Effective coverage of antenatal care services in Ethiopia: a population-based cross-sectional study.

BACKGROUND: Antenatal care (ANC) is a principal component of safe motherhood and reproductive health strategies across the continuum of care. Although the coverage of antenatal care visits has increased in Ethiopia, there needs to be more evidence of effective coverage of antenatal care. The 'effective coverage' concept can pinpoint where action is required to improve high-quality coverage in Ethiopia. Effective coverage indicates a health system's performance by incorporating need, utilization, and quality into a single measurement. The concept includes the number of contacts, facility readiness, interventions received, and components of services received. This study aimed to measure effective antenatal care coverage in Ethiopia. METHODS: A two-stage cluster sampling method was used and included 2714 women aged 15-49 years and 462 health facilities from six Ethiopian regions from October 2019 to January 2020. The effective coverage cascade was analyzed among the targeted women by computing the proportion who received four or more antenatal care visits where the necessary inputs were available, received iron-folate supplementation and two doses of tetanus vaccination according to process quality components of antenatal care services. RESULTS: Of all women, 40% (95%CI; 38, 43) had four or more visits, ranging from 3% in Afar to 74% in Addis Ababa. The overall mean health facility readiness score of the facilities serving these women was 70%, the vaccination and iron-folate supplementation coverage was 26%, and the ANC process quality was 64%. As reported by women, the least score was given to the quality component of discussing birth preparedness and complication readiness with providers. In the effective coverage cascade, the input-adjusted, intervention-adjusted, and quality-adjusted antenatal coverage estimates were 28%, 18%, and 12%, respectively. CONCLUSION: The overall effective ANC coverage was low, primarily due to a considerable drop in the proportion of women who completed four or more ANC visits. Improving quality of services is crucial to increase ANC up take and completion of the recommended visits along with interventions increasing women's awareness.

Health system's availability and readiness of health facilities for chronic non-communicable diseases: Evidence from the Ethiopian national surveys.

INTRODUCTION: Non-communicable diseases (NCDs) currently cause more deaths than all other causes of deaths. Cardiovascular disease, diabetes, cancer, and chronic respiratory diseases-threaten the health and economies of individuals and populations worldwide. This study aimed to assess the availability and readiness of health facilities for chronic non-communicable diseases (NCDs) and describe the changes of service availability for common NCDs in Ethiopia. Methods We used data from the 2014 Ethiopia Service Provision Assessment Plus (ESPA +) and 2016 and 2018 Service Availability and Readiness Assessment (SARA) surveys, which were cross-sectional health facility-based studies. A total of 873 health facilities in 2014, 547 in 2016, 632 in 2018 were included in the analysis. (ESPA+) and SARA surveys are conducted as a census or a nationally/sub-nationally representative sample of health facilities. Proportion of facilities that offered the service for diabetes, cardiovascular disease, chronic respiratory disease, cancer diseases, mental illness, and chronic renal diseases was calculated to measure health service availability. The health facility service readiness was measured using the mean availably of tracer items that are required to offer the service. Thus, 13 tracer items for diabetes disease, 12 for cardiovascular disease, 11 for chronic respiratory disease and 11 cervical cancer services were used. RESULTS: The services available for diagnosis and management did not show improvement between 2014, 2016 and 2018 for diabetes (59%, 22% and 36%); for cardiovascular diseases (73%, 41% and 49%); chronic respiratory diseases (76%, 45% and 53%). Similarly, at the national level, the mean availability of tracer items between 2014, 2016 and 2018 for diabetes (37%, 53% and 48%); cardiovascular diseases (36%, 41% and 42%); chronic respiratory diseases (26%, 27% and 27%); and cancer diseases (6%, 72% and 51%). However, in 2014 survey year, the mean availability of tracer items was 7% each for mental illness and chronic renal diseases, respectively. CONCLUSIONS: The majority of the health facilities have low and gradual decrement in the availability to provide NCDs services in Ethiopia. There is a need to increase NCD service availability and readiness at primary hospitals and health centers, and private and rural health facilities where majority of the population need the services.

A clustered randomized control trial to assess feasibility, acceptability, and impact of implementing the birth companion intervention package in Ethiopia, Kenya, and Nigeria: study protocol.

