Ethiopia’s urban primary health care reform: Practices, lessons, and the way forward

AbstractBackground: At present there is remarkable expansion of urbanization in Ethiopia. By 2050, 38% of the population in Ethiopia is expected to reside in urban settings. The majority of this future urban population is believed to live in slums. In response to this daunting health challenge, the Ministry of Health launched urban health extension program in 2009. The outcome of this initiative, however, is still uncertain - Urban Health Extension Professionals seem to have failed to meet the desired end. To improve the situation, experiences were drawn from middle-income countries and piloted in Addis Ababa in 2014. This is a report of the study conducted to assess the implementation of the pilot initiatives. In the assessment of the implementation, attempts were also made to identify lessons and challenges encountered.Methods: Qualitative data were collected from purposively selected individuals involved in the design, implementation, and use of the pilot initiative. Checklists developed on the basis of the objective of the study were used for data collection.Findings: The findings indicated that the initiative had a team of health professionals - people who had the skills needed to work as a team and implement the pilot activities. The health team improved linkages and collaboration between the health system and the community. Through the team, identification of the most neglected sections of the population was ensured and this section has accessed health services. For example, the disabled, the sick, the elderly, persons with chronic health problems, girls and women were identified as social sectors that had either no or very little access to health care. The health team created a strong sense of collaboration between itself and the community level structures. This has been recognized to have an important role in improving service delivery to community. However, the level of the team’s recognition of local community set up and structures as facilitators of health services needs improvement. Furthermore, a shortage of transportation to distant places in the catchment areas and a lack of timely provision of supplies and drugs to address some basic health problems at household and community levels were identified as major problems.Conclusions: Ensuring proper urban health care requires multifaceted and multi-sectoral responses. Defining strategies of enhancing the engagement of different sectors in achieving the objectives of the initiative is an important point to be noted. Ways to provide continuous supplies to the health teams need to be sought. An equally important point that needs to be noted to ensure further successes of the initiative is empowering and enabling community level structures to focus more on health-related activities. [Ethiop. J. Health Dev. 2018; 32(1):4-9

Degree of adherence of the urban health extension service delivery process to the standards set nationally

Background: The Urban Health Extension Program (UHEP) is an innovative Ethiopian government plan to ensure health service equity by creating demand for essential health services through the provision of appropriate health information at the household level. Even though the HEP was launched in Ethiopia in 2003 as the flagship program for the implementation of primary health care in the country, studies looking at its quality are limited. Adherence to set standards within a program is one of the parameters that indicate process quality. This paper, part of a larger survey to assess the quality of services provided by the UHEP in Ethiopia, looks at the degree of adherence to the service delivery process to the standards set nationally. Methodology: The study included an assessment of the degree of adherence of the urban health services delivery process to the national standards in selected urban health extension facilities within the catchment areas of sampled institutions. The assessment was made using observation checklists of the routine service provision of the health professionals. Data collection for the survey included the assessment of the service delivery practices of 330urban health extension professionals (UHE-ps) in five major regions. Results: When compared with the standards set in the national program implementation manual, environmental sanitation and counseling of mothers (99.4%), essential nutrition action (in terms of growth monitoring and provision of vitamin A and iron supplementation) (95.4%), HIV/AIDS and STI-related services (95.1%), antenatal care (87.6%), adolescent reproductive health(RH) services (82.1%), family planning services (81%) and facilitating immunization (63.7%) were reported to have good performance. On the other hand, childhood curative services (22%), curative care for pregnant mothers (24.2%), delivery care (25.4%), and follow-up of treatment for leprosy cases (25.5%) were reported to have comparatively low performance. Conclusions: Overall, the comparison of adherence to standards set by the UHE-ps implementation manual showed that the most preventive and health promotive services (including HIV/AIDS and STI) were regularly provided, while the low performance of UHEps was reported in delivery-related and curative services (including those given to pregnant women and children. [Ethiop. J. Health Dev. 2020; 34(Special issue 2):62-69] Keywords: Adherence to standards; Urban Health Extension Program; Urban Health Extension Professionals

Preparedness of the Urban Health Extension Program to provide priority health services identified in its packages

