Lessons Learned From the Capacity-Building and Mentorship Program to Improve Health Information Systems in 11 Districts of Ethiopia.

INTRODUCTION: Health information systems (HIS) performance in Ethiopia is currently insufficient, and improvements are required to ensure that decision making is data driven. We share our experiences from the early-stage implementation of a package of HIS capacity-strengthening interventions as part of an innovative academic-government collaboration that addresses challenges in HIS performance. METHODS: We used routine program data to assess HIS performance using the Performance of Routine Information System Management (PRISM) assessment tools. The assessment employed a pre-post design and was conducted in a total of 24 selected health facilities (6 hospitals and 18 health centers) from 11 districts in Ethiopia at project baseline (2018) and midline (2020). RESULTS: Source document completeness rate reached less than 80% for the majority of the assessed data elements. Improvements were observed in quarterly report completeness (26% vs. 83%) and timeliness (17% vs. 48%). Though data inaccuracies are noted for all assessed data elements in 2020, the majority (83%) of skilled birth attendance and HIV reports (68%) fall within the acceptable range of reporting accuracy. The identification of performance-related problems, using performance monitoring team (PMT) meetings, improved between 2018 and 2020 (67% vs 89%). Similar improvements were also observed in developing action plans to solve identified problems via the PMT (52% in 2018 vs. 89% in 2020). Data use for planning and target setting (65% in 2018 vs. 90% in 2020), reviewing performance (58% in 2018 vs. 60% in 2020), and supervision (51% in 2018 vs. 53% in 2020) all improved among assessed health facilities. DISCUSSION: This study showed that a capacity-building and mentorship program that engages experts from multiple disciplines and sectors can improve the quality and use of health data. This partnership enabled engagement between government and academic stakeholders and allowed for a more robust exchange of resources and expertise toward HIS improvement.

Current and Future Needs for Human Resources for Ethiopia's National Health Information System: Survey and Forecasting Study.

BACKGROUND: Strengthening the national health information system is one of Ethiopia's priority transformation agendas. A well-trained and competent workforce is the essential ingredient to a strong health information system. However, this workforce has neither been quantified nor characterized well, and there is no roadmap of required human resources to enhance the national health information system. OBJECTIVE: We aimed to determine the current state of the health information system workforce and to forecast the human resources needed for the health information system by 2030. METHODS: We conducted a survey to estimate the current number of individuals employed in the health information system unit and the turnover rate. Document review and key-informant interviews were used to collect current human resources and available health information system position data from 110 institutions, including the Ministry of Health, federal agencies, regional health bureaus, zonal health departments, district health offices, and health facilities. The Delphi technique was used to forecast human resources required for the health information system in the next ten years: 3 rounds of workshops with experts from the Ministry of Health, universities, agencies, and regional health bureaus were held. In the first expert meeting, we set criteria, which was followed by expert suggestions and feedback. RESULTS: As of April 2020, there were 10,344 health information system professionals working in the governmental health system. Nearly 95% (20/21) of district health offices and 86.7% (26/30) of health centers reported that the current number of health information system positions was inadequate. In the period from June 2015 to June 2019, health information technicians had high turnover (48/244, 19.7%) at all levels of the health system. In the next ten years, we estimate that 50,656 health information system professionals will be needed to effectively implement the Ethiopia's national health information system. CONCLUSIONS: Current health information system-related staffing levels were found to be inadequate. To meet the estimated need of 50,656 multidisciplinary health information system professionals by 2030, the Ministry of Health and regional health bureaus, in collaboration with partners and academic institutions, need to work on retaining existing and training additional health information system professionals.

Contribution of health information system to child immunization services in Ethiopia: baseline study of 33 woredas.