BACKGROUND: A birth companion is a simple and low-cost intervention that can improve both maternal and newborn health outcomes. The evidence that birth companionship improves labor outcomes and experiences of care has been available for many years. Global and national policies exist in support of birth companions. Many countries including Ethiopia, Kenya, and Nigeria have not yet incorporated birth companions into routine practice in health facilities. This paper presents the protocol for a trial that aims to assess if a package of interventions that addresses known barriers can increase the coverage of birth companions. METHODS: This two parallel arm cluster randomized controlled trial will evaluate the impact of a targeted intervention package on scale-up of birth companionship at public sector health facilities in Ethiopia (five study sites encompassing 12 facilities), Kenya (two sites encompassing 12 facilities in Murang'a and 12 facilities in Machakos counties), and Nigeria (two sites encompassing 12 facilities in Kano and 12 facilities in Nasarawa states). Baseline and endline assessments at each site will include 744 women who have recently given birth in the quantitative component. We will interview a maximum of 16 birth companions, 48 health care providers, and eight unit managers quarterly for the qualitative component in each country. DISCUSSION: Ample evidence supports the contribution of birth companions to positive health outcomes for mothers and newborns. However, limited data are available on effective strategies to improve birth companion coverage and inform scale-up efforts. This trial tests a birth companion intervention package in diverse clinical settings and cultures to identify possible barriers and considerations to increasing uptake of birth companions. Findings from this study may provide valuable evidence for scaling up birth companionship in similar settings. TRIAL REGISTRATION: Trial is registered with ClinicalTrials.gov with identifier: NCT05565196, first posted 04/10/ 2022.

Quality of sick child management by health extension workers: role of a complex improvement intervention.

BACKGROUND: Despite the expansion of the Integrated Community Case Management services for childhood illness, quality and utilization of services have remained low. To address the problem, the Government of Ethiopia introduced a complex intervention that included community engagement, capacity building of health workers and enhanced district-level ownership of sick child management. We examined whether this complex intervention was associated with improved management of sick children by health extension workers. METHODS: The study was conducted in four Ethiopian regions. A baseline survey was conducted in 26 intervention and 26 comparison districts from December 2016 to February 2017, followed by an end-line survey 24 months later. We observed health extension workers' consultations of sick 2-59 months old children. The analysis has evaluated if children with pneumonia, diarrhoea and malnutrition were assessed, classified and treated according to guidelines, and included difference-in-difference analyses. RESULTS: We observed 1325 consultations of sick children. At baseline, 86% of the sick children with cough in the intervention areas and 85% in comparison areas were assessed according to the guidelines, without any change at end-line associated with the intervention (difference-in-difference = -21%, p = 0.55). Sixty-two percent of children were assessed for dehydration at baseline in intervention and 47% in comparison areas, with no improvement associated with the intervention. Similarly, 87% of sick children in intervention and 91% in comparison areas were assessed for malnutrition, with no change over time associated with the intervention (difference-in-difference = 5%, p = 0.16). Appropriate pneumonia treatment with antibiotics declined and diarrhea treatment increased in both areas. Half of the malnourished children received ready-to-use therapeutic foods without any improvement associated with the intervention. CONCLUSION: The intervention was not associated with improved quality of the health extension workers' management of sick children. The lack of association may be linked to low fidelity in the implementation of the intervention. Our findings suggest that training healthcare providers without continued clinical mentoring and support does not improve the quality of care. Community-based programs can be strengthened by ensuring high coverage and continued clinical mentorships, supportive supervision, and supply of medicines and other essential commodities. TRIAL REGISTRATION NUMBER: ISRCTN12040912, retrospectively registered on 19/12/ 2017.

Socioeconomic inequity in coverage and quality of maternal postnatal care in Ethiopia.

