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.

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.

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.

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.

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.

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.

Assessing capacity of health facilities to provide routine maternal and newborn care in low-income settings: what proportions are ready to provide good-quality care, and what proportions of women receive it?

BACKGROUND: Good quality maternal and newborn care at primary health facilities is essential, but in settings with high maternal and newborn mortality the evidence for the protective effect of facility delivery is inconsistent. We surveyed samples of health facilities in three settings with high maternal mortality to assess their readiness to provide routine maternal and newborn care, and proportions of women using facilities that were ready to offer good quality care. Surveys were conducted in 2012 and 2015 to assess changes over time. METHODS: Surveys were conducted in Ethiopia, the Indian state of Uttar Pradesh and Gombe State in North-Eastern Nigeria. At each facility the staffing, infrastructure and commodities were quantified. These formed components of four "signal functions" that described aspects of routine maternal and newborn care. A facility was considered ready to perform a signal function if all the required components were present. Readiness to perform all four signal functions classed a facility as ready to provide good quality routine care. From facility registers we counted deliveries and calculated the proportions of women delivering in facilities ready to offer good quality routine care. RESULTS: In Ethiopia the proportion of deliveries in facilities classed as ready to offer good quality routine care rose from 40% (95% confidence interval (CI) 26-57) in 2012 to 43% (95% CI 31-56) in 2015. In Uttar Pradesh these estimates were 4% (95% CI 1-24) in 2012 and 39% (95% CI 25-55) in 2015, while in Nigeria they were 25% (95% CI 6-66) in 2012 and zero in 2015. Improved facility readiness in Ethiopia and Uttar Pradesh arose from increased supplies of commodities, while in Nigeria facility readiness fell due to depleted commodity supplies and fewer Skilled Birth Attendants. CONCLUSIONS: This study quantified the readiness of health facilities to offer good quality routine maternal and newborn care, and may help explain inconsistent outcomes of facility care in some settings. Signal function methodology can provide a rapid and inexpensive measure of such facility readiness. Incorporating data on facility deliveries and repeating the analyses highlighted adjustments that could have greatest impact upon routine maternal and newborn care.

Insufficient referral practices of sick children in Ethiopia shown in a cross-sectional survey.

AIM: This study aimed at assessing the referral of sick young infants and children from the community, health posts and health centres to higher levels. METHODS: A cross-sectional survey was conducted in four of the largest Ethiopian regions from December 2016 to February 2017. Referral practices were assessed at each level in 46 districts of these regions. Interviews were supplemented by reviews of registers at health posts and health centres. RESULTS: The women's development group leaders, who do not provide health services, referred half of the sick children they visited in the community to the health posts. The health extension workers referred 16% of the sick young infants and 6% of older infants and children to higher levels. From health centres, the health workers referred 6% of sick young infants and 1% of older infants and children to hospital. Many cases of possible severe bacterial infection were not referred to higher levels. A functional ambulance was available for a bit more than a third of the health centres. CONCLUSION: Referral practices of sick young infants and children at all levels were weak that may threaten the continued reduction of child mortality in Ethiopia. Referral logistics were insufficient, which partly could explain the missing referrals of severely ill infants and children.

Assessing the quality of care in sick child services at health facilities in Ethiopia.

BACKGROUND: Quality of care depends on system, facility, provider, and client-level factors. We aimed at examining structural and process quality of services for sick children and its association with client satisfaction at health facilities in Ethiopia. METHODS: Data from the Ethiopia Service Provision Assessment Plus (SPA+) survey 2014 were used. Measures of quality were assessed based on the Donabedian framework: structure, process, and outcome. A total of 1908 mothers or caretakers were interviewed and their child consultations were observed. Principal component analysis was used to construct quality of care indices including a structural composite score, a process composite score, and a client satisfaction score. Multilevel mixed linear regression was used to analyze the association between structural and process factors with client satisfaction. RESULT: Among children diagnosed with suspected pneumonia, respiratory rate was counted in 56% and temperature was checked in 77% of the cases. A majority of children (92%) diagnosed with fever had their temperature taken. Only 3% of children with fever were either referred or admitted, and 60% received antibiotics. Among children diagnosed with malaria, 51% were assessed for all three Integrated Management of Childhood Illnesses (IMCI) main symptoms, and 4% were assessed for all three general danger signs. Providers assessed dehydration in 54% of children with diarrhea with dehydration, 17% of these children were admitted or referred to another facility, and Oral Rehydration Solution was prescribed for 67% while none received intravenous fluids. The number of basic amenities in the facility was negatively associated with the clients' satisfaction. Private facilities, when the providers had got training for care of sick children in the past 2 years, had higher client satisfaction. There was no statistical association between structure, process composite indicators and client satisfaction. CONCLUSION: The assessment of sick children was of low quality, with many missing procedures when comparing with IMCI guidelines. In spite of this, most clients were satisfied with the services they received. Structural and process composite indicators were not associated with client's satisfaction. These findings highlight the need to assess other dimensions of quality of care besides structure and process that may influence client satisfaction.

