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Ethiopia's Health Extension Program

A background paper prepared for the HEPCAPS11 project

Ethiopia HEPCAPS1 Series Paper #1, September 2012

Ethiopia HEPCAPS1 Series Paper #1 September 2012

2 | Ethiopia's Health Extension Program: A background paper prepared for the HEPCAPS project

The Developing the Long-Term Capability of Ethiopia’s Health Extension Program Platform project is funded by the Bill & Melinda Gates Foundation under Grant #OPP1032075. It was awarded to the President and Fellows of Harvard College/Harvard School of Public Health in November 2011. Suggested citation: HEPCAPS1 Project Team. 2012. Ethiopia's Health Extension Platform: A background paper prepared for the HEPCAPS1 project. Ethiopia HEPCAPS1 Series Paper #1. Boston, Massachusetts and New Haven, Connecticut: Harvard School of Public Health and Yale Global Health Leadership Institute.

Cover photograph taken by Carlyn Mann, Harvard School of Public Health 1Developing the Long-Term Capability of Ethiopia’s Health Extension Program Platform, is a project abbreviated as HEPCAPS1. This project is led by the Harvard School of Public Health and the Global Health Leadership Institute at Yale University (HEPCAPS1 Project Team) to work with Ethiopia's Federal Ministry of Health, and other relevant stakeholders, to create a platform of long-term strategies in line with Ethiopia's vision for an effective, adaptable, and sustainable Health Extension Program (HEP) - Ethiopia's primary health care system. HEPCAPS1 is the first phase of this project, and the second phase (HEPCAPS2) is planned to launch in January, 2013. HEPCAPS1 Project Team (in author order): Carlyn Mann, Harvard School of Public Health; Patrick Byam, Yale Global Health Leadership Institute; Erika Linnander, Yale Global Health Leadership Institute; Elizabeth Bradley, Yale Global Health Leadership Institute; Sarah Hurlburt, Harvard School of Public Health; Peter Berman (Principal-Investigator), Harvard School of Public Health



Acknowledgements We would like to extend a special thanks to the staff of the Federal Ministry of Health (FMOH) for their continued support and enthusiasm during this project; this includes Dr. Kesesteberhan Admassu, Dr. Roman Tesfay Mebrahtu, Dr. Ferew Lemma Feyissa, and Dr. Dereje Mamo Tsegaye. We would also like to thank everyone that facilitated setting up meetings and interviews in the field during our visit in March 2012, including staff from the FMOH, Regional Health Bureaus, Woreda Health Offices, Health Centers, Health Posts, and other government and non-governmental organizations in Addis Ababa, Amhara, Tigray, Oromia, and Southern Nations, Nationalities, and People's Region. We extend our thanks to all of the interview participants for their time and patience during our field visit. The logistics of our field visits would not have been made possible without support from the Last Ten Kilometers Project of John Snow International (L10K), especially from Ms. Wuleta Betemariam, and in-country Yale staff (Rex Wong and Zahirah McNatt). Although we were unable to visit both Gambela and Afar due to safety concerns, we would still like to thank the UNICEF country office, especially Luwei Pearson, for going out of their way to organize those visits for our team. This work would not have been possible without the support and guidance from The Bill & Melinda Gates Foundation and our Program Officer, Mary Taylor.

Please note: A previous version of this document stated a main source of information was from UNICEF’s Evaluation of Health Extension Program (2010) survey and was cited as UNICEF (2010); however the survey, and report that followed, was conducted by the Center for National Health Development in Ethiopia (CNHDE). When HEPCAPS1 Series Paper #1 was written, only a draft version of this report was available. Therefore the source of this information was corrected throughout this document and, where needed, tables and charts were updated based on the final CNHDE (2011) report.