OBJECTIVE: High-quality postnatal care is vital for improving maternal health. This study examined the relationship between household socioeconomic status and both coverage and quality of postnatal care in Ethiopia. METHOD: Cross-sectional household survey data were collected in October-November 2013 from 12 zones in 4 regions of Ethiopia. Women reporting a live birth in the 3-24 months prior to the survey were interviewed about the care they received before, during and after delivery and their demographic characteristics. Using mixed effect logistic and linear regression, the associations between household socioeconomic status and receiving postnatal care, location of postnatal care (health facility vs. non-health facility), cadre of person providing care and the number of seven key services (including physical checks and advice) provided at a postnatal visit, were estimated. RESULTS: A total of 16% (358/2189) of women interviewed reported receiving at least one postnatal care visit within 6 weeks of delivery. Receiving a postnatal care visit was strongly associated with socioeconomic status with women from the highest socioeconomic group having twice the odds of receiving postnatal care compared to women in the poorest quintile (OR [95% CI]: 1.98 [1.29, 3.05]). For each increasing socioeconomic status quintile there was a mean increase of 0.24 postnatal care services provided (95% CI: 0.06-0.43, p = 0.009) among women who did not give birth in a facility. There was no evidence that number of postnatal care services was associated with socioeconomic status for women who gave birth in a facility. There was no evidence that socioeconomic status was associated with the provider or location of postnatal care visits. CONCLUSION: Postnatal care in Ethiopia shows evidence of socio-economic inequity in both coverage and quality. This demonstrates the need to focus on quality improvement as well as coverage, particularly among the poorest women who did not deliver in a facility.

Management of bacterial infections in young infants in Ethiopia: Facility preparedness, health workers' knowledge and quality of care.

AIM: We assessed primary care facility preparedness, health workers' knowledge and their classification and treatment of possible serious bacterial infection and local bacterial infection in young infants aged 0-59 days. METHOD: A cross-sectional survey was conducted in four regions of Ethiopia, including 169 health posts with 276 health extension workers and 155 health centres with 175 staff. Registers of 1058 sick young infants were reviewed. RESULT: Antibiotics to treat possible serious bacterial infection were available in 71% of the health centres and 38% of the health posts. Nine of ten health extension workers and eight of ten health centre staff mentioned at least one sign of possible serious bacterial infection and local bacterial infection. Among the registered cases with signs of bacterial infections, the health extension workers classified 49% as having a possible serious bacterial infection and 88% as local bacterial infection. The health centre staff classified 25% as possible serious bacterial infections and 86% as local bacterial infections. One-fourth (26%) of possible serious bacterial infection received the recommended treatment at health posts and 35% at health centres. CONCLUSION: Many health posts lacked antibiotics. The classification and treatment of possible serious bacterial infection did not follow guidelines. The lack of medicines and poor adherence compromise the quality of care.

Exploring data quality and use of the routine health information system in Ethiopia: a mixed-methods study.

OBJECTIVE: A routine health information system (RHIS) enables decision making in the healthcare system. We aimed to analyse data quality at the district and regional level and explore factors and perceptions affecting the quality and use of routine data. DESIGN: This was a mixed-methods study. We used the WHO toolkit for analysing data quality and interviewed staff at the point of data generation and along with the flow of data. Data were analysed using the Performance of Routine Information System Management framework. SETTING: This study was performed in eight districts in four regions of Ethiopia. The study was nested within a 2-year programme of the Operational Research and Coaching for government Analysts. PARTICIPANTS: We visited 45 health posts, 1 district hospital, 16 health centres and 8 district offices for analysis of routine RHIS data and interviewed 117 staff members for the qualitative assessment. OUTCOME MEASURES: We assessed availability of source documents, completeness, timeliness and accuracy of reporting of routine data, and explored data quality and use perceptions. RESULTS: There was variable quality of both indicator and data element. Data on maternal health and immunisation were of higher quality than data on child nutrition. Issues ranged from simple organisational factors, such as availability of register books, to intricate technical issues, like complexity of indicators and choice of denominators based on population estimates. Respondents showed knowledge of the reporting procedures, but also demonstrated limited skills, lack of supportive supervision and reporting to please the next level. We saw limited examples of the use of data by the staff who were responsible for data reporting. CONCLUSION: We identified important organisational, technical, behavioural and process factors that need further attention to improve the quality and use of RHIS data in Ethiopia.

Embedding Community-Based Newborn Care in the Ethiopian health system: lessons from a 4-year programme evaluation.