Professional advice for primary healthcare workers in Ethiopia: a social network analysis.

BACKGROUND: In an era of increasingly competitive funding, governments and donors will be looking for creative ways to extend and maximise resources. One such means can include building upon professional advice networks to more efficiently introduce, scale up, or change programmes and healthcare provider practices. This cross-sectional, mixed-methods, observational study compared professional advice networks of healthcare workers in eight primary healthcare units across four regions of Ethiopia. Primary healthcare units include a health centre and typically five satellite health posts. METHODS: One hundred sixty staff at eight primary healthcare units were interviewed using a structured tool. Quantitative data captured the frequency of healthcare worker advice seeking and giving on providing antenatal, childbirth, postnatal and newborn care. Network and actor-level metrics were calculated including density (ratio of ties between actors to all possible ties), centrality (number of ties incident to an actor), distance (average number of steps between actors) and size (number of actors within the network). Following quantitative network analyses, 20 qualitative interviews were conducted with network study participants from four primary healthcare units. Qualitative interviews aimed to interpret and explain network properties observed. Data were entered, analysed or visualised using Excel 6.0, UCINET 6.0, Netdraw, Adobe InDesign and MaxQDA10 software packages. RESULTS: The following average network level metrics were observed: density .26 (SD.11), degree centrality .45 (SD.08), distance 1.94 (SD.26), number of ties 95.63 (SD 35.46), size of network 20.25 (SD 3.65). Advice networks for antenatal or maternity care were more utilised than advice networks for post-natal or newborn care. Advice networks were typically limited to primary healthcare unit staff, but not necessarily to supervisors. In seeking advice, a colleague's level of training and knowledge were valued over experience. Advice exchange primarily took place in person or over the phone rather than over email or online fora. There were few barriers to seeking advice. CONCLUSION: Informal, inter-and intra-cadre advice networks existed. Fellow primary healthcare unit staff were preferred, particularly midwives, but networks were not limited to the primary healthcare unit. Additional research is needed to associate network properties with outcomes and pilot network interventions with central actors.

Protocol for the evaluation of a complex intervention aiming at increased utilisation of primary child health services in Ethiopia: a before and after study in intervention and comparison areas.

BACKGROUND: By expanding primary health care services, Ethiopia has reduced under-five mor4tality. Utilisation of these services is still low, and concerted efforts are needed for continued improvements in newborn and child survival. "Optimizing the Health Extension Program" is a complex intervention based on a logic framework developed from an analysis of barriers to the utilisation of primary child health services. This intervention includes innovative components to engage the community, strengthen the capacity of primary health care workers, and reinforce the local ownership and accountability of the primary child health services. This paper presents a protocol for the process and outcome evaluation, using a pragmatic trial design including before-and-after assessments in both intervention and comparison areas across four Ethiopian regions. The study has an integrated research capacity building initiative, including ten Ph.D. students recruited from Ethiopian Regional Health Bureaus and universities. METHODS: Baseline and endline surveys 2 years apart include household, facility, health worker, and district health office modules in intervention and comparison areas across Amhara, Southern Nations Nationalities and Peoples, Oromia, and Tigray regions. The effectiveness of the intervention on the seeking and receiving of appropriate care will be estimated by difference-in-differences analysis, adjusting for clustering and for relevant confounders. The process evaluation follows the guidelines of the UK Medical Research Council. The implementation is monitored using data that we anticipate will be used to describe the fidelity, reach, dose, contextual factors and cost. The participating Ph.D. students plan to perform in-depth analyses on different topics including equity, referral, newborn care practices, quality-of-care, geographic differences, and other process evaluation components. DISCUSSION: This protocol describes an evaluation of a complex intervention that aims at increased utilisation of primary and child health services. This unique collaborative effort includes key stakeholders from the Ethiopian health system, the implementing non-governmental organisations and universities, and combines state-of-the art effectiveness estimates and process evaluation with capacity building. The lessons learned from the project will inform efforts to engage communities and increase utilisation of care for children in other parts of Ethiopia and beyond. TRIAL REGISTRATION: Current Controlled Trials ISRCTN12040912, retrospectively registered on 19 December, 2017.

