(0.70 - 2.19) 0.454
Low birth weight 0.63(0.48 - 0.83) 0.001 0.67(0.47 - 0.96) 0.029 *
Gestational Age
Term 1 1
Post term 0.60(0.42 – 0.85) 0.004 0.96(0.61 - 1.50) 0.841
Preterm 0.87(0.59 -1.29) 0.494 0.93(0.59 - 1.46) 0.753
Age at presentation
<24 hours 1 1
24 – 72 hours 0.82(0.49 – 1.38) 0.470 0.45(0.16 - 1.23) 0.121
>72 hours 0.45(0.22 - 0.92) 0.031 0.64(0.28 - 1.43) 0.275
Fifth minutes APGAR
>7 1 1
<7 0.81(0.64 - 1.03) 0.091 1.03(0.78 - 1.35) 0.838
HIE stage
Stage 1 1 1
Stage 2 0.51(0.40 -0.66) 0.000 0.70(0.51 - 0.97) 0.033 *
Stage 3 0.27(0.19 - 0.40) 0.000 0.44(0.27 - 0.71) 0.001 *
Altered Consciousness
No 1 1
Yes 0.59(0.47 - 0.74) 0.000 0.97(0.72 - 1.30) 0.837
Depressed Moro reflex
No 1 1
Yes 0.49(0.39 - 0.62) 0.000 0.79(0.57 - 1.10) 0.164
Sepsis
No 1 1
Yes 0.85(0.67 - 1.07) 0.164 0.83(0.64 - 1.07) 0.143

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Covariates CHR (95% CI) P-value AHR (95% CI) P- value

Seizure
No 1 1
Yes, before 24hours 0.55(0.36 - 0.85) 0.006 0.61(0.38 - 0.97) 0.036 *
Yes, after 24 hours 0.67(0.49 - 0.92) 0.013 0.69(0.49 - 0.97) 0.034 *
Meconium aspiration syndrome
No 1 1
Yes 0.83(0.65 - 1.05) 0.121 0.89(0.68 - 1.16) 0.386
Hyperbilirubinemia
No 1 1
Yes 0.76(0.51 - 1.14) 0.191 1.28(0.81 - 2.01) 0.285
Necrotizing Enterocolitis
No 1 1
Yes 0.46(0.24 - 0.91) 0.025 0.64(0.30 - 1.36) 0.245
Acute kidney injury
No 1 1
Yes 0.69(0.40 - 1.18) 0.171 0.90 (0.49 - 1.64) 0.726
Thrombocytopenia
No 1 1
Yes 0.45(0.26 -0.75) 0.003 0.44(0.24 - 0.80) 0.007 **
Aminophylline
No 1 1
Yes 0.48(0.26 -0.89) 0.019 0.80(0.40 - 1.58) 0.515
Oxygenation
No 1 1
Yes 0.57(0.40 - 0.82) 0.002 0.69(0.45 - 1.07) 0.095
Resuscitation at delivery
No 1 1
Yes 0.80(0.60 - 1.07 0.134 1.00(0.71 - 1.41) 0.994
Ca gluconate
±±

Yes 1 1
No 0.61(0.48 - 0.79) 0.000 0.75(0.58 - 0.99) 0.039 *

Conclusion and Recommendation to hasten recovery time and increase survival of

neonates.
In conclusion, the overall incidence rate of survival
was 10 per 100 neonates-day observations with a Reference
median recovery time of 8 days. This indicates the
recovery time was prolonged. Those neonates who 1. R. KLIEGMAN, J. ST. GEME, B. stanton N schor (eds). Nelson
had low birth weight, stages of HIE, occurrence textbook of PEDIATRICS. 21th Edition. 2020. 3944–60 p.
seizure, thrombocytopenia, and taking of calcium 2. Usman F, Imam A, Farouk ZL, Dayyabu AL. Newborn mortality
gluconate in the first day of life were identified as in sub-Saharan Africa: Why is perinatal asphyxia still a major
a predictor for the survival time of asphyxiated cause? Ann Glob Heal. 2019;85(1):2.
newborns. Hence, early prevention, strict monitoring,
3. Halloran DR, McClure E, Chakraborty H, Chomba E, Wright LL,
and taking appropriate measures timely is mandatory
Carlo WA. Birth asphyxia survivors in a developing country. J
before babies are transferred into the highest stage of
Perinatol. 2009;29(3):243–9.
HIE, and managing complications are recommended

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Maternal and Child Health Service Uptake amid COVID-19 in Public Health
Facilities and Lessons Learned

Abrham Dullo 1 *, Mebratu Kebede 2, Malede Birara 3, Abreham H/Mariam 4

1
St. Paul’s Hospital Millennium Medical College, Research Directorate, Addis Ababa, Ethiopia
2
St. Paul’s Hospital Millennium Medical College, Research Directorate, Addis Ababa, Ethiopia
3
St. Paul’s Hospital Millennium Medical College, Obstetrics and Gynecology, Addis Ababa, Ethiopia
4
VSO Ethiopia, Addis Ababa, Ethiopia
*Correspondence: [email protected]

ABSTRACT

Background: Understanding the effect of the COVID-19 pandemic on the maternal, child health services and
documenting the lessons learned during the pandemic would have paramount importance in the early preparation of
strategies robust to future situations before the services are negatively affected.

Objective: To assess the impact of the COVID 19 pandemic on the pattern of reproductive, maternal, child health
services and explore lessons learned at the public health facilities of Addis Ababa, Ethiopia

Methods: A mixed design, institution-based cross-sectional triangulated with qualitative phenomenological

methods, was used. A randomly selected 25 public health facilities from five sub-cities and a purposively selected 9
policymakers, 15 providers, 10 facility directors, and 15 clients were included. RMNCH related performance of selected
health facilities pre-COVID 19 periods from March to November 2019 and during Covid-19 from March to November 2020
in Ethiopia was collected by using structured Microsoft excel data extraction forms. The qualitative data were collected
by in-depth interview using an interview guide. Open Code 4.03 software was used to code and categorize qualitative
data. Quantitative data were entered and analyzed using SPSS version 23.

Result: 80% of the studied facilities were health centers and 24 (96%) have COVID-19 isolation units. During the
pandemic, Child vaccination like BCG, Polio 0, Penta3 services showed a decline in 31.9%, 4.8%, and 28.2% respectively
compared with the same months of the pre-COVID 19 era. Further, vitamin-A and measles doses which were administered
at fifteen months were decreased by 11.4% and 3.8% respectively. The qualitative finding prevails the COVID 19 Pandemic
has challenged women in seeking MCH services, hindered providers from practicing compassionate care, created
service interruptions, challenged the quality of MCH service with scheduling follow-ups for ANC and child vaccination,
exacerbated medication and supply problems during the pandemic.

Conclusion: COVID-19 had a significant negative impact on reproductive, maternal, and child health service
uptake at the nine months during COVID 19 compared with the same months before the pandemic.

Keywords: COVID-19, RMNCH, Impact, Ethiopia

Introduction SARS-CoV-2 remains the only best strategy to reduce

the risk of infection. Despite the implementation of
Since the onset of the novel coronavirus epidemic in social distancing, emerging evidence indicates that
Wuhan, China in late December 2019 it has spread contagion is worse when healthcare is centralized
rapidly throughout the world reaching a pandemic (3,4,5,6).
state (1). For this reason, the international community
is mobilizing to limit the spread of severe acute The COVID-19 pandemic caused significant disruption
respiratory syndrome coronavirus 2 and reduce of essential health services especially in sub-Saharan
mortality from COVID-19 (2). Minimizing exposure to Africa (7). Already over-stretched health systems of

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different countries are likely to be further challenged method were employed. The study populations were
in the context of COVID-19 preparedness and all the public health facilities that provide RMNCH
response, causing risk of disruptions in essential services in Addis Ababa. In addition, for the qualitative
health and nutrition services (8, 9). So, simultaneously component, purposively selected facility directors,
engaging in strategic planning and coordinated RMNCH service providers, policymakers, RMNCH
action to maintain essential health service delivery service recipients/clients of the selected health
and mitigating the risk of system collapse is necessary facilities were available during the study period.
(10). Also, given the high burden of maternal and
neonatal mortality in sub-Saharan Africa, there is The study considers the months from March to Nov
an urgent need for innovative strategies to prevent 2019 as a pre-COVID 19 in Ethiopia and the same
the deterioration of maternal and child outcomes in months of the COVID 19 period after the confirmation
already strained health systems (2). of COVID 19 case in Ethiopia March to Nov 2020 to track
intuitional RMNCH performance on vaccine coverage,
The decline in service uptake may be attributable to Under 5 OPD cases, PMTCT, ANC1, ANC 4, institutional
restricted access to health facilities arising from city delivery, Delivery (CS), PNC, Safe abortion, and Post-
lockdowns and curfews imposed by the government, abortion care and vaccine coverage.
where pregnant women and their companions fear
harassment and arrest. In addition, fear of contracting Purposively selected 9 policymakers, 15 providers,
COVID-19 infection may keep many women from 10 facility directors, and 15 clients and randomly
attending reproductive health services (8, 11). selected 25 public health facilities for a quantitative
section from five sub-cities of Addis Ababa namely
Further, government directives and hospital policies Arada, Nisfasilk, Yeka, Kolfe, and Bole sub-cities
limit the number of family members accompanying were included for the current study. Open-Code 4.03
expecting women to hospitals and separation of software was used to code and categorize major
COVID-19-positive women from their newborns, findings from the respondents. Quantitative data
instead of room-in as usual for these mothers and were entered and analyzed using SPSS version 23.
newborns to prevent contagion (12).
Result
Evidence shows that separation disrupts the skin-to-
skin care and breastfeeding process and is associated 80% of the studied facilities were health centers and
with added physiologic stress to both the mother 52% were established before the 2000 Ethiopian
and infant (13, 14). However, there is limited data calendar and 24 (96%) have COVID-19 isolation units.
regarding the overall impact of COVID-19 on the
maternal, newborn, and child health care system Child vaccination like BCG, Polio 0, Penta3 services
at the study area as well as at the national level. showed a decline in the first three months of the
Therefore, the current study is aimed to fill the gap pandemic from March to May 2020 compared with
by assessing trajectories and lessons learned on the same months of the pre-COVID 19 era in 2019
reproductive maternal child health services from the by 31.9%,4.8%, and 28.2% respectively. In the same
COVID-19 pandemic at public health facilities of Addis fashion the overall nine-month before and during
Ababa, Ethiopia. the COVID-19 pandemic the vaccine coverage of the
study setting on BCG and polio-0 decreased has by
Objective 12.9%, and by 15.4% respectively compared to the
same duration of the period before the occurrence of
To assess the impact of the COVID 19 pandemic on the pandemic. Also, Polio-3 has decreased by 4.3%.
the pattern of reproductive, maternal, child health Further, vitamin-A and measles doses which are
services and explore stakeholders’ lessons learned at administered at fifteen months were decreased by
the public health facilities of Addis Ababa, Ethiopia 11.4% and 3.8% respectively compared with March to
November 2019. (Fig 1)
Methods

An institution-based cross-sectional health facility

assessment and phenomenological study qualitative

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Vaccine coverage before and during COVID-19

100000
2019 2020
80000

60000

40000

20000

0
BCG Polio-0 Polio-1 Polio-2 Polio-3 Penta-1 Penta-2 Penta-3 Vitamin-A Measle-9 Measle-15
month month

Figure 1, vaccine-related performance of selected health facilities in Addis Ababa, Ethiopia. March to November 2019 and March to
November 2020

The study identified a reduction in MCH service services were also decreased during the pandemic
uptake as shown below. under-five out-patient service season by 24.4% and 16.1% respectively. (Fig 2) On the
was decreased by half (48.3%) as compared with the other hand, the maternal, infant, and neonatal death
nine-month (March to November 2019) before the reports were lower than the Pre COVID 19 months.
pandemic. safe abortion and post-abortion care

Maternal & child health

200000

150000
2019 2020
100000

50000
0
Under 5 PMTCT ANC-1 ANC-4 SVD delivery CS delivery PNC Safe Post
year OPD abortion abortion
cases care

Figure 2: MCH related performance of selected health facilities in Addis Ababa, Ethiopia. March to November
2019 and March to November 2020

The majority of Interviewed respondents who were On the other hand, the deaths happening every day
service recipients, providers, and policymakers had in the world which was tracked and reported at every
been scared, terrified and so frustrated while they news time was shocking and had made everyone
heard about COVID 19 at the early stages of the panic.
pandemic. Providers were so curious about their
exposure and being prone to the virus because of their A Participant expressed the situation as follows
nature of work. The actions taken by the government
were serious, timely, and put everyone to be alert “the case and death reports on air during the
every time and it was difficult not to think of COVID news in all the broadcast was more frustrating
19 in daily life. than informative; this might be intentional to let
people take their measures but it has let us be
The qualitative findings reveal main reasons for the overstressed.”
decline in RMNCH services uptake included service
interruptions, lockdowns, clients’ fear of acquiring The qualitative finding prevails that the pandemic has
the infection, providers as a risk of COVID 19 infection, impacted the feeling of providers; it has challenged
and the stay-home messages misinterpretation by women in seeking MCH services, hindered providers
patients who follow-up at health facilities. from practicing CRC, created service interruptions,
challenged quality of RMNCH service with scheduling

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of follow-ups for ANC and child vaccination, 4. Nacoti M, Ciocca A, Giupponi A, Brambillasca P, Lussana F, Pisano M,

exacerbated medication and supply problems. a et al. At the epicenter of the Covid-19 pandemic and humanitarian

provider from hospital ‘‘ I remember in the first two crises in Italy: changing perspectives on preparation and mitigation.

weeks; a client appears with respiratory distress. She NEJM Catalyst Innov Care Del. 2020;1(2).

was managed as a COVID patient. The test result 5. Bahl P, Doolan C, de Silva C, Chughtai AA, Bourouiba L, MacIntyre
wasn’t known on time. We couldn’t treat her with a CR. Airborne or droplet precautions for health workers treating
mechanical ventilator without her result. She had an coronavirus disease 2019? J Infect Dis. 2020. https://doi.org/10.1093/
obstetric complication. She passed away on waiting infdis/jiaa189.
for the result. If there wasn’t COVID 19, she would be
6. Ministry of Health. Concern over Covid-19 infections within health
directed in ICU and not died.’’
care facilities Nairobi: Ministry of Health Kenya; 2020. https://www.

On the other hand, the pandemic was an opportunity health.go.ke/ concern-over-covid-19-infections-within-health-care-

to obtain lessons and improve practices. Some were facilities-nairobisaturday-june-27-2020/.

but not limited to improving disease prevention, 7. United Nations Population Fund. Reproductive, maternal,
creating a chance to be exposed in epidemic response newborn and adolescent health during pandemics. United Nations
team, sticking to infection prevention practices, Population Fund; 2020. https://reliefweb.int/sites/reliefweb.int/
strengthened support to solve infrastructure and files/resources/en-rmnah-web_2.pdf.
supply issues of health facilities like washing and
8. Elston, JWT, Cartwright, C, Ndumbi, P, & Wright, J. (2017). The health
sanitary, support of top managers, community
impact of the 2014–15 Ebola outbreak. Public Health, 143, 60-70.
mobilization and efficient use of a resource,
technology use for reporting and meetings using 9. Parpia, AS, Ndeffo-Mbah, ML, Wenzel, NS, & Galvani, AP. (2016).
social media and virtual methods. Effects of response to 2014–2015 Ebola outbreak on deaths from
malaria, HIV/AIDS, and tuberculosis, West Africa. Emerging infectious
Conclusion and recommendation: COVID-19 had diseases, 22(3), 433.
a significant negative impact on antepartum and
10. WHO. Covid-19: Operational Guidance for Maintaining
intrapartum care use, vaccine coverage, under-five
Essential Health Services During an Outbreak.https://www.
outpatient service deliveries activities.
humanitarianresponse.info/sites/www.humanitarianresponse.

The pandemic has brought challenges and info/files/documents/files/ jmo_who_strategicplanning-

opportunities to the health system that needs a operationalguidance_web11

robust infrastructure and resources ready to be ahead. 11. Delamou A, El Ayadi AM, Sidibe S, Delvaux T, Camara BS, Sandouno
Mitigation plans for service continuity and proper SD, et al. Effect of Ebola virus disease on maternal and child health
communications to address messages by responsible services in Guinea: a retrospective observational cohort study.
bodies are crucial. Lancet Glob Health. 2017;5(4):e448–e57.

References 12. Ministry of Health. A Kenya practical guide for continuity of

reproductive, maternal, newborn and family planning care and
1. Worldometer, COVID-19 Coronavirus pandemic, Last updated: services in the background of COVID-19 pandemic. 2020. https://
December 18, 2020, 07:26 www.health.go.ke/wpcontent/uploads/2020/04/KENYA-COVID19-
RMNH
2. Rachel Wangari Kimani, Rose Maina, Constance Shumba and Sheila
Shaibu, Maternal and newborn care during the COVID-19 pandemic 13. Moore ER, Bergman N, Anderson GC, Medley N. Early skin-to-
in Kenya: recontextualising the community midwifery model, skin contact for mothers and their healthy newborn infants.
Human Resources for Health (2020) 18:75 https://doi.org/10.1186/ Cochrane Database Syst Rev. 2016;11(11):CD003519-CD https://doi.
s12960-020-00518-3 org/10.1002/14651858.CD003519.pub4.

3. MacIntyre CR, Chughtai AA. A rapid systematic review of the efficacy 14. Widström AM, Brimdyr K, Svensson K, Cadwell K, Nissen E. Skin-
of face masks and respirators against coronaviruses and other to-skin contact the first hour after birth, underlying implications
respiratory transmissible viruses for the community, healthcare and clinical practice. Acta paediatrica (Oslo, Norway: 1992).
workers and sick patients. Int J Nurs Stud. 2020;103629. 2019;108(7):1192-20410.1111/ apa.14754.

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Introduction of a Modified WHO Safe Childbirth Checklist in Health Centers of
Ethiopia: A Pre-and-Post Introduction Study

Haile Mariam Segni 1 *, Zergu Tafesse 1, Binyam Fekadu 1, Tsega Teferi 1, Haregewoin
Getachew 1, Zebyderu Tesfay 1, Zenawork Kassa 1, Ismael Ali 1
1
JSI/Transform: Primary Health Care Activity, Ethiopia.
*Correspondence: [email protected]

ABSTRACT

Background: Checklists are useful tools to remember steps of complex childbirth processes. The WHO safe
childbirth checklist is a tool used to improve the quality of care for women giving birth. The checklist was modified by
the Ministry of Health of Ethiopia and was introduced to selected health centers in the country by the USAID Transform:
Primary Health Care Activity.

Methods: A pre and post-intervention study design with prospective data collection were employed. The availability
of essential childbirth supplies and adherence of health care providers to essential birth practices were compared for the
pre and post-intervention periods. The pre and post-intervention assessments were conducted in 247 and 187 health
centers respectively.

Results: A statistically significant improvement from 63.6% pre intervention to 83.5% post intervention was
observed in the availability of essential childbirth supplies, t (389.7) = -7.1, p=0.000. Improvements in adherence of health
care providers to essential childbirth practices were observed with the highest being at pause point three (26.2%, t (306.3)
= -10.6, p=0.000) followed by pause point four (21.1%, t (282.5) = -8.0, p=0.000), and pause point two (18.2%, t (310.8) = -9.7,
p=0.000). The least and statistically non-significant improvement was observed at pause point one (3.3%, t (432.0) = -1.5,
p=0.131).

Conclusion: Improvement in the availability of essential childbirth supplies and adherence of health care providers
towards essential childbirth practices was observed after the introduction of a modified WHO safe childbirth checklist.
Scale-up of the use of the checklist is recommended.

Keywords: Safe Childbirth Checklist, Essential Childbirth Supplies, Essential Childbirth Practices.

Background
that organize such complex and important processes
Globally, maternal mortality is unacceptably high with (3, 4). The World Health Organization (WHO) safe
most of the deaths being potentially preventable and childbirth checklist (SCC) is one of these tools, used
occurring in low- and middle-income countries (1). to improve the quality of care provided to women
Around 75% of all maternal deaths are due to severe during childbirth and in the hours afterward. It is
bleeding, infections, high blood pressure during a well-organized list of evidence-based essential
pregnancy, complications from delivery, and unsafe birth practices (EBPs) which focus on top causes of
abortions (2). maternal deaths, intrapartum-related stillbirths, and
early neonatal deaths (5).
Childbirth is a complex process, and it is essential
to remember to provide everything that is needed In Namibia, the use of the WHO SCC showed an
to ensure both the mother and newborn receive the improvement in average EBPs delivered from 68% to
safest care possible. Checklists are essential tools 95% (6). In Rajasthan, India, the use of the WHO SCC

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increased providers’ performance of best practices, print outs of the checklist were distributed to the
reflecting improvements in the quality of facility clusters. The cluster staff then conducted onsite
childbirth care for women and newborns (7). In Uttar orientations to health care providers, distributed the
Pradesh, India, birth attendants’ adherence to EBPs checklists, and collected pre-intervention assessment
was higher in facilities that used the coaching-based data. The pre-intervention data were collected by
WHO SCC program than in those that did not (8). In interviewing one health care provider per facility
Aceh, Indonesia, the use of the WHO SCC improved the and directly observing the facility for the presence
quality of maternal care and overall birth experiences of essential childbirth supplies. Regular, one-day
(9). mentoring visits were carried out every three months.
The mentors used orientation materials prepared for
The WHO SCC was modified by the Ministry of Health the purpose, the WHO SCC implementation guide,
(MoH) of Ethiopia and the USAID Transform: Primary and copies of the checklist to practice, discuss and
Health Care Activity has introduced it to its intervention fix technical and supply-related gaps. The post-
health centers. As it is a new recommendation, this intervention assessment was conducted a year later
study is carried out to generate local evidence to using the same assessment tool and the same way of
guide the potential further use of the checklist. data collection as in the pre-intervention. Adherence
to practices was assessed through interviews of
Objectives providers by asking whether they carried out the EBPs
mentioned in the modified WHO SCC or not.
The objective of this study was to assess the pre
and post-intervention changes in the availability of Results and Discussion
essential childbirth supplies and adherence of health
care providers to essential childbirth practices. Data were collected from 247 and 187 health centers
during the pre and post-intervention periods,
Methods respectively. A Welch t-test was run to determine if
there were differences in adherence of health care
Setting: The assessment was conducted in health
providers to EBPs between pre and post interventions
centers within four regions of the country (Amhara,
and an independent-samples t-test was run for
Oromia, SNPP, and Tigray) where USAID Transform:
variables that met the homogeneity assumptions.
Primary Health Care Activity has been operating since
January 2017. A statistically significant improvement from a pre-
intervention score of 63.6% to 83.5% post-intervention
Design: A health facility-based pre and post-
was observed in the availability of essential childbirth
intervention study design with prospective data
supplies in selected health centers of Ethiopia one
collection was employed.
year after the introduction of the modified WHO SCC,
Intervention: One cluster per region was selected t (389.7) = -7.1, p=0.000 (table 2). The changes in the
purposively as utilization of WHO SCC had not yet availability of essential childbirth supplies observed
started at health centers of the selected clusters. A in this study are similar to the findings of another
similar structured assessment tool was used for both study conducted in Uttar Pradesh, India which
pre and post-intervention assessments where data is a comparable setup with where this study was
on the availability of essential childbirth supplies conducted (11, 12).
and adherence of health care providers to EBPs were
A statistically significant improvement in the
collected. In the modified checklist, some items of
adherence of health care providers to EBPs was
the original WHO SCC were removed while some were
observed post-intervention which was one year
added, (table 1). In September 2017, an orientation
after the introduction of the modified WHO SCC.
on the modified WHO SCC was conducted for data
The highest level of improvement was observed at
collectors and mentors (one regional officer per region
pause point three (26.2%, t (306.3) = -10.6, p=0.000)
and three to five cluster officers per cluster, who are
followed by pause point four (21.1%, t (282.5) = -8.0,
master of public health degree holders with midwifery,
p=0.000) and pause point two (18.2%, t (310.8) = -9.7,
nursing, or public health officer backgrounds) and
p=0.000). The least and statistically non-significant

35
2013 EFY (2020/2021)
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improvement was observed at pause point one (3.3%, 8. Semrau KE, Hirschhorn LR, Marx Delaney M, et al.;
t (432.0) = -1.5, p=0.131) (table 3). The magnitude of BetterBirth Trial Group. Outcomes of a coaching-based
increment in adherence of health care providers to WHO safe childbirth checklist program in India. N Engl J
EBPs from the pre to post-intervention was found to Med. 2017 Dec;377(24):231324.
be similar with findings from studies at other similar 9. Siobhan Doria, Farah Diba, Suryane S. Susanti, Sebastian
settings of the world (13-16). Vollmer, and Ida G. Monfared. Mothers’ experiences of the
quality of care and potential benefits of implementing
Conclusion and Recommendation
the WHO safe childbirth checklist: a case study of Aceh

Improvements in the availability of essential childbirth Indonesia. BMC Pregnancy and Childbirth (2019) 19:461.

supplies at labor, delivery, and postnatal care units 10. Tuyishime E, Park PH, Rouleau D, Livingston P, Banguti PR,
and adherence of health care providers towards Wong R. Implementing the World Health Organization safe
EBPs were observed a year after the introduction of childbirth checklist in a district Hospital in Rwanda: a pre-
a modified version of the WHO SCC at health centers and post-intervention study. Maternal health, neonatology,
of Ethiopia. Scale-up of the use of the modified WHO and perinatology. 2018;4(1):7.
SCC is recommended.
11. G. Galvin, L. R. Hirschhorn, M. Shaikh, et al. Availability of

References Safe Childbirth Supplies in 284 Facilities in Uttar Pradesh,

India Maternal and Child Health Journal (2019) 23:240–249.
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national levels and trends in maternal mortality between et al. Effectiveness of a WHO Safe Childbirth Checklist
1990 and 2015, with scenario-based projections to 2030: a Coaching-based intervention on the availability of Essential
systematic analysis by the UN Maternal Mortality Estimation Birth Supplies in Uttar Pradesh, India. International Journal
Inter-Agency Group. The Lancet. 2016;387(10017):462-74. for Quality in Health Care, 2018, 30(10), 769–777.
2. Say L, Chou D, Gemmill A, et al. Global causes of maternal 13. H. M. Senanayake, M. Patabendige, R. Ramachandran.
death: a WHO systematic analysis. The Lancet Global Experience with a context-specific modified WHO safe
Health. 2014;2(6):e323-e33. childbirth checklist at two tertiary care settings in Sri Lanka.
3. Lee SH, Nurmatov UB, Nwaru BI, Mukherjee M, Grant L, BMC Pregnancy and Childbirth 2018, 18: 411.
Pagliari C. Effectiveness of mHealth interventions for 14. M. Patabendige, H. Senanayake. Implementation of the
maternal, newborn and child health in low–and middle– WHO safe childbirth checklist program at a tertiary care
income countries: Systematic review and meta–analysis. setting in Sri Lanka: a developing country experience. BMC
Journal of global health. 2016;6(1). Pregnancy and Childbirth 2015, 15:12.
4. Spector JM, Agrawal P, Kodkany B, et al. Improving quality 15. M. M. Delaney, P. Maji, T. Kalita, et al. Improving Adherence
of care for maternal and newborn health: prospective pilot to Essential Birth Practices Using the WHO Safe Childbirth
study of the WHO safe childbirth checklist program. PloS Checklist with Peer Coaching: Experience From 60 Public
one. 2012;7(5). Health Facilities in Uttar Pradesh, India. Global Health:
5. Funk KM, Axelrod S. A Review of:“Gawande, A.(2009). The Science and Practice 2017;5(2):217-31.
Checklist Manifesto–How to Get Things Right.” New York: 16. S. Albolino, G. Dagliana, D. Illiano, et al. Safety and quality
Metropolitan Books, 209 pp., Taylor & Francis; 2011. in maternal and neonatal care: the introduction of the
6. Kabongo L, Gass J, Kivondo B, et al. Implementing the modified WHO Safe Childbirth Checklist. Ergonomics, 61:1,
WHO Safe Childbirth Checklist: lessons learnt on a quality 185-193.
improvement initiative to improve mother and newborn
care at Gobabis District Hospital, Namibia. BMJ Open
Quality 2017;6: e000145.

7. S. Kumar, V. Yadav, S. Balasubramaniam, et al. Effectiveness

of the WHO SCC on improving adherence to essential
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settings. BMC Pregnancy and Childbirth (2016) 16:345.

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Annex
Table 1: List of items removed and added to the original WHO SCC in the development of the modified, Ethiopian version checklist.

Pause
points Items removed Items added
(PP)
“Quick check performed?”
PP-1 -----
“Antiretroviral medicine?”
PP-2 ----- “Antiretroviral medicine?”
“Is mother bleeding abnormally?”

“Does the mother need to start, Components of essential newborn care.

PP-3 List of both maternal and newborn danger
 Antibiotics?
signs.
 Magnesium sulfate and antihypertensive?”
“Confirm stay at the facility for 24 hours after delivery”
“Refer mother to three postnatal visits (6-24
PP-4 “Is mother’s blood pressure normal?” hours, 3 days, 7 days) and an immunization
visit at 6 weeks.”
“Is baby feeding well?”

Table 2: Pre and post-modified WHO SCC intervention changes on the availability of essential childbirth supplies at selected health
centers of USAID Transform: Primary Health Care Activity, 2017-2018.

Before After 95% CI for t df

Mean Differ-
M SD n M SD N P
ence
Availability of necessary
supplies in labor, delivery,
and postnatal rooms 63.6 33.0 247 83.5 22.5 150 -25.4, -14.4 -7.1* 389.7 0.000

Oxytocin 78.5 41.1 247 96.2 9.2 187 -23, -12.3 -6.5* 278.3 0.000
Intravenous fluids 76.1 42.7 247 96.6 6.3 187 -25.9, -15.0 -7.4 *
260.2 0.000
Antibiotics 65.6 47.6 247 91.9 11.0 187 -32.5, -20.1 -8.4 *
280.2 0.000
Magnesium sulfate 67.6 46.9 247 93.1 9.9 187 -31.6, -19.5 -8.3 *
274.4 0.000
Antiretroviral drugs 50.6 50.1 247 80.1 19.4 187 -36.3, -22.6 -8.4 *
335.6 0.000
Vitamin K 34.4 47.6 247 85.2 20.9 187 -57.4, -44.1 15.0 *
356.2 0.000
Tetracycline eye ointment 59.1 49.3 247 88.9 13.7 187 -36.3, -23.3 -9.1 *
295.0 0.000
Bacillus Calmette-Guerin 57.1 49.6 247 90.2 13.7 187 -39.7, -26.6 10.0* 294.4 0.000
vaccine
Oral Polio Vaccine 72.5 44.8 247 94.4 8.3 187 -27.7, -16.2 -7.5* 268.4 0.000
Gloves 74.9 43.4 247 95.5 7.2 187 -26.1, -15.0 -7.3 *
263.9 0.000
Syringes 77.3 42.0 247 95.7 6.8 187 -23.7, -13.0 -6.8 *
263.0 0.000
Soap 63.6 48.2 247 92.3 11.2 187 -35, -22.5 -9.0 *
280.6 0.000
Water 58.7 49.3 247 90.9 12.8 187 -38.6, -25.8 -9.8 *
288.6 0.000
Alcohol hand rub 54.7 49.9 247 87.6 16.1 187 -39.6, -26.3 -9.7 310.7 0.000
*

* p < .05, M=mean, SD=standard deviation, CI=Confidence interval, df=degree of freedom, n=preintervention sample size,
N=postintervention sample size.

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Table 3: Pre and post-modified WHO SCC intervention adherence of health care providers to essential birth practices at selected
health centers of USAID Transform: Primary Health Care Activity, 2017-2018.