Despite remarkable gains, improving neonatal survival globally remains slow paced. Innovative service-delivery packages have been developed for community health workers (CHWs) to maximize system efficiency and increase the reach of services. However, embedding these in health systems needs structural and procedural alignment. The Community-Based Newborn Care (CBNC) programme was a response to high neonatal mortality in Ethiopia. Key aspects include simplified treatment for neonatal illness, integrated outreach services and task-shifting. Using the CHW functionality model by WHO, this study evaluates the health system response to the programme, including quality of care. A before-and-after study was conducted with three survey time points: baseline (November 2013), midline (December 2015) and follow-up (December 2017-4 years after the programme started). Data were collected at a sample of primary healthcare facilities from 101 districts across four regions. Analysis took two perspectives: (1) health system response, through supplies, infrastructure support and supervision, assessed through interviews and observations at health facilities and (2) quality of care, through CHWs' theoretical capacity to deliver services, as well as their performance, assessed through functional health literacy and direct observation of young infant case management. Results showed gains in services for young infants, with antibiotics and job aids available at over 90% of health centres. However, services at health posts remained inadequate in 2017. In terms of quality of care, only 37% of CHWs correctly diagnosed key conditions in sick young infants at midline. CHWs' functional health literacy declined by over 70% in basic aspects of case management during the study. Although the frequency of quarterly supportive supervision visits was above 80% during 2013-2017, visits lacked support for managing sick young infants. Infrastructure and resources improved over the course of the CBNC programme implementation. However, embedding and scaling up the programme lacked the systems-thinking and attention to health system building-blocks needed to optimize service delivery.

Exploring women's development group leaders' support to maternal, neonatal and child health care: A qualitative study in Tigray region, Ethiopia.

BACKGROUND: Community health workers and volunteers are vital for the achievement of Universal Health Coverage also in low-income countries. Ethiopia introduced community volunteers called women's development group leaders in 2011. These women have responsibilities in multiple sectors, including promoting health and healthcare seeking. OBJECTIVE: We aimed to explore women's development group leaders' and health workers' perceptions on these volunteers' role in maternal, neonatal and child healthcare. METHODS: A qualitative study was conducted with in-depth interviews and focus group discussions with women's development group leaders, health extension workers, health center staff, and woreda and regional health extension experts. We adapted a framework of community health worker performance, and explored perceptions of the women's development group program: inputs, processes and performance. Interviews were recorded, transcribed, and coded prior to translation and thematic analysis. RESULTS: The women's development group leaders were committed to their health-related work. However, many were illiterate, recruited in a sub-optimal process, had weak supervision and feedback, lacked training and incentives and had weak knowledge on danger signs and care of neonates. These problems demotivated these volunteers from engaging in maternal, neonatal and child health promotion activities. Health extension workers faced difficulties in managing the numerous women's development group leaders in the catchment area. CONCLUSION: The women's development group leaders showed a willingness to contribute to maternal and child healthcare but lacked support and incentives. The program requires some redesign, effective management, and should offer enhanced recruitment, training, supervision, and incentives. The program should also consider continued training to develop the leaders' knowledge, factor contextual influences, and be open for local variations.

A mixed-methods study exploring adherence to the referral of severely sick children in primary health care in Southern Ethiopia.

BACKGROUND: We have shown that Ethiopian primary healthcare providers refer only half of the severely sick children who, according to guidelines, should get an urgent referral. Frequently parents of referred ill children don't bring their children to the next level. We aimed to describe the referral of severely ill Ethiopian children based on primary healthcare register reviews and explore health care providers' and parents' perceptions regarding factors that hinder or enhance referral. METHODS: A mixed-methods study was conducted in 11 districts and a town administration of the Hadiya zone in Ethiopia's Southern region from May to June 2019. Data collection included interviews and focus group discussions with healthcare providers, key informant interviews with parents of sick children who had been referred, and reviewing registers of sick children treated during the last 12 months at health posts and health centres. We analysed the association between healthcare providers' and sick children's characteristics and providers' compliance with referral guidelines for sick children 0-59 months old. Content analysis was undertaken to explore the perceived factors that influenced referral and adherence to referral from providers' and parents' perspectives. RESULTS: Healthcare providers did not refer nearly half of the severely ill children that should have been referred, according to guidelines. Providers who had received in-service training on child healthcare were more likely to adhere to referral guidelines. The severity of the child's illness and mobile phone communication and transport availability were perceived to be positively associated with adherence to referral guidelines. Lack of knowledge of treatment guidelines and skills, and high health worker workload, were among the factors perceived to be linked to lower adherence to guidelines. The healthcare providers considered parents of referred sick children as having low compliance with the referral advice. In contrast, parents had the opinion that compliance with a referral for sick children was high. Perceived awareness of severity of the child's illness, ability to afford referral costs, and availability of transport or ambulance services were perceived to motivate parents to take their children to the referral facility. Traditional illness perceptions, lack of confidence in the referral site's medical care, and a long distance were perceived to hurdle caregivers' referral compliance. CONCLUSIONS: We found that the healthcare providers' adherence to referral guidelines was not optimal. Care providers and parents had divergent opinions on parents' compliance with referral advice. Factors related to the health system, family economy, and available ambulance services influence whether care providers and parents pursued severely ill children's referral. Adequate referral of sick children is an aspect of primary healthcare quality that is essential to avoid unnecessary under-five deaths.