Acronyms

AFB Acid-Fast Bacillus AIDS Acquired Immunodeficiency Syndrome AMREF African Medical and Research Foundation ANC Antenatal Care BCG Bacillus Calmette-Guerin BOFED Bureau of Finance and Economic Development BPR Business Process Re-engineering BSC Balance Score Card CBHI Community Based Health Insurance CDMA Code Division Multiple Access CHIS Community Health Information System CHS College of Health Sciences CJSC Central Joint Steering Committee CNHDE Center for National Health Development in Ethiopia COC Center for Competence CSA Central Statistical Agency [Ethiopia] EEPCo Ethiopia Electricity and Power Corporation EFY Ethiopian Fiscal Year EHNRI Ethiopian Health Nutrition Research Institute EMRI Ethiopian Millennium Rural Initiative ENAHPA Ethiopian North American Health Professionals Association FMOH Federal Ministry of Health GOE Government of Ethiopia GSM Global System for Mobile HC Health Center HCF Healthcare Financing HCFR Health Care and Financing Reform HDA Health Development Army HEP Health Extension Program HEW Health Extension Worker HHM HSDP Harmonization Manual HIS Health Information System HIV Human Immunodeficiency Virus HMIS Health Management Information System HP Health Post HSDP Health Sector Development Plan HRIS Human Resource Information System ICCM Integrated Community Case Management IT Information Technology ITN Insecticide Treated Net JCCC Joint Core Coordinating Committee JSI John Snow International, Inc. L10K Last 10 Kilometers LIS Logistics Information System



LMIS Laboratory Management Information System MCH Maternal and Child Health MDG Millennium Development Goal M&E Monitoring and Evaluation MOE Ministry of Education MOFED Ministry of Finance and Economic Development MTCT Mother-to-Child Transmission MUAC Mid-Upper Arm Circumference NGO Non-Governmental Organization NHA National Health Accounts ORT Oral Rehydration Therapy OS Occupational Standards PBS Protecting Basic Services PFSA Pharmaceutical Fund and Supply Agency PHC Primary Health Care PHCU Primary Health Care Unit PMTCT Prevention of Mother-to-Child Transmission PNC Post Natal Care SBA Skilled Birth Attendant SHI Social Health Insurance SNNPR Southern Nations, Nationalities, and People's Region RHB Regional Health Bureau RUTF Ready-to-Use Therapeutic Food TB Tuberculosis TOT Training of Trainers TT Tetanus Toxoid TVET Technical Vocational and Education Training UHEP Urban Health Extension Professional UNICEF United Nations Children's Fund VCT Voluntary Counseling and Testing WHO World Health Organization WOFED Woreda Finance and Economic Development WorHO Woreda Health Office ZoHO Zonal Health Office



EXECUTIVE SUMMARY

Introduction

In 2004 the Government of Ethiopia implemented the Health Extension Program (HEP) to be the main vehicle for reaching people in the rural areas of Ethiopia. Health extension workers (HEWs) promote health at the kebele (village) level by implementing 16 clearly defined health service packages (Appendix A) and by service with the health development army. The early successes of the HEP led to expansion from rural agrarian communities into pastoral and agro-pastoral communities in 2006 and into urban communities in 2010. The HEP built upon the primary health care unit (PHCU) structure, and this structure is quite different between rural and urban areas. Rural PHCUs comprise of health posts (HPs), health centers (HCs), and, eventually, a primary hospital planned to serve 100,000 people. Urban PHCUs consist of HCs and urban health extension professionals (UHEPs), and serve 40,000 people. The Federal Ministry of Health (FMOH) of the Government of Ethiopia (GOE) seeks to conceptualize a plan for the long-term (20 years) capability of the HEP. Supported by the Bill & Melinda Gates Foundation, the Harvard School of Public Health and Yale Global Health Leadership Institute are working with the FMOH to achieve this goal, and therefore sought to better comprehend the current situation of the agrarian, pastoral, and urban HEP. Rather than prepare a comprehensive summary of the extensive data available, this situation analysis is organized around 5 main observations that the Harvard and Yale team (HEPCAPS1 Project Team) has made based on extensive literature review and interviews in the field.

Observation 1 Rapid scale up in HEP capacities, especially HEWs, has resulted in substantial increases in outputs related to promotion, prevention, and service use; representing real and significant progress in access and equity of basic primary health care (PHC) services.

Observation 2 Despite Observation 1, there remain unfulfilled objectives for HEP where some outputs still remain below desired levels, and there is large variation across regions and within regions.

Observation 3 Different HEP models reflect recognition of different environments in a diverse Ethiopia, but challenges in meeting perceived needs and demands of populations persist. The new models (urban, pastoral) face specific challenges to become successful, sustainable PHC platforms.

Observation 4

GOE developed an innovative approach to train HEWs to enable rapid scale up and continues commitment to improving HEW skills and skills of other HEP staff (PHC staff, supervisors, planners, etc.) through approaches like integrated refresher training, expanding other health worker training, etc. There are still important problems with training quality, support for trainees, and efforts to upgrade skills needed for improving quality and effectiveness.