Before After 95% CI for

Mean Differ- t df p
M SD n M SD N ence
Pause point 1 70.8 22.8 247 74.1 23.4 187 -7.8, 1.0 -1.5 432.0 0.131
Quick checks for danger signs per-
formed before referral/admission of 75.2 42.8 247 73.3 43.0 187 -6.3, 10 0.4 432.0 0.658
mothers
Functional referral linkages and feed-
back mechanisms for both mother 39.2 47.8 247 51.2 49.6 187 -21.3, -2.7 -2.5* 392.7 0.012
and newborn
Partograph being used for all labor-
81.3 38.1 247 82.5 37.1 187 -8.3, 6.0 -0.3 432.0 0.753
ing mothers at the facility
HIV testing and treatment services
for the mother and baby both during 87.4 33.2 247 89.6 30.3 187 -8.3, 3.9 -0.7 432.0 0.472
antenatal care and delivery
Pause point 2 71.2 27.5 247 89.4 8.9 187 -21.9, -14.5 -9.7* 310.8 0.000
Relatives are encouraged to accom-
pany laboring mothers during labor 92.5 26.0 247 98.1 12.6 187 -9.3, -1.8 -2.9* 374.8 0.004
and delivery
Essential supplies for the mother
63.0 44.9 247 85.9 12.6 187 -28.8, -17.0 -7.6* 295.4 0.000
kept at bed side before delivery
Essential supplies for the baby kept
58.0 40.3 247 84.1 12.6 187 -31.5, -20.8 -9.6* 306.8 0.000
at bed side before delivery
Pause point 3 61.2 36.7 247 87.4 11.4 187 -31.1, -21.3 10.6* 306.3 0.000
Placing baby in skin-to-skin contact 71.1 45.3 247 92.3 9.8 187 -27.1, -15.4 -7.1 *
275.7 0.000
Breast feeding initiated within one
hour of birth if mother and child are 71.6 45.1 247 92.7 9.3 187 -26.9, -15.3 -7.2* 273.1 0.000
well
Vitamin K given 1 mg intramuscular
43.1 49.5 247 77.8 21.0 187 -41.5, -27.7 -9.9* 350.7 0.000
on anterior mid-thigh
Tetracycline eye ointment given in
57.0 49.5 247 87.2 14.9 187 -36.8, -23.6 -9.1* 302.5 0.000
both eyes
Baby weighted and recorded 67.5 46.8 247 89.8 11.5 187 -28.4, -16.2 -7.2* 284.1 0.000
Bacillus Calmette-Guerin and oral
57.0 49.5 247 84.7 15.5 187 -34.4, -21.2 -8.3* 307.3 0.000
polio vaccines given before discharge
Pause point 4 69.9 40.2 247 91.0 9.6 187 -26.3, -15.9 -8.0* 282.5 0.000
Counselled on and offered family
71.8 44.9 247 92.3 9.4 187 -26.2, -14.7 -7.0* 273.9 0.000
planning
Exclusive breast feeding for 6 months 75.5 42.9 247 93.2 8.4 187 -23.2, -12.2 -6.3* 270.4 0.000
Immunization 69.4 46.0 247 91.7 10.3 187 -28.3, -16.4 -7.4 *
278.1 0.000
Hygiene 66.9 46.9 247 90.3 11.4 187 -29.5, -17.3 -7.5* 283.5 0.000
Danger signs in both mother and
71.0 45.2 247 91.3 9.9 187 -26.2, -14.5 -6.8* 276.9 0.000
newborn
Need for postnatal care and follow
64.5 47.7 247 87.1 13.0 187 -28.9, -16.3 -7.1* 293.1 0.000
up arranged
* p < .05, M=mean, SD=standard deviation, CI=Confidence interval, df=degree of freedom, n=preintervention sample size,
N=postintervention sample size.

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Contributing Barriers to Lost to Follow-up from Antenatal Care Services around

Addis Ababa: A Qualitative Study

Zergu Tafesse Tsegaye1, Hailemariam Segni Abawollo1 *, Binyam Fekadu Desta1, Tsega Teferi
Mamo1, Atrie Fekadu Heyi1, Mestawot Getachew Mesele1, Addisu Dabesa Lose1
1
JSI/ USAID Transform: Primary Health Care Activity, Addis Ababa, Ethiopia.
*
Correspondence, [email protected], +251-911-408061

ABSTRACT

Background: Problems during pregnancy, childbirth, and postpartum are the major contributors to maternal
and perinatal morbidity and mortality. Focused antenatal care provides basic services for pregnant women to reduce
morbidity and mortality. In Ethiopia, there is a significant loss to follow-up from antenatal care services. This study aims
to explore contributing barriers to the lost-to-follow-up of pregnant women from antenatal care services around Addis
Ababa.

Methods: A qualitative method was used where 20 in-depth interviews and three focus group discussions were
conducted. A qualitative data analysis software, ATLAS.ti 8, was applied.

Results: Inability to deliver essential antenatal care services which occurs primarily due to shortage of the
required medical equipment, drugs, and other supplies is a major barrier for sustainable attendance of antenatal care
services followed by poor care, respect, and receptiveness of service providers. Lack and cost of transport, as well as
partners’ approval and support, were also claimed to be part of the major barriers. Community culture and previous
maternal experiences as well as maternal socio-demographic factors such as maternal age at the time of pregnancy and
educational status of mothers were also reported as barriers to seeking and completing antenatal care services.

Conclusions: Both demand and supply-side barriers play a significant role in the loss-to-follow-up from antenatal
care services. Availing essential antenatal care services, closer to the community by improving the infrastructure, health
workforce, and supply chain system is recommended.

Keywords: ANC, lost to follow up from ANC, ANC defaulter, ANC dropout

Introduction

Globally, every year, 303,000 women die from common causes of maternal death in the country
preventable causes related to pregnancy and are hemorrhage, preeclampsia or eclampsia, sepsis,
childbirth. Additionally, 2.6 million stillbirths and 2.7 and prolonged or obstructed labor (3). The ANC-1
million newborn deaths occur annually. Antenatal coverage in the country is 74% and ANC-4+ is 43%
care (ANC) is crucial for the prevention of maternal showing a huge gap (31%) between first and fourth
and newborn deaths and stillbirths. Currently, in the ANC visits (4).
world, 86% of pregnant women access at least one
ANC with skilled providers during pregnancy and 78% The standard of services rendered in the country
deliver with the assistance of skilled birth attendants during ANC visits was also found to be low as
(1). evidenced by low early ANC initiation (20%) and low
coverage of essential ANC services like blood pressure
The maternal mortality ratio of Ethiopia is 401/100,000 measurement, urine and blood tests (55.8%), and iron
live births with 14,000 annual maternal deaths, supplementation (42%) (1, 5, 6).
almost all of which are preventable (2). The most

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The proportion of health facilities in the country that heads + MCH heads + a midwife per the two health
possess blood pressure measurement apparatus is centers, and one HEW from each of the health posts
59%; the capacity for syphilis testing is available in (HP). Three FGDs were conducted consisting of six
42% of health facilities, 27% of health facilities provide to eight participants per FGD. The three FGD groups
HIV testing, 20% of health facilities for hemoglobin were mothers who gave birth within the past 12
determination, 33% for blood glucose determination, months and had at least four ANC visits during the
and 46% for urine testing; iron supplements and index pregnancy (eight mothers), mothers who gave
tetanus toxoid vaccines are available in 61% and 65% birth within the past 12 months and were lost to
of facilities, respectively (6). follow up from ANC during the index pregnancy (six
mothers), and community volunteers/HDAs (eight
In the Debremarkos town of north-western Ethiopia, HDAs). The final sample sizes of both IDIs and FGDs
the proportion of dropouts from the maternity were also determined based on the level of saturation
continuum of care was found to be 32.2%. The major of the information required.
contributing variables associated with the dropouts
were having no exposure to media, unplanned Data collection: An IDI guide was developed
pregnancies, and having less than four ANC visits (7). and administered to health managers and service
providers. Two different FGD guides were developed,
In the Oromia region including Finfinne special zone, and one was used to facilitate the FGDs of the two
recent administrative reports showed a significant categories of women and the other guide to facilitate
loss to follow-up between ANC-1 to ANC-4 with a FGD of the HDAs. Trained data collectors who are
paucity of evidence on contributing barriers for the Master of Public Health graduates with relevant health
loss to follow-up. Hence, it is worth looking into the backgrounds conducted both the IDIs and FGDs. Two
major gaps in ANC follow-up to devise possible cost- people facilitated each of the IDIs and FGDs. Voice
effective and high-impact interventions that improve recorders were used during both the IDIs and FGDs
the lost-to-follow-up from ANC services. and both were conducted using the local language,
Afan Oromo. Transcription and translation of the IDIs
Objective and FGDs were conducted by a consultant who has
ample experience in transcription and translation of
This study aims to explore the potential contributing
IDIs and FGDs and is fluent in the local language used
barriers for loss to follow-up from ANC services and
to conduct the IDIs and FGDs.
solutions to mitigate those barriers.
Data analysis: Analysis of the study was conducted
Methods
using thematic analysis through qualitative data
Design: qualitative study design was employed. analysis software. ATLAS.ti 8 software was used
to code and categorize the transcription. The first
Setting and period: The study was conducted transcripts were used to frame the coding structures.
in villages around Addis Ababa. The study was Two research team members independently coded
conducted in July 2020. all transcripts then met and agreed on the coding
structures and discussed the emerging themes. The
Sample size and sampling method: The zonal identified contributing barriers for defaulting from
health department, one woreda in the zone, two ANC are summarized under two themes, demand
health centers in the selected woreda, and all health and supply-side barriers. Demand-side barriers are
posts within the catchment of those selected two individual, household, or community characteristics
health centers were purposefully selected based on that influence the demand for ANC services. Supply-
their high rates of loss to follow up from ANC based on side barriers are those characteristics of the health
administrative reports of the health centers. Twenty system that exist beyond the control of potential
IDIs were conducted where the participants were a health system users, including but not limited to
maternal and child health (MCH) focal person in the health facilities, equipment, drugs, finances, and
zonal health department (ZHD), an MCH coordinator health workers.
of the woreda health office (WrHO), head/deputy

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Ethical consideration: Ethical clearance was granted and turnover were some of the issues raised during
from the John Snow Incorporated (JSI) institutional the IDIs and FGDs. Lack of adequate numbers of
review board (IRB), IRB REFERENCE: IRB # 20-16 E, laboratory technicians in health facilities was also
and from Oromia regional health bureau. IDI and FGD raised repeatedly as a barrier to get the required
participants have read information sheets and signed quality ANC service. A qualitative study conducted
informed consent. Confidentiality was respected in the Somali regional state of Eastern Ethiopia and
accordingly. We also confirm that all methods were in the North West of Ethiopia reflected similar results
carried out per relevant guidelines and regulations. (9,10).

Results and Discussion The findings of this assessment also indicated that
shortage of the required medical equipment, drugs,
The results of this assessment showed that there and other supplies were other key barriers to delivery
are demand and supply-side barriers influencing of ANC services and hence loss to follow up. It was
attendance of ANC. Demand-side barriers that affect reported that there are shortages of some essential
the utilization of ANC services by pregnant women drugs like iron and folic acid in health facilities which
include socio-demographic and obstetric barriers leads to the rescheduling of mothers for another day
such as age at which the women get pregnant, resulting in disappointment of clients and interruption
intendedness of pregnancies, individual, family, and of the service. Additionally, shortages of the required
community-related barriers including workload on equipment such as blood pressure apparatus and
women, lack of partners’ support, no autonomy for weighing scales were found to be barriers to providing
women in decision making, and pervious individual ANC services resulting in disappointment and loss
and community experiences. Additionally, poor to follow up from ANC services. The bases for the
access to health facilities, particularly health centers, shortages were poor planning on both the parts of
due to lack of all-weather roads, lack of transport managerial and health facility level staff.
services, and cost of transport were mentioned
as barriers influencing utilization. The results of a This assessment also showed that lack of basic
systemic review on factors influencing the use of amenities like electricity was a determinant to
prenatal care also indicated similar findings (8). providing ANC services to clients. It has been
Another study conducted in Somali region of Ethiopia claimed by most of the participants that health
also indicated that socio-demographic, economic facilities experience shortages in electricity or have
status, cultural believes, past experiences, level of frequent power interruptions which is a key barrier
awareness, attitude toward the service, challenges for providing laboratory services leading to a referral
in accessing transportation, and shortage of supplies or rescheduling of appointments. This leads to
were identified as major barriers for ANC service dissatisfaction of clients and interruption of service
utilization (9). utilization. Additionally, per the national direction,
HEWs must refer mothers to health centers to
We identified supply-side barriers also for loss to attend the first and the fourth ANC services as some
follow up from ANC services. Some of these are health services are missing at the health post level. Despite
workers related barriers in which lack of the required this, the referral health facilities are sometimes not
number and type of service providers in health facilities able to provide the required services which deter
results in an appointment for pregnant mothers for clients from attending the facilities and results in the
another day. On occasions where there are shortages interruption of the services. Clients also complained
of midwives in health facilities, the overload of tasks about the distance of health facilities and lack of
forces them to re-schedule visiting mothers-to-be access to and cost of transportation to reach the
for another day and this means some of the women referral health facilities resulting in interruptions
may not come back to get an ANC service. Moreover, of the service. A similar finding was reported in a
according to this assessment, health workers’ lack qualitative study from Afar regional state which
of respect and perceptiveness were also among the showed that the barriers to health facilities included
major barriers for the consistent utilization of ANC distance, lack of transportation, sociocultural factors,
services. Additionally, health workers’ absenteeism and disrespectful care (11). A mixed-designed study in

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Bahir Dar Zuria Woreda also indicated similar findings of full package of ANC services, lack of interruption
that the socio-culture of the community, attitudes, of electric power, shortage of rooms, arrangement of
experience, and perception of the existing services rooms, non-favorable working environments, poor
and service provisions were also determinants of ANC linkage and technical support between the different
dropout (12). levels of facilities, and poor consultation among
service providers.
Efficient management and provision of support are
key elements to providing quality health services. Based on the findings of the study, it is recommended
Based on this assessment, the support and linkage that a full package of ANC services be availed closer to
between facilities and the management were found the community through improving the infrastructure,
to be weak, affecting the timely supply of the required equipment, supplies, drugs, and staffing of health
essential supplies, and enhancement of knowledge posts. Intensify capacity enhancement activities
and skills of service providers. A qualitative study with a focus on a motivated, competent, and
conducted in the Jimma zone of South West Ethiopia compassionate (MCC) health workforce and make
reflected that the linkage between midwives and MCC part of the periodic performance evaluation of
HEWs was found to be poor because of resource service providers and monitoring activities including
limitations and poor infrastructure (13). integrated supportive supervisions. Deploy the
required number and type of service providers in
Conclusion and Recommendation health facilities. Strengthen the supply chain system
and linkage of facilities with policy level structures so
The demand side barriers are age, educational that they identify major gaps and act timely. Demand
status, unwanted pregnancy, preference of sex of for ANC is created through informing the community
service providers, perceived problems on the use on the benefits of ANC.
of technology, the workload on women, lack of
partners’ support, community culture and traditions,
perception of the benefits of ANC service, and
availability and cost of transportation.

The supply-side barriers are shortage of medical

equipment, drugs, and other supplies; lack of
hospitality and receptiveness, timely service
provision, absenteeism from work, and lateness;
mothers want to receive services from the same
provider over the different sessions of ANC visits, lack

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References 8. Hajizadeh S, Ramezani Tehrani F, Simbar M, Farzadfar F.

Factors Influencing the Use of Prenatal Care: A Systematic
1. Catherine Arsenault, Keely Jordan, Dennis Lee, Girmaye Review. Journal of Midwifery and Reproductive Health. 2016;
Dinsa, Fatuma Manzi, Tanya Marchant et al. Equity in 4(1): 544-557.
antenatal care quality: an analysis of 91 national household
9. Abdurehman Mohammed, Alula Teklu, Senait Beyene,
surveys. Lancet Glob Health 2018; 6: 1186-95.
Abdiwahab Hashi, Zerihun Abebe, Wondimagegn
2. Trends in maternal mortality 2000 to 2017: estimates by WHO, Gezahegn et al. Barriers of Antenatal Care Service Utilization
UNICEF, UNFPA, World Bank Group and the United Nations in Somali Regional State Using Social Ecological Model
Population Division. Geneva: World Health Organization; Framework, Eastern Ethiopia, Ethiopia: a Qualitative Study.
2019. Licence: CC BY-NC-SA 3.0 IGO. Preprint doi: 10.21203/rs.2.13486/v1. (Under review at BMC
Pregnancy and Childbirth).
3. Public health emergency management center (PHEM),
Ethiopian public health institute (EPHI). August 2020. 10. Biruhtesfa Bekele Shiferaw and Lebitsi Maud Modiba. Why
National maternal and perinatal death surveillance and do women not use skilled birth attendance service? An
response (MPDSR) system annual report. Addis Ababa, explorative qualitative study in the north west Ethiopia. BMC
Ethiopia. Pregnancy and Childbirth. 2020; 20: 633.

4. Ethiopian demographic and health survey report, 2019. 11. Ruth Jackson and Assefa Hailemariam. The Role of Health
Central Statistical Agency (CSA) [Ethiopia] and ICF. 2019. Extension Workers in Linking Pregnant Women With Health
Ethiopia Demographic and Health Survey 2019. Addis Ababa, Facilities for Delivery in Rural and Pastoralist Areas of
Ethiopia, and Rockville, Maryland, USA: CSA and ICF. Ethiopia. Ethiop J Health Sci. 2016 Sep; 26(5): 471-278.

5. Central Statistical Agency (CSA) [Ethiopia] and ICF. 2016. 12. Yibeltal Alemu Bekele, Tadesse Ejigu Tafere, Amanu Aragaw
Ethiopia Demographic and Health Survey 2016. Addis Ababa, Emiru, and Henok Biresaw Netsere. Determinants of
Ethiopia, and Rockville, Maryland, USA: CSA and ICF. antenatal care dropout among mothers who gave birth in
the last six months in BAHIR Dar ZURIA WOREDA community;
6. Ethiopian Public Health Institute (EPHI). 2018. Service
mixed designs. BMC Health Services Research. 2020; 20:846.
Availability and Readiness Assessment (SARA) 2018 Final
Report. Addis Ababa, Ethiopia. 13. Nicole Bergen, Alzahra Hudani, Shifera Asfaw, Abebe Mamo,
Getachew Kiros, Jaameeta Kurji et al. Promoting and
7. Nakachew Sewnet Amare, Bilen Mekonnen Araya, Mengistu
delivering antenatal care in rural Jimma Zone, Ethiopia: a
Melkamu Asaye. Dropout from maternity continuum of care
qualitative analysis of midwives’ perceptions. BMC Health
and associated factors among women in Debre Markos
Services Research. 2019; 19:719.
town, Northwest Ethiopia. BioRxiv preprint doi: https://doi.
org/10.1101/620120

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Treatment Outcome of Sick Newborns in Primary Hospitals in Ethiopia

Efrem Teferi1, Ismael Ali1

1
USAID Transform: Primary Health Care project, Ethiopia

ABSTRACT

Background The global neonatal mortality rate has decreased by 37%, per 1000 live births, compared with
a greater than 50% reduction for mortality rates among children aged 1 to 59 months, since 1990. The main causes
of mortality were complications of preterm birth 36%, birth asphyxia 23%, and infections 23%. In Ethiopia, neonatal
mortality decreased from 39 to 29 between the 2005 and 2016 EDHS but has remained stable since the 2016 EDHS.

Methodology: Transform: Primary Health project is supporting maternal health and child survival interventions in
400 woredas in five regions. A descriptive retrospective facility-based cross-sectional study was conducted to evaluate
the outcomes of intervention in NICU (Neonatal Intensive Care Unit) October to December 2020 in 92 PHLs found in the
four regions.

Results: Sick newborns admitted were 3348, and the three main causes of admission were neonatal sepsis, birth
asphyxia, and small babies (preterm and low birth weight), comprising 86% of admission (sepsis 44.8%, birth asphyxia
14.5%, Prematurity 15.7%, and LBW 13.7%). Neonatal mortality was 6.5%, the same Problems contributed to 81.7 % of
deaths (sepsis, 33.2%, asphyxia 21.7%, preterm 16.6%, LBW 18.4%) respectively.

Discussion and conclusion: Neonatal mortality is lower than the results of most studies done in the country.
Admission due to sepsis was high. Prevention, early identification with treatment, and timely referral are important for
better outcomes.

Keywords: Neonatal Mortality, Preterm, Birth Asphyxia.

Background Every newborn action plan outlines a goal, 10 or fewer,

newborn deaths per 1000 live births and stillbirths
The global neonatal mortality rate has decreased by 2035. There are specific interventions across
by 37%, from 33 to 21 deaths per 1000 live births, the continuum of care (preconception, antenatal,
compared with a greater than 50% reduction for intrapartum, immediate postnatal period, and
mortality rates among children aged 1 to 59 months, thereafter). Increased coverage and quality in these
since 1990. The number of neonatal deaths declined interventions could avert 71% of neonatal deaths
from 5.0 million in 1990 to 2.4 million in 2019, with per year. Most (80%) of this effect is attributable to
99% occurring in low- and middle-income countries. facility-based care. The maximum benefits would be
It amounts to 47% of all child deaths under the age of accrued through integrated delivery and scale-up of
5-years, one-third dying on the day of birth, and close both community-based and primary care strategies
to three quarters within the first week of life. The main while clinical care in facilities and transport systems
causes of mortality are complications of preterm are strengthened.
birth 36%, intrapartum-related complications (birth
asphyxia or lack of breathing at birth) 23%, and In Ethiopia, the leading causes of neonatal mortality
infections 23%. Estimated 2·6 million babies were are preterm complication 26%, intrapartum related
stillborn at 28 weeks or more in 2015. 30%, sepsis 18%. Universal Health Service Coverage

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(UHC), using the coverage index in Ethiopia is birth asphyxia, 524 (14.5%) premature, 383 (13.7%)
39%, which is way below global coverage of 64%. were LBW, others (congenital anomalies, MAS,
Several high-impact child survival interventions are jaundice, birth injury, and anemia) 13.7%. (figure 2).
implemented focusing on major causes of under- The causes of death were sepsis 33%, asphyxia 22%,
five mortality. Despite all efforts, neonatal mortality prematurity 17%, and others 18% (Figure 3).
decreased from 39 to 29 between the 2005 and 2016
EDHS but has remained stable since the 2016 EDHS. Table 1. The outcome of NICU treatment in PHLs

Methodology

Admission
problem

Recovered
Admitted

On treat-
Referred
Transform: Primary Health project is supporting

ment
Died
health and child survival interventions in 400 woredas
found in five regions (Amhara, Oromia, SNNP, Sidama,
and Tigray, with 113 PHLs, 1837 HCs, and 9153 HPs. Sepsis 1499 1216 72 131 66
Several capacity enhancement activities like Bemock, Asphyxia 484 296 47 53 10
use of ultrasound, NICU, IMNCI, ICMNCI, and EPI were Prematurity 524 398 36 48 26
implemented. The support starts from preconception, Low birth
383 288 22 44 51
continues during pregnancy (ANC), delivery, and weight
postnatal (PNC) in HPs, HCs, and PHLs. Logistic, and Other 458 400 40 60 29
financial support includes purchase distribution Total 3348 2598 217 336 182
of ultrasound, construction, with the furnishing of Percentages 77.5% 6.5% 10% 5.4%
maternity waiting home, skill lab, and sub-grant.
Figure 1. The major causes of neonatal admission, percentage

Doctors and Nurses working in NICU were trained on

the standard care and treatment of sick newborns
in the teaching hospitals in their respective regions.
Project drivers repaired and installed nonfunctional
materials, some essential equipment was purchased
and distributed.

A descriptive retrospective facility-based study was

done to evaluate the outcomes of intervention in
NICU, from October to December 2020 in 92 PHLs
found in four regions (SNNP with Sidama, Amhara
Oromia). Data were collected from the newborn
registration book of NICU, including admission cure, Figure 2. The major causes of neonatal mortality, percentage

referrals, and deaths, and analyzed using excel.

Diagnosis of neonatal sepsis was made clinically, and
some additional laboratory tests like whole blood
count and differentials were done.

Results

A total of 3348 sick newborns were admitted in 92

PHLs found in the four regions. The major causes
of admission were neonatal sepsis, birth asphyxia
preterm, and LBW. As result of treatment was 2598 Discussion
(77.5%) recovered, 217 (6.5%) died, 336 (10.8%)
The three main causes of admission were neonatal
referred, and 182 (5.3%) were still on treatment during
sepsis, birth asphyxia, and small babies (preterm
data collection (table 1). From the total admissions
and LBW), comprising 86% (sepsis 44.8%, birth
1499 (44.8%) were cases of neonatal sepsis, 484 (14%)
asphyxia 14.5%, prematurity 15.7%, and LBW 13.7%

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respectively). The same problems contribute to 81.7 Recommendation

% of deaths (sepsis, 33.2%, asphyxia 21.7%, preterm
16.6%, LBW 18.4%) respectively. Neonatal mortality 1. Strengthen infection prevention in the delivery
(6.5%) is less than most of the studies done in the room to decrease morbidity and mortality due to
country, but neonatal sepsis as a problem of admission neonatal sepsis. Counsel mothers on home care
is higher than in other studies. Neonatal mortality due for newborns.
to sepsis is less than in Dilocha hospital, Dire Dawa 2. Provide appropriate essential newborn care,
(35%), in Misrata, Libya (59%). The complication of during and after delivery
preterm as a cause of admission and death is less than
the national value and other developing countries. 3. Support health workers to fill skill and equipment
Birth Asphyxia as a cause of admission and death is gaps to quickly resuscitate (first golden minute)
similar to other findings in the country. According to a neonates with birth asphyxia
study done by Mizantepi university teaching hospital 4. Expand KMC (Kangaroo Mother Care) for preterm
on 1316 NICU admissions, neonatal mortality was and LBW babies
23%, where 31% of them were preterm, 15.3%: LBW,
5. Strengthen ANC (Anti Natal Care), PNC (Post Natal
and sepsis: 30%.
Care) for early treatment and referral
The main causes of admission to neonatal care unit in
Asmara, Eritrea was sepsis 35.5%, respiratory distress
15.4%, perinatal asphyxia 10%. Major causes of death
were respiratory distress syndrome 48%, extremely
low birth weight 41%. Neonatal mortality in Misrata,
Libya, teaching hospital was 10.9% with major causes
being sepsis (59%), congenital malformation (17%),
asphyxia (12%), prematurity (29%).

Limitations

The place of birth of neonates, whether the health

facility or home was not captured, and data was
collected by our staff, which might create bias.

Conclusion

Neonatal mortality is lower than most results of

most studies done in the country. Admissions and
deaths due to sepsis were high. Early identification,
treatment, and timely referral are important for better
outcomes.

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Effectiveness of Catchment-Based Mentorship Programs on Health Care

Providers’ Competence: A Mixed-Method Study

Melaku Tamir1 *, Belete Belegu1, Zergu Tesfaye2, Hailemariam Segni2, Zenawork Kassa2,
Birhan Tenaw2, Tsega Teferi2 , Aster Worku1, Addisu Fekadu1, Fekadu Mazengia1
1
Ethiopian Midwives Association, Addis Ababa, Ethiopia
2
USAID Transform: Primary Health Care project, Ethiopia
*Correspondence [email protected]

ABSTRACT

Background: In low-income countries, the quality of care and rate of maternal and neonatal mortality is still
unacceptable. To improve the quality of care different capacity-building strategies including catchment-based clinical
mentorship were designed. However, the effectiveness and experiences of mentorship are poorly known.

Objectives: The study aimed to assess the effectiveness of catchment-based mentoring on improving mentees’
knowledge and skills and explore the experience of mentorship implementation.

Methods: This mixed-method study with a single group pre-post quasi-experimental, and exploratory qualitative
study design was conducted from 1 April to 30 May 2021. The knowledge and skills of mentees at three measurement
points were compared. Data were analyzed using the Statistical Package for Social Sciences (SPSS) Version 24. The
qualitative data were analyzed employing a thematic analysis approach using the ATLAS.ti version 8.4.25 software
package.

Result: There was a significant improvement in knowledge scores of mentees at pre-mentorship compared with
completion of mentorship. The mean difference for knowledge scores in completion of mentorship and pre-mentorship
were 25.36 and 25.87 respectively. The mean difference for skill scores in completion of mentorship and pre-mentorship
were 26.64 and 27.77, respectively. Similarly, the qualitative data show that the knowledge and skill of mentees were
improved after catchment-based mentorship. Shortage of equipment and supplies, unfair payment for the mentor, poor
motivation and readiness of the mentees and poor mentor dedication, shortage of infrastructures issues (road, transport
access, electric power, water supply), weak and non-functional structural system were some challenges identified.

Conclusion and recommendation: The implementation of catchment-based mentorship is an effective strategy

in building the capacity of health care providers. Therefore, there is a need to scale up a catchment-based mentorship
program in all regions of the country.

Keywords: Catchment based mentorship, provider knowledge, skill competence, Ethiopia

Background 2019. Despite progress, Ethiopia has failed to achieve

the HSTP-I maternal mortality target (199/100,000LB);
Ethiopia has made remarkable progress in reducing reduce under-five infant and neonatal mortality rates
maternal and neonatal morbidities and mortalities in 30, 20, and 10 per 1,000 live births.
the past two decades; pregnancy-related mortality has
decreased from a staggering 871 deaths per 100,000 Poor quality health care delivery remained a
live births to 412 from 2000 to 2016 and neonatal significant challenge, where the competency of
mortality has also decreased from 49 in 2000 to 30 in health care providers was a central challenge that

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resulted in poor satisfaction of service recipients’. took place in 30 health centers and 70 mentees in
To improve the quality of care and significantly four regions. Confidence intervals (CI) and effect
reduce mortalities, multiple capacity-building size were calculated, and a p-value of < 0.05 was
strategies have been implemented in the country so considered as a measure of statistical significance.
far. Mentorship is among the strategies to build the Data were analyzed using the Statistical Package for
capacity of health care workers to foster ongoing Social Sciences (SPSS) Version 24. One way repeated
professional development to yield sustainable measures ANOVA was used to check the mean score
clinical care outcomes. Hence, MOH introduced a differences in knowledge and skills of mentees
catchment-based mentorship (CBM) program at the
national level to enhance the capacity of health care In addition, qualitative data were collected parallel
providers to improve the quality of Reproductive with quantitative data from three mentees and
Maternal Neonatal Child Adolescent Youth-Nutrition twenty-eight key informants. The data were collected
(RMNCAY-N) service. through in-depth interviews and key-informant
interviews using a semi-structured interview guide.
Despite the growing evidence that mentoring and Mentees who passed through the catchment-based
coaching interventions can improve the quality of clinical mentorship implementation process were
care, little is known about effectively adapting and selected purposively, and the key informants were
integrating such interventions into different health recruited purposefully until the data were theoretically
system contexts. Therefore, this study aimed at saturated. The selection process of key informants was
assessing the effectiveness of catchment-based based on their responsibility in the implementation of
clinical mentorship on health care providers’ CBM. To ensure data quality: credibility, dependability,
competence to improve the quality of RMNCAY-N and transferability were taken into consideration.
service in Ethiopia. Data were thematically analyzed using the ATLAS ti
version 8.4.25 software package. Ethical clearance
Method was obtained from the Institutional Review Board
(IRB) of the Ethiopian Midwives Association with
A sensitization meeting was held to have a common ethical approval number EMwA-IRB-SOP/015/03, and
understanding about Catchment-based mentorship all subsequent ethical procedures were maintained
and the mentoring and mentee facilities were according to IRB guidelines.
selected. Then mentors and mentees are selected
according to the mentorship guideline. A baseline Result and Discussion
assessment was conducted to identify the mentee’s
knowledge and skill gap and also facility readiness Mentees’ mean knowledge scores had significantly
assessment. The mentoring was conducted for five increased by 25.36 out of 100; [95% CI 21.63 to 29.08]
consecutive working days each month for six months. from the baseline compared to the completion of the
The baseline and mid-term data were collected in 6-month mentorship. Moreover, the key Informants
October and December 2019 respectively whereas attested that there was a dramatic improvement in
the end line data was collected in March 2020. The mentees’ knowledge after catchment-based clinical
mentees’ knowledge passing score was 85%, and mentorship implementation. A 27-year-old- mentee:
their skill passing score was 90%.
“At the beginning of CBM, I was in trouble to
A mixed-method quantitative study with a single answer knowledge questions on the management
group pre-post, re-test quasi-experimental, and of Postpartum hemorrhage. However, it was
exploratory qualitative study design was conducted straightforward even to narrate the answers.”
from 1 April to 30 May 2021. The knowledge and skills
of mentees in the management of basic emergency This finding is consistent with the studies conducted
obstetric and newborn care at three measurement in Nigeria [15] and South Africa [16].
points (before mentorship, after 6 months of
mentoring, and at 12 months after completion of Catchment-based clinical mentorship has also
CBM) using a self-administered questionnaire and improved the overall skill of mentees. Mentees’ mean
observation checklist. The mentorship intervention skill competency scores had significantly increased

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by 26.64 out of 100; [95% CI 22.15 to 31.14) from the Conclusions and recommendations
baseline compared to the completion of the 6-month
mentorship. This finding is supported by a study Catchment-based mentorship programs enhance
conducted in Malawi [17]. Moreover, the qualitative the competency (knowledge and skills) of the
study informed that there was a clear improvement in mentees. The knowledge and skills of the mentees
the skill of mentees. A 24-year-old mentee from health were significantly improved after the six months
center: mentorship. The knowledge and skill achieved after
mentorship was adequately maintained 12 months
“…, I am now competent in vacuum application, after completion of mentorship.
management of severe pre-eclampsia and
eclampsia, and neonatal resuscitation.” The implementation of catchment-based mentorship
is an effective strategy in building the capacity of
In addition, health sector and partner organization health care providers. Therefore, there is a need to
leaders at different levels confirmed that catchment- scale up a catchment-based mentorship program in
based clinical mentorship had improved the skill of all regions of the country.
mentees. A health center director said:
References
“…Skill gaps of mentees were highly improved,
resulting in increased maternal health service 1. Central Statistical Agency (CSA) [Ethiopia] and ICF. Ethiopia
utilization and quality of service provision”. Demographic and Health Survey Addis Ababa, Ethiopia,
and Rockville, Maryland, USA. 2017. 2016 CSA and ICF.
Furthermore, the current assessment shows that
skill and knowledge after mentorship (6 months) 2. Central Statistical Agency (CSA) [Ethiopia] and ICF.
were maintained after 12 months of mentorship Ethiopian Mini Demographic and Health Survey 2019: key
completion. The mean difference in skill competency indicators Rockville, Maryland, USA2019
between completion of mentorship and 12 months
3. Federal Ministry of Health (FMOH). Health Sector
after CBCM completion has no statistically significant
Transformation Plan. Addis Ababa, Ethiopia October 2015.
reduction (1.13 out of 100; [95% CI -0.48, 2.74],
p=0.269). The finding of the qualitative study confirms
4. Zemedu TG, Teshome A, Tadesse Y, Bekele A, Keyes E, Bailey
this.
P, et al. Healthcare workers’ clinical knowledge on maternal
and newborn care in Ethiopia: findings from 2016 national
“… job aids and posted protocols, peer mentoring
EmONC assessment. BMC Health Services Research. 2019;
helped us in retaining our skills and knowledge”. (A
19(1):915.
mentee Midwife)
5. EPHI FA. Emergency Obstetric and Newborn Care (EmONC)
The finding of this study is in agreement with a
Assessment 2016 Final Report. Addis Ababa: Ethiopian
systematic review that reported that mentoring
Public Health Institute. 2017.
interventions had increased adherence of health
care providers to updates, guidelines, standards, and
6. Organization WH. Toolkit on monitoring health systems
protocols [18].
strengthening. WHO 2008b WHO. 2009:17-3.