District health managers perspectives of introducing a new service: a qualitative study of the community-based newborn care programme in Ethiopia.

BACKGROUND: The planning, resourcing, implementation and monitoring of new programmes by district health managers is integral for success and sustainability. Ethiopia introduced the Community-Based Newborn Care programme in 2014 to improve newborn survival: an innovative component allowed community health workers to provide antibiotics for young infants with possible serious bacterial infection when referral was not possible. Informed by the World Health Organization health system building block framework, we aimed to study the capacity and operational challenges of introducing this new health service from the perspective of programme implementers and managers at the district level 20 months after programme initiation. METHODS: This qualitative study was part of a programme evaluation. From November to December of 2015, we conducted 28 semi-structured interviews with staff at district health offices, health centres and implementing Non-Governmental Organisations in 15 districts of four regions of Ethiopia. Verbatim transcripts were analysed using a priori and emerging themes. RESULTS: In line with the government's commitment to treat sick newborns close to their homes, participants reported that community health workers had been successfully trained to provide injectable antibiotics. However, the Community-Based Newborn Care programme was scaled up without allowing the health system to adapt to programme needs. There were inadequate processes and standards to ensure consistent availability of (1) trained staff for technical supervision, (2) antibiotics and (3) monitoring data specific to the programme. Furthermore, Non-Governmental Organizations played a central implementing role, which had implications for the long-term district level ownership and thus for the sustainability of the programme. CONCLUSION: In settings where sustainable local implementation depends on district-level health teams, new programmes should assess health system preparedness to absorb the service, and plan accordingly. Our findings can inform policy makers and implementers about the pre-conditions for a health system to introduce similar services and maximize long-term success.

Coverage of antenatal, intrapartum, and newborn care in 104 districts of Ethiopia: A before and after study four years after the launch of the national Community-Based Newborn Care programme.

BACKGROUND: Access to health services across the continuum of care improves maternal and newborn health outcomes. Ethiopia launched the Community-Based Newborn Care programme in 2013 to increase the coverage of antenatal care, institutional delivery, postnatal care and newborn care. The programme also introduced gentamicin and amoxicillin treatment by health extension workers for young infants with possible serious bacterial infection when referral was not possible. This study aimed to assess the extent to which the coverage of health services for mothers and their young infants increased after the initiation of the programme. METHODS: A baseline survey was conducted in October-December 2013 and a follow-up survey four years later in November-December 2017. At baseline, 10,224 households and 1,016 women who had a live birth in the 3-15 months prior to the survey were included. In the follow-up survey, 10,270 households and 1,057 women with a recent live birth were included. Women were asked about their experience of care during pregnancy, delivery and postpartum periods, as well as the treatment provided for their child's illness in the first 59 days of life. RESULTS: Between baseline and follow-up surveys the proportion of women reporting at least one antenatal care visit increased by 15 percentage points (95% CI: 10,19), four or more antenatal care visits increased by 17 percentage points (95%CI: 13,22), and institutional delivery increased by 40 percentage points (95% CI: 35,44). In contrast, the proportion of newborns with a postnatal care visit within 48 hours of birth decreased by 6 percentage points (95% CI: -10, -3) for home deliveries and by 14 percentage points (95% CI: -21, -7) for facility deliveries. The proportion of mothers reporting that their young infant with possible serious bacterial infection received amoxicillin for seven days increased by 50 percentage points (95% CI: 37,62) and gentamicin for seven days increased by 15 percentage points (95% CI: 5,25). Concurrent use of both antibiotics increased by 12 percentage points (95% CI: 4,19). CONCLUSION: The Community-Based Newborn Care programme was an ambitious initiative to enhance the access to services for pregnant women and newborns. Major improvements were seen for the number of antenatal care visits and institutional delivery, while postnatal care remained alarmingly low. Antibiotic treatment for young infants with possible serious bacterial infection increased, although most treatment did not follow national guidelines. Improving postnatal care coverage and using a simplified antibiotic regimen following recent World Health Organization guidelines could address gaps in the care provided for sick young infants.