Health system capacity for tuberculosis care in Ethiopia: evidence from national representative survey.

OBJECTIVE: The objective of this study was to evaluate the tuberculosis (TB) health system capacity and its variations by location and types of health facilities in Ethiopia. DESIGN: We used the Service Provision Assessment plus (SPA+) survey data that were collected in 2014 in all hospitals and randomly selected health centers and private facilities in all regions of Ethiopia. We assessed structural, process and overall health system capacity based on the Donabedian quality of care model. Multiple linear regression and spatial analysis were done to assess TB capacity score variation across regions. SETTING: The study included 873 public and private health facilities all over Ethiopia. PARTICIPANTS: None. INTERVENTION(S): None. MAIN OUTCOME MEASURE(S): None. RESULTS: A total of 873 health facilities were included in the analysis. The overall TB care capacity score was 76.7%, 55.9% and 37.8% in public hospitals, health centers and private facilities, respectively. The health system capacity score for TB was higher in the urban (60.4%) facilities compared to that of the rural (50.0%) facilities (ß = 8.0, 95% CI: 4.4, 11.6). Health centers (ß = -16.2, 95% CI: -20.0, -12.3) and private health facilities (ß = -38.3, 95% CI: -42.4, -35.1) had lower TB care capacity score than hospitals. Overall TB care capacity score were lower in Western and Southwestern Ethiopia and in Benishangul-Gumuz and Gambella regions. CONCLUSIONS: The health system capacity score for TB care in Ethiopia varied across regions. Health system capacity improvement interventions should focus on the private sectors and health facilities in the rural and remote areas to ensure equity and improve quality of care.

Coverage and equity of maternal and newborn health care in rural Nigeria, Ethiopia and India.

BACKGROUND: Despite progress toward meeting the Sustainable Development Goals, a large burden of maternal and neonatal mortality persists for the most vulnerable people in rural areas. We assessed coverage, coverage change and inequity for 8 maternal and newborn health care indicators in parts of rural Nigeria, Ethiopia and India. METHODS: We examined coverage changes and inequity in 2012 and 2015 in 3 high-burden populations where multiple actors were attempting to improve outcomes. We conducted cluster-based household surveys using a structured questionnaire to collect 8 priority indicators, disaggregated by relative household socioeconomic status. Where there was evidence of a change in coverage between 2012 and 2015, we used binomial regression models to assess whether the change reduced inequity. RESULTS: In 2015, we interviewed women with a birth in the previous 12 months in Gombe, Nigeria (n = 1100 women), Ethiopia (n = 404) and Uttar Pradesh, India (n = 584). Among the 8 indicators, 2 positive coverage changes were observed in each of Gombe and Uttar Pradesh, and 5 in Ethiopia. Coverage improvements occurred equally for all socioeconomic groups, with little improvement in inequity. For example, in Ethiopia, coverage of facility delivery almost tripled, increasing from 15% (95% confidence interval [CI] 9%-25%) to 43% (95% CI 33%-54%). This change was similar across socioeconomic groups (p = 0.2). By 2015, the poorest women had about the same facility delivery coverage as the least poor women had had in 2012 (32% and 36%, respectively), but coverage for the least poor had increased to 60%. INTERPRETATION: Although coverage increased equitably because of various community-based interventions, underlying inequities persisted. Action is needed to address the needs of the most vulnerable women, particularly those living in the most rural areas.

