A geospatial analysis of accessibility and availability to implement the primary healthcare roadmap in Ethiopia.

BACKGROUND: Primary healthcare (PHC) is a crucial strategy for achieving universal health coverage. Ethiopia is working to improve its primary healthcare system through the Optimization of Health Extension Program (OHEP), which aims to increase accessibility, availability and performance of health professionals and services. Measuring current accessibility of healthcare facilities and workforce availability is essential for the success of the OHEP and achieving universal health coverage in the country. METHODS: In this study we use an innovative mixed geospatial approach to assess the accessibility and availability of health professionals and services to provide evidence-based recommendations for the implementation of the OHEP. We examined travel times to health facilities, referral times between health posts and health centers, geographical coverage, and the availability and density of health workers relative to the population. RESULTS: Our findings show that the accessibility and availability of health services in Somali region of Ethiopia is generally low, with 65% of the population being unable to reach a health center or a health post within 1 h walking and referral times exceeding 4 h walking on average. The density of the health workforce is low across Somali region, with no health center being adequately staffed as per national guidelines. CONCLUSIONS: Improving accessibility and addressing healthcare worker scarcity are challenges for implementing the primary care roadmap in Ethiopia. Upgrading health posts and centers, providing comprehensive services, and training healthcare workers are crucial. Effective outreach strategies are also needed to bridge the gap and improve accessibility and availability.

Access to primary healthcare, which encompasses essential healthcare services and often the initial point of contact between individuals and the healthcare system, is crucial for addressing the health needs of a population. In Ethiopia, ongoing efforts to reform the primary healthcare system aim to increase geographic access to health services and improve the availability of healthcare workers. This study focuses on the Somali region of Ethiopia and finds that 65% of the population is unable to reach a health center within 1 h of walking, and none of the health centers meet national and international staffing guidelines. These results play an important role in identifying areas where mobile outreach, involving trained service providers traveling to communities with limited access to healthcare facilities, can bridge gaps in healthcare accessibility and availability. Furthermore, the findings inform the implementation of primary healthcare reforms.

Non-financial Incentives for Retention of Health Extension Workers in Somali Region of Ethiopia: A Discrete Choice Experiment.

The study evaluated non-financial incentive packages to retain health extension workers in the Somali Region of Ethiopia using the Discrete Choice Experiment (DCE) technique, conducted among 66 health extension workers in 3 woredas (districts). The study used a mix of qualitative and quantitative methods in sequential order. Mixed logic regression modeling was used to determine the effect of different job attributes on the retention of the health extension workers, while Preference Impact Measure (PIM) was used to determine the combinations of preferred incentive packages to retain the health extension workers in their current workplace. Opportunity for continued education ranked first, 1.009 (0.655, 1.36), P = .000, followed by career advancement/opportunity for promotion, 0.321 (0.107, 0.534), P = .003, then supportive management 0.234 (-0.395, -0.073), P = .004. in terms of impact on retention. The most preferred incentive package for retention using the PIM model was opportunities for continued education after 3 years and always good availability of and access to amenities (running water, electricity, internet), which predicted a 77% retention rate if implemented. The identified proposed retention incentive packages will help in developing evidence-based incentive policies and strategies for the future retention of health extension workers in this region.

Prevalence and predictors of underweight and stunting among children under 2 years of age in Eastern Kenya.

OBJECTIVE: To investigate key risk factors associated with undernutrition in the first few years of life. DESIGN: A cross-sectional household survey was conducted in January 2018 collecting anthropometric data and other information on household, caregiver and child characteristics. Crude and adjusted odds ratios were calculated to assess the association of these characteristics with stunting and underweight outcomes. SETTING: Kitui and Machakos counties in south-east Kenya. PARTICIPANTS: Caregivers and their children aged 0-23 months in 967 beneficiary households of the Government of Kenya's cash for orphans and vulnerable children (CT-OVC) social protection scheme. RESULTS: Twenty-three per cent of the 1004 children with anthropometric data were stunted, 10 % were underweight and 6 % experienced wasting. The strongest predictors of stunting and underweight were being in the second year of life and being born with a low birth weight. Residing in a poor household and having more than one child under 2 years of age in the household were also significant risk factors for being underweight. Although 43 % of children did not receive the minimal acceptable diet, this was not a significant factor associated with undernutrition. When age was removed as a covariate in children aged 12-23 months, being male resulted in a significantly higher risk of being stunted. CONCLUSIONS: While only 9 % of children were born with a low birth weight, these were four to five times more likely to be stunted and underweight, suggesting that preventive measures during pregnancy could have significant nutrition and health benefits for young children in this study area.