Observation 5

Operating processes for HEP are evolving constantly, with significant changes in roles and responsibilities for different levels of the organization (e.g., region, zone, woreda), changes in supervision (HEWs now more under PHC), performance management processes (“balanced scorecard” or BSC), new information systems, financial incentives (“health care financing”). Although they can help energize organizations, these changes can also lead to uneven implementation and uncertainty, impeding effective management.

Methodology

This situation analysis draws from a comprehensive literature review, including data used from Ethiopia’s Demographic Health Surveys or DHS (2000, 2005, and 2011) and Ethiopia Health Extension Program Evaluation Study (2007-2010) conducted by the Center for National Health Development in Ethiopia (CNHDE), as well as extensive interviews conducted in the field. From February 27 – March 30, 2012 the HEPCAPS1 Project Team conducted 50 key informant and group interviews with stakeholders



from the government, partners, and community. (See Appendix B for stakeholders that were interviewed.) Key Findings on the Observations

Observation 1

The rapid scale up in HEP capacities, especially HEWs, has resulted in substantial increases in outputs related to promotion, prevention, and service use which represents real and considerable progress in access and equity of package of basic PHC services. Ethiopia has shown great improvements in infant mortality (88/1,000 live births in 2011 down from 166/1,000 in 2000) and under-5 child mortality rates (59/1,000 live births in 2011 compared to 97/1,000 in 2000) (CSA and ICF International, 2012; CSA and ORC Macro, 2006). Given these figures, Ethiopia appears to be on track in reaching the Millennium Development Goal (MDG) 4. Ethiopia's effort to achieve MDG 4 is mostly due to a rapid increase in disease prevention and control as well as an increase in vaccinations. There has been a steady increase in percentage of households with access to piped water supply, minimizing contamination; and a little over half (54%) of the Ethiopian population uses some form of improved source of drinking water in 2011, a considerable increase from 2005 (35%) (CSA and ICF International, 2012). Additionally, mothers’ health-seeking behavior for children with diarrhea has increased considerably from only 13% in 2000 to 32% in 2011 (CSA and ICF International, 2012). Immunizations are one of the most cost-effective public health interventions for reaching MDG 4. According to the latest DHS report (2011), 24% of children (12-23 months) were fully vaccinated (CSA and ICF International, 2012). Although this is not very high, it is about a 70% increase compared to coverage in 2000 (14%) (CSA and ICF International, 2012). Along with improvements that greatly influence child health outcomes, there have been a number of improvements in indicators that affect maternal and even paternal health. The use of contraceptives has increased over the last 20 years, from 5% in 1990 to 29% in 2011; coinciding with a steady decline in ideal family size (CSA and ICF International, 2012). Additionally, more women are receiving antenatal care (ANC) from a skilled provider. With Ethiopia’s HIV prevalence rate at 2.4%, it is encouraging to see the percentage of adults tested for HIV increase by 10 folds for both men and women (UNDP, 2010; CSA and ICF International, 2012). Knowledge of prevention of mother-to-child-transmission (PMTCT) increased considerably from 20% in 2005 to 42% in 2011 (CSA and ICF International, 2012). Observation 2

Despite the successes of the HEP, especially in the rural agrarian communities, a number of objectives are unfulfilled with some outputs still well below the desired levels. There is also a large variation across regions (and, likely, within regions), due to geographic, cultural, and political differences. Although a majority of the regions’ HEWs are providing 80-100% of the service packages, there are some regions (e.g., Afar and Gambela) where there is a wide range of variation in services being offered, and this lack of services may influence health outcomes in these areas. Fully vaccinated children remain very low (24% in 2011) especially in pastoral regions where health coverage has proven to be a challenge (CSA and ICF International, 2012). For hygiene and sanitation, a majority of households, 90%, do not treat their drinking water as well as only 27.2% people are hand washing at least 3 out of the 5 critical times in a day (CNHDE, 2011a; CSA and ICF International 2012). Additionally, exclusive breastfeeding is extremely low in Dire Dawa, around 10% for both under 4 and 6 months old (CNHDE, 2011a). According to CSA and ICF International (2012), 29% of children are underweight while 9% of children are severely