The mentorship program has been challenged with

7. Berhane B, Gebrehiwot H, Weldemariam S, Fisseha B,
poor readiness and motivation of the mentees,
Kahsay S, Gebremariam A. Quality of basic emergency
Lack of Infrastructure, shortage/lack of equipment’s
obstetric and newborn care (BEmONC) services from
and supplies, and poor mentor dedication, lack of
patients’ perspective in Adigrat town, Eastern zone of Tigray,
accommodation and restaurant around the mentee
Ethiopia. 2017: a cross sectional study. BMC Pregnancy and
facility, high turnover of the mentored providers, poor
Childbirth. 2019; 19(1):190.
health facility leaders’ commitment, structural issues,
and lack of budget allocation.

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8. Kumsa A, Tura G, Nigusse A, Kebede G. Satisfaction with 15. Evaluating Health Workers’ Knowledge Following the
emergency obstetric and new born care services among Introduction of Clinical Mentoring in Jigawa State, Northern
clients using public health facilities in Jimma Zone, Oromia Nigeria
Regional State, Ethiopia; a cross sectional study. BMC
Pregnancy Childbirth. 2016; 16:85. 16. National Department of Health. Clinical Mentorship
Guideline for Integrated Services. 2011.
9. African Union. Draft Policy Brief for the International
Conference on Maternal, Newborn and Child Health 17. Tang JH, Kaliti C, Bengtson A, Hayat S, Chimala E, MacLeod
(MNCH) in Africa . Johannesburg, South Africa, 2013. R, et al. Improvement and retention of emergency obstetrics
and neonatal care knowledge and skills in a hospital
10. Memirie ST VS, Norheim OF, Levin C, Johansson KA. mentorship program in Lilongwe, Malawi. International
Inequalities in utilization of maternal and child health Journal of Gynecology & Obstetrics. 2016;132(2):240-3.
services in Ethiopia: the role of primary health care. BMC
health services research. 2016; 16(1). 18. Feyissa GT, Balabanova D, Woldie M. How effective
are mentoring programs for improving health worker
11. Federal Ministry of Health (FMOH). National Guideline for competence and institutional performance in africa? A
RMNCAH catchment-based Mentorship January 2019. systematic review of quantitative evidence. Journal of
Addis Ababa, Ethiopia 2019 multidisciplinary healthcare. 2019;12:989.

12. Sherr K, Cuembelo F, Michel C, Gimbel S, Micek M, Kariaganis

M, et al. Strengthening integrated primary health care in
Sofala, Mozambique. BMC Health Services Research. 2013;
13(S2):S4.

13. Fischer EA, Jayana K, Cunningham T, Washington M, Mony

P, and Bradley J, et al. Nurse Mentors to advance quality
improvement in primary health centers: lessons from a
pilot program in Northern Karnataka, India. Global Health:
Science and Practice. 2015; 3(4):660-75.

14. Manzi A, Hirschhorn LR, Sherr K, Chirwa C, Baynes C,

Awoonor-Williams JK. Mentorship and coaching to support
strengthening healthcare systems: lessons learned across
the five Population Health Implementation and Training
partnership projects in sub-Saharan Africa. BMC health
services research. 2017; 17(3):831.

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Evaluation of the National Safe Surgical Care Strategy and the Saving Lives
through Safe Surgery (SaLTS) Program in Ethiopia: A Nation-Wide Evaluation

Ftalew Dagnaw1*, Hassen Mohammed1, Manuel Kassaye2, Berhane Redae1,2,4, Desalegn

Bekele1, Edil Mesfin3, Kassa Haile3, Mulatu Birru3, Sinidu Bekele3, Tsegaye Haile3, Wuletaw
Chane2,4, Mikiyas Teferi1
1
Ministry of Health; Addis Ababa, Ethiopia, 2Johns Hopkins Program for International Education in
Gynecology and Obstetrics, Addis Ababa, Ethiopia, 3Armauer Hansen Research Institute, Addis Ababa,
Ethiopia, 4St.Paul Millinium Medical college, Addis Ababa, Ethiopia.
*
Correspondence: [email protected]

ABSTRACT

Background: Ethiopia’s safe surgery strategic plan was developed for five-year, 2016-2020, to address the huge
unmet need for basic surgical care services. The Saving Lives through Safe Surgery (SaLTS) initiative aims to expand
access to safe surgical care in Ethiopia.

Objective: To assess the outcomes of Ethiopia’s national safe surgical care strategic plan, and lessons learned
during implementation of the surgical care plan in public and private health facilities in Ethiopia.

Methods: A cross-sectional study design with mixed quantitative and qualitative methods were used. A multi-
stage stratified convenient sampling method was used to choose 203 health care facilities both public and private. The
evaluation was conducted in the health care facilities starting from December 30, 2020, to June 10, 2021.

Results: From the total major surgeries, 40.7% of surgeries were performed in specialized hospitals and 37.6%
of minor surgeries performed were from primary hospitals. Low SSI rates detected across all public and private health
facilities ranged from 1.15 -18.5 per a thousand surgical cases. The highest SSI rate was reported from specialized
hospitals (18.5 per 1000). The longest pre-admission waiting time was in general hospitals (37.6 days) followed by
specialized Hospitals (35.9 days) and Primary Hospitals (3.6 days). The highest surgical checklist utilization rate was
recorded in specialized and general hospitals (81% and 79%, respectively) whereas in primary hospitals and health
center OR blocks was 71% and 59% respectively.

Conclusions and Recommendation: Overall, results illustrated inadequate access to surgical services,
underutilization of surgical safety checklists, and under-reporting of SSI. On the other hand, health care facilities
providing surgical services were poorly staffed and equipped with relevant human resources and equipment/supplies,
respectively. Finally, increasing access to surgical services and reducing delays in admission and initiation of surgical
procedures will help to increase the utilization of the respective services.

Keywords: Emergency and Essential Surgical Care, Access, Safety, Efficiency

Background
at the level of health facilities in low- and middle-
Globally, around 5 billion people lack access to safe, income countries (LMIC) (1,2).
affordable, and timely emergency and essential
surgical care (EESC). In 2005, the World Health To achieve this in the low- and middle-income
Organization (WHO) launched an initiative to better countries (LMIC) countries and improve their capability
access Emergency and Essential Surgical Care to deliver emergency and essential surgical care, the
(EESC) and published cost-effective surgical care Lancet Commission on Global Surgery (LCoGS) has
interventions, and released a situational analysis tool put the following targets to be achieved by 2030.
to assess the availability of EESC and needed inputs These are 80% coverage of essential surgical and

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anesthesia services per country, at least 20 surgical, conducted to evaluate the national surgical care
anesthesia, and obstetric physicians per 100 000 program which was implemented in public and
population, 5,000 procedures annually per 100,000 private health facilities. A pre-tested data collection
population, and 100% protection against catastrophic tool was used to collect data from sample health care
expenditure from out-of-pocket payments for surgical facilities of eight regions and two city administrations
and anesthesia care. in Ethiopia

The Saving Lives through Safe Surgery (SaLTs) Study location and period: This program evaluation
Program: Ethiopia’s safe surgery strategic plan was was conducted in the health care facilities starting
created for five-year, 2016-2020, to address the from December 30, 2020, to June 10, 2021. Tigray, Afar,
huge unmet need for basic surgical care services. Amhara, Oromia, SNNP, Sidama, Harari, and Somali
The proposed strategies are well aligned with the were regions of Ethiopia included in the evaluation.
WHO recommendations and Ministry of Health Addis Ababa and Dire Dawa city administrations were
(MOH) health sector transformation plan and quality also included.
strategy. The SaLTs initiative with aim of improving the
quality and access to safe, essential, and emergency Sampling procedure and sample size: A multi-
surgical and anesthesia care across the health care stage stratified convenient sampling method was
systems (3,4). used to choose public health care facilities (primary,
general, and referral or teaching hospitals) and
This strategy has been instrumental to define and private health care facilities from all regions and
standardize the minimum care packages needed city administrations for the evaluation process. The
to expand emergency and essential surgical and sample size was estimated using a single population
anesthesia care. The eight intervention pillars proportion formula (n= z2pq/e2/1+( z2pq/e2)*N) for a
described in the strategic plan includes (1) finite population with a 5% margin of error and 95%
Leadership, Management, and Governance; (2) level of confidence. Accordingly, the sample size was
Infrastructure Development; (3) Supplies and Logistics determined as 163 public hospitals. The sample size
Management; (4) Human Resource Development; (5) for each stratum of primary hospitals (np), general
Advocacy and partnership; (6) Innovation in problem- hospitals (ng), and referral hospitals (nr) was calculated
solving (7) Quality and Safety across the perioperative using the proportional allocation method and it was
continuum of surgical and anesthesia care, and (8) 105, 43, and 15 hospitals, respectively. In addition, to
Monitoring and Evaluation (9). assess the status of surgical care in the private health
sector, private health facilities providing safe surgical
Now, this study is proposed to evaluate the national care services were included. According to the data we
surgical care strategic plan and its flagship program, obtained from the MOH, 45 private health facilities
the SaLTs program. The evaluation will assess the were providing safe surgical care. Thus, using the
initiative’s design, scope, implementation status, formula n= z2pq/e2/1+( z2pq/e2)*N, the sample size for
and the outcomes the nation gained. The evidence private hospitals was estimated as 40.
generated will be used to inform the subsequent five-
year strategy and surgical care improvement plans. Data collection procedures and tools: This
evaluation program employed both quantitative and
Objective qualitative data collection methods:

To assess the outcomes of Ethiopia’s national safe Quantitative method: The quantitative data
surgical care strategic plan, and lessons learned were collected using a pretested structured self-
during implementation of the surgical care plan in administered interview questionnaire, hospital record
public and private health facilities in Ethiopia. extraction tools, and checklist uploaded on Research
Electronic Data Capture (REDCap). Participants
Methods and Materials were informed about the aim and process of the
self-administered interview. Data collectors got
Study design: A cross-sectional study with both
adequate training about the entire process of data
quantitative and qualitative research methods was
collection including quality control measures (such

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as completeness, correctness, concordance) and in the surveyed facilities, 40.7% of surgeries were
synchronizing and archiving the data with REDCap. performed in specialized hospitals where major
and complicated cases are referred to. On the other
Qualitative method: The qualitative study was hand, from the total of minor surgeries performed in
conducted from February to June 2021. An inductive the surveyed health facilities, 37.6% of the surgeries
qualitative approach was used to interpret meaning performed were from primary Hospitals which may
from the data and making comparisons. Qualitative be due to the highest proportion of surveyed primary
data were collected through an exit interview, in- hospitals in the study or due to their level of care.
depth interviews (IDI), and key informants’ interviews
(KII) to explore patient satisfaction, the safe surgical The magnitude of SSI detected through chart review
care practice, and overall experience in the health was low across all public and private health facilities,
facilities. in a range of 1.15 -18.5 per a thousand surgical cases.
The highest surgical site infection rate was reported
Data management and analysis: The evaluation from specialized Hospitals (18.5 per 1000) where most
data were collected, cleaned, and entered in a period of the major and complicated cases were performed
of six months, and the data collectors archived with prolonged post operation stay, which showed
cleaned data regularly, every week. The survey team under-reporting of SSI cases across all health facilities.
then exported the data into STATA statistical software
Version 15 for further statistical analysis. Additional The pre-admission waiting time was reported from
data cleaning and consistency checks were done using public general hospital specialized hospitals (37.6
STATA statistical software Version 15 to detect outliers days) followed by specialized Hospitals (35.9 days)
and inconsistent variables. Descriptive statistics like and primary hospitals (3.6 days). The longest pre-
mean, median, percent, frequency, visual graphs, and admission waiting time was reported in a general
other descriptive measures were calculated. hospital where low surgical beds and functional OR
tables were reported.
Ethical considerations
The overall average rate of SSC use for major surgeries
The MOH of Ethiopia secured an ethical clearance was found to be higher in public health facilities
letter from the AHRI ethical review board. A letter of (72.5%) compared to private health facilities (26%).
support was obtained from the MOH. Additionally, The highest rate was recorded in specialized and
letters of support and permissions were obtained general hospitals (81% and 79%, respectively). The
from the local administrations to conduct evaluations SSC use rate in primary hospitals and health center OR
at the selected health facilities. Consent was obtained blocks was reported to be 71% and 59%, respectively.
from each participant who was willing to take part in
this evaluation. Health facilities, particularly the government
hospitals, had a low number of surgeons, i.e., primary
Results (47) and general (123) hospitals. Primary hospitals (16)
have a considerably lower number of obstetricians
The survey included a total of 172 health facilities compared to private hospitals (77). Most of (74%)
(84.7% response rate) and 44.8%, 22.1%, 18.6%, the health care facilities did not monitor patients’
9.3% and 5.2% of the surveyed health facilities were re-admission. Full availability of emergency and
primary hospitals, general hospitals, private Hospitals essential surgical care equipment and supplies
and Health centers with OR blocks respectively. ranged from (4%-15%) for specialized hospitals and
(1%-9%) for health-centered.
Over six months, the surveyed health care facilities
had a total of 125,075 surgical admissions, (surgical,
gynecologic, and obstetric admissions), over a third
(37.6%) of which was reported at specialized hospitals.
In a quarter, 178,785 surgeries were performed
at health care facilities, of which 58% were major
surgeries. From the total major surgeries performed

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Conclusions and Recommendations References

Overall, the results illustrated inadequate access 1. World Health Organization (WHO) 2017, pp 33-38:
to surgical services. Moreover, the findings showed Surgical care systems strengthening: developing
underutilization of surgical safety checklists and national surgical, obstetric and anesthesia plans. ISBN
a high rate of surgical adverse incidents. On the 978-92-4-151224-4.
other hand, health care facilities providing surgical
2. Spiegel DA, Abdullah F, Price RR, Gosselin RA, Bickler
services were poorly staffed and equipped with
SW. World Health Organization Global Initiative for
relevant human resources and equipment/supplies,
Emergency and Essential Surgical Care: 2011 and
respectively. These results suggest sizable gaps in
Beyond. World Journal of Surgery. 2013 Jul; 37(7):1462–
readiness of health facilities for surgical services, and
9.
low access and utilization of surgical services and
safety procedures. Therefore, it is highly valuable to 3. Ministry of Health of Ethiopia. National Safe Surgery
strengthen surgical services of the health facilities with Strategic Plan: Saving Lives Through Safe Surgery
relevant human resources and equipment’s/supplies. (SaLTS) Strategic Plan, 2016-2020. Addis Ababa, 2016.
Results also indicated the importance of enhancing 4. Tadesse H, Sibhatu M, Maina E, Bari S, Reynolds C,
the availability and utilization of surgical safety Richards K, &Garringer K. (2019). Savings Lives Through
supplies to reduce adverse incidents of surgeries or Safe Surgery in Ethiopia: Project Implementation
surgical efficiency at large. Finally, increasing access Manual. Addis Ababa, Ethiopia.
to surgical services and reducing delays in admission
5. Burssa D, Teshome A, Iverson K, Ahearn O, Ashengo T,
and initiation of surgical procedures will help to
Barash D, et al. Safe Surgery for All: Early Lessons from
increase the utilization of the respective services.
Implementing a National Government-Driven Surgical
Plan in Ethiopia. World Journal of Surgery. 2017 Dec;
41(12):3038–45

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Ethiopian Health Labor Market Analysis

Mesfin Kifle1&2*, Assegid Samuel1*, Solomon Woldeamanuel1, Fikadu Asrat1, Alemu Kejela1,
Yakob Matiwos1, James Avoka3, Giorgio Cometto4, Onyema Ajuebor4
1
Ministry of Health; Addis Ababa, Ethiopia
2
World Health Organization, Country Office for Ethiopia
3
World Health Organization, Africa Regional Office
4
Word Health Organization, Head Quarter
*
Correspondence: [email protected] and [email protected]

ABSTRACT

Background: The achievement of the SDGs and UHC, has been connected to having a responsive and resilient
health system supported by an appropriate and well-trained health workforce that is equitably distributed, motivated,
and enabled to operate optimally. Despite the implementation of various transformative initiatives towards a functional
and fit-for-purpose health workforce, there are remaining health workforce challenges in Ethiopia including workforce
shortages, mal-distribution, unemployment, and sub-optimal productivity and performance. Health Labor Market
Analysis (HLMA), helps to clearly understand factors affecting the supply of, demand for, and need for health workforce
and inform dialogue towards the design of effective policies and strategies to address current and potential labor
market imbalances.

Methods: Multiple methodological approaches were combined to collect and analyze data on the health workforce
situation and health labor market dynamics. These included desk review, stakeholders’ discussions, data triangulation,
descriptive analysis of existing quantitative data, and supply-demand modeling.

Results/Conclusion: Remarkable improvement in health workforce density has been observed in the last 10
years. There is an urgent need to strengthen health workforce (HWF) regulation and improve the quality of training.
There is a need-based shortage of HWF to deliver EHSP (SAR: 49 – 68%). Fixed facility staffing norms no longer fit for
purpose. Economic capacity is not keeping pace with both supplies and needs: Probability of affording current levels
of production: 82-86%; Probability of affording staffing norms: 61-97%, and Probability of affording EHSP is 45 – 62%.
Potential unemployment: 9.2 – 20.5% (11% - 20% was estimated from the 2019 cohorts of qualified health workers).
About 0.49% of GDP annually or some US$400 million annual investments in training, job creation, and sustenance of
those currently employed.

Keywords: Health Labor Market

Background UHC which is labor-intensive. The contribution of

the health and social workforce is not only towards
The attainment of the Sustainable Development the attainment of better for populations but also a
Goals (SDGs) including Universal Health Coverage vehicle for accelerating economic prosperity, youth
(UHC) is firmly linked with having a responsive and employment, and women’s labor participation. To
resilient health system underpinned by an adequate create responsive and reactive policies to optimize
and well-trained health workforce who are equitably access to health services and unlock economic
distributed, motivated, and supported to optimally benefits, it is essential to understand the dynamics
perform. The health workforce is such a critical and challenges that the health labor market faces at
health system input as they design it, manages the the country level.
system, and delivers the services as required for

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Despite the implementation of various transformative 3. Model and cost the workforce production,
initiatives towards a functional and fit-for-purpose deployment, and retention in Ethiopia to inform
health workforce, there are remaining health workforce affordability of wage bill and scale-up plans,
challenges in Ethiopia which including workforce including financial sustainability.
shortages, mal-distribution, unemployment, and sub-
4. Update the inventory of current skills, and review
optimal productivity and performance. Health Labor
the role of the private sector in HRH education
Market Analysis (HLMA), helps to clearly understand
factors affecting the supply of, demand for, and need Methods
for health workforce and inform dialogue towards the
design of effective policies and strategies to address Multiple methodological approaches were combined
current and potential labor market imbalances. to collect and analyze data on the health workforce
situation and health labor market dynamics which
Figure 1: Health Labour Market Framework for UHC
included desk review, stakeholders’ discussions,
triangulation of data sources, descriptive analysis
of existing quantitative data, and supply-demand
modeling. Relevant policy/strategic documents,
academic publications, and datasets were reviewed
and triangulated to gain contextual insights. A series
of meetings were held to gain wider perspectives and
WHO experts in HLMA undertook a scoping mission
to Ethiopia and held a half-day workshop with key
stakeholders to build consensus on methodological
approaches.

Data acquisition was undertaken across departmental

efforts in collaboration with the Regional Health
Bureaus (RHB). Ministry of Science and Higher
Source: Sousa et al., 2013 Education, Ministry of Finance, Civil Service
Commission, Ethiopia Public Health Association,
Objective Midwifery Association, and HERQA were contacted
and additional data and their perspective were
The main objective of the Ethiopian HLMA is to sought. The size, composition, distribution, and
generate evidence to support policy decisions to trend of the health workforce were analyzed through
improve health workforce availability, distribution, descriptive statistics. Labor market modeling (need,
and efficient use to support the government in supply, and economic space) was undertaken guided
achieving its health sector and broader development by established methods and frameworks. Additionally,
targets as earlier outlined. According to the MOH an exploratory assessment of productivity analysis for
priorities on HRH, the following specific objectives regions was undertaken using a previously published
were outlined: methodology1. Data was collected using an agreed-
upon data collection tool then triangulated from all
1. Assess the adequacy of HRH supply capacity, available sources.
projected needs, and health labor market
absorption capacity (in both public and private Result and Discussion
sectors)
Ethiopia had about 273,054 health workers of various
2. Propose short and long-term health workers’
occupational groups as of December 2019. Of this
projections based on the essential need, demand,
number, about 30,238 (22%) are working in the private
and supply.
and other sectors of the economy of which 32%

1
Marko Vujicic, Eddie Addai, and Samuel Bosomprah, ‘Measuring Health Workforce Productivity: Application of a Simple Methodology in Ghana’, 2009
<https://openknowledge.worldbank.com/handle/10986/13735> [accessed 5 December 2015].

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were found to be administrative and support staff of the income of General Practitioners while the
while 68% were the clinical and para-clinical staff. highest-earning occupations (Medical Specialists and
The current stock translates into health workforce dentists) earn about 124% of the income of General
density (doctors, nurses, midwives, and health Practitioners. When the salaries are compared with
officers) of 10.3 per 10,000 population - about 23.3% the country’s per capita Gross Domestic Product
of the threshold of 45 per 10,000 population which is (GDP), the average health worker earns about 1.7
deemed necessary for the progressive realization of times that of the GDP per capita.
UHC and the SDGs. The public health sector workers
are made up of 53% females and 47% males, which is Out of 20,936 health professional graduates who
a 22% increase in the proportion of the female health qualified in 2019, about 80% (n=15,910) were recruited
workforce since 2009. Except for health extension into the public health sector, leaving about 5,026
workers (HEW) (95.9%) and midwives with 63%, all (~20%) potentially unemployed or underemployed
other health occupational groups are dominated by (if not engaged in the private sector). When the
males. private sector absorption rate of 22% is considered,
the potential unemployment is reduced to about
Inequitable distribution of the health workforce is 10.6%. Thus, the possible unemployment among
often partly underpinned by inequitable distribution 2019 cohorts could be between 11% and 20% which
of health and social infrastructure. When the share of is quite similar to the general unemployment rate of
the health workers in the various regions are compared 19.1% in Ethiopia.
with their respective share of the population,
significant inequity in the regional distribution of the The government has maintained a constant 8% of its
health workforce is observed in which the best-staffed general annual budget dedicated to health where 80%
region (Addis Ababa) is about 4 times better off than of which sub-vented to the Regions as block grants.
the worst staffed region (Somali region). Available Of the regional block grants, Regions are spending an
data between 2007 and 2019 shows that in aggregate, average of 11.1% (range: 5.1% - 15.7%) less than the
the country has a theoretical capacity to produce at Abuja target of 15% of their general budget allocation
least 24,318 health workers annually. on all health-related expenditure. Out of the health
budget regions are spending between 45% and 57%
The MOH in 2018 instituted pre-licensure examination on health workforce remuneration.
for health professionals upon graduation. Data on the
first cohort of the licensing examination revealed that The aggregate health workforce productivity analysis
out of a total of 10,480 candidates that sat for the revealed that on average, for every 1,000 Birr (US$36)
examination, about 6,430 (61.4%) passed at their first spent on the salaries and wages of health workers, it
attempt. It also shows that a substantial gap exists yields various service outputs that are equivalent to 9
between the public training institutions and those outpatient consultations. With 95% confidence, if this
of the private-for-profit institutions. The average analysis is repeated severally it may yield between
pass rate for public sector training institutions across 6 and 12 people receiving various health services
disciplines was 78% as compared to 33.4% in the per every 1,000 Birr spent on the health workforce
private-for-profit institutions. remuneration.

Ethiopia operates fixed facility staffing norms by Under an optimistic scenario of 2.1% annual attrition,
its very nature of being a fixed-facility type, has no the aggregate health workforce stock in Ethiopia is
defined flexibility mechanism to adjust for changing anticipated to increase by some 73% by the year 2030.
workload. Fixed facility staffing norms no longer fit for Even when future population growth is accounted for,
purpose. the increases are likely to translate into an increase
of 75% in the health worker to population density
The average annual income of public sector health between 2019 and 2030, translating into almost 18
workers is about Birr 96,462 (US$ 3,445) – ranging from doctors, health officers, nurses, and midwives per
Birr 47,208 (US$1,686) for clerical/support staff to Birr 10,000 population by 2030. In sensitivity analysis, a
150,948 (US$5,391) for specialized doctors. In relative worst-case attrition scenario of 6.6% was modeled
terms, the least paid health workers earn about 39% which showed up to 24% lower estimates in the

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aggregate future supply of health workers which bill. Compared with the projected need for health
would have led to a conclusion of higher estimates of workers, the employment cost of filling the staffing
shortages. norms in the public sector is estimated to be US$1.18
billion (Birr 33.04 billion) which could increase by
Concerning the projected need for the health 26.2% within 5 years and 34.5% by 2030. On the
workforce, two scenarios of health workforce needs other hand, the cost of wages to meet the staffing
have been modeled–health facilities (staffing norms) needs of the EHSP is estimated to be nearly US$1.9
and essential health services package (EHSP) billion (Birr 52.8 billion) in 2020 and may increase
approaches. The health facilities approach (with by some 14% to US$2.2 billion (Birr 60.2 billion) in
outdated staffing norms that have been minimally 2025 and to US2.5 billion (Bir 68.5 billion) by 2030.
adjusted) projects an overall health workforce However, the estimated public sector fiscal space for
requirement of about 368,812 which is expected to health workforce employment (including federal and
reach 479,082 by 2025 and 512,333 by the year 2030. regional level) is roughly US$652.1 million (Birr 18.3
This scenario yields a required density of 17.16 Doctors, billion) could reach US$1.15 billion (Birr 34.1 billion)
Health Officers, Nurses, and Midwives per 10,000 by 2030 under a linear growth assumption. Taking
population in 2020 and 21.43 per 10,000 population into account the private sector’s contribution to
by 2030 – represents only 48% of the global threshold health workforce employment (estimated at 22%), the
of 45 physicians, nurses, and midwives per 10,000 composite economic capacity (economic demand)
population. To effectively deliver the recently finalized for health workforce employment is about US$795.6
EHSP, The country requires at least 580,148 health million (Birr 22.3 billion) at baseline (2020) and could
workers of various occupational groups at baseline expand up to US$1.4 billion (Birr 39.2 billion) by 2030.
(2020) which will increase by 14% to 661,239 by 2025
and 751,787 by the year 2030 (about 30% increase The economic space to absorb all health workers is
from baseline). These are expected to translate into growing at a smaller pace and it is feasible to absorb
a workforce density of 23.29 per 10,000 population in between 76% and 85% of the anticipated supply
2020 and 30.18 per 10,000 population by the year 2030 of the health workforce. This leaves a possibility
- represents some 68% of the global threshold of 44.5 of some 15% unemployment of health workers at
doctors, nurses, and midwives per 10,000 population baseline (2020) which could increase to 24% by 2025
necessary for the progressive realization of UHC and and then decline gradually to 19% by 2030. These
the health SDGs. estimates from an economic space perspective are
quite similar to and corroborate with an estimated
The supply of health workers may be able to meet 11 – 20% rate of unemployment amongst the 2019
72% of the health workforce requirements under cohort of health-related graduates. Under prevailing
the health facilities/staffing norms scenario which is prioritization of health workforce investment, the
likely to reach 79% by 2025 and 93% by 2030. Many potential affordability of the staffing level required to
occupational groups under this scenario will tend deliver the EHSP varies between 45% and 62% whilst
to be over-produced. In contrast, under the EHSP the health facilities staffing norms are between 61%
scenario, the current stock of health workers may only and 97%.
be able to meet 49% of the health workforce required
to deliver the EHSP in 2020. Without any intervention, Towards a progressive realization of UHC and the
this may progressively improve to 61% by 2025 and SDGs, Ethiopia requires an investment of 62.1 billion
68% by 2030. Birr (US$2.2 billion) up to 2030 to train additional
health workers of various cadres to fill the need-based
The cost of wages for the current stock of health shortage estimated to deliver the essential health
workers in both public and private sectors is services package. This represents an increase of 21%
conservatively estimated to be about US$876 million over the current health training investments. Also, the
(Birr 24.5 billion). Under the current trends of health additional investments in the form of employment
workforce production, this is anticipated to increase required to meet the need for health workers under
by 52% to US$1.33 billion (Birr 37.2 billion) by 2025, the EHSP are estimated at US$305 million annually.
this will cost an additional 87% of the current wage Thus, the total additional HRH investments required in

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Ethiopia for both training and job creation (including Upon the necessary review and validation of
currently employed health workers) is about US$ 4 this report, the FMOH in collaboration with its
billion over 10 years which represents about 0.49% of stakeholders will guide to finalize policy options and
GDP annual investments in training, job creation, and recommendations. This will guide the development
sustenance of those currently employed. of a multi-stakeholder and multi-sectoral action
plan with clear milestones and timelines to catalyze
Conclusions and Recommendations the current efforts and facilitate the necessary policy
shifts to address the prevailing and anticipated
The national HLMA revealed that, while there has health workforce challenges in Ethiopia. Below are
been a significant increase in health workforce density illustrative policy options addressing:
over the last ten years, there is still a significant need-
based shortage of HWF to deliver EHSP (SAR: 49–  Harnessing resources to expand investments in
68%). The existing fixed facility staffing norm is also decent health workforce employment and job
no longer fit for purpose and should be replaced by creation towards the progressive realization of
a scalability mechanism that allows adjusting for Universal Health Coverage
changing workloads. The potential unemployment
 Re-aligning health workforce production capacity
from the 2019 cohorts of qualified health workers
with needs and economic demand
was estimated between 11% - 20% demanding the
development of innovative job creation initiatives  Strengthen health professions regulatory
and mobilization of resources to increase investments mechanisms to engender and uphold high
in decent health workforce employment. There is standards of quality training and professional
also an urgent need to strengthen health workforce practice
regulation and improve the quality of training. The
 Optimizing health workforce distribution,
economic capacity/expenditure prioritization for
retention, and utilization for Universal Health
HWF does not keep up with both supply and need.
Coverage
The probability of being able to afford the current
levels of production, staffing norms, and EHSP are 82-  Strengthening institutional capacity for health
86%, 61-97%, and 61-97%, respectively. About 0.49% workforce stewardship, planning, management
of GDP annually or around US$400 million annual across the federal and sub-national levels.
investments are required in training, job creation, and  Investing in health workforce information, data,
sustenance of those currently employed. and evidence for decision making.

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References

1. Marko Vujicic, Eddie Addai, and Samuel Bosomprah, ‘Measuring Health Workforce Productivity: Application of a Simple
Methodology in Ghana’, 2009 <https://openknowledge.worldbank.com/handle/10986/13735> [accessed 5 December 2015].