Can child-focused sanitation and nutrition programming improve health practices and outcomes? Evidence from a randomised controlled trial in Kitui County, Kenya.

INTRODUCTION: In Kenya's Kitui County, 46% of children under 5 years are stunted. Sanitation and nutrition programmes have sought to reduce child undernutrition, though they are typically implemented separately. We evaluate the effectiveness of an integrated sanitation and nutrition (SanNut) intervention in improving caregiver sanitation and nutrition knowledge and behaviours. METHODS: We conducted a cluster-randomised controlled trial to evaluate the impact of the SanNut intervention on caregiver knowledge, sanitary and hygiene practices, sanitation outcomes and nutrition outcomes. The evaluation included caregivers of children under 5 years across 604 villages in Kitui County. 309 treatment villages were randomly assigned to receive both the SanNut intervention and the standard Community-Led Total Sanitation (CLTS) intervention, while 295 control villages only received the CLTS intervention. 8 households with children under 5 years were randomly selected from each evaluation village to participate in the endline survey, for a total of 4322 households. RESULTS: SanNut led to modest improvements in sanitary knowledge and practices emphasised by the programme. Caregivers in treatment villages were 3.3 pp (+32%) more likely to mention lack of handwashing after handling child faeces as a potential cause of diarrhoea, and 4.9 pp (+7.8%) more likely to report safe disposal of child faeces than caregivers in control villages. Treatment households were 1.9 pp (+79%) more likely to have a stocked handwashing station and 2.9 pp (-16%) less likely to report incidences of child diarrhoea. However, SanNut appears to have had no impact on nutritional practices, such as breastfeeding, vitamin A supplementation or deworming. Non-child outcomes traditionally associated with CLTS, including latrine use and homestead sanitary conditions, were similar in treatment and control groups. CONCLUSION: Child-focused messaging can potentially be integrated into CLTS programming, though this integration was more successful for topics closer to CLTS objectives (sanitation practices, including limiting faecal contamination and handwashing) than for more disparate topics (nutritional practices). TRIAL REGISTRATION: Pan-African Clinical Trials Registry (PACTR201803003159346) and American Economic Association registry for randomised controlled trials (AEARCTR-0002019).

Addressing the human resources crisis: a case study of Cambodia's efforts to reduce maternal mortality (1980-2012).

OBJECTIVE: To identify factors that have contributed to the systematic development of the Cambodian human resources for health (HRH) system with a focus on midwifery services in response to high maternal mortality in fragile resource-constrained countries. DESIGN: Qualitative case study. Review of the published and grey literature and in-depth interviews with key informants and stakeholders using an HRH system conceptual framework developed by the authors ('House Model'; Fujita et al, 2011). Interviews focused on the perceptions of respondents regarding their contributions to strengthening midwifery services and the other external influences which may have influenced the HRH system and reduction in the maternal mortality ratio (MMR). SETTING: Three rounds of interviews were conducted with senior and mid-level managers of the Ministries of Health (MoH) and Education, educational institutes and development partners. PARTICIPANTS: A total of 49 interviewees, who were identified through a snowball sampling technique. MAIN OUTCOME MEASURES: Scaling up the availability of 24 h maternal health services at all health centres contributing to MMR reduction. RESULTS: The incremental development of the Cambodian HRH system since 2005 focused on the production, deployment and retention of midwives in rural areas as part of a systematic strategy to reduce maternal mortality. The improved availability and access to midwifery services contributed to significant MMR reduction. Other contributing factors included improved mechanisms for decision-making and implementation; political commitment backed up with necessary resources; leadership from the top along with a growing capacity of mid-level managers; increased MoH capacity to plan and coordinate; and supportive development partners in the context of a conducive external environment. CONCLUSIONS: Lessons from this case study point to the importance of a systemic and comprehensive approach to health and HRH system strengthening and of ongoing capacity enhancement and leadership development to ensure effective planning, implementation and monitoring of HRH policies and strategies.