Health Extension Workers' diagnostic accuracy for common childhood illnesses in four regions of Ethiopia: a cross-sectional study.

AIM: The Ethiopian primary care of sick children is provided within the integrated Community Case Management of childhood illnesses by Health Extension Workers (HEW). There is limited knowledge whether this cadre correctly assess and classify common diseases. The aim was to study their ability to correctly classify common childhood illnesses. METHODS: A survey was conducted from December 2016 to February 2017 in four regions of Ethiopia. Observations of the HEWs' assessment and classification of sick children were followed by child re-examination by a trained health officer. RESULTS: The classification by the HEWs of 620 sick children as compared to the re-examiner had a sensitivity of 89% and specificity of 94% for diarrhoea, sensitivity 52% and specificity 91% for febrile disorders, and a sensitivity of 59% and specificity of 94% for acute respiratory tract infection. Malnutrition and ear infection had a sensitivity of 39 and 61%, and a specificity of 99 and 99%, respectively. CONCLUSION: Most cases of diarrhoea were correctly classified, while other illnesses were not frequently identified. The identification of malnutrition was especially at fault. These findings suggest that a significant number of sick children were undiagnosed that could lead to absent or incorrect management and treatment.

Contextual factors in maternal and newborn health evaluation: a protocol applied in Nigeria, India and Ethiopia.

BACKGROUND: Understanding the context of a health programme is important in interpreting evaluation findings and in considering the external validity for other settings. Public health researchers can be imprecise and inconsistent in their usage of the word "context" and its application to their work. This paper presents an approach to defining context, to capturing relevant contextual information and to using such information to help interpret findings from the perspective of a research group evaluating the effect of diverse innovations on coverage of evidence-based, life-saving interventions for maternal and newborn health in Ethiopia, Nigeria, and India. METHODS: We define "context" as the background environment or setting of any program, and "contextual factors" as those elements of context that could affect implementation of a programme. Through a structured, consultative process, contextual factors were identified while trying to strike a balance between comprehensiveness and feasibility. Thematic areas included demographics and socio-economics, epidemiological profile, health systems and service uptake, infrastructure, education, environment, politics, policy and governance. We outline an approach for capturing and using contextual factors while maximizing use of existing data. Methods include desk reviews, secondary data extraction and key informant interviews. Outputs include databases of contextual factors and summaries of existing maternal and newborn health policies and their implementation. Use of contextual data will be qualitative in nature and may assist in interpreting findings in both quantitative and qualitative aspects of programme evaluation. DISCUSSION: Applying this approach was more resource intensive than expected, in part because routinely available information was not consistently available across settings and more primary data collection was required than anticipated. Data was used only minimally, partly due to a lack of evaluation results that needed further explanation, but also because contextual data was not available for the precise units of analysis or time periods of interest. We would advise others to consider integrating contextual factors within other data collection activities, and to conduct regular reviews of maternal and newborn health policies. This approach and the learnings from its application could help inform the development of guidelines for the collection and use of contextual factors in public health evaluation.

'The development sector is a graveyard of pilot projects!' Six critical actions for externally funded implementers to foster scale-up of maternal and newborn health innovations in low and middle-income countries.

BACKGROUND: Donors often fund projects that develop innovative practices in low and middle-income countries, hoping recipient governments will adopt and scale them within existing systems and programmes. Such innovations frequently end when project funding ends, limiting longer term potential in countries with weak health systems and pressing health needs. This paper aims to identify critical actions for externally funded project implementers to enable scale-up of maternal and newborn child health innovations originally funded by the Bill & Melinda Gates Foundation ('the foundation'), or influenced by innovations that were originally funded by the foundation in three low-income settings: Ethiopia, the state of Uttar Pradesh in India and northeast Nigeria. We define scale-up as the adoption of donor-funded innovations beyond their original project settings and time periods. METHODS: We conducted 71 in-depth, semi-structured interviews with representatives from government, donors and other development partner agencies, donor-funded implementers including frontline providers, research organisations and professional associations. We explored three case study maternal and newborn innovations. Selection criteria were: a) innovations originally funded by the Bill & Melinda Gates Foundation ('the foundation'), or influenced by innovations that were originally funded by the foundation; b) innovations for which a decision to scale-up had been made, allowing us to reflect on the factors influencing those decisions; c) innovations with increased geographical reach, benefitting a greater number of people, beyond districts where foundation-funded implementers were active. Our data were analysed based on a common analytic framework to aid cross-country comparisons. RESULTS: Based on study respondents' accounts, we identified six critical steps that donor-funded implementers had taken to enable the adoption of maternal and newborn health innovations at scale: designing innovations for scale; generating evidence to influence and inform scale-up; harnessing the support of powerful individuals; being prepared for scale-up and responsive to change; ensuring continuity by being part of the transition to scale; and embracing the aid effectiveness principles of country ownership, alignment and harmonisation. CONCLUSIONS: Six critical actions identified in this study were associated with adopting and scaling maternal and newborn health innovations. However, scale-up is unpredictable and depends on factors outside implementers' control.