Annex 1: Figures
Figure 2: Aggregate Need and Supply Equilibrium Graph: Comparison of EHSP and Staffing Norms Scenario to Anticipated Supply
800,000

700,000

600,000

500,000

400,000

300,000

200,000

100,000

-
Year 2021 Year 2022 Year 2023 Year 2024 Year 2025 Year 2026 Year 2027 Year 2028 Year 2029 Year 2030

Estimated Supply Health Need-based Requirements (Essential Health Service Package) Health Facility-based Requirements (Staffing Norms)

Figure 3: Economic feasibility analysis under different projection scenarios

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Knowledge of Essential Newborn Care among Nurses and Midwives Working in

Lideta Sub-city Public Health Centers

Filmona Mekuria1*, Tinebeb Seyoum2, Alemayehu Bekele3

1
Clinical Trial Department, Armauer Hansen Research Institute, Addis Ababa, Ethiopia
2
St. Peter Specialized Hospital, Department of Family Medicine, Addis Ababa, Ethiopia
3
Alemayehu Bekele, Ethiopian Public Health Institute, Addis Ababa, Ethiopia
*
Correspondence: [email protected]

ABSTRACT

Background: Neonatal mortality constitutes a major public health problem. Ethiopia has made great progress on
the institutionalization of deliveries where deliveries and neonatal care are mainly facilitated by midwives and nurses.
Hence, assessing their knowledge is a priority.

Objective: The objective of this study was to assess the knowledge of essential newborn care and the factors
associated.

Methods: Facility-based cross-sectional study was conducted. Simple random sampling was used to select the
estimated 126 participants from those who provide delivery and neonatal care. Self-administered questionnaires were
distributed to participants to collect data facilitated by data collectors. Data was entered into SPSS version 21 and
analyzed.

Results: The mean knowledge score of study participants was 12.66. The study revealed that 55% of the respondents
had good knowledge of ENC. The field of the study was found to have a significant association with the knowledge of
essential newborn care (AOR = 0.08, 95%CI: 0.03-0.22).

Conclusions and Recommendation: The study population had poor knowledge of some components of essential
newborn care. The field of the study was found to be an independent predictor of knowledge. Therefore, strengthening
and incorporation of all components of essential newborn care in the curriculum was recommended.

Keywords: Knowledge; Essential Newborn Care; Midwives; Nurses

Introduction Some non-breathing babies with primary apnea will

respond to simple stimulation alone, such as drying
The immediate neonatal period is the most crucial and rubbing. As many as two-thirds of neonatal deaths
period for neonatal survival and subsequent well- can be saved with ENC. The promotion of ENC is one
being. Identification of high-risk pregnancies and strategy for improving newborn health outcomes [2,
neonates requiring neonatal resuscitation is critical 3]. Knowledge is one of the most important aspects of
at this stage in delivery rooms, neonatology units, health systems to adhere to ENC practices.
and pediatric intensive care units to safeguard the
health and well-being of neonates [1]. The WHO Ethiopia is one of the ten countries with the highest
recommends the Essential Newborn Care protocol number of neonatal deaths globally and neonatal
which is a series of time-bound and chronologically- mortality has remained stable around 28 deaths per
ordered that a baby receives at birth and it has 1000 live births in recent years [4]. Previous studies in
standardized effective procedural steps [2]. Ethiopia show that health workers’ mean knowledge
score for immediate newborn care was relatively low

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[5, 6]. Therefore, the main purpose of this study is to aware of cleaning the cord with soap and water and
identify whether there is a knowledge gap on essential dry with a sterile bandage and no need to cover.
newborn care among nurses and midwives.
Knowledge of Newborn Resuscitation
Methods
According to the study 64 (53.3%) of the respondents
Facility-based cross-sectional study was conducted were aware of how to improve the ventilation by
in six health centers. The questionnaire was adapted repositioning the head, reapply the mask, clearing
from published articles and further modification was secretions, open the mouth slightly and squeeze the
based on the Ethiopian MOH newborn care training bag harder, and continuing ventilation and afterward
manual and the interest of the study. All qualified if the HR is > 100, the baby is breathing spontaneously
diploma and degree nurses and midwives providing and if there is no chest in-drawing and/or grunting
delivery and neonatal care services were included. the baby can be put in skin-to-skin contact with the
Data were coded and entered to SPSS version 21 mother. 49 (40.8%) of the participants were aware
and analyzed. Each correct knowledge question was that suctioning a baby unnecessarily might make the
graded as 1 point and dichotomized as good and poor baby stop breathing by blocking the airway.
knowledge by taking the median score as the cut-off
point. Bivariate and multivariate logistic regression Factors associated with knowledge of essential
was done to identify independent predictors of newborn care
knowledge of ENC.
The field of the study was significantly associated
Results with participants’ knowledge of essential newborn
care (p<0.001). Midwives were 8 times more
Socio-demographic characteristics knowledgeable about essential newborn care than
nurses [AOR (95%CI) 0.08 (0.03-0.22)].
From the total 126 estimated samples, six
questionnaires were excluded as a result of Discussion
incompleteness and inconsistencies, making the
response rate 95.23%. Of the participants, 51 (42.5%) Knowledge is one of the crucial aspects of health
were Diploma midwives and nurses. systems to adherence of ENC and lack of knowledge
may impede the provision of ENC.
Knowledge of Attending Delivery
The study revealed that 55% of the respondents
112 (93.3%) of the participants were found had good knowledge of ENC whereas 45% had poor
knowledgeable about hand washing and the use of knowledge. Knowledge gaps on the steps of ENC were
sterile gloves while attending delivery and the need to noted, mainly with the measures to be taken during
ensure the area for newborn resuscitation is prepared the ‘golden minute’ and identification of neonates
and necessary equipment is clean and ready for every that can receive routine care where 35% and 41.7%
delivery. 78 (65.5%) of the participants responded of the participants were found not knowledgeable.
that during the Golden minute, it is important to help Major knowledge gaps were also seen with the
a baby breathe if necessary. steps of cleaning a dirty umbilicus, consequences of
unnecessary suctioning, and steps to undertake if a
Knowledge of Immediate Newborn Care baby fails to respond to initial steps of resuscitation,
where 82.5%, 59.2%, and 75.8% of the respondents
Regarding knowledge of immediate newborn care were found to have less knowledge.
70 (58.3%) of the participants were aware that only
those newborns who cry and/or breathe well can In this study, the average knowledge score of ENC was
receive routine care and 104 (86.7) of them know that 63.3%. This is lower compared to the study conducted
routine cares involve drying the baby, removing wet in Egypt [7] and India [8]. The difference could be due
clothes and positioning the baby skin-to-skin with the to the lack of in-service training and the educational
mother. To prevent infection from the dirty umbilical level of study participants.
cord, only 22 (17.6%) of the study participants were

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Limitations of the study References

1. The sample size used in this study was smaller 6. Nasor Taha FA (2013) Assessment of knowledge,
compared to similar studies. attitude and practices of nurse midwives towards
immediate care of the newborn in Khartoum state
2. The study focused on knowledge, which is not the teaching hospitals 2011. J Am Sci 9: 263-270.
only component of competency.
7. Silvestre AM (2014). Early essential newborn
care: Clinical practice pocket guide, World Health
Conclusion and Recommendations
Organization. Regional Office for the Western Pacific.
Lack of knowledge can impede the practice of ENC 8. Worku B, Gessesse M (2012) Newborn care training
and increase the risk of neonatal mortality and manual, essential new born care for every baby. Federal
morbidity. The study participants had a knowledge Ministry of Health Ethiopia EPS.
gap on the measures to be taken during the ‘golden 9. Federal Democratic Republic of Ethiopian Ministry of
minute’ and identification of neonates that can Health (2011) Integrated management of newborn and
receive routine care, precise cord clamping time, and childhood illness, Part 1. Blended learning module for
the care given to dirty umbilicus and resuscitation the health extension programed.
domains including, consequences of unnecessary
10. Central Statistical Agency [Ethiopia] and ICF
suctioning and steps to undertake if a baby fails to
International (2012). Ethiopia demographic and health
respond to initial steps of resuscitation, which leads
survey 2011. Addis Ababa, Ethiopia and Calverton,
to malpractice and increase the risk of asphyxia and
Maryland, USA: Central Statistical Agency and ICF
its complications.
International.

Based on the study findings, the following 11. Debelew GT, Afework MF, Yalew AW (2014) Determinants
recommendations were forwarded: and causes of neonatal mortality in Jimma zone,
southwest Ethiopia: A multilevel analysis of prospective
1. Strengthen the quality of undergraduate follow up study. PLoS One 9: e107184.
education provided especially regarding delivery 12. Fattah E, Zein NA, Dein E (2012) Assessment of quality
and newborn care in the curriculum for both of nursing care provided immediately after birth at
diploma and degree programs. university hospital. Life Sci J 9:2115-2126.
13. Malhotra S, Zodpey SP, Vidyasagaran AL, Sharma K, Raj
2. Facilitate in-service training to nurses and
SS, et al. (2014), Assessment of essential newborn care
midwives on ENC including newborn resuscitation
services in secondary-level Facilities from two districts
and upgrade their educational level.
of India. J Health Popul Nutr 32: 130-141.
Annex 1: Table 1 Association of socio-demographic and some selected variables with participants’ level of knowledge on essential
newborn care in Lideta Sub-City, Addis Ababa, Ethiopia.

Variable Knowledge COR (95% CI) P-Value AOR (95%CI) P-Value

Good Poor
Level of Education
Diploma 28(54.9%) 23(45.1%) 1.75 (0.83-3.7) 0.14 0.58(0.24-1.4) 0.23
Degree 47(68.1%) 22 (31.9%) 1 1
The interest in working in the delivery ward
Yes 62 (62.6%) 37 (37.4%) 0.97 (0.37-2.56) 0.95 1.3(0.4-3.9) 0.67
No 13 (61.9%) 8 (38.1%) 1 1
Field of study
Nursing 31(44.9%) 38(55.1%) 7.7(3.0-19.4) <0.001 0.08(0.26-0.23) <0.001
Midwifery 44(86.3%) 7(13.7%) 1 1
*Adjusted for all significant variables of p<0.05

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Status of Histopathology Services in Ethiopia

Giorgis Yeabyo1*, Bereket Berhane1, Mesfin Nigussie2, Aster Tsegaye3, Fatuma Hassen3
1
St Paul Hospital Millennium Medical College, Addis Ababa, Ethiopia
2
International Clinical Laboratories, Addis Ababa, Ethiopia
3
Addis Ababa University, Addis Ababa, Ethiopia.
*
Correspondence: [email protected] and [email protected]

Background laboratories were concentrated in Addis Ababa,

which contains an estimated population of 4 million.
Sub-saharan Africa countries are the poorest nations Six (46.2%) are spread in Tigray (1), Amhara (2),
in the world while experiencing increasing numbers Oromia (2), SNNPR (1). However; in Afar, Somali,
of cancer cases due to the human immunodeficiency Benishangul-Gumuz, Harari, Gambella, and Dire
virus epidemic, growth and aging of the population, Dawa city administration have no histopathology
and adoption of westernized life styles. For patients services where a population of 40,239,100 resides.
throughout the region with cancer, the scarcity of
histopathology services has often been an obstacle
to receiving appropriate diagnosis and treatment.
The lack of infrastructure along with lack of training
for pathologists is a further problem for the delivery
of the service in these countries. The availability of
pathologists in the region is typically less than one
per million populations versus more than 60 per
million populations in the United States (1-3).

Ethiopia is one of the sub-Saharan African countries

located in East Africa, with a population of about
102,403,196 (2016 estimate) and a geographical
area of 1,127,127 km2. It is divided into nine federal
regions and two city administrations, and the capital
is Addis Ababa. In Ethiopia, the incidence of cancer
is increasing without an increase in histopathology Figure 1: Distribution of current histopathology service centers
services. Here, the practice of cytopathology and in Ethiopia (black circles)
fine-needle aspiration cytology started after the
All histopathology laboratories possessed at least one
establishment of the Department of Anatomic
functioning rotary microtome. Eleven labs (84.6%)
Pathology in Tikur Anbesa Hospital in 1965 (4).
had an automatic tissue processor, six (46%) had
A cross-sectional study has been conducted to assess automatic staining equipment but only two (15.2%)
histopathology laboratory facilities in Ethiopia. A had automated mounting equipment; seven (53.8%)
checklist was prepared to assess the location of the owned a cryostat. Five laboratories (38.5%) had no
histopathology service, availability of equipment, archival mechanism for slides and tissue blocks. When
number of professionals, and turnaround time in all it comes to safe tissue grossing, most histopathology
regions and city administrations of Ethiopia. There are laboratories were found lacking; 11 (84.6%) of the
13 histopathology laboratories in the whole country, laboratories lacked fume hoods for toxic chemicals in
nine governmental and four private institutions. Of grossing.
the 13 histopathology laboratories, seven are located
As turnaround time (TAT) is one of the quality indicators
in the capital, Addis Ababa. This indicates 53.8% of all
of the laboratory, it was assessed at all visited
histopathology
institutions. As a result, the shortest turnaround time

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for biopsy reporting was 7 days while the longest was

30 days. There were 44 Pathologists responsible for the
diagnosis of cancer and registered at the institutions
assessed. There were also 38 laboratory professionals
active in the anatomic pathology laboratory among
them there were few (10) Histo-technicians or Histo-
technologists with formal training in the profession.

Of the 13 assessed histopathology services, seven

(53.8%) are located in the capital, Addis Ababa,
whereas 80% of the population resides in rural areas.
Figure 2: The turnaround time at assessed institu-
This finding agrees with the study by Yeshi et al (4) tions.
which found that most of the service was delivered in
urban areas while most of the population resides in Turnaround time was not assessed at the Ethiopian
rural areas. The same is true in the Sudan where 78.4% Public Health Institute because it is a research
of pathologists were found to reside in Khartoum (1). center. AFGH, Ethiopian Armed Forces General
Hospital; AGHMC, Adama General Hospital, and
The scarce and outmoded equipment, in addition to Medical College; AHRI, Armauer Hansen Research
the lack of expertise for operation and maintenance, Institute, Armed Forces General Hospital; ASUH,
has resulted in an inadequate histopathology service Ayder Specialized University Hospital; GGH, Gambi
in Ethiopia. For instance, in Gambi General Hospital General Hospital; GUH, Gondar University Hospital;
there is only one outmoded microtome and other HUH, Hawassa University Hospital; ICL, International
tasks are done manually. Most of the institutions Clinical Laboratories; JUSH, Jimma University
do not utilize a cryostat due to either installation Specialized Hospital; KGH, Kadisco General Hospital;
problems or lack of training, or both. Most of the P, Public; Pt, Private; SPHMMC, St Paul Hospital
cryostats are donations and training was not Millennium Medical College; TASUH, Tikur Anbessa
included with the gift. Contributions from donors are Specialized University Hospital.
gratefully received, but the cryostats may be left idle
for many years. Our findings agree with the study in References
Uganda (5), which described the donation of a tissue
processor whose manual was written in a language 1. Awadelkarim K, Mohamedani AA, Barberis M. Role of
not understood by the histology technicians. As a pa- thology in Sub-Saharan Africa: an example from
result, the machine was left idle for 3 years. Another Sudan. Pathol Lab Med Int. 2010;2:49-57.
study from Afghanistan (6) reported that a set of 2. Okesina AB. Pathology in West Africa: problems
histopathology equipment was left for more than 1 of training and practice. Bull Royal Coll Pathol.
year without installation because no instructions or 2009;148:306-308.
assistance to set it up had been provided with the 3. Gopal S, Krysiak R, Liomba NG, et al. Early experience
equipment (2). after developing a pathology laboratory in Malawi,
with emphasis on cancer diagnoses. PloS One.
The average turnaround time for surgical pathology
2013;8:e70361.
samples was 15.9 days in our survey, whereas the
UK Royal College of Pathologists recommended that 4. Yeshi MM, Tambouret RH, Brachtel EF. Fine-needle

histopathology diagnostic biopsy turnaround time aspiration cytology in Ethiopia. Arch Pathol Lab Med.

is within 7 days. This is found to be a great problem 2013;137:791-797.

for patients traveling long distances from rural areas. 5. Benediktsson H, Whitelaw J, Roy I. Pathology services in
Patients are forced to wait for the report from the developing countries: a challenge. Arch Path Lab Med.
histopathology laboratory, even after they have been 2007;131:1636-1639.
discharged from the inpatient ward. This may result 6. Deck JH. The face of pathology in Afghanistan in 2006-
in lengthy delays in the therapeutic management of 2007. Arch Pathol Lab Med. 2011;135:179-182.
the disease as well as an unnecessary expense for the
patient. Keywords: Histopathology; Cancer; Turnaround ime

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Evaluation of the Effectiveness of Competency-based Training of Women

Development Army Leaders in Improving the Uptake of Health Care Services in
Ethiopia
Mulusew Gerbaba Gebena1,2, Yibeltal Kiflie Alemayehu1,2, Yibeltal Tebekaw3, Israel
Ataro Otoro4, Girmay Medhin1,5, Mekdess Demissie1,5,6, Bantalem Yeshanew Yihun9, Fasil
Walelign Fentaye1,7*, Kassahun Sime4, Alula Meressa1, Challa Tesfaye4, Desalew Emaway3,
Biruhtesfa Bekele3, Wuleta Betemariam3, Frehiwot Nigatu8
1
MERQ Consultancy PLC, Addis Ababa, Ethiopia
2
Jimma University, Jimma, Ethiopia
3
The Last Ten Kilometers Project of JSI, Addis Ababa, Ethiopia
4
Health Extension and Primary Care Directorate, Ministry of Health, Addis Ababa, Ethiopia
5
Addis Ababa University, Addis Ababa, Ethiopia
6
Haramaya University, Harari, Ethiopia
7
Wollo University, Dessie, Ethiopia
8
International Institute for Primary Health Care - Ethiopia, Addis Ababa, Ethiopia
9
Policy, Plan, Monitoring, and Evaluation Directorate, Ministry of Health, Addis Ababa, Ethiopia
*Correspondence: [email protected]

ABSTRACT

Introduction: The Ministry of Health uses a network of women volunteers, known as the Women’s Development
Army, to promote community engagement and ownership in the health sector. To build the capacity of women
development army leaders, the Ministry of Health and regional health bureaus, and their partners implemented the
Competency-Based Training program. The program involves training women development army leaders based on Health
Extension Program packages and communication skills.

Objective: This evaluation assessed the effectiveness of competency-based training and explored the barriers and
facilitators of competency-based training implementation.

Methods: The evaluation used mixed methods based on Kirkpatrick’s model of training evaluation and it was
conducted in three regions (Amhara, Oromia and Southern Nations, and Nationalities and Peoples). Data were collected
from a total of 2,937 respondents for quantitative study (187 trained women development army leaders with 911 network
members and 374 non-trained women development army leaders with 1,465 network members) and 24 key informants
for an in-depth interview.

Results: Competency-based training was found to be effective in improving the knowledge and practices of women
development army leaders and their network members concerning water, sanitation and hygiene, disease prevention
and control, and maternal and child health. The effect of competency-based training was, however, not uniform across
all targeted behaviors of women development army leaders and their network members.

Conclusion: Addressing the multi-level determinants of competency-based training needs engaging all relevant
stakeholders and considering other viable approaches of capacity building.

Key words: competency-based training, women development army, community capacity-building, training
effectiveness, training evaluation

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Introduction Results and discussion

In 2011, the Ministry of Health (MoH) introduced Coverage and sociodemographic characteristics
the Women’s Development Army (WDA) structure to of participants: We interviewed 187 CBT-trained
promote community engagement and ownership WDA leaders with 911 network members, and
in the health sector. However, efforts to build their 374 nontrained WDA leaders with 1,825 network
capacity have been limited. To fill this gap, the MoH members. The two groups were comparable in their
and its partners started the Competency-Based sociodemographic and economic characteristics
Training (CBT) program in collaboration with the except in educational status, membership in
Federal Technical and Vocational Education Training community-based health insurance (CBHI), and
Institute, regional health bureaus, non-governmental marital status. Compared to their counter parts,
implementing partners, and funding agencies. The trained WDA leaders were more likely to have formal
program involves training WDA leaders based on education (65% vs. 45.7%; p < 0.001), to be members
Health Extension Program (HEP) packages and of community-based health insurance (CBHI) (73.3%
communication skills. However, evidence generated vs. 61.8%; p=0.007) and their network members were
using a well-designed study on the effectiveness of more likely to be married (83.5 % vs. 79.5%; p = 0.012),
CBT is not yet available. CBHI members (58.1 % vs. 50.6 %; p < 0.001), and
attended school (45.0 % vs. 38.9%; p <0.002).
Objective
Satisfaction of WDA leaders with CBT: About two-
To evaluate the effectiveness of CBT in improving thirds of trained WDA leaders (66.6%) were satisfied
the knowledge and practices of WDA leaders and with the training, and most of them gave a high rating
their network members, and to identify barriers and for the training content, mode of delivery, and trainers.
facilitators of implementing CBT. However, the timing and the training materials were
reported as being inadequate.
Methods
Knowledge and practices of WDA leaders:
We evaluated the effectiveness of CBT using a mixed- Awareness of WDA leaders concerning water,
methods design based on Kirkpatrick’s model of sanitation, and hygiene (WASH); disease prevention
training evaluation that classifies outcomes of and control; and family health issues was relatively
training programs into four levels: reaction, learning, high. However, in-depth knowledge about each topic
behavior, and results. We randomly sampled trained and practice was generally low and variable. Specific
and non-trained WDA leaders with their network knowledge of toilet use ranged from 48.7% to 88.2%
members from Amhara, Oromia, and the Southern among trained WDA leaders, and 40.9% to 83.7%
Nations, Nationalities, and Peoples Regions. We among non-trained WDA leaders.
also investigated barriers and facilitators of CBT
implementation by conducting in-depth interviews There are important gaps in knowledge required for
with key informants including CBT trainees, trainers, taking appropriate preventative actions. For instance,
and training coordinators, at woreda and kebele 89.9% of trained and 83.1% of nontrained WDA
levels. We compared the intervention group (CBT- leaders knew that TB can be cured. Knowledge of
trained WDA leaders and their network members) with condom use to reduce the chance of getting HIV was
the comparison group (nontrained WDA leaders and 84.9% among trained and 74.7% among nontrained
their network members). We used a doubly robust WDA leaders.
estimation method to obtain the average treatment
effect of the CBT.

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The current use of modern contraceptives was 39.3% Compared with network members of non-trained
among trained and 44.1% among nontrained WDA WDA leaders, network members of trained WDA
leaders in the reproductive age group. Coverage of leaders were more likely to deliver in health facilities
four or more visits for antenatal care (ANC) and health (53.3% versus 44.5%; p < 0.001) and seek treatment
facility delivery was 72% and 55%, respectively, for sick children (54.5% versus 49.8%; p = 0.016).
among trained WDA leaders and 58% and 43.3%,
respectively, among nontrained WDA leaders. Of Effect of CBT on HEP-related knowledge and
trained WDA leaders, 71% reported seeking treatment behaviors of WDA leaders and their network
for a sick child during the last two weeks, while 43% of members: Among 30 assessed indicators, CBT was
nontrained WDA leaders reported doing so. positively and significantly associated with 13 (43.3%)
for WDA leaders and 19 (63.3%) for WDA members.
Knowledge and practices of WDA network CBT delivered for WDA leaders were significantly
members: Among WDA network members with associated with better knowledge about FP, health
trained leaders, knowledge of specific benefits of facility delivery, household treatment of drinking
using a toilet ranged from 35.6% to 77.6%, criteria water, covering food and protecting it from flies,
for a healthy home ranged from 18.6% to 65.5%, and improved sources of drinking water, participation
methods of preventing insect and rodent infestation in WASH campaigns, knowledge about HIV/AIDS,
ranged from 10.4% to 60.3%. For WDA members with awareness of NCDs, and awareness of cervical
nontrained leaders, knowledge of specific benefits cancer, both among WDA leaders and their network
of using a toilet ranged from 33.4% to 72.7%, criteria members. For both WDA leaders and their network
for a healthy home ranged from 18.8% to 60.5%, and members, there was no significant association
methods of preventing insect and rodent infestation between CBT and the use of long-acting reversible
ranged from 8.5% to 63.9%. contraception (LARC), postnatal care coverage (PNC),
washing hands at critical times, separate kitchen,
Compared with network members of non-trained separate sleeping room, separate room for animals,
WDA leaders, network members with trained WDA and improved sanitation facilities.
leaders are in a better condition in terms of practicing
open defecation (20.3% versus 30.5%; p < 0.001), Compare with non-trained WDA leaders, those who
having water for handwashing in their compound received CBT knew significantly more FP methods
(27.4% versus 24.7%; p = 0.001) and having access to (mean difference = 2.408, 95% CI: 1.97, 2.841). Similarly,
an improved source of drinking water (88.4% versus the number of FP methods known by WDA members
82.5%; p < 0.001) with trained leaders was higher than among WDA
members with nontrained leaders (mean difference
Awareness about communicable diseases, including = 1.255, 95% CI: 1.03, 1.48). CBT was not significantly
TB and HIV, was higher among network members associated with the use of modern contraceptives
with trained than nontrained leaders. However, among WDA leaders (mean difference = –0.023,
knowledge of network members on detailed issues 95% CI: –0.103, 0.056]), while there was a weak yet
with implications for prevention was suboptimal: statistically significant association with that of WDA
83.7% of WDA network members with trained members. Network members of trained WDA leaders
and 84.0% with nontrained leaders believed that had a higher modern contraceptive prevalence rate
HIV can be transmitted by sharing food with HIV- (mCPR) than those of nontrained WDA leaders (mean
infected persons. Awareness of the use of ARVs for difference = 0.0482, 95% CI: 0.012, 0.084).
the prevention of mother-to-child transmission of
HIV was 70.2% among WDA network members with
trained leaders and 60.5% among members with
nontrained leaders.

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Effect of CBT on the functionality of WDA Acknowledgment: This evaluation was conducted
structure: Trained WDA leaders conducted a higher under the auspices of JSI – L10K; we would like to
number of meetings as compared to nontrained WDA extend our gratitude to JSI – L10K for supporting us
leaders. The WDA functionality index of WDA networks both financially and technically. Technical inputs from
led by CBT-trained leaders was also significantly investigators, co-investigators, and reviewers from
higher as compared to those led by nontrained ones. the International Institute for Primary Healthcare in
In the adjusting model, WDA networks led by trained Ethiopia, the Ministry of Health, and other stakeholders
leaders have a higher mean of functionality index than were critical in ensuring the relevance and utility of the
their comparison group (mean difference = 2.255, 95% evaluation. We would also like to extend our heartfelt
CI: 1.898, 2.612). thanks to the data collectors, supervisors, and study
participants for their participation.
Facilitators and barriers of CBT implementation:
Trainers’ motivation, trainees’ level of understanding
or literacy level, trainer–trainee relationships,
community acceptance, distance from the training
place, availability of resources (e.g. teaching materials,
incentives, and coordination) emerged as important
determinants of the implementation of CBT.

Conclusions and recommendations

Although not uniform across all targeted behaviors,

CBT was effective in improving the knowledge and
practices of WDA leaders and their network members
concerning WASH, disease prevention and control,
and maternal and child health.

The implementation of CBT was facilitated and

hindered by factors operating at individual,
community, and health-system levels. The between
and within regional variability in the implementation
of CBT and satisfaction of trainees calls for re-
examining the WDA selection criteria, teaching
methods, training materials, and refreshments
modalities during training and addressing context-
specific barriers of the training. The variability in the
effectiveness of CBT in achieving its objectives calls
for more stringent monitoring of implementation
fidelity and the design of mechanisms to address
additional social determinants of health behavior.

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 SECTION TWO

NEW INITIATIVES

SECTION TWO: NEW INITIATIVES

SPECIAL BULLETIN MINISTRY OF HEALTH, ETHIOPIA

Clean and Timely Care in Hospital for Institutional Transformation (Catch-It) Project

Fekadu Jiru 1, Kasu Bifa 1, Yakob Ahmed1, Abass Yusus1, Gezashign Kasa1, Deneke Abebe1
1
Ministry of Health-Ethiopia, Clinical Services Directorate, Addis Ababa, Ethiopia.
Correspondence: Fekadu Jiru: [email protected]

Introduction Methods
Ethiopian Hospitals Alliance for Quality (EHAQ) is a Each EHAQ cycle begins after the closing and
national platform and mechanism for systematic recognition ceremony of the focus areas of the
collaboration and learning among hospitals to previous cycle. The EHAQ third cycle initiative was
promote the sharing of best practices as hospitals identified through expert consultations, desk review,
implement different reforms. The EHAQ was and MoH management recommendation. The project
designed as a vehicle to improve the quality of care was implemented in three phases:
by identifying locally developed best practices and
encouraging the sharing and implementation of Phase One: As the preparatory phase included:
strategies for successful performance improvement. finalization of all relevant documents, including EHAQ
After successful completion of two cycles that focused guideline, CATCH-IT Project document, CATCH-IT
on improving patient satisfaction and Maternal, change package, and Monitoring and evaluation tool,
newborn health and CASH, the third cycle EHAQ identification of relevant stakeholders, and mapping
collaboration focused on the implementation of of potential resources. Advocating for CATCH-IT
Clean and Timely Care in Hospital for Institutional Project among stakeholders to gain a common
Transformation (CATCH-IT) Initiative. The initiative is understanding was also undertaken at phase.
designed to improve the quality of clean care, Timely
access to basic services, and revitalization of Hospital Phase Two: As the implementation phase was
reform initiatives for Institutional transformation. commenced by the national launching of the CATCH-
IT Project and re-arrangement of Hospitals in EHAQ
CATCH-IT Initiative came to existence to systematically Clusters categorizing hospitals as LEADS, Members
answer for the national call to address the existing as well as assigning teaching hospitals as co-LEADs
major challenges for better healthcare delivery, by followed by the Regional level launching of the
improving timeliness and cleanness of care, through CATCH-IT Project at each region during which the
the implementation of different change package and Hospitals introduced key interventions and change
re-vitalizations of previous hospital initiatives. packages to be implemented. The implementation of
the change packages was initiated following baseline
Objective assessment of each cluster. During phase continuous
regular integrated supportive supervisions, onsite
To transform the quality of services in hospitals
mentorships, and regional performance review
through clean and timely care improvement. The
meetings were conducted in all regions.
specific objectives are:
Phase Three: Evaluation, Recognition, and
• To strengthen clean care practice in hospital
Closing
services.
• To reduce waiting time in hospital services. Upon successful completion of the EHAQ cycle, an
• To revitalize the existing hospital service independent validation team conducted validation
transformation initiatives. assessment on the best performing hospitals
• To identify best practices and scale up through identified by each Regional Health Bureau and the
collaborative learning. independent audit team audited the score of each
hospital validated by the validation team.

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CATCH-IT Key Interventions Result

1. Cleanliness interventions The CATCH-IT initiative was implemented in all

public hospitals in all regional states categorized
• Monthly cleaning Day into 61 clusters. Respective Regional Health Bureaus
• Regular recognition scheme for clean wards identified 44 hospitals for National champions of
• Implement kaizen 5S champion’s competitions. Through the independent
• The hospital should make sure the outsourcing validation and audit conducted at the regional
contracts stipulate the required housekeeping identified champion hospitals, the average CATCH-IT
training. score of the hospitals is 85% with a range of 99.83%
to 33.36%. Compared to the baseline assessment,
• Conduct standardized regular internal and
surgical waiting time was reduced from 52 days to 33
external cleaning audit
days, the OPD waiting time was improved by 50%, the
• Assign ward master to sustain cleaning practice EHSTG score was increased from 59% to 75.5%, and
the overall CATCH-IT score raised by 35% from 50%
2. Timeliness interventions
to 85%. With the minimum Cut-off score of 76.92%,
• Digitalize management of liaison office. 25 hospitals were awarded 2 Million Birr, Crystal Cup,
and Certificate of second rank Performers and 10
• Central/Regional management of surgical
hospitals were awarded 3 Million Birr, crystal cup and
backlogs.
Certificate for first rank achievers while the remaining
• Introduction of the expected date of discharge 9 hospitals were recognized by certification for their
during patient admission. participation. The recognition and closing ceremony
• Introduce a queue management system (Manual for the CATCH-IT and the introduction of the next cycle
or automated) at medical record rooms. EHAQ focus area was held in August in the presence of
• Early initiation of clinics and late working of relevant stakeholders and the leadership.
clinics.
Conclusion and way forward
• Shift Morning sessions into lunch sessions and
seminars into weekends. As EHAQ is a learning platform that builds on the
sustainability of prior cycle initiatives, the cumulative
3. Transformation of the institution Intervention:
reform implementation capacity built at each
EHAQ enrolled hospital and the best experiences
• Implementation of Pain-free Hospital Initiative
identified during the implementation periods of
• Ethiopian Hospital Service Transformational
three cycles will be a stepping stone for the Ministry
Guidelines (EHSTG) implementation
and its key stakeholders to launch the fourth cycle
• HSTQ standards implementation of EHAQ initiative which will focus on Evidence-
• CRC initiative implementation based Care. As a way forward continues technical
• DHIS 2 implementation and data use support, mentorship and supportive supervision,
national-level review meeting and facilitation of best
• SaLTS implementation
experience scale-up have to be continued to make
this platform sustainable.