BACKGROUND: Monitoring progress using appropriate data, with a functional health information system (HIS), believed to be very crucial for success of immunization program. Baseline study was conducted to assess, immunization service coverage, HIS performance status, and their relationships. METHODS: A linked facility and population-based survey was conducted concurrently from September 21 to October 15, 2020. A total of 3016 households were reached to interview mothers having children aged 12-23 months in the 33 woredas. Overall 81 health posts, 71 health centers, and 15 hospitals were selected for the facility survey. The study used modified Performance of Routine Information System Management (PRISM) tools for the facility survey and a structured questionnaire for the household survey. Using STATA 14.0 software, mixed effect modeling was employed to control the effect of clustering and potential confounders. RESULTS: The proportion of fully immunized children was 58%. Coverages of measles (at least one dose) and penta3 immunization (received all 3 doses of DPT-HepB-Hib vaccine) were 86%, and 85% respectively. About 27% of mothers had missed their child immunization card mainly due to misplacing or lost. Except 'source document completeness' (85%) and 'use of data for planning and target setting' (84%), other data quality and use indicators like 'data accuracy' (63%), 'data use for performance review and evidence-based decision making' (50%), and 'data use to produce analytical reports' (31%) show low performance. The odds of fully immunized children is 37% lower in Muslims compared with Orthodox Christians (AOR, 0.63; 95%CI: 0.46, 0.88), higher by 42% with father's secondary education compared with no education (AOR, 1.42; 95%CI: 1.05, 1.92), and highest wealth quintile compared with lowest quintile (AOR, 2.49; 95%CI: 1.54, 4.03). For each additional score of HIS infrastructure availability, the odds of fully immunized children increased by 22% (AOR:1.22; 95% CI: 1.03, 1.44). CONCLUSIONS: Child immunization coverages are promising However, the current HIS performance is suboptimal. Both service user and HIS related factors are important for immunization service uptake. Documenting required information and advising mothers to keep immunization cards by health workers, and working to have functional HIS are recommended.

Strengthening the national health information system through a capacity-building and mentorship partnership (CBMP) programme: a health system and university partnership initiative in Ethiopia.

BACKGROUND: A strong health information system (HIS) is one of the essential building blocks for a resilient health system. The Ministry of Health (MOH) of Ethiopia is working on different initiatives to strengthen the national HIS. Among these is the Capacity-Building and Mentorship Partnership (CBMP) Programme in collaboration with public universities in Ethiopia since November 2017. This study aims to evaluate the outcomes and share experiences of the country in working with universities to strengthen the national HIS. METHODS: The study employed a mixed-methods approach that included 247 health organizations (health offices and facilities) of CBMP-implementing woredas (districts) and 23 key informant interviews. The programme focused on capacity-building and mentoring facilities and woreda health offices. The status of HIS was measured using a connected woreda checklist before and after the intervention. The checklist consists of items related to HIS infrastructure, data quality and administrative use. The organizations were classified as emerging, candidate or model based on the score. The findings were triangulated with qualitative data collected through key informant interviews. RESULTS: The results showed that the overall score of the HIS implementation was 46.3 before and 74.2 after implementation of the programme. The proportion of model organizations increased from 1.2% before to 31.8% after the programme implementation. The health system-university partnership has provided an opportunity for higher education institutions to understand the health system and tune their curricula to address real-world challenges. The partnership brought opportunities to conduct and produce local- and national-level evidence to improve the HIS. Weak ownership, poor responsiveness and poor perceptions of the programme were mentioned as major challenges in programme implementation. CONCLUSION: The overall HIS has shown substantial progress in CBMP implementation woredas. A number of facilities became models in a short period of time after the implementation of the programme. The health system-university partnership was found to be a promising approach to improve the national HIS and to share the on-the-ground experiences with the university academicians. However, weak ownership and poor responsiveness to feedback were the major challenges identified as needing more attention in future programme implementation.

Kangaroo Mother Care implementation research to develop models for accelerating scale-up in India and Ethiopia: study protocol for an adequacy evaluation.

INTRODUCTION: Kangaroo Mother Care (KMC) is the practice of early, continuous and prolonged skin-to-skin contact between the mother and the baby with exclusive breastfeeding. Despite clear evidence of impact in improving survival and health outcomes among low birth weight infants, KMC coverage has remained low and implementation has been limited. Consequently, only a small fraction of newborns that could benefit from KMC receive it. METHODS AND ANALYSIS: This implementation research project aims to develop and evaluate district-level models for scaling up KMC in India and Ethiopia that can achieve high population coverage. The project includes formative research to identify barriers and contextual factors that affect implementation and utilisation of KMC and design scalable models to deliver KMC across the facility-community continuum. This will be followed by implementation and evaluation of these models in routine care settings, in an iterative fashion, with the aim of reaching a successful model for wider district, state and national-level scale-up. Implementation actions would happen at three levels: 'pre-KMC facility'-to maximise the number of newborns getting to a facility that provides KMC; 'KMC facility'-for initiation and maintenance of KMC; and 'post-KMC facility'-for continuation of KMC at home. Stable infants with birth weight<2000 g and born in the catchment population of the study KMC facilities would form the eligible population. The primary outcome will be coverage of KMC in the preceding 24 hours and will be measured at discharge from the KMC facility and 7 days after hospital discharge. ETHICS AND DISSEMINATION: Ethics approval was obtained in all the project sites, and centrally by the Research Ethics Review Committee at the WHO. Results of the project will be submitted to a peer-reviewed journal for publication, in addition to national and global level dissemination. STUDY STATUS: WHO approved protocol: V.4-12 May 2016-Protocol ID: ERC 2716. Study implementation beginning: April 2017. Study end: expected March 2019. TRIAL REGISTRATION NUMBER: Community Empowerment Laboratory, Uttar Pradesh, India (ISRCTN12286667); St John's National Academy of Health Sciences, Bangalore, India and Karnataka Health Promotion Trust, Bangalore, India (CTRI/2017/07/008988); Society for Applied Studies, Delhi (NCT03098069); Oromia, Ethiopia (NCT03419416); Amhara, SNNPR and Tigray, Ethiopia (NCT03506698).