underweight; where the highest underweight rates are among the pastoral regions, Afar and Somali (40.2% and 33.5%, respectively). Despite substantial focus on family health services, there has been little improvement in Ethiopia's maternal mortality rate. Ethiopia struggles to reach its targets for institutional deliveries, mainly in rural areas (2.3% in 2005 to 4.1% in 2011) and post-natal care ups (0.2% in 2005 to 5% in 2010) (CSA and ORC Macro, 2006; CSA and ICF International, 2012; CNHDE, 2011a). These are two important indicators for maternal health. It appears that the HEP alone may not be sufficient to achieve the maternal health MDG (5). As of 2011, the maternal mortality rate was 676 per 100,000 live births (CSA and ICF International, 2012). Despite Ethiopia's achievements, inequitable access to health facilities due to lack of critical infrastructure (access to safe water, electricity, proper waste disposal, passable road networks, etc.) and low quality of care within the health facilities are major contributors to the high maternal mortality rate. Observation 3

In recognition of Ethiopia’s demographic differences, the FMOH has developed 3 distinct models of the HEP (urban, agrarian and pastoral) to better suit the needs of these communities. While these different HEP models reflect the diverse environmental, social, and cultural contexts, all 3 of them face challenges in meeting the perceived needs and demands of the populations they serve. This is especially the case for the more recently developed pastoral and urban models. The agrarian model is the gold standard for the HEP and has achieved much success in meeting many of the health prevention needs of the communities. However, community members are increasingly demanding curative services which HPs and HCs are often not well suited to provide. The agrarian model will eventually need to be adapted to reflect changing community demands. In order to address the differences between the agrarian and urban context, the urban HEP has been tailored to address the needs of urban communities (refer to Appendix A for the 15 service packages that UHEPs implement). However this adaptation of the HEP has not fully met people’s demands. For example, UHEPs focus on preventative rather than curative, and their main visiting hours are during the day when most urban dwellers are not at home. Additionally, certain prevention methods might not be adequately tailored for urban environments given issues with space and land ownership (e.g., building latrines and seepage pits for food waste). Despite many modifications to the HEP model, the urban HEP is still primarily based on the agrarian context and not necessarily on urban need. The pastoralist HEP has been slightly modified from the agrarian context but falls short in meeting the needs of the highly dispersed mobile populations seen in the pastoral regions. The pastoralist HEP was not developed, piloted and evaluated in consultation with relevant stakeholders. As a consequence, interventions relevant to agrarian livelihoods such as spring water protection, housekeeping, and construction design were emphasized during training as opposed to topics relevant to pastoral livelihoods including: hand dug wells, health and mobility, and housing and latrine design pertinent to arid climate (AMREF, 2010). The result is that the pastoral HEP does not fully address the needs of pastoral communities. Observation 4



The GOE has developed an innovative approach to train HEWs to enable rapid scale up and continues its commitment to improve HEW skills and skills of other HEP staff (PHC staff, supervisors, planners, etc.) through things like integrated refresher training, expanding other health worker training, BSC management tools, etc. According to key informant interviews there are inconsistencies across regions with training quality, support for trainees, and efforts to upgrade skills needed for improving quality and effectiveness. The need for quality performance from HEWs is especially important given extremely low coverage of medical doctors, health officers, and midwives in Ethiopia. Despite a standardized exam provided by the center of competence (COC), there is high regional variation in competency and quality of services provided by HEWs and UHEPs. The FMOH sets the occupational standards for HEWs and UHEPs, and based on these the Technical Vocational and Education Training (TVET) Agency develops guidelines and model curriculum for TVETs and College of Health Sciences (CHS) to follow when training both HEWs and UHEPs. Upon visiting a CHS in Mekelle, Tigray and interviewing HEWs/UHEPs, it was clear that the inability to obtain high quality trainers as well as the training materials written in advanced English, which is incompatible with the HEWs level of education, adversely effects the training that HEWs/UHEPs receive and ultimately performance. However, one way that the TVET Agency is aiming to address the funding and lack of expertise issues is by instituting ‘cooperative training’ (onsite learning). As part of HEWs/UHEPs ongoing training, integrated refresher training courses are offered - improving their skills and expertise. During our field visit, it appeared that regions were offering these courses fairly regularly, with an exception of Amhara (at the time of interview, HEWs had not received any of these trainings but were expected to start the following month). The FMOH envisages for HEWs to ultimately become “family physicians”, and have a new long-term strategic plan to reach this goal, which is comprised of credit-based training. This type of training would be based on HEWs committing to years working in kebeles in order to receive a higher learning – reducing the possible brain drain of skilled health workers. Observation #5