Stated job preferences of three health worker cadres in Ethiopia: a discrete choice experiment.

Attracting, training and retaining high-quality health workers are critical for a health system to function well, and it is important to know what health workers value in their roles. Many studies eliciting the labour market preferences of health workers have interviewed doctors or medical students, and there has been little research on the job preferences of lower-skilled cadres such as community health workers, mid-skilled clinical care staff such as nurses and midwives, or non-patient facing staff who manage health facilities. This study estimated the job preferences of public health sector community health extension workers (HEWs), care providers including nurses and midwives, and non-patient-facing administrative and managerial staff in Ethiopia. We used a discrete choice experiment to estimate which aspects of a job are most influential to health worker choices. A multinomial logistic regression model estimated the importance of six attributes to respondents: salary, training, workload, facility quality, management and opportunities to improve patient outcomes. We found that non-financial factors were important to respondents from all three cadres: e.g., supportive management [odds ratio (OR) = 2.96, P-value = 0.001] was the only attribute that influenced the job choices of non-patient-facing administrative and managerial staff. Training opportunities (OR = 3.45, P-value < 0.001), supportive management (OR = 3.26, P-value < 0.001) and good facility quality (OR = 2.42, P-value < 0.001) were valued the most amongst HEWs. Similarly, supportive management (OR = 3.22, P-value < 0.001), good facility quality (OR = 2.69, P-value < 0.001) and training opportunities (OR = 2.67, P-value < 0.001) influenced the job choices of care providers the most. Earning an average salary also influenced the jobs choices of HEWs (OR = 1.43, P-value = 0.02) and care providers (OR = 2.00, P-value < 0.001), which shows that a combination of financial and non-financial incentives should be considered to motivate health workers in Ethiopia.

Factors associated with the referral of children with severe illnesses at primary care level in Ethiopia: a cross-sectional study.

CONTEXT AND OBJECTIVE: Ethiopia's primary care has a weak referral system for sick children. We aimed to identify health post and child factors associated with referrals of sick children 0-59 months of age and evaluate the healthcare providers' adherence to referral guidelines. DESIGN: A cross-sectional facility-based survey. SETTING: This study included data from 165 health posts in 52 districts in four Ethiopian regions collected from December 2018 to February 2019. The data included interviews with health extension workers, assessment of health post preparedness, recording of global positioning system (GPS)-coordinates of the health post and the referral health centre, and reviewing registers of sick children treated during the last 3 months at the health posts. We analysed the association between the sick child's characteristics, health post preparedness and distance to the health centre with referral of sick children by multivariable logistic regressions. OUTCOME MEASURE: Referral to the nearest health centre of sick young infants aged 0-59 days and sick children 2-59 months. RESULTS: The health extension workers referred 39/229 (17%) of the sick young infants and 78/1123 (7%) of the older children to the next level of care. Only 18 (37%) sick young infants and 22 (50%) 2-59 months children that deserved urgent referral according to guidelines were referred. The leading causes of referral were possible serious bacterial infection and pneumonia. Those being classified as a severe disease were referred more frequently. The availability of basic amenities (adjusted OR, AOR=0.38, 95% CI 0.15 to 0.96), amoxicillin (AOR=0.41, 95% CI 0.19 to 0.88) and rapid diagnostic test (AOR=0.18, 95% CI 0.07 to 0.46) were associated with less referral in the older age group. CONCLUSION: Few children with severe illness were referred from health posts to health centres. Improving the health posts' medicine and diagnostic supplies may enhance adherence to referral guidelines and ultimately reduce child mortality.

Health extension workers' perceived health system context and health post preparedness to provide services: a cross-sectional study in four Ethiopian regions.

