Effect of ethiopia's health extension program on maternal and newborn health care practices in 101 rural districts: a dose-response study.

BACKGROUND: Improving newborn survival is essential if Ethiopia is to achieve Millennium Development Goal 4. The national Health Extension Program (HEP) includes community-based newborn survival interventions. We report the effect of these interventions on changes in maternal and newborn health care practices between 2008 and 2010 in 101 districts, comprising 11.6 million people, or 16% of Ethiopia's population. METHODS AND FINDINGS: Using data from cross-sectional surveys in December 2008 and December 2010 from a representative sample of 117 communities (kebeles), we estimated the prevalence of maternal and newborn care practices, and a program intensity score in each community. Women with children aged 0 to 11 months reported care practices for their most recent pregnancy and childbirth. The program intensity score ranged between zero and ten and was derived from four outreach activities of the HEP front-line health workers. Dose-response relationships between changes in program intensity and the changes in maternal and newborn health were investigated using regression methods, controlling for secular trend, respondents' background characteristics, and community-level factors. Between 2008 and 2010, median program intensity score increased 2.4-fold. For every unit increase in the score, the odds of receiving antenatal care increased by 1.13 times (95% CI 1.03-1.23); the odds of birth preparedness increased by 1.31 times (1.19-1.44); the odds of receiving postnatal care increased by 1.60 times (1.34-1.91); and the odds of initiating breastfeeding immediately after birth increased by 1.10 times (1.02-1.20). Program intensity score was not associated with skilled deliveries, nor with some of the other newborn health care indicators. CONCLUSIONS: The results of our analysis suggest that Ethiopia's HEP platform has improved maternal and newborn health care practices at scale. However, implementation research will be required to address the maternal and newborn care practices that were not influenced by the HEP outreach activities

Barriers to the uptake of community-based curative child health services in Ethiopia

Background Uptake of services to treat newborns and children has been persistently low in Ethiopia, despite being provided free-of-charge by Health Extension Workers (HEWs). In order to increase the uptake of these services, the Optimizing the Health Extension Project was designed to be implemented in four regions in Ethiopia. This study was carried out to identify barriers to the uptake of these services and potential solutions to inform the project. Methods Qualitative data were collected in October and November 2015 in 15 purposely selected districts in four regions. We conducted 90 focus group discussions and 60 in-depth interviews reaching a total of 664 participants. Thematic analysis was used to identify key barriers and potential solutions. Results Five demand-side barriers to utilization of health services were identified. Misconceptions about illness causation, compounded with preference for traditional healers has affected service uptake. Limited awareness of the availability of free curative services for children at health posts; along with the prevailing perception that HEWs were providing preventive services only had constrained uptake. Geographic challenge that made access to the health post difficult was the other barrier. Four supply-side barriers were identified. Health post closure and drug stock-out led to inconsistent availability of services. Limited confidence and skill among HEWs and under-resourced physical facilities affected the service delivery. Study participants suggested demand creation solutions such as increasing community awareness on curative service availability and educating them on childhood illness causation. Maintaining consistent supplies and ensuring service availability; along with regular support to build HEWs’ confidence were the suggested supply-side solutions. Creating community feedback mechanisms was suggested as a way of addressing community concerns on the health services. Conclusion This study explored nine demand- and supply-side barriers that decreased the uptake of community-based services. It indicated the importance of increasing awareness of new services and addressing prevailing barriers that deprioritize health services. At the same time, supply-side barriers would have to be tackled by strengthening the health system to uphold newly introduced services and harness sustainable impact

Child health service provision in Ethiopia: outpatient, growth monitoring and immunization

Background: Ethiopia has made tremendous effort by cutting under five mortality by two third from the 167 in 1999 to 68 in 2012. Nevertheless, nearly 277,186 under five children die each year mostly from diseases which can be prevented or treated. Sound information on the supply and quality of health services is necessary for health systems management, monitoring, and evaluation. Objective: The objectives of this study are to assess the availability of child health services and how often these services are available in Ethiopian health facilities. Method: The assessment is part of the 2014 Ethiopia Service Provision Assessment Plus (ESPA+) Survey which was designed to be a cross-sectional study, which combines MEASURE DHS SPA, World Health Organization's service Availability and Readiness Assessment (SARA) and the World Bank's Service Delivery Indicator (SDI). A total of 1,327 health facilities were assessed. All hospitals, selected health centres, private clinics (Higher, Lower, & Medium), and health posts were assessed using a facility inventory questionnaire. Results: Among all facilities, 62 % of them provide all three basic child health services (out-patient curative care for sick children, routine childhood vaccination services (EPI), and routine growth monitoring services) as a package. Seventy three percent of government facilities provide all three basic child health services. While 68 % of rural facilities provide all the services, in urban settings, 32 % of the facilities provide all the three basic child health services while majority of Health centres (82 %) provide all the services, only 1 % of lower clinics provide all three basic services. Out-patient curative care for sick children is the most commonly provided (95 %) service of all the three basic services. These services are almost universally available across all facility types, except in higher clinics which are less than 80 %. Among all facilities offering outpatient curative care for sick children, majority (78 %) of them offer the service 5 or more days per week at the facility. Conclusion: Majority of facilities provide all three basic child health services (Outpatient Curative Care, Child Vaccination, and Child Growth Monitoring). Out-patient curative care for sick children is the most commonly provided service. Government facilities mostly provide all three basic child health services. Among all facilities offering outpatient curative care for sick children, majority of them offer the service 5 or more days per week at the facility

Map of Ethiopia showing the study areas and location of primary sampling units (i.e., kebeles).

<p>Map of Ethiopia showing the study areas and location of primary sampling units (i.e., kebeles).</p

Counterfactual analysis of the effects of HEP intensity measures on maternal and newborn health indicators.

<p>Only the statistically significant effects in <a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0065160#pone-0065160-t007" target="_blank">Table 7</a> are reported here.</p>µ<p>All the program effects are attributable fractions (percentage-points); while the program effects on knowledge are attributable means.</p

Kebele-level correlation between HEP intensity and maternal and newborn outcomes.

<p>Kebele-level scatter plots with fitted regression lines between changes in maternal and newborn health care practices/knowledge and changes in <i>program intensity score</i> between 2008 and 2010 (n = 117). Foot note: Regression coefficient of the fitted line and its 95% confidence interval are included with the figures.</p

<i>Kebele</i>-level HEP intensity measures at baseline and follow-up surveys (n = 117).

<p><i>Kebele</i>-level HEP intensity measures at baseline and follow-up surveys (n = 117).</p

Characteristics of the respondents: women with children 0 to 11 months, baseline and follow-up surveys.

<p>β The wealth index score was constructed for each household with the principal component analysis of the household possessions (electricity, watch, radio, television, mobile phone, telephone, refrigerator, table, chair, bed, electric stove, and kerosene lamp), and household characteristics (type of latrine and water source). The households were ranked according to the wealth score and then divided into five quintiles indicating poor, medium poor, medium, medium rich and rich households <a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0065160#pone.0065160-Filmer1" target="_blank">[32]</a>.</p

Maternal and newborn health services provided by the Health Extension Program.

<p>Maternal and newborn health services provided by the Health Extension Program.</p

Time line for the study.

<p>Time line for the study.</p