Operating processes for HEP are evolving constantly, with significant changes in roles and responsibilities for different levels of the organization (e.g. region, zone, woreda), changes in supervision (HEWs now under the PHCU), performance management processes (BSC), new information systems, healthcare facilities and other critical infrastructure, and financial incentives (“health care financing”). These changes/reforms can help energize organizations, but they can also lead to uneven implementation and uncertainty, impeding effective management. Implementation of the HEP follows Ethiopia's decentralized political and administrative organization. The FMOH is responsible for developing policy and planning, while each region is responsible for implementing federal policy. The FMOH is divided into 17 newly created directorates, many of which contribute to the HEP. Therefore the tasks for monitoring and decision-making are split up among the appropriate directorates. Although the division of expertise is somewhat efficient, this system may result in disjointed monitoring and decision-making. Ultimately, this may lead to sub-optimal implementation of the HEP. Ethiopia has a detailed Health Sector Development Plan (HSDP), and works in collaboration with national financing mechanisms. The plan is harmonized across all levels of government and is developed in



collaboration with donors. The Health Management Information System (HMIS) and the Community Health Information System (CHIS) play important roles in informing the planning process. Supportive supervision of the PHCU is the responsibility of all levels of government with each level within the government playing distinct roles. With the construction of primary care hospitals and changing reporting structures, supervisory roles within the PHCU are ever evolving. Supportive supervision models vary by region and between the agrarian, urban and pastoral models. Critical health infrastructure (health facilities, roads, water, electricity and telecommunications) have transformed dramatically in the last 5 years and will continue to do so in the upcoming years with a profound impact on both households and primary health care facilities across Ethiopia. Since the Health Care Financing Reform (HCFR) Strategy was passed in 1998, health care financing is seen as a sustainable way for hospitals and health centers to procure drugs and supplies as well as provide minor infrastructure improvements. This level of autonomy is increasingly important given the share of GOE’s health expenditure contribution has decreased over the years (20.9% in 2007/2008 compared to 38.82% in 1995/1996) (FMOH 2010c; FMOH 1998). This has led to external donors funding mostly prevention care for maternal and child health and prevention of communicable diseases – suggesting that the HEP is particularly reliant on this funding source. Despite an increasing level of autonomy in government health institutions achieved by retaining revenue for quality improvements, cost burdens for households increased due to an increase in out-of-pocket expenses partially influenced by a growing involvement of the private sector. To address the increasing need for more sustainable financing mechanisms for health care, the GOE has recently focused its efforts on developing health insurance for the formal and informal sector as well as performance-based financing in order to assure quality services. Conclusions

Overall, there has been a very positive and impressive increase in access to health promotion, prevention and curative services through the HEP. Over the last 8 years, rapid expansion of critical health infrastructure, human resources and health worker capacity has resulted in dramatic improvements in performance indicators including under-five mortality. Ethiopia is a bit closer to being on track to reaching MDG 4, attributed to improvements in access to safe water supply, construction of latrines, and personal hygiene - contributing to decreases in diarrhea and fever prevalence. However, Ethiopia still faces many hurdles in its quest to attain the health outcomes of a middle-income country in the next twenty years. In order for Ethiopia to achieve MDG 5 in the next 3 years there is a need to dramatically improve health indicators like institutional deliveries and ANC. It appears that the HEP alone will not be able to accomplish the achievement of MDG 5. High variability across regions, pastoral and urban HEP models inadequately meeting populations’ needs presents a need for new strategies to improve the quality, effectiveness, and sustainability of the HEP. Despite the extensive findings presented in this situation analysis, some areas that influence HEP outcomes are not covered in this paper. These main areas are:

Variations within regions, especially across different communities.

Variation in human resource capacity and its development as Ethiopia transitions into a middle-income country.



Understanding the day-to-day performance of HEWs, UHEPs and HEW supervisors.

A more in-depth understanding of the pastoral HEP.

The future of capacity building efforts for the urban HEP.

The effectiveness of the health development army (HDA) and cost burden on households becoming model families.

Performance of health care financing, and the future direction of Ethiopia's health expenditure.

Role and development of the private sector and its influence on the HEP.

Understanding the inter-sectoral relationships with the FMOH that may affect the growth and development of the health sector.

While these knowledge gaps exist, this analysis helped us comprehend the current state of Ethiopia’s HEP and furthered our understanding of areas where we could help the FMOH develop key strategies for the long-term development of Ethiopia’s primary care system.