Early postnatal home visits: a qualitative study of barriers and facilitators to achieving high coverage.

BACKGROUND: Timely interventions in the postnatal period are important for reducing newborn mortality, and early home visits to provide postnatal care are recommended. There has been limited success in achieving timely visits, and a better understanding of the realities of programmes is needed if improvements are to be made. METHODS: We explored barriers and facilitators to timely postnatal visits through 20 qualitative interviews and 16 focus group discussions with families and Health Extension Workers in four Ethiopian sites. RESULTS: All sites reported some inaccessible areas that did not receive visits, but, Health Extension Workers in the sites with more difficult terrain were reported to make more visits that those in the more accessible areas. This suggests that information and work issues can be more important than moderate physical issues. The sites where visits were common had functioning mechanisms for alerting workers to a birth; these were not related to postnatal visits but to families informing Health Extension Workers of labour so they could call an ambulance. In the other sites, families did not know they should alert workers about a delivery, and other alert mechanisms were not functioning well. Competing activities reducing Health Extension Worker availability for visits, but in some areas workers were more organized in their division of their work and this facilitated visits. The main difference between the areas where visits were reported as common or uncommon was the general activity level of the Health Extension Worker. In the sites where workers were active and connected to the community visits occurred more often. CONCLUSIONS: If timely postnatal home visits are to occur, CHWs need realistic catchment areas that reflect their workload. Inaccessible areas may need their own CHW. Good notification systems are essential, families will notify CHWs if they have a clear reasons to do so, and more work is needed on how to ensure notification systems function. Work ethic was a clear influencer on whether home visits occur, studies to date have focused on understanding the motivation of CHWs as a group, more studies on understanding motivation at an individual level are needed.

Capacity of health facilities for diagnosis and treatment of HIV/AIDS in Ethiopia.

BACKGROUND: There are dearth of literature on the capacity of the health system to diagnose and treat HIV/AIDS in Ethiopia. In this study we evaluated the capacity of health facilities for HIV/AIDS care, its spatial distribution and variations by regions and zones in Ethiopia. METHODS: We analyzed the Service Provision Assessment plus (SPA+) survey data that were collected in 2014 in all regions of Ethiopia. We assessed structural, process and overall capacity of the health system based on the Donabedian quality of care model. We included 5 structural and 8 process indicators and overall capacity score was constructed by taking the average of all indicators. Multiple linear regression was done using STATA 14 to assess the association of the location and types of health facilities with overall capacity score. Maps displaying the average capacity score at Zonal level were produced using ArcGIS Desktop v10.3 (Environmental Systems Research Institute Inc., Redlands CA, USA). RESULTS: A total of 873 health facilities were included in the analysis. Less than 5% of the private facilities provided antiretroviral therapy (ART); had national ART guideline, baseline CD4 count or viral load and tuberculosis screening mechanisms. Nearly one-third of the health centers (34.9%) provided ART. Public hospitals have better capacity score (77.1%) than health centers (45.9%) and private health facilities (24.8%). The overall capacity score for urban facilities (57.1%) was higher than that of the rural (38.2%) health facilities (ß = 15.4, 95% CI: 11.7, 19.2). Health centers (ß = - 21.4, 95% CI: -25.4, - 17.4) and private health facilities (ß = - 50.9, 95% CI: -54.8, - 47.1) had lower overall capacity score than hospitals. Facilities in Somali (ß = - 13.8, 95% CI: -20.6, - 7.0) and SNNPR (ß = - 5.0, 95% CI: -9.8, - 0.1) regions had lower overall capacity score than facilities in the Oromia region. Zones located in emerging regions such as Gambella and Benishangul Gumz and in remote areas of Oromia and SNNPR had lower capacity score in terms of process indicators. CONCLUSIONS: There is a significant geographical heterogeneity on the capacity of health facilities for HIV/AIDS care and treatment in Ethiopia. Targeted capacity improvement initiatives are recommended with focus on health centers and private health facilities, and emerging Regions and the rural and remote areas.