The Ethiopian Health Extension Program and Variation in Health Systems Performance: What Matters?

BACKGROUND: Primary health care services are fundamental to improving health and health equity, particularly in the context of low and middle-income settings where resources are scarce. During the past decade, Ethiopia undertook an ambitious investment in primary health care known as the Ethiopian Health Extension Program that recorded impressive gains in several health outcomes. Despite this progress, substantial disparities in health outcomes persist across the country. The objective of this study was to understand how variation in the implementation of the primary health care efforts may explain differences in key health outcomes. METHODS AND FINDINGS: We conducted a qualitative study of higher-performing and lower-performing woredas using site visits and in-depth interviews undertaken in 7 woredas. We classified woredas as higher-performing or lower-performing based on data on 5 indicators. We conducted a total of 94 open-ended interviews; 12-15 from each woreda. The data were analyzed using the constant comparative method of qualitative data analysis. Substantial contrasts were apparent between higher-performing and lower-performing woredas in use of data for problem solving and performance improvement; collaboration and respectful relationships among health extension workers, community members, and health center staff; and coordination between the woreda health office and higher-level regulatory and financing bodies at the zonal and regional levels. We found similarities in what was reported to motivate or demotivate health extension workers and other staff. Additionally, higher-performing and lower-performing woredas shared concerns about hospitals being isolated from health centers and health posts. Participants from both woredas also highlighted a mismatch between the urban health extension program design and the urban-dwelling communities' expectations for primary health care. CONCLUSIONS: Data-informed problem solving, respectful and supportive relationships with the community, and strong support from zonal and regional health bureaus contributed to woreda performance, suggesting avenues for achieving higher performance in primary health care.

Quality and use of IMNCI services at health center under-five clinics after introduction of integrated community-based case management (ICCM) in three regions of Ethiopia.

BACKGROUND: The Integrated Management of New born and Childhood Illness (IMNCI) and the related Integrated Community Case Management (iCCM) are evidence-based strategies to reduce childhood mortality in Ethiopia at health centres and community health posts, respectively. The effect of introducing iCCM on IMNCI is not known. OBJECTIVE: To assess the caseload and quality of lMNCI service in under-five clinics in health centres after iCCM implementation. METHODS: This cross-sectional study used register review to assess the IMNCI service use (before and after iCCM, in 2010 and 2012, respectively) and quality throughout the period in randomly selected health centers in three regions of the Integrated Family Health Program (Oromia, SNNPR [Southern Nations and Nationalities and Peoples Region] and Tigray). RESULTS: Caseload of sick children at 28 health centers increased by 16% after iCCM implementation (21,443 vs. 24,882 children in 2010 and 2012, respectively. The consistency of IMNVCI treatment with classification for pneumonia, diarrhea and malaria was low (78, 45, and 67%, respectively) compared to iCCM treatment (86, 80, and 91%, respectively). CONCLUSION: Health center case load increased modestly after iCCM was introduced, but was lower than expected, even when combined with health post use from other studies. The demand strategy for sick children needs review. The quality of IMNCI needs improving even to bring it to the quality of iCCM at health posts, as measured by the same methods. Successful quality assurance approaches from iCCM, e.g., the Performance Review and Clinical Mentoring Meeting, could be adapted for IMNCI.

Effect of integrated community case management of common childhood illnesses on the quality of malaria case management provided by health extension workers at health posts.