APPENDIX A: SERVICE PACKAGES FOR HEP MODELS TABLE A1: SERVICE PACKAGES AND COMPONENTS FOR THE AGRARIAN/PASTORAL MODELS

AGRARIAN/PASTORAL SERVICE PACKAGES*

HYGIENE AND ENVIRONMENTAL SANITATION:

1 Building and Maintaining Healthful House 2 Construction, Usage and Maintenance of Sanitary Latrine 3 Control of Insects, Rodents and other Biting Species 4 Food Hygiene and Safety Measures 5 Personal Hygiene 6 Solid and Liquid Waste Management 7 Water Supply Safety Measures

FAMILY HEALTH SERVICE:

8 Family Planning 9 Maternal and Child Health 10 Vaccination Service 11 Nutrition 12 Adolescent Reproductive Health

DISEASE, PREVENTION, AND CONTROL:

13 HIV/AIDS and Tuberculosis Prevention and Control

14 Malaria Prevention and Control 15 First Aid

HEALTH EDUCATION AND COMMUNICATION:

16 Health Education and Communication

* Later the service packages increased to 17 to include emergency services

TABLE A2: SERVICE PACKAGES AND COMPONENTS FOR THE URBAN HEP MODEL

URBAN SERVICE PACKAGES

ENVIRONMENTAL HYGIENE:

1 Solid and Liquid Management 2 Personal and Occupational Hygiene 3 Food and Water Hygiene 4 Latrine Construction and Usage FAMILY HEALTH SERVICE:

5 Maternal and Child Health 6 Vaccines 7 Reproductive Health 8 Family Planning 9 Nutrition

DISEASE PREVENTION:

10 Malaria 11 Tuberculosis/Leprosy 12 HIV/AIDS Prevention and Control 13 Non-Communicable Diseases 14 Mental Health ACCIDENT/PREVENTION INJURY

15 Accident/Prevention of Injury



APPENDIX B: INSTITUTIONS INTERVIEWED BY REGION The table below outlines institutions interviewed in March 2012 as part of the situation analysis. The rationale for each visit is described in the column adjacent to the list of institutions/interviewees. TABLE B1: DATA COLLECTION METHODOLOGY FOR SITE VISITS

Region Health Institutions/ Community

Reason for Site Visit

Mekelle, Tigray

1 Health Post (1 HEW) 2 Health Center 3 2 Woreda Health Offices 4 Regional Health Bureau 5 College of Health Sciences

One of the "Big 4" regions, Tigray provides insight in the agrarian HEP systems and structure.

North Shoa, Oromia

1 Regional Health Bureau 2 Woreda Health Office 3 Upgraded Health Post to

Health Center 4 Health Post (2 HEWs) 5 Model Family

One of the "Big 4" regions, Oromia provides insight in the agrarian HEP systems and structure. Additionally, how a region adjusts to the shift to the health centers supervising the health posts.

Bahir Dar, Amhara

1 Regional Health Bureau 2 Woreda Health Office 3 Health Center 4 Health Post (2 HEWs) 5 Town Administration 6 4 Urban Health Professionals 7 3 Urban Health Professional

Supervisors

One of the "Big 4" regions, Amhara provides insight in the agrarian HEP systems and structure. The urban HEP is a relatively new model and wanted to understand the struggles and successes as well as the effectiveness of implementing a rural conceptualized model in an urban setting, especially outside a large city administration like Addis Ababa.

Awassa, SNNPR

1 Regional Health Bureau 2 Health Center (upgrade to

hospital) 3 JSI 4 3 Urban Health Professionals 5 1 JSI Regional Supervisor

One of the "Big 4" regions, SNNPRR demonstrates a unique case of upgrading a health center into a hospital financed by the revenues generated. Additionally, wanted to understand the urban HEP outside a large city administration like Addis Ababa.

Addis Ababa

1 Federal Ministry of Health 2 City Administration Health

Bureau 3 TVET Agency 4 Ministry of Agriculture 5 Ministry of Civil Service 6 Agriculture Transformation

Agency 7 EHNRI 8 JCCC 9 Woreda Health Office 10 5 Urban Health Professionals 11 3 Urban Health Professional

Supervisors 12 Model Family 13 Partners (JSI, UNICEF, UNFPA,

IFHP, Tulane, L10K, AMREF)

To understand the roles and responsibilities of the various Ministries and their involvement in the 3 HEP models as well as partners. The urban HEP is a relatively new model and wanted to understand the struggles and successes as well as the effectiveness of implementing a rural conceptualized model in an urban setting.