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The National Health Promotion Strategic Plan: The Development Process and its
Objectives

Segedu Workineh1, Israel Otoro1, Zenaw Merie1*, Hailemariam Yesemaw1

1
MOH, Health Extension Program, and Primary Health Care Directorate, Addis Ababa, Ethiopia
*Correspondence: [email protected]

that considers the variability in the needs of specific

Background behavioral outcomes and cultural contexts [2]. The
ministry of health is currently revising its community
Health and development today face unprecedented
engagement platforms such as the women’s
threats. The financial crisis threatens the viability of
development group (WDG).
national economies in general and health systems in
particular. Health promotion has the potential to bring Furthermore, emerging global pandemics and
a huge impact on health, yet it is given low priority [1]. frequent public health emergencies such as COVID-19,
However, health promotion is more relevant today malaria resurgence, zoonotic diseases (Brucellosis,
than ever in addressing public health problems Scabies, Anthrax, avian flu), and overburdening of
globally. In the 21st century with ever-increasing public the NCDIs both in the urban and rural areas require a
health threats and challenges, the health scenario more specific, robust, and coordinated preparedness
is positioned at unique crossroads as the world is and response strategies, which may need to be
facing a ‘triple burden of disease’2 constituted by the highlighted in the national health promotion strategic
unfinished agenda of communicable diseases, newly plan.
emerging and re-emerging diseases, emergence,
and rise of antimicrobial resistance as well as the The Strategy was designed to respond to the National
unprecedented rise of non-communicable chronic Health Policy; its aim is health promotion and disease
diseases and injuries (NCDIs). prevention [3] and to the sustainable development
goal (SDG) agenda 2030; to ensure healthy lives and
Health promotion has a significant role to play promote well-being for all at all ages (SDG 3) [4].
in reducing the burden of disease to the health The policy documents that have informed the need
system, by addressing the key social, behavioral, and to revise the existing National Health Promotion
structural determinants of health. Therefore, investing and Communication Strategy (NHPCS 2016-2020)
in health promotion is a promising prospect in are The Second Health Sector Transformation
realizing Universal Health Coverage (UHC). Universal Plan (HSTP II, 2021–2025), The Health Extension
health coverage will be financially feasible only when Program (HEP) Optimization Roadmap(2020-2035)
Ethiopia implements strong evidence-based health and the introduction of Community Engagement
promotion programs. However, challenges are many Implementation Guideline, which emphasize the
and careful consideration and analysis to redeemed need to recognize, prioritize and scale up health
time is required. As the traditional individualistic promotion interventions in the implementation of the
information provision and behavioral interventions essential health package to address health problems
are no longer enough in preventing and controlling and to effectively utilize technologies in conveying
major public health problems effectively and the key message to the end-users.
efficiently, an innovative health promotion approach
is imperative. There is adequate evidence that justifies The HSTP II (2021-2025) emphasized innovative
shifts in strategic approaches to health promotion. Health Promotion and community engagement
For example, the HEP assessment conducted in 2019 interventions fitting to the changing needs and
strongly suggested revision of the current social and contexts at community and facility levels. Two out
behavior change theories and strategies in a way of 14 strategic directions of the HSTP II are directly

2
Disease burden from communicable and non-communicable diseases as well as related to injuries.

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linked to the health promotion case team; to mention: Strategic Plan will include sustainable skills on
ensure community engagement and ownership and health promotion planning, implementation, and
enhance health in all policies and strategies [5]. M&E, health infrastructure or service development,
program maintenance and sustainability, building
The National Health Promotion Strategic Plan problem-solving capability, organizational structures,
(2021/22-2025/6) encompasses the following resources, and commitment to health improvement in
strategic directions as set out in the Ottawa Charter health and other sectors. Outcomes at the individual
for health promotion: capacity building, health in level will include the improved level of knowledge,
all policies (HiAP), create supportive environments, personal skills, and confidence to take action to
community engagement, and develop personal skills improve personal and community health by changing
(improve health literacy) [6]. Therefore, considering personal lifestyles and living conditions.
shifts and concurrent contexts in the health sector,
a new national health promotion strategy needed More specifically, the expected outcome of the
to be developed to guide meaningful and efficient successful implementation of the strategy will include
implementation of health promotion interventions. a supportive environment, increased access to
health services and information, increased utilization
Objective of health services, improved health behavior and
lifestyle, increased health literacy, increased health
The general objective of the National Health system literacy, and increased compliance to public
Promotion Strategic Plan is to enable individuals, health laws, with the resultant impact of the improved
families, and communities to adopt healthy behaviors health status of the society.
and lifestyles. It intends to enable individuals,
families & communities to take ownership and Conclusion and way forward
control of their health; promote health in all policies
and strategies and reduce their health consequences; The National Health Promotion Strategic Plan has
implement health-promoting school initiatives and a significant role to play in reducing the burden of
advocate for greater mass media involvement and disease to the health system and improve health stats,
use of technologies to enhance health transformation by addressing key social, behavioral, and structural
initiatives. determinants of health. Hence, we urge strong
coordination and collaboration across stakeholders
Method for its realization.

The National Health Promotion Strategic Plan (2021- References

2025) was developed through a participatory process
involving partners both within the Ministry of Health 1. Coe G, de Beyer J. The imperative for health promotion
Ethiopia (MOH), Regional Health Bureaus (RHBs), in universal health coverage. Global Health, Science
Universities, and partners who are implementing and Practice. 2014 Feb;2(1):10-22. DOI: 10.9745/
health promotion activities on the ground; to identify ghsp-d-13-00164. PMID: 25276559; PMCID: PMC4168610.
health promotion priorities in the country. 2. Teklu AM, Alemayehu YK, Medhin G, et al. National
assessment of the Ethiopian Health Extension Program.
In the process of National Health Promotion Strategic Addis Ababa, Ethiopia:2020.
Plan development, the technical working group
3. FDRE draft Health Policy, 2019
conducts a SWOT analysis of the previous national
health promotion and communication strategy, 4. United Nations (2015) Resolution adopted by the General
validation workshops to get stockholders’ feedback, Assembly on 25 September 2015, Transforming our
and alignment of prioritized activities with other world: the 2030 Agenda for Sustainable Development
directorates’ health program strategy activities. 5. HSTP II (2021-2025)
6. Ottawa Charter for Health Promotion. First International
Results Conference on Health Promotion, Ottawa, Canada, 17–
21 November 1986. Geneva: World Health Organization;
The expected outcome and impact of the
1986
implementation of the National Health Promotion

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Employees’ Performance Appraisal Problems and Lessons Learned at Ministry of

Health

Ismael Degefa Gutema1*, Mulugeta Debel Bultume1

1
Ministry of Health, Addis Ababa, Ethiopia
*
Correspondence: [email protected]

Background effect on the employees’ performance appraisal. To

fulfill the purpose of this study, secondary data such
The objective of the second Health Sector as admin reports and raw data were used for analysis.
Transformation Plan (HSTP-II) entails strengthening The quantitative data were triangulated and validated
the health system to ensure people live longer healthier with the qualitative data which was collected through
lives through reducing disease conditions, unhealthy group discussions and experts’ opinions. Finally, a
lifestyles, and accidents. To realize this strategic plan, descriptive survey method was employed for the data
the Ministry of Health (MoH) is organized by a Minister explanation. The target population of the study was
Office having three state ministers, 25 directorates, 88 all eligible employees for the performance appraisal
teams, and a total of 1213 employees. For decades, which accounts for 966 out of 1137 employees working
the Ministry has been undertaking employees’ at the Ministry. Finally analyzed data were presented
performance appraisals with a weak monitoring and in charts and text format depending on the data type
evaluation. This has made the health sector have less and content; phrases, sentences, paragraphs, and
experience in employees’ performance appraisal. In ideas.
2020-21 fiscal year the revised performance appraisal
guideline was approved and implemented. During Results and Discussion
the implementation of the guideline, some pertinent
problems were observed that require an efficient and The performance appraisal guideline states that all
effective performance management system that has eligible employees during the appraisal period must
the capacity of improving performance and overall be evaluated. Accordingly, performance appraisal
quality of the organization (1). It is also believed formats which consist of two sets of items with planned
that without proper research being performed on activities and behavioral appraisals were expected to
the identified problems, organizations that are be filled and collected from eligible 1137 employees;
implementing a performance management system out of these, 716 (63%) were evaluated and the rest
will be confronted with the same problems repeatedly, 421 (37%) were not. From this we can understand
resulting in inefficiency (2). that abundant number of eligible employees was not
evaluated. This indicates that, though attending the
As a result, more research into this specific topic appraisal session was obligatory for every eligible
is required to heighten the chance of a successful employees of the Ministry, huge number of the
performance management system. employees’ lack readiness for performance appraisals
(see Fig. 1).
Objectives
Figure 1: General status of employees at MoH, 2020/21 Fiscal
This research aimed to explore problems faced, Year

lessons learned in the process of employees’

performance appraisal, and to recommend possible 421
solutions. Eigible for appraisal
Uneligible for evalauation
1137
Methods evalauted
716 Eligibile not evalated
This study employed a mixed approach of quantitative
and qualitative research methods for a better
82
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The finding further illustrates that 14% (98) of the is also epitomizes individual employees’ performance
employee’s performance appraisal rresultsranked appraisal result.
very outstanding (95% and above) and 79.3% (568) of
employees ranked outstanding (80% to 94.99%) (See Conclusion/Lessons Learned
Fig. 2).
• The new guideline states that the weight given
According to the guideline, employees’ performance for strategic direction should be equal to main
appraisal result has to follow normal distribution activities. However, this was not seen to be the
curve which means 5% of the total eligible employees actual practice.
should be ranked very outstanding, 15% of the total • The Ministry performance appraisal guidelines
eligible employees should be ranked outstanding, also clearly set that achievement has to be
60% of the total eligible employees should be ranked evaluated against the target plan, but this was
average, 15% of the total eligible employees should not turn out to be true for many of the employees’
be ranked low and 5% of total eligible employees appraisal report.
should be ranked very low.
• Lack of willingness to attend the orientation
Based on this principle, from total eligible employees on revised performance appraisal guidelines
for appraisal, it was expected that 36 (5%), 107 (15%), resulted to failure to follow the steps during
430 (60%) employees could have been ranked very appraisal which resulted in poor employees’
outstanding, outstanding, and average respectively. appraisal report which made the recognition
The remaining 107 (15%) and 36 (5%) from total process so complicated.
eligible employees could have been scored low and • Contrary to the obligatory explanation of the
very low-performance appraisal results respectively, guideline, performance appraisal results of most
during the study time. of the employees lay down in outstanding range
though significant number of employees lacks
On the contrary to what was expected, the number
readiness to be evaluated.
of employees whose performance appraisal results
scored low and the very low range was nil. During Recommendations
the appraisal, participants were not following
the procedures set in the guideline. This was one • Though the ministry has developed and
of the reasons why the employee’s performance implemented a revised system for performance
appraisal result is not as such consumable. This appraisal, it didn’t get due attention. Therefore,
was also confirmed by the ad-hoc committee which employees’ performance appraisal should be
was organized for monitoring and follow-up of the conducted every six months understanding that
performance appraisal. The committee explained that appraisal will contribute paramount share for the
most employees and their supervisors were not ready success of the organization.
to follow the guideline or they lack the skill to evaluate
• To ease the performance appraisal process,
the employees. The committee also witnessed various
agreed and approved employees’ individual
problems such as incomplete individual plan which
plan which is cascaded from the directorates’
misses baseline and target, inequality of weights
plan should send to the HRA Directorate in time
given to main activities vis-a-vis the strategic direction
and every employee’s performance should be
achievement. Lack of willingness to attend appraisal
monitored according to the readymade formats.
sessions and late submission of the performance
appraisal results were also amongst the challenges. • A strong motivation and recognition package
As the appraisal is not associated with any kind of should be in place to attract the employees’
rewards or punishment, most of the employees tend and leaders’ attention towards the performance
to ignore the performance appraisal. appraisal.
• Additional studies and pilot projects should be
As it can be seen from figure 3 (Annex 1), most of the
applied to build on the existing knowledge and
directorates performance appraisal result fall in the
experience in the area.
range of blue which is above the average. This result

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References

1. Counet, L. l. (2009). Lessons learned from performance management systems implementations.

2. De Waal, A. (2002). Quest for Balance, The Human Element in Performance Management Systems.

Annex 1: Figures

Fig 2. Employees performance appraisal result at Ministry of Health, 2020/21 Fiscal Year

Employees Performance Appraisal Result

Actual Individual expected Individual
Performance appraisal result Performance appraisal result
Number of Employees

600 568
400 430

200
107 107 98
0 36 50 36
0 0
< 55% 55% – 64.99% 65% – 79.99% 80% – 94.99% ≥ 95%
Performance appraisal result Levels

Figure 3: Performance evaluation result of directorates

Directorates Cummulative Result

18
Number of Directorates

20
15
10 4
2
5 0 0
0
< 55% 55% – 64.99% 65% – 79.99% 80% – 94.99% ≥ 95%
Directorates Performance result

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Leadership in Action: How Ethiopia Embraced the Nurturing Care Agenda

Tina A. Belayneh1* , Nesibu Agonafr2 , Debjeet Sen2 , Matthew Frey2 , Sheila Manji3 , Bernadette
Daelmans4 ,Teshome Desta Woldehanna4 ,
1
Ministry of health, Addis Ababa, Ethiopia
2
PATH-Ethiopia, Addis Ababa, Ethiopia
3
Partnerships for Maternal, Newborn &amp; Child Health, Addis Ababa, Ethiopia
4
WHO-Afro, Harare, Zimbabwe
*Correspondence: [email protected]

Background Method

Clear and consistent government leadership at Desk review of published articles, grey literature, and
all levels, starting with executive leadership at the documents was conducted to understand the status
highest level, facilitates implementation of the of the ECD initiative in Ethiopia. In addition, KII was
nurturing care (NC) agenda. Ethiopia’s vision for an conducted with ECD focal persons and program
inclusive and prosperous nation has encouraged all experts from the stakeholder ministries (MoH, MoE
ministries and sectors to play their part and created & MoWCY) and development partners (PATH, WHO,
an enabling environment for new ways of working: USAID, UNICEF, Children’s believe) using semi-
this opened the door for greater attention to ensuring structured questioners, National, and international
that all children in Ethiopia aged under 5 years experts were engaged in developing the case study.
receive NC (1). Since 1990, Ethiopia has made steady Program managers and the ECD Technical Working
progress in improving child survival, with under-5 Group (TWG) members reviewed and validated the
mortality dropping from 205 per 1,000 live births case study report.
in 1990 to 59 per 1,000 live births in 2019 (2). While
Result
more and more children are surviving, the Ministry
of Health (MOH) is cognizant that not all can reach Advocacy and leadership actions
their full developmental potential. The new enabling
environment made it possible for the MOH, to Within three years, the MOH, together with other
expand its focus beyond surviving to include thriving key ministries and partners, has created a vibrant
and transforming children’s lives. It also served to environment that enabled multiple sectors and
reinforce collaborations with development partners diverse stakeholders to work together at different
and stakeholder ministries including MOH, Ministry levels to promote NC. This section captures the five
of Education (MoE), Ministry of Women, Children, key building blocks of Ethiopia’s collective dedication
and Youth (MoWCY). This case study sets out the and commitment to advancing NC.
process followed in developing a shared vision, and
implementation initiatives by different sectors and i. Learning about NC and the power of investing in
stakeholders. ECD

Objective The Lancet’s ECD series (3) (2016) and the NC

Framework (2018) provided the global foundation
The objective of this case study was to describe for the promotion of NC generally, and particularly
how the MOH has been collaborating with other responsive caregiving and early learning through
ministries to elevate attention to and investment in routine services. Throughout 2018, representatives
early childhood development (ECD) and leading a from the MOH, together with other ministries and
multisectoral effort to operationalize the NC agenda. development partners including PATH, USAID, the
World Bank, the World Health Organization, and
UNICEF, participated in multiple learning events
that provided the essential underpinnings for the

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design of Ethiopia’s NC roadmap. These included: a health sector is often the only way to reach young
presentation on The Lancet’s ECD series for partners children and their caregivers consistently during the
in Ethiopia; a learning visit to China to see ECD early years. It also discovered limited multisectoral
programs and multisectoral collaboration in action; coordination, insufficient public financing, and a
and a visit to see how responsive caregiving and early lack of national evidence around best practices. A
learning were being integrated into health services in subsequent policy brief and strategy produced by the
Mozambique. A large Ethiopian delegation attended a ECD Research Advisory Council identified promising
regional consultation in Nairobi, Kenya (4) to discuss models of service delivery approaches and played
the operationalization of the NC Framework within an instrumental role in shaping the MOH’s vision of
the health sector, resulting in the development of a promoting NC.
national action plan. In 2019, additional learning visits
to Brazil and Denmark were organized for the Minister V. Building capacity to seize NC within existing
of Health and delegates from the Prime Minister’s health platforms
Office and the Addis Ababa City Administration
In early 2019, the MOH conducted a ToT on the Care
ii. Establishing a multisectoral ECD Technical for Child Development package (5) to develop a pool
Working Group (TWG) led by the MOH of master trainers who in turn technically supported
the development of Contextualized Care for Child
In May 2018, the MOH facilitated the establishment of Development training package and the cascading of
the ECD TWG, which ensured representation from a training for health workers.
range of ministries and stakeholders.
Achievements
iii. Organizing a national sensitization workshop
on NC Together, these advocacy and leadership actions
created conditions in which Ethiopia was able
A national sensitization workshop on NC for ECD to rapidly translate the NC Framework into well-
convened in late 2018 was the first high-level forum. conceived and coordinated action which is already
The workshop brought together over 200 participants beginning to bear fruit through the development
representing national and regional representatives of enhanced policies, strategies, and programs for
from four ministries (MoH, MoE, MoLSA, and MoWCY), young children and their families.
UNICEF, WHO, the World Bank, PATH, USAID, DFID,
CCF, academia, regional bureaus representing Enabling a multisectoral policy environment
the sectors and the media. The workshop raised
awareness and fostered a common understanding The national sensitization workshop revitalized
of ECD, the importance of investing in ECD, the commitment to multisectoral collaboration at
contribution that each sector could make, and the national and regional levels and positioned the NC
value of multisectoral coordination. agenda as a collective responsibility. Coordinated
efforts by ministries and development partners led
iv. Gathering and using evidence to inform to the revision of the Early Child Care and Education
planning policy framework. The newly named Early Childhood
Development and Education (ECDE) framework,
In 2019, a Research Advisory Council thematic group adopted in 2019, emphasizes the importance of
for ECD was established by the MOH to gather, responsive caregiving and recognizes the need
analyze, and translate evidence to ensure evidence- to leverage all touch-points. Most importantly, it
based program implementation. Following this, the specifies the roles and responsibilities of each sector
MOH, financially supported by UNICEF, conducted in advancing the NC agenda.
a situational analysis of the extent to which existing
health services were promoting NC. The analysis
revealed that responsive caregiving and early learning
were not promoted through the health sector: a
critical gap and missed opportunity because the

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A clearly defined way forward for the MOH Success factors

The enabling national environment, and lessons Cultivating champions at the highest level of
learned from the various workshops and country government and across key ministries.
exchange visits, enabled the MOH to reinforce support
for NC in influential guiding documents. Examples NC in Ethiopia has benefited from consistent
include the National Mental Health Strategy (2020– leadership and a harmonized vision at all levels of
2025) (6), the Health Sector Transformation Plan government. The Prime Minister’s encouragement
(2020–2030) (7), and the National Health Strategic to ministries to expand their mandate to ensure the
Plan (NHSP) for ECD (2021–2025) (8). The NHSP is all-round development of Ethiopians has opened
aligned with the revised ECDE policy framework the door for individual ministries to promote the NC
and the NC Framework and is complemented by a agenda. Focal persons have been appointed in each
monitoring and evaluation framework developed by ministry and empowered to work on this agenda.
the ECD Research Advisory Council. Within the MOH, the Minister, and MCH Director
frequently check on progress and motivate ECD
Integration of early learning & responsive TWG members. The dedication and passion of the
caregiving into MNCH training packages ECD Focal Person have been critical for the MOH’s
embracing of the NC agenda, for collaboration with
Following extensive consultation, the Care for Child other sectors and partners.
Development package was contextualized and
adapted to include developmental monitoring Opportunities for learning and exchange at all levels.
counseling, and play box session contents, and
was made more conducive to participatory adult The multiple learning opportunities and effective
learning. Content on responsive caregiving and early dissemination approaches were instrumental in
learning was integrated into various tools such as the garnering and maintaining enthusiasm. For example,
Integrated Refresher Training for Health Extension the global experts meeting in Geneva (9), visits to
Workers (HEWs), the IMNCI training packages, and Brazil and Denmark by the Deputy Mayor of Addis
COVID-19 guidelines. In addition, key messages were Ababa, which influenced his decision to establish and
introduced into the existing mHealth platform for co-finance the demonstration project in Addis Ababa.
awareness creation and promotion.
Collaborative engagement from the outset
Financing at national and regional levels to
promote NC within health services The composition of the ECD TWG and the various
learning events were deliberately structured to
The MOH leveraged financing from the USAID- include representation from multiple institutions and
funded Transform Primary Health Care Project to sectors. This approach recognized and appreciated
reinforce counseling on NC in routine health services the contributions of each sector, with dialogue and
in four woredas of four regions. The Addis Ababa collaboration forming the basis of joint action plans.
City Administration, Big Win Philanthropies, and For example, the national sensitization workshop
the Bernard van Leer Foundation are co-financing on NC brought together a range of stakeholders
a multisectoral initiative to promote NC in Addis from multiple sectors, making it easier for all actors
Ababa. With a grant from Banium Family Foundation to own the revision of the ECDE policy framework.
PATH provides technical assistance to MOH and the These deliberate multisectoral actions, driven not by
Addis Ababa ECD initiative to support integrating the external partners or funders but by champions within
promotion of the NC in health facilities and at the government, facilitated the contextualization of the
community level. NC agenda and ensured its alignment with national
priorities.

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Harnessing partnerships to drive the agenda platforms at community and health facility levels.
Efforts to build capacity and ownership at multiple
Strong collaboration between the key ministries, levels of the stakeholders and communities will be
coupled with commitments by several UN and non- enhanced to help that all children survive, thrive, and
governmental partners to help the government reach their full developmental potential. While there
advance its vision and priorities, helped to catalyze is currently a high level of interest in and commitment
and sustain momentum for the NC agenda. Financial to the NC agenda across all key ministries, it cannot be
contributions and technical assistance from UNICEF, assumed that this will always be the case. Historically,
WHO, Transform Primary Health Care, the World emergencies or changing priorities at the highest
Bank, and PATH helped the government to achieve levels of government have tended to divert attention
key activities and. and resources as is being observed during the ongoing
COVID-19 pandemic. During such crises, the focus
Barriers reverts to child survival, leaving aside interventions
that support the new thrive agenda, and even risking
Initially, when the MOH was ready to explore what
reversal of recent achievements. Ongoing advocacy
it would mean to advance NC through the health
efforts are therefore needed at all levels to ensure
sector alongside other sectors, there were no global
that decision-makers see NC as a priority, even during
resources to guide the implementation of the NC
times of crisis.
Framework. Moreover at first, while MOH technical
leads and ECD TWG members were enthusiastic REFERENCE
about the NC agenda, they did not know how to go
about strengthening health services to promote NC. 1. MoH, MoE, MoWCY & MoLSA. ECDE policy framework 2021
This resulted in a lack of confidence and clarity on
2. EPHI and ICF. 2021, Ethiopia Mini Demographic and Health
where to start and what to do. Participation in the
Survey 2019: Final Report, Rockville, Maryland, USA: EPHI
national training on the Care for Child Development
and ICF
package and the regional stakeholder consultation
in Nairobi, Kenya provided much-needed clarity and 3. Black MM, Walker SP, Fernald LCH et al. Early childhood
gave the MOH the confidence it needed to own and development coming of age: science through the life course.
drive the agenda. Lancet. 2017, 389(10064):77–90.

4. Participating countries: Ethiopia, Kenya, Malawi,

Conclusion and the way forward
Mozambique, Tanzania, Zambia, Zimbabwe. For the meeting
Ethiopia has shown that the NC agenda can be report: https://nurturing-care.org/events/stakeholders-
contextualized and rapidly scaled up when the consultation-meeting/.
following conditions are in place: government 5. Care for Child Development is a toolkit that equips front-
commitment; strong and participatory coordination line workers, such as health and social workers, with the
and collaborative structures; dedicated focal experts knowledge and skills to counsel and empower caregivers
in key ministries and departments; openness to learn to communicate and play with their children. See: https://
from each other, as well as from experiences both www.who.int/maternal_child_adolescent/documents/
inside and outside the country; and national and care_child_ development/en/.
international partners’ support to realize the vision.
6. MOH Ethiopia. (2021, July). National Mental Health Strategic
Within three years, Ethiopia’s MOH established a
Plan for 2020-2025.
solid foundation for promoting NC in the health
sector and collaboration with other sectors. The 7. MOH Ethiopia. The Health Sector Transformation Plan II
focus has now shifted to sustaining, scale-up and 2020/21–2024/25
building on this progress. The MOH will continue
8. MOH Ethiopia. (2020, October). National Health Sector
its work with partners to reinforce missing NC
Strategic Plan for ECD 2020/21-2024/25
elements and to integrate them into key policies,
strategies, guidelines, and tools. It will also maximize 9. Global technical meeting: Strengthening programming for
opportunities to integrate responsive caregiving NC. https://nurturing-care.org/innovating_for_ecd-2/.
and early stimulation into essential service delivery

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 SECTION THREE

BEST PRACTICES OR LESSONS FROM

PROGRAM IMPLEMENTATIONS

SECTION THREE: BEST PRACTICES OR LESSONS FROM PROGRAM IMPLEMENTATIONS

SPECIAL BULLETIN MINISTRY OF HEALTH, ETHIOPIA

Bridging the Gulf between the Academia and Social Sector; the Case of Capacity
Building and Mentorship Program of the MOH of Ethiopia

Mesoud Mohammed1 *, Bantalem Yeshanew1, Biniam Tilahun2, Daniel Getachew1, Wubshet

Denboba1, Naod Wendirad1
1
Policy, Plan, Monitoring and Evaluation Directorate, Ministry of Health, Addis Ababa, Ethiopia
2
College of Medicine and Health Science, University of Gondar, Gondar, Ethiopia
*Correspondence: [email protected]

hasten the digitization of information systems and

Background foster a culture of data use and thereby realize the
agenda. As such, the MOH considered engaging
In this time of globalization with a dynamic and
universities to support health facilities to implement
competitive economic ecosystem, the sustainable
the connected woreda program.
socio-economic development of a country largely
depends on its capacity to generate knowledge and
Due to the lack of prior experience of working with
produce skilled labor capable of generating and
universities, the decision to engaging universities was
applying knowledge and cutting-edge innovations.
a daunting prospect for the ministry due to several
Universities have long been the source of essential
reasons. Universities in Ethiopia were mainly focused
knowledge and centers to cultivate skilled human
on basic researches and were distant from supporting
resources that are critical to charting the socio-
the actual implementation of interventions at the
economic trajectory of a country. Nowadays, their role
ground level. There was fear of failing to meaningfully
in driving socio-economic development has become
engage universities and efficiently utilize allocated
more evident than ever [1, 2]. As such, universities are
resources. Despite all odds, the ministry took an
supposed to play a leading role in advancing scientific
audacious decision to “give it a try” and start bridging
innovations poised to address contemporary
the gulf between the health sector and universities.
challenges and meeting arising needs of the public
To this end, the capacity building and mentorship
through human resource development, research, and
program (CBMP) was designed to engage academic
innovations [3]. In Ethiopia, the role of universities
institutions in supporting the health sector and
has been recognized as one of the key pillars to
enhance their contributions in informing health
the country’s economic and social transformation
programming and the health system’s performance
processes as described in the first and second growth
improvement through the generation of scientific
and transformation plans that aspire to realize the
evidence. The goal of the program was to strengthen
country’s vision of being a middle-income country by
the health information system through implementing
2020-2025. However, the link between the academia
the information revolution agenda of HSTP [5-7].
and social sectors and industries in Ethiopia has been
limited or non-existent [1]. The Doris Duke Charitable Foundation (DDCF) through
the African Health Initiative (AHI), which intends
The first Health Sector Transformation Plan (HSTP I)
to support the development of government-led
of the health sector prioritized information revolution
health learning platforms including implementation
as one of the four transformation agendas.3 The
researches, became interested in investing in the
connected woreda program was designed to be the
CBMP platform. Under AHI, DDCF has committed to
pathway to realize the information revolution agenda
making a five million dollar investment in the Ethiopia
focusing on improving data quality, data use culture,
Data Use Partnership (DUP) that aims to improve the
and digitization of health information systems [4].
collection and use of high-quality routine information
The ministry of health (MOH) solicited increasing
in the health sector in Ethiopia, contributing to
the capacity of health institutions through providing
improved quality, efficiency, and availability of
mentorship support as the main intervention to

3
A transformation agenda is coined to galvanize momentum and provide a platform to synergize multifaceted efforts of a sector to alleviate the most critical interre-
lated systemic barriers constraining attainment of the sector’s goal and targets.

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primary health services at all levels. So far, DDCF

Methods
has invested close to 80 million birrs to support the
program through the MOH. Implementation of the program involved three
approaches, namely competitive selection process,
The program was designed to be a collaborative
co-creation, and joint implementation and monitoring
partnership between local universities, health science
of the program.
colleges, DUP, regional health bureaus (RHB)4, and the
MOH. The universities have been supporting selected 1. Competitive Selection process: The ministry
woredas5 since 2018 to implement components of in collaboration with the DDCF made a call for
the connected woreda program to realize information application for local universities to apply with
revolution within their district health system through proposals showing how they would engage in
improvements in data quality and use of health supporting the information revolution agenda of
information for decision making at administrative the MOH through implementing the connected
unit and health service levels by integrating capacity- woreda program. About six universities,
building elements and digital tools. The connected namely Addis Ababa, Hawassa, Haramaya,
woreda program enables woredas and primary Mekelle, and Jimma universities, were selected
health care units6 to realize these objectives while through a competitive process. Universities
targeting health care facilities and health workers. with a better experience in implementing HIS-
Besides, the support of universities revolves around related interventions, those with demographic
supports to create information revolution model surveillance sites, and with the more innovative
woredas, provide pre and in-service training and proposals were selected. The six universities
documentation, and dissemination of best practices. selected their consortia universities and colleges
in their implementation areas. Along with the RHB,
the six universities have been assigned to support
the implementation of the connected woreda
program in about 36 woredas selected from the
six implementation areas. Addis Ababa university
supports Addis Ababa City, Gondar University
supports Amhara and Benishangul Gumuz regions;
Jimma University supports Oromia and Gambella
regions; Haramaya University supports Diredawa,
Hararia nd Somali regions; Hawassa University
supports Sidama and SNNP regions; Mekelle
university supports Tigray and Afar regions (fig 1).

Figure 1, implementation areas of CBMP

4
RHB are administrative bodies that oversee the health system with the regional states. Ethiopia is a federal republic of 10 regional states and 2 city administrations.
5
A woreda or district is the lowest governance structure with an average of 100,000 populations and 20 kebeles or communities. Kebeles are the smallest administrative units
with an average of 5000 populations. A woreda health system is the functional unit of Ethiopia’s health system and is composed of a primary hospital, four health enters, and 20
health posts. The woreda health office manages health facilities, coordinates stakeholders, and regulates health service provisions in the woreda.
6 Primary health care unit is composed of one health center and five satellite health posts.

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2. Co-creation process: After selecting

Result
the universities, the interventions and
implementation approaches were designed The implementation of the programs has advanced
through the collaboration of the MOH, selected the engagement of universities with the health sector
universities, RHB, and the DUP. Collaboration with while strengthening the health information systems
RHB and creating consortia with local academic in the selected woredas. The academicians have
institutions were identified as major strategies for become more familiar and capable of supporting
the program. The interventions include; health information systems through pre-service
and in-service training, generation of evidence, 44
• Create a center of excellence in the
publications of 27 of them were published, and
information revolution
development of implementation guidelines tailored
• Support implementation of HIS in the to local contexts. The universities played key roles
university hospitals in the revision of curriculum for health information
• Document and produce publications in technicians (HITs), and the development of generic
the areas of health information systems curriculum for degree level HITs. The program
has also been instrumental in generating a pool
• providing training and mentorship on of academicians that are capable to supervise
data analytics and evidence generation postgraduate students (57 MSc. And eight Ph.D)
to health workers at health facilities of doing researches related to health information
selected woredas systems. The program has also laid the foundation
• Support demographic surveillance sites for conducting various implementation researches
and documentation of best experiences and it has
• Development of new and revision of
been effective in knowledge transfer between the
curriculums for disciplines related to
academicians and implementers. Besides, through
health information systems and training
the platform, five verified model woredas verified by
• Supervising masters and Ph.D. students external team were created, that would be learning
doing researches on topics related to HIS. centers for woredas in their respective areas.