INTRODUCTION: The Integrated Family Health Program supported the government of Ethiopia to implement the Integrated Community Case Management (iCCM) strategy to control childhood illness of which malaria is a major cause. OBJECTIVE: To assess the effect of ICCM training on quality of malaria case management at health posts. METHODS: . A comparative cross-sectional study was conducted among 170 Health Extension Workers (HEW) providing either integrated or vertical malaria case management for children less than five years of age in 14 woredas (districts) of West Hararghe Zone using a multi-stage sampling procedure. HEWs in seven intervention woredas were trained in malaria case management and rapid diagnostic test (RDT) procedures through iCCM, and HEWs in comparison woredas were trained vertically through the national malaria control program. Performance was assessed using interview, review of registers, and observation of RDT procedure. RESULTS: Intervention HEWs performed better than their counterparts in correct drug prescription (90.8 vs. 81.0%, p = 0.03), treatment duration (97.7 vs. 89.9%, p = 0.001), and treatment schedule (95.4 vs. 75.9%, p = 0.000). Intervention HEWs recorded case management with more consistency than their counterparts (≥ 80% consistency between: classification and assessment [23.0 vs. 3.8%; p = 0.000], classification and treatment [24.1 vs. 7.6%; p = 0.003], and classification and follow up [24.1% vs. 0.0%; p = 0.000]); however, there is room for improvement. CONCLUSION: ICCM training has a positive effect on the quality of malaria case management at the community level.

A descriptive study of the changes in coverage of preventive and promotive interventions before and after the introduction of integrated community case management (ICCM) in Ethiopia.

BACKGROUND: The effect of integrated community case management (iCCM) of common childhood illness on use of vital preventive services is not known. OBJECTIVE: To measure the coverage of maternal and child health preventive and promotive interventions before and after scaling up iCCM. METHODS: In 2011 and 2013, we conducted cross-sectional, population-based, household coverage surveys in four Integrated Family Health Program target regions: Amhara, Oromia, SNNP, and Tigray. RESULTS: Coverage increased for 10 of 15 indicators, mainly for maternal, immunization, and nutrition services. In some cases, we observed dramatic increases, i.e., for ≥ 4 antenatal care visits, antenatal iron and folate, and exclusive breastfeeding. Some increase occurred even when 2011 levels were already high, i.e., for immunization. Three indicators remained high and unchanged (bednet ownership, children sleeping under bednets, and any latrine). Two indicators decreased (tetanus toxoid and households with ≥ 2 bednets). CONCLUSION: Scale-up of iCCM was consistent with increased coverage of most preventative and promotive interventions, which may contribute to the life-saving effect of iCCM.

Effect of ethiopia's health extension program on maternal and newborn health care practices in 101 rural districts: a dose-response study.

BACKGROUND: Improving newborn survival is essential if Ethiopia is to achieve Millennium Development Goal 4. The national Health Extension Program (HEP) includes community-based newborn survival interventions. We report the effect of these interventions on changes in maternal and newborn health care practices between 2008 and 2010 in 101 districts, comprising 11.6 million people, or 16% of Ethiopia's population. METHODS AND FINDINGS: Using data from cross-sectional surveys in December 2008 and December 2010 from a representative sample of 117 communities (kebeles), we estimated the prevalence of maternal and newborn care practices, and a program intensity score in each community. Women with children aged 0 to 11 months reported care practices for their most recent pregnancy and childbirth. The program intensity score ranged between zero and ten and was derived from four outreach activities of the HEP front-line health workers. Dose-response relationships between changes in program intensity and the changes in maternal and newborn health were investigated using regression methods, controlling for secular trend, respondents' background characteristics, and community-level factors. Between 2008 and 2010, median program intensity score increased 2.4-fold. For every unit increase in the score, the odds of receiving antenatal care increased by 1.13 times (95% CI 1.03-1.23); the odds of birth preparedness increased by 1.31 times (1.19-1.44); the odds of receiving postnatal care increased by 1.60 times (1.34-1.91); and the odds of initiating breastfeeding immediately after birth increased by 1.10 times (1.02-1.20). Program intensity score was not associated with skilled deliveries, nor with some of the other newborn health care indicators. CONCLUSIONS: The results of our analysis suggest that Ethiopia's HEP platform has improved maternal and newborn health care practices at scale. However, implementation research will be required to address the maternal and newborn care practices that were not influenced by the HEP outreach activities.

Effect of depressive symptoms and social support on weight and CD4 count increase at HIV clinic in Ethiopia.