APPENDIX C: DIFFERENCES BETWEEN THE URBAN, AGRARIAN AND PASTORAL PROGRAMS (OBSERVATION 3) The data presented below describe the Education and Selection Criteria; Program Implementation and Partner Support; Community Orientation and Support; Capacity Building Efforts; Budget, Reporting and Supervision; and General Challenges for each of the 3 Health Extension Programs (Urban, Agrarian and Pastoral). TABLE C1: EDUCATION AND SELECTION CRITERIA

TABLE C2: EDUCATION AND TRAINING



TABLE C3: PROGRAM IMPLEMENTATION AND SUPPORT

TABLE C4: COMMUNITY ORIENTATION



TABLE C5: COMMUNITY ORIENTATION AND CAPACITY BUILDING

TABLE C6: BUDGET, REPORTING AND SUPERVISION



TABLE C7: GENERAL CHALLENGES



APPENDIX D: SUPERVISORY ROLES AND RESPONSIBILITIES TABLE D1: REGIONAL HEALTH BUREAU

Agrarian Model

Amhara Tigray Oromia SNNPR

4 groups take a sample of HPs, HCs, WorHOs, and visit every ZoHO for bi-weekly evaluations to identify problems, create action plans, sign agreement, and teams will provide necessary technical support.

Teams (various disciplines), deployed by-annually, use standardized checklist from RHB to assess and provide feedback to WorHOs, HCs, HPs, Women’s Groups, and households. Takes 1 month to conduct, and 1 team (approx. 8 people) is assigned to 5 woredas and spend 5-6 days in each woreda.

Very little information collected on supportive supervision at the RHB, many tasks were delegated to ZoHO, in which the RHB would monitor but only stated financial support.

Monthly review meetings (460 members attend: WorHO Heads, selected HEWs, ZoHO Heads, major development partners, and other stakeholders). Regional management team assigned to provide support in implementing plans from meeting and meet weekly.

Urban Model Pastoral Model

RHBs not really involved in providing supportive supervision for the lower administrative levels. City Administration provides any support, and therefore provides supportive supervision to the supervisors that sit at the HCs on a monthly basis and periodically evaluate the HCs and UHEPs performance.

Unable to interview RHBs to understand supportive supervision at regional level. However, SNNPRR has a Bureau for Pastoral Areas that provides support to the lower institutions.

TABLE D2: ZONAL HEALTH OFFICE

Oromia SNNPR Amhara

No information given by RHB and did not interview ZoHO.

ZoHOs are responsible to implement, coordinate, follow-up on disease and prevention activities, expand facilities within the zone, and increase healthcare financing. Every 2 months there are review meetings with the zones and 'special woredas' to report performance of each zone/special woreda. [There are 4 ‘special woredas’, where each woreda is a different nationality and could not formulate a zone.]

Amhara has 3 unique zones, the ZoHO acts more like a RHB; however did not receive information on how it provides supportive supervision.

TABLE D3: WOREDA HEALTH OFFICE

Agrarian Model

Amhara Tigray Oromia SNNPR

All staff, except the Head and Vice President are assigned to a cluster (8 total) and depending on population 1-2 staff per cluster to supervise. Assigned staff sit at a HC for 1 month to review performance and provide technical support to HCs and HEWs. During this time also take a sample of HPs to check if performing well.

Variation within region. In Wukro, the WorHO staff visit health post 2 times per year, more often if needed.

In Adigudum, supervisor for HC GOEs every two weeks and visit HPs, under the catchment area, monthly. 3 ways performance evaluated: 1. HEWs have work plans and

WorHO officials go to the HC to monitor their performance (not clear how often). Additionally, WorHO regularly monitors HC budget and conducts annual audits.

WorHOs conduct monthly meetings with facility heads to review performance and identify gaps.



Supervisors report back to the WorHO and stay there for one week before heading back to the HC. WorHO compiles all reports and every 3 months ranks each cluster based on performance in accordance with Woreda Plan.

supervisors review plans and identify gaps and current situation. 2. Community satisfaction surveys (administered on average 15 households/kebele to understand how HEWs are performing in community) - done randomly and annually (majority of times different households assessed). 3. Sample households to observe performance.

