Strengthening health SyStemS for improved Service deliveryA Case Study of a Primary Health Care Unit in Kokosa Woreda, Oromia

Kokosa Woreda, located 120kms south of West Arsi Zone in Oromia gives oversight to 22 rural and two urban kebeles serving a total of 169,712 people with promo-tive, preventive, and curative services. In Kokosa Woreda, there are six functional primary health care units (PHCUs). Nurye Abuna, Head of Kokosa Woreda Health Office, describes the PHCU as a health service delivery system in which the health center serves as the main coordinating unit of the activities of health posts in its area. Each health center manages an average of five health posts. In addition to their day-to-day activities, health centers take the re-sponsibility of assisting health posts in on-the-job training as well as sharing their allocated budget. The woreda plays a supporting role, allocating budgets, assigning the required staff and monitoring the day-to-day operations.

To ensure efficient health service delivery, Kokosa Woreda Health Office has empowered and motivated the health workers and support staff. Decentralization and good governance are at the heart of the woreda’s management practices. The Woreda builds the capacity and confidence of health center heads to exercise their authority and make important decisions. Woreda health office experts are assigned to assist PHCUs to ensure functionality and quality service delivery. Under-performing health centers receive special attention from the woreda health office.

The woreda is transparent in its budget allocation and utilization. Each health center is made aware of its yearly operational budget. Health centers are also encouraged to properly use their retained income to improve services. In the current fiscal year, the six health centers in Kokosa have collected an average of birr 200,000 each in retained revenue in addition to the annual block grant the woreda health office allocates for them.

The woreda’s encouragement and support also extends to health posts. The woreda allocates annual budgets for the routine operation cost of health posts through the PHCU in which they are found. In this fiscal year, birr 66,000 has been allocated for each health post in Kokosa, of which, 24,000 is to pay per diem for HEWs when they are required to come to the health center for work purposes. The remaining budget is used to purchase items needed for day-to-day operations such as stationery. Accord-ing to Nurye, Kokosa Woreda has greatly benefited from the rigorous application of the government-introduced reforms such as business process re-engineering, health care financing (HCF) and health management information system (HMIS).

Kokosa Woreda Health Office takes an active role in man-aging the PHCUs in its area. The health office reviews the regular reports it receives from the PHCUs, makes assess-ments to verify the reports, and makes decisions based on the analysed information. It also convenes an annual review meeting with all health staff to evaluate performance through the management tool of SWOT analysis(strengths, weaknesses, opportunities and threats). Strengths and weaknesses are identified and plans are made based on identified gaps. The woreda then prepares a memorandum of understanding (MOU) that describes the identified gaps and the measures that need to be taken. The MOU is signed by each health center. The quarterly and yearly review meetings which follow begin with an assessment of

Roles of KoKosa WoReda HealtH office

This is a meeting of health center heads and midwives convened by Kokosa Woreda to discuss maternal and newborn health issues and recognize the best perform-ing health center in skilled birth attendance. Kediro Shumbura, a Midwife, was awarded for assisting 185 deliveries in nine months.

Kediro Shumbura (R)

2

Nurye Abuna, Head of Kokosa Woreda Health Office

the extent to which each health center has accomplished the activities in the MOU. This has helped to compare the performance of health centers. Health centers are encouraged to compete amongst themselves and the woreda health office awards the most outstanding cent-ers in an annual event. Health centers also recognize their best performing staff and provide awards every quarter in their respective offices.

Since the implementation of the reforms, particularly the PHCU system, the woreda has significantly improved the quality of services. Families receive improved maternal, newborn and child health services at all levels in a timely

manner. The woreda acknowledges that though there are encouraging results, there is a long way to go to maintain the achievements and continue to progress in all of the health indicators. The woreda health office counts on its highly dedicated and motivated health and support staff in the health system and appreciates the support from the USAID-funded Integrated Family Health Program (IFHP). As described by Nurye, “IFHP is part and parcel of our health system and participates in the planning, implemen-tation, and monitoring of activities. All of IFHP’s capacity building trainings are accompanied by follow up and on-the-job support. Our woreda has greatly benefited from the program.”