'The stars seem aligned': a qualitative study to understand the effects of context on scale-up of maternal and newborn health innovations in Ethiopia, India and Nigeria.

BACKGROUND: Donors commonly fund innovative interventions to improve health in the hope that governments of low and middle-income countries will scale-up those that are shown to be effective. Yet innovations can be slow to be adopted by country governments and implemented at scale. Our study explores this problem by identifying key contextual factors influencing scale-up of maternal and newborn health innovations in three low-income settings: Ethiopia, the six states of northeast Nigeria and Uttar Pradesh state in India. METHODS: We conducted 150 semi-structured interviews in 2012/13 with stakeholders from government, development partner agencies, externally funded implementers including civil society organisations, academic institutions and professional associations to understand scale-up of innovations to improve the health of mothers and newborns these study settings. We analysed interview data with the aid of a common analytic framework to enable cross-country comparison, with Nvivo to code themes. RESULTS: We found that multiple contextual factors enabled and undermined attempts to catalyse scale-up of donor-funded maternal and newborn health innovations. Factors influencing government decisions to accept innovations at scale included: how health policy decisions are made; prioritising and funding maternal and newborn health; and development partner harmonisation. Factors influencing the implementation of innovations at scale included: health systems capacity in the three settings; and security in northeast Nigeria. Contextual factors influencing beneficiary communities' uptake of innovations at scale included: sociocultural contexts; and access to healthcare. CONCLUSIONS: We conclude that context is critical: externally funded implementers need to assess and adapt for contexts if they are to successfully position an innovation for scale-up.

Measurement of delayed bathing and early initiation of breastfeeding: a cross-sectional survey exploring experiences of data collectors in Ethiopia.

BACKGROUND: Delayed bathing and early initiation of breastfeeding are among the essential interventions recommended to save newborn lives. Although survey coverage reports are key to monitoring these interventions, few studies investigated whether such reports accurately reflect the proportion of mothers and children who received these interventions. In order to gather accurate data, guidance on how to interview and probe mothers is provided. In this study, we investigated experiences of data collectors when asking mothers survey questions that assessed delayed bathing and early initiation of breastfeeding. METHODS: In November 2013, using a self-administered semi-structured questionnaire, we interviewed data collectors who had taken part in a population-based newborn health household survey in Ethiopia during October-November 2013. A total of 130 out of 160 invited data collectors completed and returned the self-administered questionnaire. Descriptive statistics were used to analyse quantitative data using SPSS software version 19. Qualitative data showing the variety of probes used by data collectors was analysed by listing, screening to identify common themes, and grouping by category. RESULTS: Most data collectors reported that, in their opinion, mothers were able to understand the meaning of the question about newborn bathing (n = 102, 79%) and breastfeeding initiation (n = 106, 82%) without the need for probes. However, fewer mothers were able to recall the event for either newborn behaviours and describe it in minutes, hours or days without the need for probes. Overall, only 26% (n = 34) and 34 % (n = 44) of all data collectors reported that they did not need any probing for the questions related to newborn bathing and breastfeeding initiation questions, respectively. We identified a variety of probes used by data collectors and present examples. CONCLUSION: Considerable probing was necessary to facilitate maternal recall of the events and approximate their responses of time regardless of mothers' age, level of education and parity. This could potentially lead to inaccurate coverage reports due to subjective and inconsistent interpretation of the indicators. Therefore, we recommend inclusion of standard probes or follow-on questions to the existing survey tools assessing the two indicators. Data collectors also require further guidance in using appropriate probes to gather accurate maternal responses.