Urban Model

Addis Ababa Amhara: Bahir Dar

3 supervisors in Woreda 7 (equivalent to 1 supervisor for every 3-5 UHEPs). This woreda is unique because the UHEPs have an office next to the WorHO and therefore have contact on a daily basis, and every 15 days there is a meeting (including UHEPs, supervisors, and head of HC) to discuss referral linkages and types of referrals. UHEPs fill out reports (including number of home visits) and send to WorHO supervisors for review. Based on reports, the supervisors work with the UHEPs to prioritize problems to address, typically:

1. Poor liquid waste management and disposal system. 2. Poor latrine utilization and management system 3. Unsanitized kitchen and food preparation 4. Poor solid waste management and disposal system 5. Low VCT coverage 6. Low family planning coverage

There are weekly meetings between the supervisors, UHEPs, and Kebele Administrator to evaluate performance of UHEPs and provide feedback. Additionally there are daily review meetings, usually in the mornings, between the UHEPs and Kebele Administrator.

TABLE D4: HEALTH CENTER

Agrarian Model

Tigray Oromia Amhara

2 supervisors to cover 6 HPs. Supervisors visit weekly, and the only way to communicate is during visits. If a HP needs drugs and supplies then would have to wait the following week.

Supervisors visit HPs every 2 weeks, and if needed agree on a revised workplan which is discussed with Kebele Administrator.

Urban Model

SNNPR: Awassa

There are three different forms of supervision in this region for the urban HEP: 1. UHEPs attend weekly review meetings at the HC, and use this opportunity to pick up any necessary drugs. 2. A supervisor from the HC provides technical support on a daily basis - usually in the mornings. 3. Every month, the supervisors evaluate the UHEPs workplans using a standardized checklist.



APPENDIX E: ADDITIONAL INFORMATION ON THE PLANNING AND PROCESS FOR THE HIS FIGURE E1: FLOW OF MONITORING REPORTS

Source: FMOH, 2007

These data are reported according to the following reporting schedule: TABLE E1: REPORTING SCHEDULE FOR THE MONITORING REPORTS

Source: FMOH, 2007



APPENDIX F: HEALTH POST INFRASTRUCTURE TABLE F1: COMPARISON OF RESULTS OF 2007 AND 2010 SURVEYS IN THREE REGIONS, OROMIA, SNNPR, AND AMHARA

Indicators (N=53) (N=174)

A. Characteristic of Health Facilities 2007 2010

Percent of HPs with the following characteristics % of HPs

HPs with at least 2 room infrastructure 98 79.3 HPs with a separate room for delivery service 81.1 72 HPs staffed as per the HEP standard 64.2 89.9 HPs supported by CHWs/vCHP 80.1 75.6 HPs with toilet accessible to clients/patients 64.2 77.2 HPs with access to safe water source 11.3 41.4 HPs with medical waste disposal mechanisms 54.7 72.5 HPs with electricity 5.6 11 HPs with access to telephone (mobile/landline) 3.8 69.6 %with access to mobile phone - 52.6 % with access to land line - 28

B. Service Provision and Organization 2007 2010

Percent of HPs open for service % of HPs

HPs opened at least five days per week 26.5 50.1 HPs opened on Saturdays and/or Sundays 56.6 63.4

C. READINESS OF HEALTH POSTS TO PROVIDE HEP SERVICES 2007 2010

1) Percent of HPs equipped with at least 60% of medical equipment for % of HPs Delivery and newborn care 22.6 57.3 Child care 30.2 33.2 Immunization 67.9 64.4 First aid care 32.1 46.7 2) Availability of drugs and supplies on day of survey % of HPs Oral contraceptives 79.3 78.1 Depo-provera injections 81.1 78.6 Condoms 56.6 61.4 Any contraceptive drug 86.8 85.4 Coartem (ACT) 64.2 45.3 ORS 58.5 64.2 Iron tablets 24.5 45.3 Folic acid 18.9 5.8 3) Percent of HPs with no stock-outs in 3 months preceding the survey % of HPs Oral contraceptives 67.9 66.4 Depo-provera injections 62.3 66.2 Coartem (ACT) 45.3 37.5 ORS 47.2 53.9 4) Percent of HPs where vaccine was available on day of survey % of HPs BCG 26.4 7.7 DPT-HEPS-HIB 34 8.2 OPV 34 7.5 Measles 28.3 7.7 TT 32.1 8.2 All vaccines 23 6.5

Source: CNHDE, 2011b



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