OBJECTIVE: The health system context influences the implementation of evidence-based practices and quality of healthcare services. Ethiopia aims at reaching universal health coverage but faces low primary care utilisation and substandard quality of care. We assessed the health extension workers' perceived context and the preparedness of health posts to provide services. SETTING: This study was part of evaluating a complex intervention in 52 districts of four regions of Ethiopia. This paper used the endline data collected from December 2018 to February 2019. PARTICIPANTS: A total of 152 health posts and health extension workers serving selected enumeration areas were included. OUTCOME MEASURES: We used the Context Assessment for Community Health (COACH) tool and the Service Availability and Readiness Assessment tool. RESULTS: Internal reliability of COACH was satisfactory. The dimensions community engagement, work culture, commitment to work and leadership all scored high (mean 3.75-4.01 on a 1-5 scale), while organisational resources, sources of knowledge and informal payments scored low (1.78-2.71). The general service readiness index was 59%. On average, 67% of the health posts had basic amenities to provide services, 81% had basic equipment, 42% had standard precautions for infection prevention, 47% had test capacity for malaria and 58% had essential medicines. CONCLUSION: The health extension workers had a good relationship with the local community, used data for planning, were highly committed to their work with positive perceptions of their work culture, a relatively positive attitude regarding their leaders, and reported no corruption or informal payments. In contrast, they had insufficient sources of information and a severe lack of resources. The health post preparedness confirmed the low level of resources and preparedness for services. These findings suggest a significant potential contribution by health extension workers to Ethiopia's primary healthcare, provided that they receive improved support, including new information and essential resources.

Strengthening routine health data analysis in Ethiopia: the Operational Research and Coaching for Analysts (ORCA) experience.

Many routine health information systems (RHIS) show persistent gaps between recording and reporting data and their effective use in solving problems. Strengthening RHIS has become a global priority to track and address national health goals. In Ethiopia, the Ministry of Health and Bill & Melinda Gates Foundation introduced the Operational Research and Coaching for Analysts (ORCA) capacity development project, co-designed with the London School of Hygiene & Tropical Medicine, which delivered training, coaching and mentoring support. We present the development, experiences, and perceptions of ORCA as a mechanism to enhance data quality, analysis, interpretation and use. ORCA integrated capacity development activities into national data analysts' routine workload over a period of 2 years. Participating analysts were drawn from across the Ministry of Health directorates and two of its closely aligned agencies: the Ethiopian Public Health Institute and the Ethiopian Pharmaceutical Supply Agency. We used mixed methods (knowledge questionnaire, semi-structured interviews, programme records) to document the fidelity, feasibility, reach, and acceptability of ORCA and identify early signs of improved knowledge and changing institutional practices. Thirty-six participants completed the programme. Working in interdisciplinary groups on specific national health indicators, they received training workshops and support for study design, fieldwork, and analysis to build skills in assessing data quality and interpreting findings relevant to policy. Personal development grants and laptops provided incentives for sustained engagement. Participants appreciated ORCA's applied and practical approach as well as good communication from administrators and clear links to national strategy. They also expressed frustration with delays, difficulties prioritising project work over routine responsibilities, and lack of formal accreditation. Knowledge and analytic skills increased and participants were able to integrate experiences from the project into their future work. Health system managers saw potential in longer-term improvements in data analysis and application to policy, although no clear changes were observed yet.

Association between a complex community intervention and quality of health extension workers' performance to correctly classify common childhood illnesses in four regions of Ethiopia.

BACKGROUND: Due to low care utilization, a complex intervention was done for two years to optimize the Ethiopian Health Extension Program. Improved quality of the integrated community case management services was an intermediate outcome of this intervention through community education and mobilization, capacity building of health workers, and strengthening of district ownership and accountability of sick child services. We evaluated the association between the intervention and the health extension workers' ability to correctly classify common childhood illnesses in four regions of Ethiopia. METHODS: Baseline and endline assessments were done in 2016 and 2018 in intervention and comparison areas in four regions of Ethiopia. Ill children aged 2 to 59 months were mobilized to visit health posts for an assessment that was followed by re-examination. We analyzed sensitivity, specificity, and difference-in-difference of correct classification with multilevel mixed logistic regression in intervention and comparison areas at baseline and endline. RESULTS: Health extensions workers' consultations with ill children were observed in intervention (n = 710) and comparison areas (n = 615). At baseline, re-examination of the children showed that in intervention areas, health extension workers' sensitivity for fever or malaria was 54%, 68% for respiratory infections, 90% for diarrheal diseases, and 34% for malnutrition. At endline, it was 40% for fever or malaria, 49% for respiratory infections, 85% for diarrheal diseases, and 48% for malnutrition. Specificity was higher (89-100%) for all childhood illnesses. Difference-in-differences was 6% for correct classification of fever or malaria [aOR = 1.45 95% CI: 0.81-2.60], 4% for respiratory tract infection [aOR = 1.49 95% CI: 0.81-2.74], and 5% for diarrheal diseases [aOR = 1.74 95% CI: 0.77-3.92]. CONCLUSION: This study revealed that the Optimization of Health Extension Program intervention, which included training, supportive supervision, and performance reviews of health extension workers, was not associated with an improved classification of childhood illnesses by these Ethiopian primary health care workers. TRIAL REGISTRATION: ISRCTN12040912, http://www.isrctn.com/ISRCTN12040912.

