Drivers and Barriers to Improved Data Quality and Data-Use Practices: An Interpretative Qualitative Study in Addis Ababa, Ethiopia.

INTRODUCTION: An objective of the Information Revolution Roadmap of Ethiopia's Health Sector Transformation Plan was to improve health management information system (HMIS) data quality and data use at the point of health service delivery. We aimed to assess drivers of and barriers to improving HMIS data quality and use, focusing on key Information Revolution strategies including Connected Woreda, capacity building, performance monitoring teams, and motivational incentives. METHODS: We conducted an interpretative qualitative study across all 11 health centers in 3 subcities of Addis Ababa, Ethiopia: Yeka, Akaki-Kaliti, and Ledeta. A total of 40 key informant interviews and 6 focus group discussions with a total of 43 discussants were conducted. We coded information gathered line-by-line and grouped responses under thematic codes as they emerged. Findings were triangulated and validated. RESULTS: Our findings indicate that the main drivers of data quality and use at the point of service delivery were the use of the Connected Woreda strategy and its tools, capacity-building activities including mentorship, performance monitoring-team activities that led to active leadership engagement, and motivational incentives for data producers and users. Barriers to optimal data-use practices were the use of duplicative data collection tools at health facilities, under-developed health information system infrastructure, inadequate health information technician staffing and capacity limitations at the health facility level, insufficient leadership commitment, and unfavorable health worker attitudes toward data. DISCUSSION: Improvements in quality and use of HMIS data at health facilities are expected to result in delivering better-quality health services to the community as data enable health workers to identify gaps in health care, fix them, and monitor improvements. Future investments should focus on strengthening the promising data-use practices, resolving bottlenecks caused by duplicative data collection tools, enhancing individual and institutional capacity, addressing suboptimal health worker attitudes toward data, and overcoming infrastructure and connectivity challenges.

Maternal Service Coverage and Its Relationship To Health Information System Performance: A Linked Facility and Population-Based Survey in Ethiopia.

BACKGROUND: Studies in Ethiopia show an increasing trend in maternal health service use, such as having at least 4 visits of antenatal care (ANC4+) and skilled birth attendance (SBA). Improving the health information system (HIS) is an intervention that can improve service uptake and quality. We conducted a baseline study to measure current maternal service coverage, HIS performance status, and their relationship. METHODS: We conducted a linked health facility-level and population-based survey from September 2020 to October 2020. The study covers all regions of Ethiopia. For the population-based survey, 3,016 mothers were included. Overall, 81 health posts, 71 health centers, and 15 hospitals were selected for the facility survey. A two-stage sampling procedure was applied to select target households. The study used modified Performance of Routine Information System Management tools for the facility survey and a structured questionnaire for the household survey. Multilevel logistic regression was employed to account for clustering and control for likely confounders. RESULTS: Maternal service indicators, ANC4+ visits (54.0%), SBA (75.8%), postnatal care (70.6%), and cesarean delivery (9%) showed good service uptake. All data quality and use indicators showed lower performance compared to the national target of 90%. Maternal education and higher levels of wealth index were significantly and positively associated with all selected maternal service indicators. Longer distance from health facilities was significantly and negatively associated with SBA and the maternal care composite indicator. Among HIS-related indicators, availability of electronic HIS tools was significantly associated with maternal care composite indicator and ANC4+. CONCLUSIONS: Maternal service indicators showed promising performance. However, current HIS performance is suboptimal. Both service user and HIS-related factors were associated with maternal service uptake. Conducting similar research outside of the project sites will be helpful to have a wider understanding and better coverage.

Factors contributing to motivation of volunteer community health workers in Ethiopia: the case of four woredas (districts) in Oromia and Tigray regions.

BACKGROUND: The use of community health workers (CHWs) has been considered as one of the strategies to address the growing shortage of health workers, predominantly in low-income countries. They are playing a pivotal role in lessening health disparities through improving health outcomes for underserved populations. Yet, little is known about what factors motivate and drive them to continue working as CHWs. In this study, we aimed to examine factors contributing to the motivation of volunteer CHWs (vCHWs) in Ethiopia currently known as one-to-five network leaders (1to5NLs) and explore variations between attributes of social and work-related determinants. METHOD: We conducted a cross-sectional study in four selected woredas (the second lowest administrative structure in Ethiopia, and similar to a district) of Oromia and Tigray regions and interviewed 786 1to5NLs. The effects of each motivational factor were explored using percentage of respondents who agreed and strongly agreed to each of them and Mann-Whitney U test. RESULTS: Individual, community, and health system factors contributed to the motivation of 1to5NLs in this study. Intrinsic desire to have a good status in the community as a result of their volunteer service (81.86%) followed by a commitment to serve the community (81.61%) and to gain satisfaction by accomplishing something worthwhile to the community (81.61%) were some of the factors motivating 1to5NLs in our study. Despite these motivational items, factors such as lack of career development (51.47%), unclear health development army guideline (59.26%), limited supervision and support (62.32%), and lack of recognition and appreciation of accomplishments (63.22%) were the factors negatively affecting motivation of 1to5NLs. Lack of career development, limited supervision and support, and lack of recognition and appreciation of accomplishments were significantly varied between attributes of educational level, marital status, service year as 1to5NLs, and previous volunteer engagement (at P < 0.05). CONCLUSION: Findings of our study indicated that non-financial incentives such as the creation of career development models is the key to motivating and retaining CHWs where they are not receiving stipends. Sustainability of CHW program should consider exploring enhanced innovations to strengthen supportive supervision, development of better mechanisms to publicize the role of CHWs, and improvement of recognition and appreciation schemes for CHWs' efforts and accomplishments.

Ethiopia's health extension workers use of work time on duty: time and motion study.

Ethiopia implemented an innovative community-based health program, called the health extension program, to enhance access to basic health promotion, disease prevention and selected curative services by establishing health posts in every village, also called kebeles, with average of 5000 people, staffed with two health extension workers (HEWs). This time and motion study was done to estimate the amount of time that HEWs spend on various work duties and to explore differences in urban compared with rural settings and among regions. A total of 44 HEWs were observed for 21 consecutive days, and time and motion data were collected using tablet computers. On average, HEWs were on duty for 15.5 days out of the 21 days of observation period, and on average, they stayed on duty for about 6 hours per day. Out of the total observed work time, the percentages of total time spent on various activities were as follows: providing health education or services (12.8%); participating in meetings and giving trainings (9.3%); conducting community mapping and mobilization (0.8%); recordkeeping, reporting, managing family folders (13.2%); managing commodities and supplies (1.3%); receiving supervision (3.2%); receiving training (1.6%); travel between work activities (15.5%); waiting for clients in the health post (or health centre in urban settings) (24.9%); building relationships in the community (13.3%); and other activities that could not be meaningfully categorized (4%). The proportion of time spent on different activities and the total time worked varied significantly between rural and urban areas and among the regions (at P < 0.05). Findings of this study indicate that only a minority of HEW time is spent on providing health education and services, and substantial time is spent waiting for clients. The efficiency of the HEW model may be improved by creating more demand for services or by redesigning service delivery modalities.