Studies have reported an inverse relationship between depressive symptoms and weight and CD4 gain and a positive association between social support and weight and CD4 gain. The main objective of this study was to explore the effect of depressive symptoms and perceived social support on weight change and CD4 cell progression in an HIV clinic in Ethiopia. The study design was descriptive cross-sectional, with a sample of 1815 HIV-infected adults age 18 years or above. Depressive symptoms and perceived social support were the independent variables, while weight and CD4 cell count were the dependent variables. Regression modeling was the main statistical approach used for the analysis. A significant proportion of females reported depressive symptoms: being bothered by things that do not bother other people, they had been depressed, and their sleep had been restless for 5-7 days a week. A lesser proportion of males reported these problems. A significant proportion of study participants did not have someone to borrow a small amount of money (6 USD) from for immediate help and did not have somebody to support them if they were confined to bed for several weeks. Worse depressive symptoms had a negative effect on weight gain and CD4 cell progression, while better perceived social support had a positive effect on both weight gain and CD4 cell progression. Interventions that address both of these background factors need to be designed and implemented as part of the HAART program to improve weight gain and CD4 cell progression.

Correlates of highly active antiretroviral therapy adherence among urban Ethiopian clients.

There has been a massive expansion of highly active antiretroviral therapy (HAART) services in Ethiopia since 2005. To assess clients' self-reported adherence to HAART medication, a descriptive, comparative cross-sectional study was carried out among adults receiving HAART medication at the Zewditu Memorial Hospital ART clinic in Addis Ababa. Of 1 808 clients eligible for the study, 1 722 agreed to participate. The data were collected over six weeks in February and March 2010. Ordered and binary logistic regression models were applied to analyse the data. The majority of participants were over age 30 years, most were females, and 90% had some formal education. More than half reported being 'extremely sure' about their ability to take most or all of their medication. Self-reported adherence to the medication was generally good, as 62% said they had never missed a dose. The most commonly cited reason for missing medication was being busy (57.5%). The odds of ever missing a dose of HAART were lower for males (adjusted odds ratio [AOR]: 1.44; 95% confidence interval [CI]: 1.15-1.79), older persons (AOR: 0.98; 95% CI: 0.97-0.99), and those who did not drink alcohol regularly. Similarly, the odds of being self-confident about taking the medication properly were higher for males and for those who did not drink alcohol regularly (AOR: 0.48; 95% CI: 0.35-0.64). The odds of self-confidence in taking the medication were lower among those in lower income group. Those who reported an expenditure income of Birr 501-999 (AOR: 0.35; 95% CI: 0.24-0.49) or Birr 1 000-1 999 (AOR: 0.41; 95% CI: 0.29-0.60) had less self-confidence in taking their medication properly as compared to those who had an expenditure income of Birr 2 000 or more. There is a need to design and implement targeted adherence interventions that could lead to better treatment outcomes.

Factors predisposing out-of-school youths to HIV/AIDS-related risky sexual behaviour in northwest Ethiopia.

Ethiopia is a developing country with a demographic profile dominated by a young population. Due to biological, psychological, sociocultural and economic factors, young people, particularly those aged 15-24 years, are generally at a high risk of HIV/AIDS and other reproductive health problems. This paper presents results of a cross-sectional descriptive study conducted in Bahir Dar town, northwest Ethiopia, to assess factors that predispose out-of-school youths to HIV/AIDS-related risk behaviours. Both quantitative and qualitative data-collection methods were employed to conduct the study. For quantitative data collection, a household interview survey was conducted among 628 out-of-school youths, aged 15-24 years, within the 17 kebeles (villages) of the town. The number of respondents in each kebele was assigned proportional to the size of kebele, and the required numbers of respondents within each kebele were selected through a systematic random-sampling technique. Qualitative data were collected by conducting five focus-group discussions with 46 participants and in-depth interviews with 10 participants. Institutional ethical clearance and informed verbal consent from the study participants were obtained before undertaking the study. Of the 628 study subjects, 64.8% had experienced sexual intercourse at the time of the survey. The mean age at first sexual commencement was 17.7 (+2) years. Of those sexually active, 33% had sexual intercourse with non-regular partners (the proportions were 40.6% among males and 24.7% among females, suggesting that males tended to be about two times more likely to have sex with non-regular sexual partners than females (odds ratio = 1.78, with 95% confidence interval 1.16-2.73). Furthermore, consistent condom-use among those who had sex in exchange for money was low (36%). Alcohol intake, chewing of khat (a green leaf), low educational background, and being male were significantly associated with having sex with either a commercial or a non-regular sexual partner. In view of the magnitude of high-risk sexual behaviours among out-of-school youths that may expose them to HIV/AIDS and other sexually transmitted infections, efforts need to be exerted to deal with the identified predisposing factors and to address the problems of idleness, lack of jobs, and hopelessness.