3. Joint implementation and monitoring: In addition, CBMP has been the platform to mobilize
the universities collaborated with RHB and resources and technical expertise from various
consortium academic institutions to leverage stakeholders. The USAID-Digital Health Activity
local capacities to implement the interventions. (DHA) has invested through the platform to support
The MOH organized regular coordination creation of center of excellences (CoE) including CoE
meetings to jointly monitor performances and for electronic community health infroamtion system
facilitate cross-fertilization of learnings among (eCHIS) with Jimma university, and CoE for EMR
implementation areas. To address the arising with Mekelle University. Universities have pledged to
challenges and build on the gains, policy, plan, allocate resources for implementation of HIS activities
monitoring, and evaluation directorate of at their teaching hospitals. In addition, universities
the MOH has staged multiple forums to bring have dedicated offices, cars and other supplies for
stakeholders together and get their reflections HIS related activities.
and made adjustments accordingly. In addition,
stakeholders have been collaborating to provide
supportive supervision and conduct verification
of performance of woredas.

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Lessons Learnt References

Through implementing the program, the ministry has 1. Mulu, N.K., The Links between Academic Research and
become cognizant that the program has been a great Economic Development in Ethiopia: The Case of Addis Ababa
platform for advancing sustainability and ownership University. European Journal of STEM Education, 2017. 2(2): p.
of health information system interventions through 5.
creating local capacity and functional linkages 2. Etzkowitz, H. and L. Leydesdorff, The dynamics of innovation:
between universities and various administrative from National Systems and “Mode 2” to a Triple Helix of
levels of the health sector and health facilities. It also university-industry-government relations. Research policy,
became evident that the platform has become an 2000. 29(2): p. 109-123.
additional avenue for resource mobilization and an
3. Lee, Y.S., ‘Technology transfer and the research university: a
extra arm to the MOH and RHB to support the health
search for the boundaries of university-industry collaboration.
information system. In addition, the program has been
Research policy, 1996. 25(6): p. 843-863.
pivotal in evidence generation and documentation
4. MOH, The Connected Woreda Strategy Implementation Manual
through leveraging the capacities of universities in
(draft). Policy Document, 2016.
research and write-up capabilities. Most of all, the
program has showcased the academia and other 5. FMOH, Health Sector Transformation Plan I. Policy document,
sector relationship and linkage is a possibility and 2015.
workable. The major challenges faced were delayed 6. FMOH, Information revolution roadmap. Policy document,
in the creation of model woredas and centers of 2016.
excellence in the information revolution, which 7. FMOH, Health Sector Transfromation Plan II. Policy document,
were largely ascribed be the limited engagement 2021.
of RHB and consortium academic institutions. The
engagement of all partners in all steps of the process
starting from selection, proposal development, and
pro-active engagement of them in implementation
of the interventions could enhance the role of all
partners.

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Implementation of Medical Devices Installation and Maintenance Campaign in

Public Hospitals

Tadesse Waktola1*, Zerihun Ketema1, Samuel Tadesse1, Mulugeta Mideksa1, Lemlem Degafu1,
Addisu Feyera1, Asfaw Afework1, Alemu Abibi1, Mahdi Abdella1, Regasa Bayisa1
1
Pharmaceuticals and Medical Equipment Directorate, Ministry of Health, Addis Ababa, Ethiopia
*
Correspondence: [email protected]

beneficiaries, compromised quality and efficiency of

Introduction
healthcare services. Previous interventions and efforts
Ethiopia has made great progress in improving the implemented to ensure the availability of functional
health status of the community through coordinated, medical devices in health facilities were insufficient.
rigorous efforts and extensive investments in Hence, it was important to initiate new problem-
medical devices over a couple of decades. Ethiopian solving interventions to functionalize medical devices
expenditure in medical devices and pharmaceuticals and enhance healthcare delivery in public hospitals.
was estimated to value between $800 and $900
Objectives
million with a growth of up to 25% over the last 10
years and predicted to reach $3.6 billion by 2030 General objective
with an annual growth rate of 15%. Moreover, the
Ministry of Health in partnership with stakeholders The general objective of this initiative was to generate
established 24 maintenance workshops, provided evidence to inform planning for improving increased
capacity-building training to over 300 biomedical functionality, accessibility, availability, improved life
professionals, developed training manuals, span, and optimized utilization of medical devices in
operational guidelines, and strategic documents on public hospitals. The study specifically intended to
medical devices management. These interventions investigate the extent of and factors for not-installed
augmented and improved the supply and availability and non-functional medical devices; inform efforts
of medical devices over the years which increased to functionalize un-installed and non-functional
the accessibility, equity, and coverage of healthcare medical devices; increase the availability of spare
services in health facilities. Despite the high investment parts needed for maintenance; and improve the skill
and efforts done during the implementation of HSTP I, of biomedical and clinical staffs on proper operation
there are still several gaps in availability, maintenance and maintenance
system, proper management, and optimized
utilization of medical devices which are indicated as Methods
areas of intervention in HSTP II.
This installation and maintenance campaign was
Irrational use, unavailability of spare parts, lack of targeted for implementation in public hospitals at the
skilled manpower, poor regular maintenance, and national level with active engagement of high-level
delayed installation practices are the major reasons management bodies throughout the execution of the
for frequent failure and mal-functionality of medical initiative. The multi-level approach was used for the
devices in Ethiopia. The national survey conducted implementation of this nationally initiated campaign
by the pharmaceutical and medical equipment as shown in figure 1.
directorate (PMED) in 82 public hospitals in November
2019 indicated that 26% of medical devices were non-
functional while only 58.13% of the medical devices
were installed within six months of delivery. These
problems resulted in unnecessary referrals, increased
service costs, wastage of resources, reduced trust of

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Figure 1: Approaches and stages followed during medical devices maintenance and installation campaign

Preparation stage
Asssessment stage
•4 million birr budget was transferred to
•Data collection tools were developed, shared regions to facilitate this initiative
and orientation was provided to regions •170 million birr budget was allocated for
•Verified data of 30,500 medical devices was spare parts procurement
collected from 198 hospitals in 9 regions and 2 •Total of 159 biomedical experts were
city administration mobilized and received orientation
•Data of non-functional and not-installed •Implementation plan was devised
meidcal devices was analyzed and intervention
•Regions, hospitals, EPSA and private
areas were identified
suppliers were actively engaged

Campaign stage Monitoring stage

•Campaign was formally launched on 25th •Reporting tools were shared,
March, 2021 in all regions except Tigray •Communication platform was created and daily
•Installation and maintenance of medical activities were monitored
devices was performed •Final installation and maintenance reports
•Spare parts were identified and quantified were collected, aggregated and evaluated
•Training and orientation was provided to regularly
clinical staffs on utilization •Spare parts report were separately aggregated
•Coordination and supervision was provided and purchase order was initiated
at all levels

technologies in hospitals. The intervention was

Results
focused to install capital medical equipment and
Status of medical devices installation and functionalize failed medical devices.
functionality
Medical Devices Installation
The assessment report collected from 198 public
The COVID-19 diagnostic and therapeutic devices
hospitals in November 2020 revealed that there were
were prioritized during the installation which included
5,471 non-installed medical devices. Besides, the
X-rays, mechanical ventilators, oxygen concentrators,
report indicated 3,255 non-functional medical devices
PCR machines, patient monitors, and anesthesia
out of 22,490 devices obtained from inventory. Among
machines. Installing, inspecting, performing
the reported not-installed medical devices 29.57%
acceptance testing, provision of user training on
(1,618) were found not requiring installation, 47.35%
proper operation and handling, and initiation of
(2,590) require minor installation by biomedical
essential medical services were the major activities
professionals in the target hospitals whereas
done during the installation campaign. A total of 733
23.08% (1,263) were capital equipment that needed
capital medical devices were installed during the
an intervention. Major problems for not-installed
campaign intervention which saved an estimated cost
devices were the placement of devices as a reserve;
of over 24 million Ethiopian birr (ETB). Simultaneously,
suppliers associated problems, lack of accessories,
PMED coordinated and supported medical devices
and lack of site readiness. Non-functional devices
suppliers in the installation of 769 capital medical
reported were due to the absence of necessary spare
equipment that is delivered to hospitals. The specific
parts, software corrupts and repeated company-level
capital medical devices installed during the campaign
password updates, poor calibration, and preventive
and follow-up are illustrated in figure 2.
maintenance practices, and the presence of obsolete

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Figure 2: Number of medical devices installed during the campaign and follow up

Medical devices installed during campaign and follow-up

330
250

150
91 99 109
44 60 63 70
1 1 5 6 7 7 8 11 12 13 13 20 23 25 26 26 33

t y

rs
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ar e
He tal c C

M R L rs
Ot er

m ve
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NI atol ir

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l3

AP

tra ay

Di the s
un m le

PC cub G
di a r
EP
ac e

Cr mi r
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Co th y
e o
Ra m ato

es ed

en ap
Pa Au x-ra
t w ni
y m in
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tie un
m ha

Iro O ES

In C
CU og

yo str
git si

to
La ing Tab

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Ve rato
m

ob ig

Ch onit
Ul X-r

nt cla
ve

LE
hi
De LIN

CP

an ch

h
dr ach

An t b

nc er
Pa so

ila
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fa
In

Medical Devices Maintenance life span, and proper use of medical devices play
a major role in the provision of improved essential
The maintenance activities during the campaign healthcare services in hospitals. This first national
initiative included inspection, troubleshooting, and initiative brought new opportunities for hospitals,
repair, training of equipment users, and experience regions, and healthcare professionals to enhance
sharing among biomedical experts. During the hospital services, build capacity, share experiences
maintenance, spare parts identification and and build coordination in improving the quality and
quantification were also performed. A total of 1056 effectiveness of medical services. The integrated
(32.44% of 3,255) non-functional medical devices work between regional health bureaus, hospital
were repaired and made ready to provide essential management, biomedical experts, and coordination
healthcare services in hospitals. The medical devices and supervision of the PMED played a significant role
maintained include essential COVID-19 medical in the successful implementation of this initiative.
devices such as mechanical ventilators, oxygen
concentrators, patient monitors; OR, and MCH The campaign continues towards the completion of
medical devices. The details of maintained medical installing and maintaining the remaining medical
devices are depicted in figure 3. This campaign devices available in hospitals. For the sustainable
enabled hospitals to save an estimated cost of 44 improvement of medical devices’ functionality and
million ETB. Moreover, the procurement of 2,560 utilization, strengthening maintenance workshops,
spare parts costing 71 million ETB was initiated and deployment of adequate biomedical experts and
being processed. building their skills, and creating strong systems for
uninterrupted access to essential spare parts are vital
These spare parts are forecasted to maintain and domains that need emphasis. To reduce resource
functionalize more than 800 non-functional medical wastage, improve and re-engineer disposal of medical
devices. devices, establishing a national level medical devices
refurbishment center is essential.
Conclusion and Way Forward

A total of 2558 medical devices were made functional

and ready for service by the campaign initiative.
This increased accessibility, availability, improved

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Figure 3: Quantities of medical devices maintained during the campaign implementation

List of Medical Devices Installed During The Campaign

206

109 95
82 73
52 44 40 36 33 32
28 27 26 24 17 16 13 12 12 12 11 11 11 8
6 5 5 5 5

Ironing…
Others

CPAP
ESU
Warmer

Vntilator

Pulse Oximeter

Distiller
Refrigerator

Room heater
Phototherapy
ECG

Infusion pump
Autoclave

OR Table

Ultrasound
Concentrator

Anesthesia

Laundry

X-ray

Fetal monitor
Suction

Centrifuge

Microscope

Slit lamp
OR Light
Patient monitor

Chemistry

Hematology
Incubator

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Networking Patients with Health Extension Workers for Improved Care

Misganaw Wolie1, Mengesha Geta1, Hailegebriel Bedane2 *, Abbas Yusuf2, Gezashign Kassa2,
Biniyam Seid2, Abebaw Deso, Sem Abreham2, Deneke Ayele2, Kasu Bifa2
1
Bona General Hospital, Bona, Sidama Region
2
Ministry of Health- Ethiopia, Clinical Service Directorate, Addis Ababa, Ethiopia
*Correspondence: [email protected]

to-home follow-up on prescribed drug adherence

Background
and lifestyle modifications and look on their drug
Bona general hospital (BGH) is one of 18 public usage, storage, treatment response, and notify
hospitals in Sidama Regional State. It is located complications and adverse effects early.
386 km southwest of Addis Ababa and 112km from
Methodology
southwest of Hawassa in Bona Zuria woreda. The
hospital provides service for about 1.6 million people
1. Tracing chronic patients’ addresses and full
including the southern part of Oromia regional
information from the registry. Collect chronic
state and 12 woredas from Sidama Regional State.
follow-up patients’ MRN, full names, Phone
The hospital provides service predominantly for
numbers if there is and address from liaison
the rural population where there is no essential
registry and prepare another registry specific to
infrastructure like electric service, network/internet,
the project including patient identification and
and transportation. Its yearly OPD patient flow is
contact.
about 67,000 of which 587 chronic follow-up patients.
2. Contact each health center authority in each
Patients who are having chronic diseases like
woreda. The project shall have its bases in health
diabetes mellitus (DM), hypertension, chronic heart
centers so that patients will be checked their
failure (CHF), asthma, epilepsy, and others need to be
vital signs like BP, blood glucose levels, etc in the
followed regularly to monitor their health conditions.
nearby health centers.
However, our patients are from remote areas with
no services for transportation, mobile networks, and 3. Collect HEWs contacts from respective health
electric supply which makes it very difficult to have a centers. Tracing HEW contacts from all health
regular follow-up in BGH. Therefore, it creates a barrier centers in the selected woreda under the health
in proving better to follow up and quality care. On a center and matching the patients’ addresses with
clinical audit which was done on NCDs, we identified the health extension workers in each kebele.
patients that have not been notified/ recalled on their
appointment day, losses to follow up and no effort 4. Orientation to the health center authorities and
to return them to service from the providers, gaps in HEWs on the project. Orientations emphasized
closely following responses of a drug, drug adverse the objective of the project, mechanisms to give
reactions, and complications. Patients have no basic quality of care and better appointment system,
knowledge on prescribed drug usage and adherence, and on patients’ confidentiality and privacy. After
poor treatment response monitoring, side effect, and the orientation, the HEWs are expected to be
early complications. familiar with the checklist on how to fill monthly
and the way of submission.
With this problem in mind, networking patients
with health extension workers (HEWs) was designed 5. Implementation of the project after signing
mainly to build a better appointment system and MoU with health center authorities. During the
provide quality of care and to decrease patients from implementation phase, HEWs are expected to do
losing follow-up and return patients to service in case their home-to-home service and are obliged to
they lose their follow-up. It also aims to make home- report the checklist monthly.

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Fig. 1 Framework of the project in which the HEW has to do in her catchment.

Results
care. In addition to the reminder, the HEWs notify the
A baseline study conducted at BGH indicated that only treating physician in the chronic follow-up clinic via
8.3% of chronic follow-up patients got the chance to liaison whenever there are acute complications.
receive phone call reminders from the hospital mainly
due to connection problems, lack of electricity, and Knowledge gaps on side effects and complications
access to mobile phones. After the implementation of from a prescribed drug, drug usage and adherence,
the project, the phone call reminder for chronic follow- drug storage were also improved significantly to 78%,
up increased to 80% and it had a strong positive effect 87%, and 83% respectively (Fig 2).
on improving the appointment system and quality of

Fig 2. Level of Basic knowledge before and after implementation of the project

On the other hand, patients with consecutive well-controlled blood glucose levels were increased from the baseline
of 33% to 71% at the BGH chronic follow-up clinic (Fig. 3).

Fig 3. The proportion of controlled blood glucose levels before and after the implementation of the project

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The proportion of loss to follow-up was also Loss to follow up was also dropped significantly
dropped significantly from 48 % to 12.3% after the from 48 % to 12.3% after the implementation. On
implementation of the project. On the other hand, the other hand, 57% of patients who lose follow-
there was no effort to bring loss to follow-ups back to up have got chance to be advised and returned to
service prior to the implementation of the project and service. Knowledge gaps like prescribed drug usage
the proportion of patients who returned to service and adherence, drug storage, side effects, and
has increased to 57% after the implementation of the complications were also improved significantly. The
project (Fig 4). final target to get consecutive well-controlled blood
glucose levels were also achieved.

Therefore, networking patients with health extension

workers has brought us a new way of providing a
better follow-up system and highly contributed to the
quality of care. As it has proven to be effective in the
case of BGH, it can be disseminated to other hospitals
so that they can adopt the practice in their catchment
areas to improve their follow-up system and quality
of care.

Fig. 4 Comparison of proportion of patients lost to follow-ups

and proportion of patients after the effort to bring back them
to service.

Conclusions

After the implementation of the project in Phase I,

the phone call reminder could reach up to 80% of
the patients for the chronic follow-ups, which was
encouraging to continue to improve the quality of
care to chronic follow-up clinics in collaboration with
the health extension workers.

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Impact of the Innovation Phase of the Seqota Declaration: Promising Evidence for
Expansion Across the Country

Bezawit Tamiru1 *, Dr. Sisay Sinamo1, Kebede Mamo1, Fesseha Tekle1, Mesfin Gobena1, Bisrat
Haile1, Tamrat Seyoum1
1
Ministry of health, Seqota Declaration Program Delivery Unit, MCHD, Addis Ababa, Ethiopia
*Correspondence: [email protected]

Introduction Objective

The Seqota Declaration is the government of Ethiopia’s The purpose of this report is to share the impact of the
commitment to end stunting among children under Seqota Declaration investment during the Innovation
two years by 2030. This declaration is led by H.E Phase.
the Deputy Prime Minister of Ethiopia where nine
sector ministries work together to achieve the goal Methods and approaches
of the declaration. Accordingly, the government has
committed to preventing about 7,852,216 children LiST Methodology is used to estimate the impact of
from stunting in 15 years period divided into three the Innovation Phase of the Seqota Declaration in
phases each spanning five years. The innovation terms of changes made on the neonatal mortality rate
phase (2016-2020) focused on the implementation (NNMR), Under-5 mortality rate (U5MR), Stunting rate,
of priority intervention packages that were being additional lives saved, and stunting cases averted.
monitored and evaluated to generate learnings and The model considered multi-sectoral interventions
evidence to inform the design and implementation coverage from baseline using data from the
of the expansion phase (2021-2025). The Expansion Ethiopia HMIS and the Seqota Declaration Program
phase will reach more vulnerable woredas across Performance Scorecard from March 2018 to February
the country before a national scale-up phase (2026- 2020.
2030). The National scale-up will involve full-blown
The Seqota Declaration (SD), is operationalized
implementation of evidence-based, innovative, and
through a multi-sectoral program involving nine
sustainable multi-sectoral interventions.
different sector ministries including Ministries of
During the Innovation Phase, multi-sectoral nutrition- Health; Agriculture; Education; Water, Irrigation
specific, nutrition-sensitive, and infrastructure and Energy; Women, Children and Youth, Transport
interventions were implemented in 40 woredas in and Finance, MOLSA, and Culture and Tourism.
Amhara and Tigray regional states covering over The Seqota Declaration objectives use nutrition-
4.7 million people. In the past three years, nine specific, sensitive, and infrastructure pathways to
government sector ministries at the federal and end stunting. These objectives will enable us to
regional level jointly with development partners have address the immediate, underlying, and root causes
been implementing the Innovation Phase Investment of malnutrition as indicated in the Seqota Declaration
Plan which comprises ten strategic objectives and 50 theory of change which is developed with the global
strategic initiatives. Moreover, six innovations were frameworks for malnutrition and nutrition security.
tested to draw key learnings in program management,
Seqota Declaration works with all the sectors to
data revolution, community labs, agriculture, and
ensure the health and nutrition of pregnant and
water technologies, cost woreda-based multi-
lactating mothers and children under the age of five;
sectoral planning, and the first 1000 days plus public
strengthen access to nutritious foods for pregnant
movement for social and behavior change. Lessons
and lactating mothers and infants under five years of
and insights from this phase will allow the government
age; improving and benefiting the public’s access to
to outline and develop a program to address child
safe drinking water; benefiting pregnant and lactating
stunting in the country during the Expansion Phase.
others and children under five who are at risk for

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malnutrition; construction of roads connecting

Results
kebeles and woredas for the benefit women, children
and adolescents in the prevention of malnutrition and In Amhara Region Stunting prevalence decreased
harmful tradition practices; women capacity building from 51.01% to 43.06% (7.9% absolute reduction
and economic empowerment activities. of 15.5% relative reduction and in Tigray Region
from 39.7% to 32.3% (6.7% absolute reduction of
The Seqota Declaration innovation phase was
18.5% relative reduction). In terms of mortality: the
implemented through One Goal, One Plan, and
Innovation Phase interventions prevented almost
One Monitoring and Reporting framework that
1,031 child deaths in both regions and averted over
facilitated all the Seqota Declaration implementing
109,831 stunting cases of under 5 years old children.
sectors at federal, regional, and woreda levels
Increased complementary feeding was the primary
and development partners to contribute towards
driver of stunting reductions, accounting for over 90%
one goal and coordinate their investments for the
of the stunting cases averted. Agricultural, nutrition,
ending stunting goal of the Seqota Declaration. The
SBCC, WASH, and improvements in the treatment of
Community ownership and participation were also
sick children accounted for the greatest reductions in
high in the project design and implementation during
mortality and stunting aversion.
the innovative phase.

2018 2019 2020 2021

Tigray
NNMR Seqota implementation 20.82 20.54 20.46 20.42
Reference (no intervention) 20.82 20.81 20.81 20.81
U5MR Seqota 41.56 39.27 38.58 38.24
Reference 41.56 41.21 40.98 40.93
Stunting Rate Seqota 39.71 36.73 34.66 32.31
Reference 39.71 39.79 39.91 39.97
Amhara
NNMR Seqota 25.11 24.73 24.69 24.61
Reference 25.11 25.1 25.1 25.1
U5MR Seqota 46.88 44.22 43.53 43.1
Reference 46.88 46.5 46.27 46.21
Stunting Rate Seqota 51.05 47.68 45.56 43.06
Reference 51.05 51.26 51.5 51.64

Table 1: Seqota Declaration: Innovation Phase Impact Assessment (JHU: June 2021)

Lessons learned

Implementation of the Innovation Phase of the Seqota deployment of PDUs staff at federal, regional, and
Declaration succeeded in increasing coverage of woreda levels;
interventions to reduce stunting and child mortality.
The success factors during the innovative phase were 2. Collaboration and effective networking with
development partners were also strong: Joint
1. There was high Federal and Regional Government financing for innovations and implementing
commitment and ownership: in terms of innovations; Deployment of technical partners
planning, approval, and leadership during the and assistances to support the innovations;
implementation of the interventions at all levels;
Rigorous Financial allocations from the treasury 3. The six tested Innovations also contributed a lot
and regional governments for example the federal towards Innovation Phase outcomes;
government allocated more than 450 million birrs
from the treasury in 2012, 2013 and 2014 EFY for 4. The planning was Gender-responsive.
each year. Its commitment also reflected with the

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The main benefit of the project is to end the high through the nutrition BCC intervention, resulting in
prevalence of stunting in the woreda by addressing improvements in breastfeeding practices. Increases
its underlying and root causes. These are households in vitamin A supplementation also reduced child
residing in chronically food-insecure woredas, deaths by reducing diarrhea-related mortality. During
high wasting prevalence, low gender equity and the program period, vitamin A supplementation
economic opportunity, lower social service coverage: increased by 27.5% in the program area. The
low infrastructure to facilitate the provision of contribution of WASH interventions was more limited,
basic services, and inadequate government and due to the limited number of households reached by
development partner’s investment. efforts to improve water and sanitation infrastructure
and improve hygienic behaviors.
Implementation of the Innovation Phase of the
Seqota Declaration succeeded in increasing coverage The best practices and lessons learned during the
of interventions to reduce stunting and child innovations phase and ready for Expansion phase are
mortality. The program focused on interventions descry
to reduce stunting, including agricultural, nutrition,
SBCC, and WASH interventions and improvements During the Innovation Phase, six innovations were
in the treatment of nutrition-related conditions. tested. These innovations were tested to inform
Agricultural interventions had the greatest impact how they could solve the problem of multi-sectoral
on stunting. Based on program performance records, coordination and governance, performance
over 75% of households in the target population were management, and evidence-based decision making,
reached with at least one agricultural intervention. empower the community to identify and solve its
problems, address issues of water access and efficient
Improved agriculture translates to reduced utilization in water-stressed settings, improve the
household food insecurity and better nutrition for various social and behavior change related issues as
pregnant women and young children. Improvements well as how to build the capacity of local government
in infant and young child nutrition, achieved through for effective resource mobilization, partnership
complementary feeding and reduced household management, and evidence-based decision making.
food insecurity, accounted for 90% of the stunting
cases averted. Reductions in stunting and child The following table summarizes the achievements
undernutrition also resulted in fewer child deaths and lessons learned of the Seqota Declaration
from infectious diseases. Again, improved child Innovations tested during the Innovation Phase and
nutrition was a driving force in preventing child deaths recommendations
via reductions in both stunting and wasting. SBCC
targeting improved nutrition practices also contributed
to reductions in child mortality. Approximately a
third of pregnant and lactating women were reached

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Keywords: Innovation phase, List Analysis, impact.

Multi-sectoral
Innovation
challenges to be Status of the innovations
Tested
resolved

Inadequate government The establishment of the PDU enabled the government of Ethiopia to
leadership ensure high-level government ownership and leadership and effective
Program Delivery
coordination among sectors at all levels. The PDU implementation
Unit Poor coordination among guideline has been documented and adopted for use for the
sectors establishment of Food and Nutrition Offices in other regions.

The Community Lab process enabled the community to identify their

Lack of community
own problems and come up with local solutions. A community Lab
Community Lab participation to solve
manual was developed and tested. Solutions driven by through the
their own problems
community lab process are being implemented in xx woredas.

A multisectoral Unified Nutrition Information System for Ethiopia is

Lack of timeliness, quality
Data Revolution developed and tested in 9 SD and other woredas. This tool has been able
of data
to support the data transfer using a web-based platform.

The PDUs has developed a 1000 plus public movement strategy using
1000 days plus High social and behavior an ecological model and implemented at all levels. This enabled to
public movement related factors affecting create wide range of public movement for SBCC. In addition to SBCC
for SBCC children and women mainstreaming guideline was developed to support sectors in their
planning.

The costed woreda based planning process enabled the woreda cabinet
Costed woreda Lack of ownership,
to own the multi-sectorial plan; mobilize local resources (government,
based planning accountability and
community and partners) and utilize the plan for performance
(CWBP) resource allocation
management in all the 40 Innovation Phase woredas

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Community Lab: Seqota Declaration Innovation to Empower Communities to

Identify Local Solutions for Local Problems

Fesseha Tekele1, Dr. Sisay Sinamo1, Kebede Mamo1, Mesfin Gobena1, Bisrat Haile1, Bezawit
Tamiru1, Tamrat Seyoum
1
Ministry of health, Seqota Declaration Program Delivery Unit, MCHD, Addis Ababa, Ethiopia
Correspondences: [email protected]

of new solutions towards local problems in Debark

Introduction woreda, Kino kebele of the Amhara national regional
state so that the model can be scaled up into other
Seqota declaration is a government commitment
non-seqota declaration areas as a tool to solve local
declared to end stunting by 2030. Currently the
problems through active participation and ownership
government is implementing the first phase of
of communities.
the declaration called Innovation Phase where six
innovative areas were given due attention to be tested Method and Approach
and scale-up during the expansion and scale-up
phases. Among the six innovations, Community Lab The source of data for the community lab experience
is one innovation that aims to bring multi-sectoral in Debrak woreda is collected by the Amhara
stakeholders to combat nutritional problems through Region Seqota declaration Program Delivery Unit
the identification of local solutions for grass root level through routine performance reports sent by the
nutritional problems that the actors could plan and woreda administration. At the regional level, there
implement. is a community lab advisor who is responsible for
capacity building, technical support, and compiling
Community Lab uses a three-step model called CL performance reports.
Learn-Reflect-Innovate/Implement LRI which is a
community diagnosis and response methodology Accordingly, the Community Lab stakeholders utilized
that bring stakeholders together, ensures that there the LRI approach to diagnose one of the critical
is multi-sectoral coordination and collaboration to problems that the community in Derbark woreda
deliver agreed-upon community-based solutions Kino 01 kebele is facing: poor dietary diversity among
innovated or adopted to address the community children under two and pregnant and lactating
priority problems. mothers. To address this challenge stakeholders used
the LRI method to diagnose the community problem
Community Labs are set at woreda and kebele levels and come up with solutions that are doable at the
and members are from a government institution, community level:
religious leaders, influential peoples, women
developments groups, kebele level frontline workers, Learn: The first step in the methodology was to learn,
partners, etc. These stakeholders identify their local surveying the landscape of challenges andneeds –
problems and propose and prioritize solutions starting from the grassroots level. Accordingly, CL
together. They also mobilize resources, meet regularly members conducted a visit to households, discussed
to review the implementation and make the necessary with the pregnant and lactating mothers, visited
corrective measures. institutions and agricultural activities.

This lesson learned will focus on how the Community Reflect: Reflecting is about understanding how
Lab members come up with solutions for one of the to best use insights that were gathered through
problems that they identified during the IRL process. learning. During reflection, it was found that several
problems make pregnant women, lactating mothers,
Objective and children vulnerable to malnutrition. One of
the problems found during the reflection was most
To share the community lab experience of local
household reside in Debark woreda of Kino 01 kebele
communities in identification, testing, and scale-up
did not access or consume vegetables throughout

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the year and vegetable was found to be one of the to promote the consumption of nutrient-dense foods.
food ingredients that are missing from pregnant Currently, most of the target groups in Debark woreda
women, lactating mothers and children under two consume vegetables grown in the backyard. The
diets. This was mainly due to a lack of knowledge kebele level frontline workers, health and agriculture
and appropriate agricultural technologies and extension workers conduct close follow-up of the
techniques. A review of the growth monitoring and pregnant women and lactating mothers starting from
reporting data also showed children under two years registering the target beneficiaries to the provision of
are mostly underweight. technical support.

Innovate: To improve access to vegetables at the Conclusion and the Way forward
household level the stakeholders come up with an
innovative approach called Keyhole Gardening to Community Lab LRI methodology is a community
promote vegetable production at the household level. empowering tool that enabled communities to come
This technology is water-saving and could provide up with practical solutions for the problems that they
access to vegetables for the households throughout face in their community. Effective mobilization and
the year. It is also cost-effective that the community providing technical support will enable communities
could afford to implement. To test the innovation to give attention to combat a problem they can think
the first Keyhole garden was tried at the kebele they cannot do anything about it.
administrator backyard before it is scaled up to other
target groups. To ensure appropriate introduction,
the kebele administrator was provided with technical
support and follow by the woreda agriculture office,
kebele level agricultural extension workers, and
regional Program Delivery Unit Agricultural Manager
and Community Lab Advisor. Following the success
of the innovation at the Kebele Administrator garden,
the Program Delivery Unit organized experience-
sharing visits and the open day before taking the
technology at scale to other pregnant and lactating
mothers and community gardens in the kebele.