3

Binyam Bekele is the Head of Kokosa Health Center. The health center with the five health posts in its catchment is serving 32,000 people. Kokosa Health Center is respon-sible for providing promotive, preventive, and curative services at the facility. Binyam works hard to ensure that his team perform to their utmost capacity to provide quality health services.

In addition to the services provided at the health center, each health worker is responsible for supporting a health post for successful implementation of the Health Exten-sion Program (HEP). The health workers participate in community mobilization activities and assist health posts technically. Previously, there was only one person in a health center who supervised health extension workers. However, all health center staff now recognize the impor-tance of extending technical and on-the-job assistance to the health posts to bring about tangible improvement.

Kokosa Health Center allocates resources to provide health posts with supplies such as stationery, work gowns, and name tags. When health posts declare open defeca-tion free (ODF) villages, the health center covers the cost to make signboards for the kebeles. It also allocates mon-ey for building model houses in health post compounds for the purpose of educating the kebele communities.Alongside assisting health posts technically, the health center staff also attend the weekly kebele meetings that discuss about health. They use the opportunity to edu-

cate the community and provide services such as preven-tion of mother to child transmission (PMTCT), family planning such as implant insertions and removals, and vol-untary counselling and testing. Kebeles compete among themselves and when the best performing kebeles with increased number of model household are recognized in public, the HEW as well as the responsible health center staff are also recognized. This has created increased self-esteem for the health center staff and has set an example for others.

Binyam says, “Our effort to improve health services has paid off. Eight years ago, there were so many communica-ble diseases in our kebeles. Very few children were vac-cinated and most families did not use our antenatal, post natal, or delivery services. Very few women utilized our family planning services. Now, the health practices of the communities has improved due to the increased aware-ness and utilization of the health extension program. Even more so after the PHCU system was introduced.”

Kokosa Health Center is recognized on several occasions for providing quality comprehensive health services and has been awarded for its best performance and imple-mentation of the reforms, integration of services, staff capacity building, and sustainable for the last three years. It makes efficient use of the income it retains through the health care financing (HCF) to improve services and to support the health posts under it.

This sign board announces Guutu Kebele has been declared an open defeca-tion free kebele. Everyone in the kebele has a latrine and they use it properly. Kokosa Health Center paid for this sign board from its retained income.

HealtH centeR PeRsPective

4

Binyam expresses his appreciation to IFHP for its sup-port in capacity building for health professionals and health managers, logistics support such as family planning commodities, as well as maternal health equipment and supplies, and far-reaching technical support through its follow-up visits and performance review meetings. “The

kind of support we get from IFHP,” continues Binyam, “has enabled us to improve our services in a sustainable manner, to use our resources effectively, and to serve our community efficiently.”

Binyam Bekele, Head of Kokosa Health Center

5

“I have been serving the Guutu kebele community as a health extension worker for the past six years,” explains Safaye Torbi. “When I began work at Guutu Health Post, there were so many health problems in the kebele. Chil-dren were not vaccinated. The residents did not know the benefits of using latrines and sanitation was very poor, resulting in poor health. Families did not use family planning services. Pregnant women were not aware of maternal and newborn health services. The magnitude of the problem was overwhelming at first which made me realize I cannot solve these problems on my own. Soon my colleague and I began to collaborate with the kebele administration to find solutions. We began educating the community on the sixteen Health Extension Pro-gram elements by going house-to-house and speaking with community members who were visiting the health post. Formerly volunteers and now health development armies are our right hands to reach the community with various health messages.”

Safaye describes, “The health of the community has improved over time. Families have become aware of family planning services and use both long and short acting methods. All children in our kebele are vac-cinated. Pregnant women have become active seekers of maternal health services. The kebele is all in all clean and free of open defecation as all household has built and used their latrines properly. Diarrheal diseases have significantly decreased. Families are cautious for

their health now. This improvement in the community’s health is a result of the coordinated effort of everyone in the kebele, and the continuous support that we at the health post get from the woreda and the health center to do our job. The health center staff visit our health post every week to provide services to the community, with focus on pregnant women, and to assist us with our work.” Safaye knows that improving health in her community will continue to be a team effort and will require the support of the health center and woreda health of-fice. “The health center and the woreda health office are dedicated to support us. They perform supportive supervision, guide us to identify drawbacks and, together with the kebele administration, they help us get solu-tions. They also congratulate and encourage us for our good work.”