Routine health management information system data in Ethiopia: consistency, trends, and challenges.

Background: Ethiopia is investing in the routine Health Management Information System. Improved routine data are needed for decision-making in the health sector. Objective: To analyse the quality of the routine Health Management Information System data and triangulate with other sources, such as the Demographic and Health Surveys. Methods: We analysed national Health Management Information System data on 19 indicators of maternal health, neonatal survival, immunization, child nutrition, malaria, and tuberculosis over the 2012-2018 time period. The analyses were conducted by 38 analysts from the Ministry of Health, Ethiopia, and two government agencies who participated in the Operational Research and Coaching for Analysts (ORCA) project between June 2018 and June 2020. Using a World Health Organization Data Quality Review toolkit, we assessed indicator definitions, completeness, internal consistency over time and between related indicators, and external consistency compared with other data sources. Results: Several services reported coverage of above 100%. For many indicators, denominators were based on poor-quality population data estimates. Data on individual vaccinations had relatively good internal consistency. In contrast, there was low external consistency for data on fully vaccinated children, with the routine Health Management Information System showing 89% coverage but the Demographic and Health Survey estimate at 39%. Maternal health indicators displayed increasing coverage over time. Indicators on child nutrition, malaria, and tuberculosis were less consistent. Data on neonatal mortality were incomplete and operationalised as mortality on day 0-6. Our comparisons with survey and population projections indicated that one in eight early neonatal deaths were reported in the routine Health Management Information System. Data quality varied between regions. Conclusions: The quality of routine data gathered in the health system needs further attention. We suggest regular triangulation with data from other sources. We recommend addressing the denominator issues, reducing the complexity of indicators, and aligning indicators to international definitions.

Does a complex intervention targeting communities, health facilities and district health managers increase the utilisation of community-based child health services? A before and after study in intervention and comparison areas of Ethiopia.

INTRODUCTION: Ethiopia successfully reduced mortality in children below 5 years of age during the past few decades, but the utilisation of child health services was still low. Optimising the Health Extension Programme was a 2-year intervention in 26 districts, focusing on community engagement, capacity strengthening of primary care workers and reinforcement of district accountability of child health services. We report the intervention's effectiveness on care utilisation for common childhood illnesses. METHODS: We included a representative sample of 5773 households with 2874 under-five children at baseline (December 2016 to February 2017) and 10 788 households and 5639 under-five children at endline surveys (December 2018 to February 2019) in intervention and comparison areas. Health facilities were also included. We assessed the effect of the intervention using difference-in-differences analyses. RESULTS: There were 31 intervention activities; many were one-off and implemented late. In eight districts, activities were interrupted for 4 months. Care-seeking for any illness in the 2 weeks before the survey for children aged 2-59 months at baseline was 58% (95% CI 47 to 68) in intervention and 49% (95% CI 39 to 60) in comparison areas. At end-line it was 39% (95% CI 32 to 45) in intervention and 34% (95% CI 27 to 41) in comparison areas (difference-in-differences -4 percentage points, adjusted OR 0.49, 95% CI 0.12 to 1.95). The intervention neither had an effect on care-seeking among sick neonates, nor on household participation in community engagement forums, supportive supervision of primary care workers, nor on indicators of district accountability for child health services. CONCLUSION: We found no evidence to suggest that the intervention increased the utilisation of care for sick children. The lack of effect could partly be attributed to the short implementation period of a complex intervention and implementation interruption. Future funding schemes should take into consideration that complex interventions that include behaviour change may need an extended implementation period. TRIAL REGISTRATION NUMBER: ISRCTN12040912.