Result
Figure 01:- A mother with her Keyhole Garden
Through an open day, it was possible to scale up the
In the case of Debark 01 kebele, it was possible to
experience within the kebele and to other vicinities. An
create access to vegetables in their backyard all year
Open Day provides an opportunity for Communities
round with this simple and water-saving technology
to reconnect with Community Lab members to review
and feed their child at home, which the community
progress, celebrate successes, and capture learning.
did not imagine before. Scaling up such intervention
Currently, 938 pregnant and lactating women are
to all target groups needs a gradual process and
using Keyhole gardening technologies in Debark
ensuring local ownership and understanding among
woreda by growing different vegetables and feed
the stakeholders. Allowing the community to employ
under-two children. The technology was scaled to
LRI methodology gives an insight for communities
155 households living in the surrounding 18 kebeles
and professionals to innovate many solutions for
of Debark woreda and to other Seqota Declaration
the nutrition-related problems that the community
woredas too. The experience was also transferred to
especially children, pregnant and lactating women
other farmers through experience sharing events for
face on a day-to-day basis. Community Lab also
model farmers, religious leaders, and influential people
allowed the community-level stakeholders to have
from other kebele. The first 1000 plus days plus public
strong multi-sectoral coordination platforms to
movement strategy for social and behavior change
address other nutrition challenges that they identify
communication was utilized to educate communities
in their community.
about the preparation of vegetable foods as well as

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Implementation of Electronic Medical Record Project and Improvements in Service

Quality at Yekatit 12 Hospital Medical College

Ayele Teshome1 *, Bereket Zelalem1, Hailegebriel Bedane2, Abbas Yusuf2 , Gezashign Kassa2,
Biniyam Kemal2, Sem Abreham2, Deneke Ayele2, Kasu Bifa2
1
Yekatit 12 Hospital Medical College, Addis Ababa, Ethiopia
2
Ministry of Health, Clinical Service Directorate, Addis Ababa, Ethiopia
*Correspondence: [email protected], [email protected]

Introduction Method/ Approach

Yekatit 12 Hospital Health Medical College (Y12 HMC) A phase-based approach in four phases was employed
undertook situational analysis to understand major as follows.
challenges to improve the quality of service it’s
providing. This analysis showed among others that Phase I: EMR Implementation was started on
the number of clients not seen on the same day of the January 13, 2020, and included automating at the
visit was very significant due to mainly poor medical Reception, Triage, Billing, and Registration.
record management. Manual tracer cards and Master Phase II: Implementation was started on September
Patient Index (MPI) were used to track patient medical 14, 2020, and included modules of Emergency, OPD,
records. However, missed cards, misplaced cards, lost Diagnostic, and Pharmacy.
cards, and duplicate cards were common problems.
Phase III: Implementation was started on January
In addition, lab requests and results were prone to
5, 2021, and included Inpatient, OR, ICU, and
be misplaced and missed which has contributed to
Procedural OPDs
client dissatisfaction. Patients’ waiting time was long
to receive their result and take it to the attending Phase IV: Implementation includes dashboard
physician. development, Reporting ART, and Machine
Integration.
To improve this situation, the hospital initiated the
implementation of Electronic Medical Recording Result
(EMR) QI project aiming at easing the flow of
Within six weeks of EMR implementation, patients not
information among health care providers working
seen on the same day of visit significantly reduced
at different hospital departments such as reception,
from 140 to 0. The implementation of EMR has made
triage, emergency, OPD, diagnostic units, pharmacies,
possible an automatic triaging and color-coding of
and inpatient departments and improving service
each patient. The patients’ Triage Early Warning Score
quality including client satisfaction. Implementation
calculates and assigns the patients’ score and color
of the EMR project at Yekatit 12 Medical College was
code. EMR has also enabled the application of Scope-
started on January 14, 2020, and implementation is
Based Practice as each patient is assigned only to a
ongoing in four phases
physician with the appropriate level of professional
Objectives scope of practice.

The objective of this assessment was to describe the Implementation of EMR has also improved
experience of the hospital in implementing EMR to completeness of inpatient medical records from
improve the quality of care and convenience of the 79.8% to 98.8 % in a year time based on daily record
service delivery for both providers and patients. It completeness audits. This was achieved by making
also aimed to showcase the efforts to improve care important components of a patient’s history and
coordination among a team of health care providers, physical examination a mandatory requirement.
to achieve efficiencies in clinical practice, and
minimize the cost of service delivery.

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120

100 Inpatient medical completeness(%) 98.8

95
80 85.6
77.7 76.5 77.8 79.8
69 66.7 70.3
60 60.2 64.1

40 EH
20

0
Q1-2011 Q2 Q3 Q4 Q1-2012 Q2 Q3 Q4 Q1-2013 Q2 Q3 Q4

Fig 1: Inpatient medical record completeness

concept of ‘mandatory filling of required information’
Laboratory test results are sent directly to the also applies here and obliges physicians to take a full
physician and there is no need for patients to go back history and physical examination before ordering any
to the laboratory to collect their results. This in turn has medication or investigation. As soon as the physician
decreased unnecessary patient stay in the hospital. finishes their initial evaluation, the ‘Order and
The automation has also helped the physicians to investigation page’ will be active and they can inscribe
know which tests are available or not. The Pharmacy accordingly. Each order given by the physician will be
module tracks each drug and supply from storage to automatically displayed on the nurses’ page so that
dispensing and automatically generates a report for they can treat the patient as ordered. The inpatient
each item. It has allowed a strict follow-up system nurse page has tabs for Nursing Evaluation, nursing
for each drug and supply. Automation also allowed progress, and follow-up care.
the electronic transfer of prescriptions from one
pharmacy to the other (For instance, If the drug is After the implementation of the EMR, cancellation of
not available at the emergency pharmacy, but if it is the elective surgery has decreased from 44 to 22 in the
available at OPD pharmacy), so that patients can get past six months.
the service within the hospital.
Safe Surgery Checklist (SSC) has been integrated with
The inpatient module provides a single page for the system and the utilization of the safety checklist
physicians, nurses, and clinical pharmacists. The same has risen from 75% to 98.1%.

Figure 2: Cancellation at Y12HMC in the year 2013 EFY

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Implementation of the EMR improved the efficiency Key components of the EMR that represent new ways
of clinical care practice through advancing of using information secure messaging, in-baskets,
communication among the care provider and referral correspondence, documentation tools, and
saved around nine million birrs per year required patient portals, can add to the efficiency of electronic
for currency to print and procurement of patient records but will require new skill sets to ensure
charts. The automation of these services areas has appropriate use.
made major components of patient information
mandatory requirement before it is transferred to any Conclusion
next service area. These in turn have made it possible
to capture all necessary clinical data and socio- The EMR is a user-friendly system that supports
demographic information of patients completely. The effective, efficient, timely, and patient-centered care
system automatically generates and assigns Medical for the betterment of patient clinical outcomes. The
Rerecord Number (MRN) for each individual, and implementation of EMR at Yekatit 12 Hospital Medical
in case of patients lost their service cards or do not College has established an integrated system that
remember their assigned MRNs, tracing and retrieval enabled the hospital to serve patients efficiently.
can be done easily by searching their name or phone
The EMR has benefited patients by reducing chart loss,
number.
enhancing confidentiality of information, retrieving
Lessons Learned past medical information easily which saves time.

The commitment of the leadership to improve the The EMR has enabled the care providers (clinicians)
situation, resource mobilization, and flexibility were to manage the patients well and provide standardize
identified to be important elements of a successful clinical service. It also ensured accountability and has
implementation. raised productivity among the service providers and
resulted in a better patient clinical outcome.
Obtaining buy-in and acceptance from managers and
professionals at different levels early in the process Even though its implementation was challenging
was critical. during the initial phase of the process, the outcome
is very rewarding both for the client and for the health
Meticulous planning on how to approach the rollout care system as a whole.
as well as how and when to train users can also ease
the transition and allow providers to return to a
normal practice schedule more quickly.

Users then benefit from the knowledge that

opportunities will be available to optimize their use of
the EMR once they have had some time to work with
the system itself.

Furthermore, a process as complex as EMR

implementation requires considerable flexibility and
learning not only on the part of end-users but also
on the part of the information technology team. This
flexibility has been witnessed by our experience of
implementing the admission order process.

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Ethiopia Digital Health Projects Inventory System

Health Information Technology Directorate (HITD), MoH, Ethiopia

Correspondence: [email protected]
*

with the Ethiopian eHealth architecture, it has not

Introduction been possible to properly manage these important
assets and properly coordinate the stakeholders
Digital health projects have been recognized as a
working on them.
major transformational tool in the Ethiopian health
sector transformation plan (Information revolution As part of developing the eHealth architecture, digital
road map, April 2016; Health sector transformation health application inventory has been conducted
plan II, December 2020, FMoH). In line with this many nationally, and based on the assessment around 280
digital health, projects have been implemented in the various digital health projects have been identified of
country to improve the efficiency and effectiveness of which 77 were found to be unique.
health service delivery. The numerous digital health
projects being implemented and to be implemented A new web-based application called Ethiopian
in the sector by the different stakeholders in the digital health projects inventory (eDHPI) has been
various health facilities and regions of the country developed based on the requirement document and
should be properly governed and managed if we after rigorous testing and feedback collection from all
need to maximize the benefits of the projects and the relevant stakeholders the application is deployed
avoid duplication of efforts and resource wastage. at the FMoH data center

The Ethiopian eHealth Architecture (January 2018, Objective:

FMoH) is the foundational plan or blueprint that creates
a framework for how the HIS subsystems interact. The Major Objective The major objective of this initiative
eHA is created to ensure that information and data is strengthening the HIS governance mechanism of
can be easily shared and appropriately used across the health sector
the health system. The eHA ensures that systems are
developed and maintained to support patient care The Specific objectives of the E-DHPIS are
and the collection and aggregation of population
• Establish transparency of the digital health
health data. Adherence to the eHealth Architecture,
projects validation and certification process
an agreed-upon blueprint for HIS systems and data,
enables the MOH to share knowledge, collaborate • Align digital health efforts with the national (?)
on care, and understand the reports and population eHealth architecture
health data available for use throughout the health • Avail robust visualization and reporting
system. eHealth Architecture supports the creation mechanisms about digital health projects in the
of patient-based longitudinal health records through country for informed decision
the establishment of an interoperability layer. This • Encourage stakeholders’ integration and
architectural framework creates the HIS system coordination
support needed to help achieve health equity. • Strengthen information sharing
So far due to lack of proper governance mechanism • Realize data exchange and integration of various
to identify the existing digital health tools, their digital health projects
geographic distribution, their intended purpose, the
technology they used, the organizations involved in
the development and roll-out, and their alignment

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Method: This project has been implemented as

part of developing the Ethiopian ehealth architecture
(eHA) .

Inventory of the digital health application

implemented in the health sector was conducted
(August 2018) and the result has been incorporated
in the WHO digital health atlas. After analyzing
the features of the WHO digital health atlas and
identifying the requirements of the FMoH a new
software requirements (SRS) document has been
developed. Feedbacks were collected from all the
relevant stakeholder and incorporated by presenting Fig. 2 Dashboard of the application
the various stages of the software development.
Conclusion and way forward
After the digital health projects inventory application
is fully developed both technical and end-user training This is a major milestone in the endeavor towards
was provided. The application has been presented to aligning digital health initiatives with ehelath
the ministry’s management. architecture. However, without clear governance and
implementation mechanism of the E-DHPIS, it will be
Results/outputs: impossible to achieve the intended benefits of the
system. There should be a coordinated effort among
A web-based application is implemented and It is all the major stakeholders and continue reviewing to
now accessible globally via a hyperlink (https://dhpi. update and incorporate any new features. Regional
moh.gov.et/) All the relevant documentation has health bureaus should own this system and register
been produced. any digital initiative being implemented in their
respective regions. The system will be used as a main
repository and source of truth or the authorized
source for all digital health information systems
and will serve as a reference for new digital health
initiatives to avoid duplication of efforts

Fig. 1 How a new system is to be registered in the digital health

project

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Web-Based Unified Nutrition Information System for Ethiopia for Multi-Sectoral

Food and Nutrition Data Management System, Seqota Declaration Woredas

Kebede Mamo1, Dr. Sisay Sinamo1, Etsegenet Awash1, Fesseha Tekle1, Mesfin Gobena1,
Bisrat Haile1, Bezawit Tamiru1, Tamrat Seyoum1.
1
Ministry of health Seqota Declaration Program delivery unit, MCH directorate, Addis Ababa, Ethiopia
Correspondence: [email protected]

Introduction and encoded into the UNISE/DHIS2 platform to

manage and monitor multi-sectoral nutrition
Nutrition has a multi-sectoral dimension, and data at all administrative levels. Using this web-
multidimensional nutrition problems require based platform, the data revolution innovation
a multi-sectoral approach. It requires different aims to bring all nutrition data from different
sectors engagement like agriculture, health, sectors into a single common hub for joint and
education, trade and industry, women, children routine monitoring by all sectors, to help in data
and youth, finance, labor and social affair, analysis, visualization, and use for decision.
water, irrigation and energy sectors, and other
nutrition stakeholders. Tackling malnutrition Objective
requires coordination and integration among General objective
food and Nutrition implementing sectors for
effective implementation of nutrition-specific To develop, pilot, and scale up the implementation
and nutrition-sensitive interventions. Multi- of the UNISE Platform for regular multisectoral
sectoral coordination requires joint planning, food and Nutrition data collection, analysis,
implementation, monitoring, and evaluation visualization, and use for decision at national
through exchanging information, sharing and among regional levels through piloting
resources, and enhancing sector capacity for the platform at SD woredas, documenting best
mutual benefit and a shared vision. practices and lessons, then use at the expansion
and scale-up SD woredas; and improve the
Seqota Declaration activities are wide-ranging culture of data-driven decision-making at all
in terms of the sectors and geographies they levels and finally contribute for the reduction of
cover, which makes monitoring and evaluation Malnutrition particularly childhood stunting.
more complex than the average large-scale
program. The Seqota Declaration (SD) has Specific Objective
identified a “data revolution” in nutrition as one
of its innovative approaches to improve data • To develop and implement the Unified Nutrition
availability essential to design and implement information system for Ethiopia
effective, evidence-based policies and programs, • To pilot or introduce the UNISE platform at Seqota
mobilize resources, and monitor progress. To declaration woredas
this end, the Unified Nutrition Information
• To document lessons/best practices and major
System for Ethiopia (UNISE) has introduced in
challenges
Seqota declaration Woredas that designed to
track routine multi-sectoral nutrition data from • To build the capacity of frontline workers on food
lower to higher levels, and effectively analyze and nutrition data management
data to get meaningful information and show • To implement the findings from the pilot for the
performance progress in a dashboard, for use by expansion and national scale-up and contribute
decision-makers and implementers. to the reduction of malnutrition particularly
childhood stunting.
The list of nutrition-specific and sensitive
indicators was finalized in agreement with the
national food and nutrition implementing sectors

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Children, Labor and Social Affairs, Water Irrigation

Method and Energy, and Education) were defined. The
UNISE platform is a multisectoral nutrition UNISE user guide was developed and the system
information system that has merged to the was installed into the woreda, zone, region, and
national DHIS2 system and was introduced in federal system of these six sectors. Adequate
8 Seqota declaration Woredas of Amhara and training on the use of the system was provided to
Tigray region. The System is designed to track staff of the six implementing sectors at all levels
routine multi-sectoral nutrition data on Key to enter input data and track progress. And this
performance indicators of the sectors which platform will be planned to be scaled up to other
follow the exact data definition of the DHIS2 regions and woredas by including in the Seqota
platform. Key nutrition-sensitive and nutrition- Declaration Expansion phase.
specific indicators for six priority SD implementing
sectors (Health, Agriculture, Women, Youth, and

O ffline D at a E nt r y in S D W or edas
Online pre-designed Dashboard reports and
Federal PDU – Imports all the regions reports
on-demand reports generated by the
using UNSIE and generate reports for all federal
Federal sectors ministries and be used at all levels
sectors use whenever there is connection

Region PDU – Imports all the woreda reports using UNSIE,

verifies the data and generate reports for the region use, then
Region
exports the data then send to the Federal PDU

Woreda PDU – Imports the sector bureaus data using UNISE, verifies the data and
Woreda generate consolidated report for local use, then exports data send to Region PDU
Offline UNISE installed in each sector
bureaus and Data is entered , Reports
generated for local use then Data
Exported sent the Woreda PDU
(Nutrition Coordination Body of the
BoA BoLSA BoWCA BoE BoWIE BoH SD woreda)

Figure 1: UNISE Data Flow from the implementing sector Woredas to Federal level

Result

Computer distributed for 8 UNISE implementing and Energy and Education sector. The system
Woredas and training was given for Sector nutrition resolved the data accessing gap in multisectoral
focal person at all levels and successfully piloted a nutrition intervention and has been ensured the
Unified Nutrition Information System for Ethiopia data visualization features for easy tracking and
(UNISE) data management and sharing system in interpretation of nutrition data. Based on this sectors
this Piloted Seqota Declaration woredas. Continuous enabled in multi-sectoral data capturing, data entry,
onsite technical support and orientation were analysis, visualization, and utilization for evidence-
provided for the Woredas. The pilot was successful as based decision making. Though there is good uptake
key partners and sectors at all levels of government of UNISE at the woreda level, data quality and internet
were able to use the outputs of the data collection. accessibility across sectors need to be resolved.
Currently, UNISE is implemented in 6 sectors per
woreda. These are Health, Agriculture, Women, youth
and children, Social and Labor Affairs, Water Irrigation,

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In the current version of UNISE only indicators of six

Conclusion
sectors are designed and implemented, however,
Expanding the web-based UNISE data system are UNISE is endorsed as the data management tool for
promising solutions to overcome the challenge to multisectoral nutrition score-card. To automate fully
ensure real-time nutrition data reporting, analysis, the multisectoral nutrition score-card, data elements
and use at all levels to adjust program plans and the and indicators of the remaining sectors should be
course of program implementation in a timely way. designed in UNISE, and nutrition focal staff should be
Elatedly, there should be capacity-building training trained on the tool.
for implementing sectors at all levels on data analysis
UNISE expansion requires rigorous capacity building
and visualization tools. The regional coordination
and reliable internet connectivity for implementing
office should have a fully dedicated M&E expert that
sectors at all levels on data analysis and visualization
should own and lead the Seqota Declaration data
to ensure data quality during the Expansion Phase.
revolution during the Expansion Phase responsible
for coordinating timely data collection and reporting Keywords: UNISE, Data, Decision making,
on the analysis, Multi sectorial, data quality

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The Role of the Health Sector in the Civil Registration and Vital Statistics Eco-
system; Yesterday, Today and Tomorrow.

Daniel Getachew1,4*, Wubetsh Asnake1,5*, Hailu Dawo1, Yitbarek Tefera1, Tsega Hailu1,
Gezahegn Mekonnen2, Getachew Gebo2, Hibret Bireda2, Sehin Merawi3, Anteneh Habte3,
Naod Wendrad1
1
Ministry of Health, Ethiopia
2
Immigration Nationality and Vital Events Agency
3
Central Statistics Agency
4
World Health Organization
5
Vital Strategies
*
Correspondence: [email protected], [email protected]

In principle, the CRVS system as a whole typically

Background involves three key organizations, namely the Ministry
of Health that notify the occurrence of births, death,
Civil Registration and vital statistics system (CRVS) is
and cause of death; the registrar office which holds
a compulsory, continuous, universal, and permanent
the registrar system that registers and certify the
recording of the occurrence of vital events from which
occurrence of events and the Central Statistics Agency
vital statistics (VS) can be produced for planning,
that produces vital statistics reports (5).
policy-making, and research purposes (1). Under the
United Nations (UN) Principles and Recommendations
CRVS system in Ethiopia has passed different forms
for Vital Statistics, the UN recommends countries
and the modern CRVS system is established in
register 10 vital events which include: birth; death;
2012 after Ethiopia has approved the proclamation
fetal death; marriage; divorce; annulment; judicial
of 760/2012 by the Parliament in July 2012 (6).
separation; adoption; legitimation; and recognition
Following this proclamation, the Federal Vital Events
(judicial declarations of paternity). However, not
Registration Agency (FVERA) that is responsible to
every country records all vital events as per the UN
lead and coordinate the nationwide registration of
recommendation due to different reasons, even
vital events was established by regulation 278/2012
though they should (2).
(7). In 2019, the Ethiopian government introduced
administrative reforms resulting in the merge of
Registration of vital events immediately after the
the FVERA to the department of Immigration and
occurrence of the event enables individuals to
Nationality Affairs by regulation of the Council of
be recognized and serves as a legal document or
Ministers No.449/2019. The new agency was named
certification. Information obtained from the CRVS
the Immigration, Nationality, and Vital Event Agency
system mainly has three benefits namely legal,
(INVEA) and placed under the Ministry of Peace. In
administrative and statistical benefits (3). The legal
these reform processes of the CRVS systems, the role
benefit enables an individual to access a wide
of the ministry of health has evolved from an inactive
variety of rights to which an individual is entitled.
phase where no birth and death events are notified
In addition to issuing a certificate to provide legal
to a legally grounded, well-coordinated, strategically
benefits, the CRVS system yield different paybacks
planned, and improving part of the CRVS systems.
for public administration by the continuous process
This has been clearly articulated under the recent
of recording, maintaining, and retrieving vital records
Proclamation No. 1049/2017 which urges the health
that cover the entire population (3). The vital statistics
institutions to notify the birth, death, and cause of
derived from the CRVS systems provide reliable and
death and the civil registration related to refugees
disaggregated data at any level and even at a low cost.
and non-Ethiopian nationals residing in the territory
It helps the government to have a more accurate plan
as the legal basis.
and deliver services accordingly. Vital statistics also
provide dependable information which can be used
for monitoring of different national and international
commitments including the SDGs (4).

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the health sector to notify events happening both at

Objectives the health facility and in the community (8).
This study reviews the status of the CRVS system Currently, the registration of vital events takes place
in Ethiopia and the role of the health sector in the in 89% of the registration centers and 30 refugee
improvement of this system. Specifically, the study registration centers (9). The INVEA annual technical
was aimed to review the role of the health sector in report for the year 2020/2021 indicates that 18.02 %
the CRVS eco-system, gauge the status of the CRVS of births and 9.32% of deaths have been registered
system the role of the health sector in the past, nationally. This is below Ethiopia’s GTP II target of
present, and future; describe the long-run plan of the 50% of births to be registered by 2020 and SDG target
health sector in the improvement of the CRVS system of 16.1(10). In addition, it also affects the regional
(Strategic plan- customized for health sector). and global numbers of children with a legal identity
which are measured by the percentage of children
Methods
under-5 with births registered by civil authorities. Key
The content of this paper is a desk review based factors contributing to the low registration are lack of
on information collected through a review of the demand for vital event registration and certification,
available documents relevant to the CRVS system in limited public awareness on the importance of
Ethiopia including the CRVS national comprehensive registration, and lack of full-time dedicated registrars
assessment report and the five-year CRVS strategic at many kebele level registration centers (9).
plan of the country. The meticulous literature
Current status of birth and death notification
review was also conducted from global publications
(World Bank, UNICEF, WHO, UNFPA, etc.) to refer to When birth and death happen in the health facility,
international standards. Three years of HMIS data the health professional who attends the event is
was also used to analyze the national progress on responsible to complete the notification form and
notification of birth and death events. In addition, provide it to the attendant. It is the responsibility of
joint supportive supervision documents, review the health care providers to notify deaths within 30
meetings, and consultative workshop minutes are days and births within 90 days after the occurrence of
used as an additional data source. events in the health facility. Similarly, health extension
workers (HEWs) are required to notify deaths and
Results
births occurring in the community in the same span
The status of the CRVS system and the role of the of period specified above.
health sector:
In health facilities, the District Health Management
As per the proclamation 760/2012, seven vital events Information System (DHIS-II) is filled to aggregate
need to be registered in Ethiopia. These include data, while the paper-based birth notification form
birth, death, marriage, divorce, adoption and is completed with three copies, one archived by the
acknowledgment, and judicial declaration of paternity health facility, the other for the guardian/attendant
(6). In the implementation of the CRVS system, the and the other to be given to OCS at the nearest civil
Ministry of Health (MOH) has a major responsibility administrative office.
in notifying of birth, death, and causes of death that
For the past many years notification of birth and death
happen at the facility and in the community while the
were only limited to the health facility and there is no
Central Statistical Agency (CSA) is mainly responsible
established reporting system at the health sector to
to produce an official statistic that further is used
notify events outside of the health facility. Due to this,
by different bodies for planning and policy-making
the coverage of birth and death notification is below
purposes. The proclamation of 760/2012 mandated
expected that further affects the registration of these
the health sector to notify the occurrence of birth
vital events.
and death that happens only at the health facilities.
However, this Proclamation was amended by
Proclamation No. 1049/2017 which depicts the role of

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The facility birth and death notification The data from the HMIS report shows, the health
performance facility birth notification performance from live births
that occurred in the facility has shown significant
In latest years, the birth and death notification progress over the last three years. In 2011EFY, only
activities have been significantly strengthened 21.26% of the live births were notified by the health
due to the promising collaborative efforts made by facilities. However, this has progressed to 54.4%
the three key stakeholders: INVEA, MOH, and CSA. in 2012EFY and 66.04% in 2013EFY. On the other
This collaboration ignited the stagnated pace of its hand, the facility death notification has progressed
implementation due to the loose focus it has given, from 18.12% in 2011EFY to 42.15% in 2013EFY. The
weakened follow up and poor monitoring. The performance of death notification on the latest
increased number of review meeting platforms, the year has shown a slight decrement as compared to
integrated supportive supervision, the performance 2012EFY. The reason for such decrement should be
follow-up and feedback, and the recurrent workshops further investigated in the future.
and training between these key stakeholders could be
mentioned as the critical reasons for such progress. Even though, more than 90% of death and 50% of
Moreover, the Ministry of Health has started to put birth occur outside of the health facility, notification of
this responsibility as its prime agenda and integrated birth and death is limited to the health facility (11). So
it with different relevant directorates roles. To this far, there is no established health information system
regard, the facility birth and death notification for reporting birth and death notifications happening
performance has shown a significant improvement outside of the health facility. Moreover, even though
over the past two years. (Fig 1 & 2) the community birth and death notification pad has
already been designed, printed, and distributed; the
Figure 1: National facility birth notification, 3 years comparison
orientation training to HEWs and all relevant bodies
is not yet completed. For this reason, the community
National Facility Birth Notification, 3 Years Comparison birth and death notification activity could not be
Birth Notification Given
Birth Notification %
Total Live Birth
started. When the performance of birth and death
66.04% notification is calculated from the expected live birth
2,500,000 70.00%
2,090,454
2,232,409 and death (CRD), the coverage is still way below the
2,014,967 60.00%
2,000,000 54.40% target set for the HSTP II. See Fig. 3: Total birth and
50.00%
1,474,248 death notification performance.
1,500,000 40.00%
1,137,186

1,000,000
21.26% 30.00% Figure 3: Total birth and death notification performance
20.00%
428,330
500,000
10.00%

0
2011EFY 2012EFY 2013EFY
0.00%
TOTAL BIRTH AND DEATH
NOTIFICATION YEARLY TREND
Figure 2: National facility death notification, 3 years compari-
son Total Birth Notification %
Total Death Notification %
45.9%
National Facility Death Notification, 3 Years Comparison 38.8%
Death Notification Given Total Death in the Facility 15.2%
43,900 1.6% 3.6% 3.1%
50,000 44.30% 42.15% 50.00%
45,091 43,899

40,000 40.00%
2011EFY 2012EFY 2013EFY
30,000 30.00%
18.12%
20,000 20.00%
19,449 18,502
The birth notification performance from the expected
10,000 10.00%
8,169 live birth for that specific period was only 15.2% in
0 0.00% 2011EFY. However, this has been doubled and tripled
2011EFY 2012EFY 2013EFY
in the two consecutive years respectively (2012EFY
and 2013EFY) with 38.8% and 45.9% birth notification.

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Whereas the death notification in the year 2011EFY community causes of death identification system
was only 1.6% from the total expected death in through Verbal Autopsy procedure, establishing
that specific period. Though this performance has pre- and in service training programs to health
increased to 3.6% in 2012EFY, it has shown a slight professionals to improve causes of death assignment,
decrement (3.1%) in the following year. The total and strengthening the community and facility birth
birth and death notification performance should be and death notification with a coordinated monitoring
calculated as an aggregate of the community and mechanism of the actual event registration. The
facility birth notification reports. However, since the strategy document has also given the assignment
community birth and death notification are not yet to all key stakeholders to minimize the copy of
started, the total notification performances cut to a registration from 4 to 2 and digitalize the birth and
low value when only calculating the facility notification death notification, hire an independent civil status
from the expected projected values of birth and death. officer at lower registration centers, and produce an
Therefore, in the coming years when health extension annual vital statistics report (12). Moreover, it is highly
professionals start to notify community birth and believed that the most important of the success
death events, the total notification performances are factors is leadership that will deliver coordinated
expected to significantly increase to reach the HSTP political and executive decisions through a formally
II targets. established National CRVS Steering Committee (NSC).

The Next 5-year plan to improve CRVS Conclusion and Recommendation

By the next 5 years, Ethiopia has planned to increase CRVS system is an infant system in Ethiopia that was
coverage of birth notification to 80% and death legally established in 2012. Even if there are some
notification with causes of death data to 50%. To improvements on birth notification and registration,
achieve this, the country prepared and endorsed a death and causes of death notification and registration
5-year CRVS strategic plan that is effective from 2021- are still below 4%. The low notification performance
2016. This strategic plan has envisioned Ethiopia to is also attributed to the inexistence of the community
be a country where everyone is recognized through a notification for events that occur outside the health
strong CRVS system. This strategic plan has prepared facility.
to achieve four strategic outcomes: (i) Conducive legal
and policy framework, (ii) Improved governance and Hence, the collaborative effort started in recent years
expanded services, (iii) Reliable vital statistics, and (iv) needs to be further strengthened to achieve both
Modernization of the CRVS system (12). the national and international commitments and
the targets set on the CRVS strategic plan, HSTP II
They are designed to focus on what is important strategic plans, and SDG. As CRVS is one of the data
to transform the CRVS landscape of Ethiopia. The sources which help for planning, policy-making, and
strategic plan is prepared based on the finding monitoring of different national programs, improving
from the comprehensive assessment (9) and the the coverage, completeness, and quality of CRVS data
desk review. From the national assessment, poor remains to be vital in the system. Finally, the active
coordination, legal, material, infrastructure, human engagement and coordination of all relevant sectors,
resource, and financial limitations were identified as partners, and stakeholders is a central point for the
a potential constraint that compromise the country’s improvement of the CRVS eco-system in general.
CRVS system. Therefore, based on such findings, the
five year strategic plan has given the health sector
a tedious but rewarding journey of establishing a

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References 8. ETHIOPIA FNGOTFDRO. Proclamation no.1049/2017,

Vital Events Registration and National Identity
1. United Nations (UN). Principles and recommendations for a Card proclamation (amendment) proclamation.
vital statistics system RU, 2001. https://unstats.un.org/unsd/ https://wwwrefworldorg /cgi-bin/texis/vtx/rwmain/
publication/SeriesM/SeriesM_19rev2E.pdf. opendocpdfpdf?reldoc=y&docid=5ec7fa674. 2017.

2. United Nations (UN). Principles and recommendations for a 9. Immigration NaVEAwMoHaCSAoE. The Ethiopian
vital statistics system RU, 2014. https://unstats.un.org/unsd/ Civil Registration and Vital Statistics (CRVS) Systems
demographic/standmeth/principles/m19rev3en.pdf. Comprehensive Assessment Report. 2021.

3. https://crvsgateway.info/The-benefits-and-beneficiaries-of- 10. National Planning Commission. The Second Growth and

CRVS-systems~551. Transformation Plan (GTP II) (2015/16-2019/20). https://
wwwafricaintelligencecom/c/dc/LOI/1415/GTP-IIpdf.
4. Community P. Civil Registration and Vital Statistics (CRVS) September 2015
and the Sustainable Development Goals (SDGs). 2016
https://getinthepicture.org/sites/default/files/resources/ 11. Ethiopian Public Health Institute FMoH. Ethiopia
CRVS_and_the_SDGs_2016.pdf. Mini Demographic and Health Survey 2019. https://
dhsprogramcom/pubs/pdf/FR363/FR363pdf. 2019.
5. Mills S, Lee JK, Rassekh BM. A multisectoral institutional
arrangements approach to integrating civil registration, vital 12. Immigration NaVEAwMoHaCSAoE. CRVS SYSTEMS
statistics, and identity management systems. Journal of IMPROVEMENT STRATEGY AND COSTED ACTION PLAN OF
Health, Population and Nutrition. 2019;38(1):19. ETHIOPIA: 2021/22 – 2022/26. 2021.

6. ETHIOPIA FNGOTFDRO. Proclamation No.760/2012

Registration of Vital Events and National Identity. https://
chilotfileswordpresscom/2013/04/proclamation-no-760-
2012-registration-of-vital-events-and-national-identity-
card-proclamationpdf. 2012.

7. ETHIOPIA FNGOTFDRO. Regulation 278/2012, Vital Event

registrationn Agency establishment. https://chilotme/wp-
content/uploads/2017/04/regulation-no-278-2012-vital-
events-registration-agency-establishmentpdf. 2012.

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The Health Sector’s Response to the COVID-19 Pandemic: Experience from the HRH
perspective

Biniyam Biresaw1 *, Kirubel Abera1, Adane Demeke1, Mulugeta Debel1

1
Ministry of Health; Human Resource Administration Directorate, Addis Ababa, Ethiopia
*
Correspondence: [email protected]

On March 13th, 2020, Ethiopia reported its first case of COVID-19, an infectious disease caused by a novel coronavirus
that is now renamed severe acute respiratory syndrome coronavirus 2 (SARS-COV-2). The Ministry of Health as being the
primary responder to any threat to the nation’s health and the Human Resources Administration Directorate being one
of the main players in deploying the needed Health Workforce has been fully engaged since then.