Background: The Urban Health Extension Program (UHEP) – an innovative Ethiopian government plan to ensure health service equity by creating demand for essential health services through the provision of appropriate health information at a household level – is one of the three approaches of the national Health Extension Program (HEP).The UHEP is organized to deliver services within 16 packages. This study is aimed at assessing the preparedness of the program to provide priority health services identified in its packages. Methodology: The study covered sampled urban health extension facilities within five study regions, and included 26 facility assessments, and 330 urban health extension professionals’ (UHE-ps’) assessments. Results: According to the findings of the facility assessment, most items within the UHEP packages are available, even though very few facilities were found to stock delivery kits, dressing materials, and oxytocin. Adrenaline was also observed to be found in only a limited number of facilities. Regarding teaching aids and services guidelines, most of the facilities had health education materials, Health Management Information System (HMIS) recording and reporting formats, family health services guidelines, disease prevention guidelines, family planning guidelines, and environmental health guidelines. All of the facilities observed seemed to have most of the services that are prioritized within the UHEP packages. The items less available include HIV testing and counseling guidelines, first aid kits, and infant weighing scales. A knowledge assessment through a test of 327 UHE-ps using questions based on the guideline manual showed a mean score of 76.2% (32 out of 42), with a minimum of 33.3% (10 out of 42) and maximum of 90.5% (38 out of 42). Considering the mean score (76.2%) as the passing grade, only 43% of the UHE-ps scored above the average. Questions on controlling communicable diseases and postnatal care (PNC) were items on which the UHE-ps scored highest. Conclusions and Recommendations: The findings of the present survey show that there is an overall fair level of preparedness within the UHEP to provide the services identified within its various component packages. However, there are still a few services packages for which the UHE facilities do not seem to be well prepared. [Ethiop. J. Health Dev. 2020; 34(Special issue 2):76-82] Keywords: Preparedness; Urban Health Extension Program; Urban Health Extension Professionals

Patterns of utilization, expectations, and satisfaction of the community to urban health extension services

Background: The Urban Health Extension Program (UHEP) – an innovative Ethiopian government plan to ensure health service equity by creating demand for essential health services through the provision of appropriate health information at the household level – is one of the three approaches of the national Health Extension Program (HEP). There are very few studies on the quality of health care provided by the UHEP in Ethiopia. This study is part of a comprehensive survey designed to assess the quality of health service delivered by the UHEP, and looks at the pattern of utilization, expectations, and satisfaction of the community in relation to services provided within the UHEP. Methodology: The study covered sampled households for a community-based cross-sectional survey using structured questionnaires among 589 households within five major regions (Amhara; Harari; Oromia; Southern Nations, Nationalities, and Peoples’ (SNNP); and Tigray), as well as the two city administrations of Addis Ababa and Dire Dawa. Results: According to the findings, about 88% of the respondents have heard about urban health extension services in general, and the majority (51.6%) of them have heard about the services from the urban health extension workers (UHEWs), while 28.4%, 10.6%, and 9.3% heard about it from mass media, health centers and neighbors, respectively. Service packages reported to have been used most include environmental health (75.7%), health education (56.5%), and immunization of children (39.2%). On the other hand, services such as first aid (2.2%), referral (3.1%), HIV/AIDS care and support (3.7%), postnatal care (7.8%) and nutritional screening of children (9.7%) seem to have very low rates of utilization. With regard to the overall satisfaction of respondents on their visits to UHE facilities, more than 40% of the survey households responded as being satisfied or very satisfied with most of the items, except for the availability of UHEPs for home visits, availability of medical supplies, and referrals for consultations. Conclusions: Beneficiary communities seem to have an overall positive impression of the services provided by the UHEP, even though knowledge about and utilization of some of the services seem to be minimal. There are tendencies among many community members of associating the program with kebele political activities. There are also instances where communities expect too much from the urban health extension professionals (UHE-ps), while some others tend to undermine the knowledge and skills of UHE-ps and do not consider them as health professionals. [Ethiop. J. Health Dev. 2020; 34(Special issue 2):83-90] Keywords: Utilization of urban health extension; Urban Health Extension Program; Urban Health Extension Professionals

Expectations and satisfaction of urban health extension workers regarding their service delivery environment

Background: The Urban Health Extension Program (UHEP) – an innovative Ethiopian government plan to ensure health service equity by creating demand for essential health services through the provision of appropriate health information at a household level – is one of the three approaches of the national Health Extension Program (HEP). As health extension workers (HEWs) are the backbone of the program, the present study was designed to assess their expectations and satisfaction regarding their service delivery environment. Methodology: The study for this assessment involved in-depth interviews that included urban health extension professionals (UHE-ps), supervisors of UHE-ps, as well as village health committee members and health service managers and supervising health workers in 76 selected urban health extension facilities within the five major regions (Amhara; Harari; Oromia; Southern Nations, Nationalities, and Peoples’ (SNNP); and Tigray), as well as the two city administrations of Addis Ababa and Dire Dawa. Findings: Most UHE-ps seem to be less motivated in their jobs and consider it as only temporary. A lack of training opportunities and absence of a clear career structure, non-uniformity of payment and being engaged in administrative routines that are not directly related to health services are among the reasons mentioned for dissatisfaction by UHE-ps. On the other hand, there are also some who are satisfied with their work and who feel that they are making changes to the health status of their communities. Conclusions: The findings of the study show that there are UHE-ps who are satisfied in their professional activities and consider themselves as contributing to changes in the health status of their communities. However, most of the UHE-ps are said to be less motivated in the jobs and seem to consider their roles as temporary (until they get a better job). Many complain about the lack of training opportunities, the absence of a clear career structure, and having to engage in non-professional activities. To address UHE-ps’ lack of motivation, it is recommended that the government should propose a clear career structure for them and implement a uniform payment structure across the country. [Ethiop. J. Health Dev. 2020; 34(Special issue 2):70-75] Keywords: Expectations & Satisfaction; Urban Health Extension Program; Urban Health Extension Professionals