“The woreda allocates budget every year to buy sta-tionery, gowns, name tags for us and provides us with stamps. After the Kebele reviews our monthly plan with us and approves it, we put the stamp that the woreda bought for us to make our report official, and send it to the health center. As part of strengthening the PHCU link, Kokosa Health Center provides us with drugs for ICCM, other tracer drugs and kerosene. This has facili-tated our work greatly. “

The hard work of the health extension work-ers and their joint effort with the health center has resulted in increased number of families who apply all the sixteen health extension program elements. These families are named model families and Dibbo Arato, a resident of Guutu Kebele, is one of them. Dibbo heads a household that has a clean compound and a well-kept house. His wife is a family plan-ning user and all his children have been vaccinated. He thinks that the Health Exten-sion Program packages needs to be reinforced continually and for that purpose he has listed the HEP packages on a large paper and posted them on the wall of his house. He says, his children are asked to read the list from time to time and apply it for themselves.

Guutu HealtH Post

6Dibbo Arato

As described by Safaye, partnership with IFHP has helped bring about improvement: “We have had the privilege of attending trainings such as integrated com-munity case management, safe motherhood, implant insertion, integrated refresher training with focus on community maternal, neonatal and child health, along with community mobilization and behavior change com-munication. These trainings have increased our skills and motivated us to better serve the community.”

“It is rewarding to see that our effort to educate the community has resulted in great improvements in health. It is now common to see families compete amongst themselves to be models by applying all the health extension program elements. The support from the woreda, the health center, IFHP, the kebele administra-tion and health development armies has increased our confidence in the service we provide to the commu-nity.”

7

Safaye Torbi, HEW at Guutu Health Post, Kokosa Woreda

John Snow, Inc.44 Farnsworth StreetBoston, MA 02210617-482-9485www.jsi.comjsiinfo@jsi.com

The Integrated Family Health Program is implemented byPathfinder International andJohn Snow, Inc. IFHP is one of many assistance projects made possible through the United States Agency for International Develop-ment (USAID).

IFHP/Addis AbabaNefasilk Lafto Sub-CityKebele 05Haji Kelifa Sabit BuildingP.O. Box 1392 Code 1110Addis Ababa, EthiopiaPhone: 251.113.20.35.01Fax: 251.113.320.3572

This publication is made possible by the support of the American people through the United States Agency for International Devel-opment (USAID). The contents are the sole responsibility of John Snow, Inc. under Cooperative Agreement No. 663-A-00-08-00414-00, and do not necessarily reflect the views of USAID or the United States Government.

inteGRated family HealtH PRoGRamThe Integrated Family Health Program (IFHP) is a five-year (2009-2013) USAID-funded program that is implemented jointly by Pathfinder International-Ethiopia and John Snow, Inc. (JSI). IFHP supports USAID-Ethiopia’s strategic objective of “Investing in People” with the overall goal of creating and consolidating a functional and effective network of a diversified and well-inte-grated package of family health services to communities within the framework of the PHCU and more specifically the Health Extension Program. The network is based on a continuum of care linking communities, health posts, and health centers for improved healthy life. IFHP is implemented in the four large regions of Ethiopia: Amhara, Oromia, SNNPR, and Tigray, and, to a limited extent, Benishangul Gumuz and Somali regions. A total of 301 woredas are covered by the program, benefiting more than 35 million people.

Health systems strengthening is one of the program elements of IFHP. The program builds the capacity of health managers and professionals in the public health sector in areas of integrated supportive supervision, use of health data for decision mak-ing, and managing performance review meetings. IFHP participates in these activities to ensure the health system elements are properly implemented at each level and collaborates with regional health bureaus, zonal health departments and Woreda health offices to strengthen the link within PHCUs for effective primary health care provision. In coordination with the Oromia Regional Health Bureau and six zonal health offices in the region (West Arsi, East Hararge, Arsi, North Shoa, West Hararge, and Bale), IFHP trained 4,857 technical and support staff on HMIS and 729 PHCU manages on integrated supportive supervision. The program has continued to provide technical and financial support to performance review meetings at zonal or district levels. IFHP is an active participant of woreda-based planning and works closely with the government for effective implementation of health programs.