Despite the unfamiliarity of public health emergencies of international concern in the country, the Ministry was able to
deploy an additional 6,721 health professionals at various fronts to control the pandemic and save our precious citizens’
lives. Deploying healthcare workers to be the front-line combaters against COVID-19 didn’t come without a cost as it
demands a huge resource mobilization to effectively motivate and retain these professionals. Amongst huge milestones
achieved regarding Health Workforce motivation and retention mechanisms used in such a life-threatening pandemic
were the introduction and implementation of the special risk allowance payment guideline for COVID-19 workers, life
insurance coverage in case of fatality, recognition week for acknowledgment of all stakeholders involved in the response
against COVID-19 and permanently employing health professionals that have been deployed in the fight against the
pandemic.

Undoubtedly, this pandemic has presented us with various challenges including taking 5,254 Ethiopian lives till present
day while on the other hand, it allowed us to evaluate our public health emergency response and the need for local,
national, and global multi-sectoral collaboration in overcoming such global health tackles and its deemed sustainability
in a much more integrated and aligned manner for future endeavors.

Keywords: Global Human Resources for Health Strategy, Health Workforce, COVID-19, Multi-Sectorial Collaboration,
Motivation, and Retention Mechanisms, Resilient Health Systems

Background
one of the main players in deploying the needed
On March 13th, 2020, Ethiopia reported its first case Health Workforce has been fully engaged since then.
of COVID-19, an infectious disease caused by a novel
coronavirus that is now renamed as severe acute The pandemic has caused greater devastation
respiratory syndrome coronavirus 2 (SARS-COV-2). since its outbreak. It has put a detrimental effect
The news was overwhelming just as it was announced on developing countries and its effect is no less in
2 days after it has been waged as a global pandemic developed countries that were assumed as having a
by the World Health Organization on March 11th, resilient health system. As such, the world has gained
2020. The Ministry of Health as being the primary a learning experience on how to improvise its health
responder to any threat to the nation’s health and the system.
Human Resources Administration Directorate being

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Ethiopia, being a developing country, had a worrisome Health and care workers’ celebration week and
expected outcome from the pandemic. The Ministry of ensuring the continuity of job security of the HWF
Health had to set up a responsive system in combating who were engaged in the COVID-19 response were
COVID-19 through deploying HWF on a contract basis amongst the effective recognition methods applied.
departing from the routine HWF deployment cultures Multi-sectorial collaboration at local, national
which have enormously decreased the anticipated and international levels have greatly contributed
devastations. The importance of effective HRH in tackling the various detrimental effect through
management in deploying the right number of HWF, multiple efforts.
at the right place and at the right time has been noted
well in such times of crisis through systematic and Results
digitized ways of registration, screening, recruitment,
and deployment methods. As part of COVID-19 prevention and control measures,
the Ministry had set up an online registration platform
General Objective to recruit and mobilize health professionals. As a
result, we were able to register 10,131 professionals
Safeguarding the health of our citizens through of various categories and recruited 546 general
creating effective and efficient HRH responsive to all practitioners, 821 nurses,123 laboratory professionals,
health threats. 11 pharmacists, 143 health officers, after effective
screening methods were applied.
Specific Objective
Another merit was the Memorandum of Understanding
 Determining the impact of new recruitment signed between our Ministry and Ethiopian Insurance
methods in times of global health crisis Corporation in providing life insurance coverage
for healthcare workers in times of fatality due to
 Establishing and evaluating the effectiveness of COVID-19. Sadly, we lost 46 healthcare workers to
new motivation and retention mechanisms in COVID-19 and premium payments were given to their
motivating and retaining the health workforce in loved ones even though their dearest lives couldn’t be
times of pandemic. replaced.
Method We were able to transfer the recruitment modality
of 6,721 health professionals to permanent staff
New challenges require new solutions. Routine
after successful agreement with the Public Service
responses to the public health crisis of international
Commission which is to be recorded as the first time in
concern are not sufficient in alleviating the detrimental
history without having the formalities applied which
consequences of COVID-19. Digitized methods of
was formerly used in employing permanent recruits.
registration, screening, recruitment, and deployment
of health professionals have been effectively applied Health and care workers’ week is markedly celebrated
to mobilize HWF at various fronts in the prevention nationally and globally from July 17-23, 2021 in
and control of the pandemic. Establishing new ways recognition of the HWF’s utmost contribution to the
of motivation and retention mechanisms like special public.
risk allowance payment to the HWF and life insurance
coverage have also been successfully introduced and
implemented to the benefit of the HWF.

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has demonstrated to our recent experience affecting

Conclusion and recommendations
the global economy. Due to the collaboration of all
A digital method needs to be applied at all levels of the stakeholders, our country was able to control the
health system especially in recruiting and deploying damage before it could have reached the projected
HRH. They have been found effective in consuming mortality and morbidity thanks to all engaged parties.
less time and advantageous in monitoring, evaluation, A special thanks to health care workers first and
and tracking of healthcare workers. foremost who have also sacrificed their lives fighting
the deadly virus.
Mechanisms have to be set in place to motivate and
retain healthcare workers in times of a pandemic that As the HWF being the main pillar of the health
is of international concern amongst which setting system, investing in the HWF as clearly outlined in
up a special risk allowance payment to frontline the GLOBAL HRH STRATEGY 2030 by the World Health
healthcare workers, providing life insurance coverage, Organization is a benefit for all. Various recognition
and ensuring job security to healthcare workers are methods are vital in creating a motivated, competent,
amongst the few that have been applied. These and compassionate health workforce.
actions have greatly kept in balance and gave birth
Let’s all commit ourselves to create healthier citizens for a
to continuous related initiatives like revising the
prosperous nation.
incentive guideline of healthcare workers, drafting an
insurance coverage scheme for healthcare workers,
and creating diversified employment opportunities
which will enable the long-term durability of creating
a motivated, competent and compassionate health
workforce.

Establishing a resilient health system requires

multi-sectoral collaboration locally, nationally, and
internationally with government bodies, the private
sector, and development partners. A threat to the
health system is the threat to all sectors as COVID-19

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Maternal and Newborn Health Quality of Care initiative in the 14 learning districts
of Ethiopia: implementation status and results

Ftalew Dagnaw1*, Desalegn Bekele1, Aynalem Legesse1, Hassen Mohammed1, Berhane

Redae1
1
Ministry of Health, Addis Ababa, Ethiopia
*
Correspondence: [email protected]

To operationalize the NQS agenda of improving the

Background
Quality of Care for Mothers, Newborns, and Children,
Ethiopia has achieved a substantial decline in maternal the Ministry of Health with its development partners
and under-five mortality in the last subsequent years. has developed an MNH quality of care Roadmap.
Under-5 mortality declined from 166 deaths per 1000
Objectives and approaches
live births in 2000 to 67 deaths per 1000 live births in
2016, representing a 60% decrease over 16 years [1]. The Goal of the Maternal and Newborn health Quality
Similarly, maternal mortality declined by 53%, from of care (MNH QoC) initiative is to halve Institutional
871 per 100,000 live births in 2000 to 412 death per maternal and newborn deaths and improve clients’
100,000 live births in 2016. [1, 2]. experience of care in the participating learning health
facilities over five years period.
Though overall under-five mortalities reduced
significantly, the proportion of deaths occurring • Moreover, four strategic objectives named LALA
during the neonatal period was reducing at a slower were identified adopted from the World Health
rate and the current burden of maternal mortality Organization (WHO) MNH QoC framework,
with 412 maternal deaths per 100,000 live births Leadership, Action, Learning, and Accountability
and neonatal mortality with 29 neonatal deaths per (4).
1000 live births is still higher [2]. On the other hand,
a recent Mini EDHS 2019 study revealed that, with • Leadership: Build and strengthen national
improved maternal health coverage, 74% of women institutions and mechanisms for improving the
received antenatal care from a skilled provider, 43% quality of care in the health sector.
received four or more ANC visits and 48% of women
delivered at a health facility. These findings indicated • Action: Accelerate and sustain implementation
improvement in maternal health coverage needs to of quality of care improvements for mothers and
integrate health care quality to address the current newborns.
persistent disparities and unmet need for maternal
health care. • Learning: Facilitate learning, share knowledge
and generate evidence on quality of care.
Cognizant of this, the Ministry of Health of Ethiopia has
prioritized maternal and newborn quality of care and Accountability: Develop, strengthen and sustain
has been designing and implementing several Quality institutions and mechanisms for accountability.
improvement initiatives. Accordingly, Ethiopia to join
The initiative implemented in the selected 14 districts
the WHO-led Global network to ‘Improve Quality
representing the agrarian, pastoralist, and urban
of Care for Mothers, Newborns, and Children. The
setups in the country (3 - 5 learning health facilities
Network provides a platform for countries to ensure
per district with a total of 48 learning health facilities
that quality of care becomes an integral part of health
consisting of 8 Referral & General hospitals, 12 primary
care delivery; it facilitates intercountry learning,
hospitals, and 28 health centers) since July 2018.
knowledge sharing, and generation of local evidence
and best practices.

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• A district-based learning collaborative network MNH and QI staff in all learning health facilities,
was established, and technical support has been districts, and RHBs. Besides, maternal deaths
provided on the implementation of the identified and death responses in the 48 learning health
MNH QoC roadmap packages which includes; facilities were regularly tracked and monitored
and feedbacks were provided to Regional Health
• National coordination mechanism established Bureaus.
through forming Maternal & newborn Health
QoC technical working group (TWG) comprising National MNH QoC learning network learning
relevant directorates from Ministry of Health and platforms were established and bi-annual learning
all partners working on maternal and newborn collaborative sessions have been organized where
QoC and regular monthly meetings has been all the 48 health facilities share the best experience
conducted to guide technical aspect of the and lessons amongst themselves. Global MNH
implementation including overall monitoring of QoC summit was organized to exchange the best
the initiative. experiences and lessons learned among the network
countries.
• The WHO MNH QoC Monitoring and Evaluation
framework was also adopted and implemented As part of the regular MNH QoC monitoring, 15
to track the implementation of the program common core indicators were used for monitoring of
and results that include fifteen common core process and outcomes and quarterly feedback was
indicators measuring provision of care, the provided.
experience of care, and WaSH.
Major results and lessons
• MNCH quality standards were developed based
on the WHO standards included as one chapter Three outcomes measures included in the MNH
in the Ethiopian Health sector transformation for common core indicators reporting system which have
quality guideline (HSTQ) and used to undertake a been collected and reported by the 48 learning health
clinical audit in the learning Hospitals. facilities were used to assess the achievement of the
network intended outcomes. The implementation
• Existing Health care Quality structures at Period Performance was compared with the pre-
National, sub-national, and Health facility levels implementation period or baseline reference year of
were capacitated through providing basic and 2010 EFY. The three outcome measures used for the
advanced QI training. assessment are institutional pre-discharge maternal
mortality, institutional pre-discharge neonatal deaths,
• National QI Coaching Guide was also developed, and fresh stillbirth. Stillbirth is a fetal death with no
and two rounds of QI coaching training were signs of life at ≥ 28 completed weeks of gestation (5).
provided to the established pool of QI coaches
from Districts and lead Hospitals who provided • Accordingly comparing the follow-up
quarterly on-site QI coaching support to their period performance against the baseline for
respective learning health facilities. Besides, reporting health facilities, (Fig.1-3).
in collaboration with supporting partners.
• Pre-discharge maternal mortality ratio (MMR)
(Transform PHC, Transform HDR, IHI, CHAI
per 100,000 live births declined by 17% (from
& WHO) who provide technical support to
163 to 135 per 100,000 live births).
learning districts, on-site support regular
mentoring, and coaching support provided to • Pre-discharge neonatal mortality rate (NMR)
build clinical and QI skills of learning health per 1000 livebirths decline by 5.4%, from 24.0
facilities. to 22.7 per 1000 live births.

• Maternal and Perinatal death surveillance and Fresh stillbirth per 1000 births declined by 18%, from
response system (MPDSR) strengthening were 19.7 to 16.1 per 1000 births.
one of the key areas of support. Accordingly,
four rounds of MPDSR training were provided to

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References
Conclusions and lessons learned
13. Ethiopia Demographic and Health Survey: 2016. Addis
Nevertheless, the performance across the health Ababa, Ethiopia, 2017.
facilities may be affected by the variation in the
availability of the existing resources such as medical 14. Ethiopia Mini Demographic and Health Survey 2019:
supplies, human resources, and other structures, the Key Indicators. Rockville, Maryland: EPHI and ICF; 2019.
early results of the MNH QoC network implementation 15. Ethiopian National MNH quality of care roadmap: 2017,
has shown promising result concerning the reduction MOH, Addis Ababa, Ethiopia, 2017.
in institutional mortality outcomes. On the other
16. Quality of care for maternal and newborn health: a
hand, continued and sustained implementation of
monitoring framework for network countries, updated
the quality improvement efforts may also be required
February 2019.
for long-term and sustained results.
17. Ethiopian Maternal and Perinatal death surveillance
and response Technical Guidance: 2017, MOH, Addis
Ababa, Ethiopia, 2017

Annex 1: Figures

Fig 1. Pre-discharge maternal mortality ratio per 100,000 live births, 2017 Q2 – 2021 Q2.

Follow up, median of 135

Baseline, median of 163

Fig.2. Pre-discharge neonatal mortality rate per 1000 live births, Baseline and follow up the median, 2017 Q2 – 2021 Q2.

Baseline, median of 24.0 Follow up, median of 22.7

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Blended Learning- an Efficient Way to Build Knowledge and Skills of Community

health workers

Melaku Yilma*1, Wondesen Nigatu1 , Israel Ataro1 , Abraham Zerihun2

1
Directorate of Health Extension Program and Primary Health Care, Ministry of Health, Addis Ababa, Ethiopia
2
Last Mile Health- Ethiopia, Ministry of Health, Addis Ababa, Ethiopia
*Correspondence: [email protected]

Background Objective:

The Health Extension Program (HEP) was designed The report aims to show the experience of developing
as a community health program delivered by a team blended with a combination of face-to-face and
of two Health Extension Workers (HEWs) to serve digital sessions, high-quality, learning content for the
in community health posts with a catchment area RMNCH module of the in-service training for HEWs
population of 5,000 people. The goal of the program is accessible on mobile devices anywhere, anytime.
to increase geographic access to primary health care
services and address the high burden of preventable Method
diseases. HEWs provide preventive, promotive, and
curative health services at their health post, house to The development of the RMNCH blended learning
house, and outreach (1). content included three components:

To improve the knowledge, skills, and attitude of 1. Instructional Design: The competencies of the
HEWs, 15-30 days of in-service Integrated Refresher RMNCH module were mapped against the HEWs
Training (IRT) is provided to HEWs once every two scope of practice and occupational standards.
years at the district level for each of the following Based on that, a blended-model instructional
six modules: 1) reproductive, maternal, newborn, design plan was developed. Accordingly, content
and child health; 2) hygiene and sanitation; 3) non- for face-to-face training and content for digital
communicable diseases; 4) communicable diseases; self-learning were identified. The instructional
5) social behavior change communication; and 6) first design was reviewed and endorsed through
aid/emergency (2). an instructional design workshop involving
participants from the MoH, Regional Health
The reproductive, maternal, newborn, and child Bureaus, District and Zonal Health Offices,
health (RMNCH) in-service training module is one of Partners, and HEWs.
the IRT modules which has a seven days schedule. 2. Multimedia: Locally relevant and culturally
The Ethiopia Ministry of Health (MoH) and partners appropriate multimedia content was developed
have prioritized updating this module. However, in three local languages, including illustrations,
the current IRT, which is dependent on only face- animated videos, and animated character stories.
to-face sessions, face many challenges including
length of time required to complete the training, 3. Digital platform: The training app called Extension
cost of the training, limited innovative tools for Essentials was developed using OppiaMobile, an
learning, dependency on only face-to-face training, open-source learning app for health workers, to
a limited competency framework, and ineffective deliver content on mobile devices. The app has
measurement and evaluation processes (3). been tested and found to be interoperable with the
national electronic community health information
The MoH has partnered with Last Mile Health, an system (e-CHIS).
organization that has worked for 15 years to build
exemplary community health systems in partnership User testing of the app was conducted to ensure the
with governments, to overcome these challenges by design was user-centered using the following method:
developing a blended learning design for the RMNCH
• Five users were selected from three regions
module of the in-service training for HEWs.
with purposive sampling and matched HEW
representativeness by age, experience, and sex.
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• Using the cumulative binomial probability formula The user testing showed that HEWs were very
claim that a sample size of five users is sufficient to receptive to the blended design, and they provided
detect 85% of problems in an interface. The given vital feedback on the functionality of the app, as well
probability a user would encounter a problem as content and multimedia resources, which were
is 31% (as determined by an average problem used to further enhance the design. Quizzes and
frequency from several studies). multimedia resources were chosen by HEWs as the
best features of the training. One user said that “The
• The participants were selected based on their videos and quizzes are good in adding the practical
familiarity with technology, using eCHIS to get knowledge. As a refresher course, knowing the basics
better feedback on the application. knowledge in our previous training, I say the contents
are good.’’ They were determined to be effective for
• Data collection tools used were screen recording,
retraining, interactive, easy to understand as they
question and answer, observation checklist, use local languages, related to real-life community
dashboard monitoring, and focused group challenges, and easy to navigate as mentioned by one
discussion. user who said ‘’The application orientation has made
us to be familiar with the app and know how to use it.
• User testing was conducted on June 29 and 30,
I say I am confident to complete the training at home
2021 at Adama, Oromia region.
using this knowledge.’’
• User testing was facilitated by female staff to
Conclusion and way forward
integrate gender consideration and create a
friendly environment where participants can The blended learning design can address challenges
speak up. related to long duration of training, limited interactive
content and ineffective learner engagement by
Results
enhancing the training content through content
A blended learning training was designed, which review and competency mapping, development of
includes an initial 2-days of training in person, multimedia-aided blended design, and integration
followed by 5 days for digital self-learning, and with a digital platform that can deliver content
concludes with a 2-day closing in-person session. on mobile devices. Moreover, the digital platform
The Extension Essentials app contains all training provides real-time data to evaluate the training,
content and a daily schedule for digital and facilitated including participation and time spent in activities
learning. and course completion, learner’s reaction to the
course, pre and post-training knowledge and self-
Once downloaded onto the user’s device, all the efficacy assessments, quizzes, and engagement with
contents and activities of the module can be digital components after the training. The RMNCH
accessed offline by the learner anytime, anywhere. blended learning approach will be piloted in 20
The approach integrates effective learning activities districts between August 2021 and January 2022, and
such as role-plays, case studies, group discussions, the lessons learned will inform the scale-up of this
case-based pre-and -post-knowledge questions, module and the future IRT modality nationwide.
pre-and post-self-efficacy questions, quizzes, and
skills assessments. Multimedia resources including References
illustrations, animated videos, and character stories
1. Ministry of Health of Ethiopia. A roadmap for optimizing the
were effectively integrated with the blended design.
Health Extension Program of Ethiopia (2020-2035). 2020;
The learning methods used in the approach are
interactive and engaging to keep the learner focused 2. Ministry of Health of Ethiopia. Reproductive, Maternal,
and interested in the content. Newborn, Child, Adolescent, Youth Health and Nutrition
(RMNCAYH-N) Integrated Refresher Training Module. 2020.
By understanding user experiences and preferences, 3. Teklu AM, Alemayehu YK, Medhin G. The National Assessment
we were able to amend the training content, format, of The Ethiopian Health Extension Program Abridged Report
and resources to better meet learner expectations Recommended Citation [Internet]. 2020. Available from: www.
and needs. merqconsutlancy.org

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Accelerating the Implementation of Auditable Pharmaceutical Transaction and

Service in Public Health Facilities of Ethiopia

Mahdi Abdella1*, Natnael Solomon1, Edessa Diriba1, Regassa Bayisa1

1
Pharmaceutical and Medical Equipment Directorate, Ministry of Health, Addis Ababa, Ethiopia
*
Correspondence: [email protected]

Introduction Objectives
Before 2012, there was no appropriate system To accelerate the expansion of Auditable
established for pharmacy service. This led to Pharmaceutical Transaction and Service
pharmaceutical wastage, medication diversion, implementation in public health facilities of Ethiopia
illegal medication trafficking, and improper budget from July 2020 to June 2021.
utilization. The economic and social impact of these
consequences was very high. These were because Approach
of poor pharmaceutical service organization and
management, unscientific workforce deployment To reverse this lethargic progress in the expansion
and development, non-standardized workflow and of APTS implementation, the ministry devised a
processes, lack of systems and tools that ensure new approach to implementing this service in July
transparency and accountability, inefficient use of 2020. The following were key interventional made
meager resources, poor infrastructure, and lack of by the Ministry to accelerate the expansion of APTS
legal frameworks. implementation in public health facilities in Ethiopia.

Recognizing all these problems, Auditable 1. A one-year strategy to implement APTS in

Pharmaceuticals Transactions and Services (APTS) 100 public health facilities was devised by
was one of the strategic initiatives designed to improve the Pharmaceutical and Medical Equipment
pharmacy practice by the Ministry of Health, Ethiopia. Directorate.
APTS is a data-driven package of interventions
designed to establish an accountable, transparent, Before June 2020 the implementation of the service
and responsible pharmacy practice. APTS has five was donor-dependent and most facilities engaged
result areas: efficient budget utilization, transparent only in hiring human resources needed to run the
and accountable transactions, reliable information, service. To accelerate the rate of service expansion, it
effective workforce development and deployment, is believed that increasing the role of health facilities
and improved customer satisfaction, and ultimately, in the initiation should be increased so that the sense
it contributes to better health outcomes. of ownership and competition between facilities to
implement the service will be increased. Accordingly,
Ministry of Health, all regional states, and City in addition, to provide the necessary human resource
Administrations of Ethiopia have enacted a legal to run the service, it was believed that health facilities
framework for its implementation. In HSTP I it was should allocate half of the budget for renovation,
targeted to scale up APTS in all health facilities by shelving, and training necessary to initiate the
2020. However, only 217 of them were implemented service. The Ministry secured a budget of around 18
until the end of June 2020. Analyzing this sluggish million birr for this activity to be matched with public
progress, the Pharmaceutical and Medical Equipment health facilities and their respective regional Health
Directorate of the Ministry of Health, devised and Bureaus (RHB). Accordingly, to select health facilities
implemented a new approach for accelerating the that could implement the service, facilities that have
expansion of APTS implementation. enough human resources, those that have already

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renovated their pharmacies as per APTS layout, and communicates and monitors the progress of the
those facilities that can allocate budgets through RHBs and presents their progress to the directorate.
matching funds for shelving and training were set as Immediate action was taken for those regions not
criteria. abiding by the implementation plan.

2. Data was collected to identify public health Results

facilities that could implement the service
in collaboration with Regional and City As indicated in the figure below, starting from 2012
Administration Health Bureaus to June 2021, the number of health facilities that
implemented APTS was 217. Around 32% and 19% of
A data collection tool was sent to the Regional and these facilities were in Amhara and Oromia regions
City Administration Health Bureaus to collect data respectively. During the same period, 10.5%, 11%,
from their respective public health facilities under and 11.5% of the facilities that implemented APTS
their jurisdiction. They were trained on how to use were those under Addis Ababa, SNNP region, and
the tool and told to collect the data within two weeks. Federal Government jurisdiction.
Two weeks after the data collection tool was sent, a
team of experts was deployed to the Health Bureaus From July 2020 to June 2021, the number of health
to confirm and clarify the data collected. Each team facilities that were implemented based on the new
assigned to RHBs was contacted and confirmed strategy developed by the Ministry was 107. This figure
data collected from each health facility identified to is around half of the efforts made in the nine previous
implement APTS within one year. years. From all facilities that implemented the service
during this period, around 36% and 21% of them
3. Necessary budget support was provided to were in Amhara and Oromia respectively. In Harari,
public health facilities through their respective Afar, and Sidama regions, of all the health facilities
regional health bureaus that are expected to implement APTS, around 80%,
75%, and 68% of them were implemented during this
After identifying health facilities that could implement accelerated expansion period. These tremendous
the service until the end of June 2021, these facilities achievements were mainly related to different efforts
were sorted into two categories. The first category being made to involve health facilities in exerting their
included those that require training, renovation, efforts to implement the service. This fostered a sense
and shelving and can allocate a matching budget to of ownership of the service as well as a competitive
implement the service. The second category included environment among health facilities and RHBs.
those who only needed training to implement the Special focus in terms of allocating budget and follow
service. Consequently, considering public facilities’ up by the Ministry also played a great role in these
level of readiness and based on federalism budget achievements (see Fig. 1).
calculation, the Ministry transferred the budget for all
RHBs.

4. Implementation phase and monitoring the

progress of regional health bureaus regularly

Health facilities having enough human resources,

those that have already renovated and shelved
their dispensaries, and those committed to allocate
matching funds were included in the implementation
plan for the accelerated APTS expansion from July
2020 to June 2021. After the implementation plan
was reached in consensus with RHBs, the training,
renovating, and shelving, and onsite mentoring to
initiate the service was undertaken in most of the
facilities as per the plan. The assigned focal person

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Conclusion that implemented APTS and around half of those

implemented in nine years. Health facilities and
It has been around ten years since APTS was started other administrative bodies, dedication to allocating
to be implemented in Ethiopia, and all these years matching funds from their limited resources also
later, there are still only 324 health facilities that played a crucial role. The approaches designed and
have implemented the service. In the past fiscal achievements brought will be good lessons for all
year, the accelerated expansion plan enabled the stakeholders to continue exerting more efforts in the
implementation of the service in 107 health facilities, next years.
and this accounted for 34% of all the health facilities

Annex 1: Figure 1: Number of Health facilities that implemented APTS Nationally

Number of Health facilities that implemented APTS Nationally

350 324
300
250 217
200
150
108 107
100 64 70
41 38
50 23 231235 25 32 22 24 25
9 211 7 325 134 202 101 145 715 10010 1
0
NP

i
ba

ar

r
ra

la
l

l
a

al
al
a
iya

gu

na
ra

ra
am
w

be

er
Af
ha

m
ba

SN

Ha
an

tio
g
om

Da

d
So

Sid

Ti
Am
sA

Fe
sh

Na
Ga
Or

re

n
di

Di

Be
Ad

2012 to June 2020 July 2020 to June 2021 Total

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The Outcome of A Short Course, Onsite Integrated Management of Newborn and

Childhood Illness) Training in Four Regions of Ethiopia

Efrem Teferi1, Ismael Ali1, Binyam Fekadu1, Hailu Abebe1, Simachew Chekol1, Asrat
Gebeyehu1, Ruth Gebreselassie1, Zergu Tafesse1
1
USAID Transform: Primary health care project, Addis Ababa, Ethiopia

ABSTRACT

Background

Pneumonia, newborn problems, and diarrhea remain among the top causes of death in young children in
developing countries. Implementation of IMNCI as a strategy to prevent and treat major childhood illnesses
has contributed to reductions in child mortality. The problems in IMNCI implementation are inadequate
budget for training, human resources including insufficient quality and quantity of staff, and turnover.

Methodology

Short course onsite IMNCI training using the standard materials was conducted in learning woredas. The
quality of case management was compared with those trained on a standard approach. The selection of
woredas and HCs was purposive. The results were entered in excel, and significance was tested using the
p-value.

Results

Correct classification in < 2months children was 81%, and 86% in onsite, and standard approach trained
HWs respectively, p- 0.502, correct treatment 76% and 62% respectively, p-0.145. In 2 months to 5 years,
children’s correct classification was 91%, 81% onsite, and standard approach trained respectively, p-0.09
and correct treatment in both approaches was 81%, p-1.

Discussion

There was no significant difference in the quality of case management by health workers trained onsite
and standard approach. The average cost of training per trainee was much lower to 22% of the standard
training.

Conclusion

Onsite IMNCI can be an alternative approach to standard training where many health workers need to be
trained, where staff turnover is high, and resources are limited.

Introduction
to 39 in 2018. Globally 85 percent of deaths among
Over the past quarter-century, child mortality has children and young adolescents in 2018 occurred in
more than halved, dropping from 91 to 43 deaths per the first five years of life, accounting for 5.3 million
1000 live births between 1990 and 2015, the rate fell deaths.

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Pneumonia, newborn problems, and diarrhea remain the onsite training approach, but selected exercises
among the top causes of death in young children. from each topic were included. Very essential practical
Integrated Management of Childhood Illness (IMCI) parts of EPI were integrated.
strategy was launched in 1995 by UNICEF and WHO.
It aimed to collate technical guidance related to the The training was conducted in learning woredas, four
management of the leading causes of childhood woredas were selected purposively for the study (one
mortality in a holistic and child-centered way. per region), two HCs with onsite trained HWs and
another two with standard trained HWs were selected
IMNCI is used in the generic 11-day course that purposively from each woreda, and the quality of
combines classroom work with hands-on clinical the performance was evaluated by two experienced
experience. It was expanded to include care for IMNCI facilitators and supervisors.
sick newborns under 1 week of age and has been
regularly updated to reflect advancements in Data analysis: results of performance were entered in
technical knowledge. Evidence suggests that IMCI an excel sheet, and p-value was calculated to measure
has contributed to reductions in child mortality over the significance between the two approaches. The
the era of the Millennium Development Goals (MDGs), study period; was one year, January to December
and a recent Cochrane review found the strategy was 2018
associated with a 15% reduction in child mortality
when activities were implemented in health facilities Results
and communities. Ethiopia adopted IMNCI in 1997
Evaluation of the onsite training using the registration
and ICCM in 2010.
book for the quality of case management, program
The foremost problems are inadequate budget for integration, budget, and time was done. Table 1
training, human resources including insufficient shows the number of cases, with a ratio of 1:1.7
quality and quantity of staff, and turnover. At the in onsite and standard trained respectively. The
regional level, 84% of countries cited staff turnover, cases were a very severe disease, preterm low birth
and at the facility level 80% identified staff retention weight and local bacterial infections in under two
as a barrier to IMCI implementation months, Pneumonia, Malaria, Diarrhea, and severe
uncomplicated malnutrition in 2 months up to five
This research was conducted to evaluate the quality of years of children.
case management by short course onsite trained HWs Table 1: Number of cases reviewed
compared with those trained by standard approach.
Standard
Materials and methods Age group Onsite Approach
Approach
USAID Transform: Primary Health Care works to < 2 months 37 86
strengthen the quality of child health services through
targeted training and technical assistance in 400 2 months to 5
68 106
years
woredas found in the four regions (Amhara, Oromia,
SNNP, and Tigray). A review of cases showed correct classification of <
2months children was 81% in onsite trained HCs and
Onsite IMNCI training
86% in HWs trained on standard approach, p-value
The name on site was used to denote training that 0.502, correct treatment 76% and 62% respectively,
took place at the health center level. The agenda was p-0.145. In 2 months to 5 years, children’s correct
the same as the standard one and uses the same classification was 91%, in onsite trained HCs, and
materials. The theoretical part was given on two 81% in standard trained approach, p-0.09., correct
weekends - 4 days. Practical part, clinical sessions treatment in both approaches it was 81%, p-1.
were conducted during the weekdays (10 days) in their
facilities, after busy working hours. Chart booklets
were used, while the six modules were omitted from

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Figure 1. Consistency of case management, onsite and standard training approaches

Cost: Average budget for the standard IMNCI training was 81%, p-1, shows that there was no significant
was 130,000- 150,000 to train 25 HWs, and that of difference in the quality of treatment given by health
onsite is 35,000-40,000 birr (1250-1667 /trainee). workers trained by onsite and standard approach.
Money spent to print six modules is also saved. The
indirect cost saved during onsite training is 650 birr/ Promoting monitoring and supervision; encouraging
trainee (salary of one HW for one week). on-the-job training for health workers; and
strengthening training programs, counseling and
Time: The number of days to train IMNCI standard other promotional activities are important for
training is seven days out of their workplace, but that promoting IMCI implementation
of onsite is two weekends, and weekdays in their
health facilities without interruption of their routine Limitation of onsite training; the evaluation
activities after busy hours. Facilitators were from their was conducted only in four woredas, selected
health centers or woreda. purposively by project staff. The quality was reviewed
from IMNCI registration, direct case review was not
Service integration: Health workers in delivery, done.
EPI, nutrition, FP, emergency area participated in the
training which helped them to assess children when Conclusion
assigned.
Onsite IMNCI training can be an alternative approach
Supervision: The health workers were able to provide to standard training where many health workers
technical support on IMNCI, iCCM, CBNC, and EPI to are needed to be trained, in hard-to-reach areas
their satellite health posts where staff turnover is high, in the case of budget
limitation, and in HFs where the service quality and
Discussion utilization is poor. Training must be supplemented
with supervision and review meetings to improve
The standard IMNCI training is resource-intensive knowledge and skills.
and requires displacing staff from their workplace.
Evaluation of the cases managed by health workers Conflict of interest; authors declare that there is no
trained through the onsite and the standard training conflict of interest.
approach revealed similar case management quality.
Correct classification of < 2months children 81% and
86% in HWs trained on onsite and standard approach,
p-value 0.502, correct treatment 76% and 62%
respectively, p-0.145.Correct classification was 91%,
and 81%, trained in onsite and standard approach
p-0.09, correct treatment in both approaches

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