Quality of Care in Family Planning Services in Ethiopia

Background Annually approximately 303,000 maternal deaths occurred globally in 2015, of which 99% occurred in Low-and Middle-income countries (LMIC). Estimates suggest that Ethiopia is one of the ten countries that account for about 60% of these maternal deaths. Studies demonstrate that use of Family Planning (FP) can contribute to reducing maternal deaths. While a proportion of women are using FP services, more than 214 million reproductive aged women in LMIC who desired to avoid or postpone pregnancy are not using any modern contraceptive methods. This trend in the use of FP services is also found in Ethiopia. Along with socio-demographic and cultural factors, the quality of care in FP services has been shown to influence the use of FP services. However, few studies have been conducted on the quality of care in FP services in Africa, and little evidence has been reported on the factors determining quality of care in FP services. While a few small studies that have assessed quality of care in FP services in Ethiopia, no study has identified systematically the factors associated with quality of care or the influence of facility type on quality of care. Aim The overall aim of the study is to identify the determinants and differences in quality of care in FP services. The overall study consisted of four interrelated studies each with their own inter-related but specific aim. These were: to assess and explore factors associated with quality of care in FP services in Africa (Study 1); to identify the client and facility-level determinants of quality of care in FP services in Ethiopia (Study 2); to compare the quality of FP services in private and public primary health care facilities and users’ characteristics of these facilities (Study 3), and since the use of FP guidelines was a factor in quality of care, the last study’s aim was to understand provider perspectives on barriers to and facilitators for FP guidelines use in FP services (Study 4). Methods This study employed a mix of study designs using three different methods and analytic approaches. Firstly, informed by a published systematic review protocol, a systematic review was conducted to evaluate the best available evidence on factors affecting the quality of care in FP services in Africa (Study 1). The systematic review included studies published between 1990 and 2016 in English. Quantitative studies reporting on factors affecting quality of care and qualitative studies exploring client and provider experiences and/or perceptions of the factors that determine quality of care in FP services were considered for inclusion in the review. For quantitative studies, client satisfaction was used as a measure of quality of care and was assessed in three ways: First, it was assessed using proxy questions reflecting client satisfaction on a range of issues such as waiting time, privacy for not being seen or heard by others, cleanliness of the facility, and costs of the services. Then clients’ responses for these questions were aggregated into a single variable using principal component analyses to create a measure either as a continuous or binary outcome in terms of satisfied or not satisfied; Secondly, using a likert scale in ten categories with the higher scale indicating greater satisfaction and then creating a binary variable using the mean as a cutoff point (i.e those who scored below the mean regarded as less satisfied while those who scored equal to or above the mean regarded as highly satisfied). Thirdly, using client’s overall satisfaction and then creating a binary outcome comprising satisfied or not satisfied. I performed separate synthesis of the two evidence types: the quantitative data were summarised in narrative and tables; the qualitative findings were synthesised using meta-aggregation. Secondly, informed by the findings of the systematic review, I conducted a quantitative analysis of secondary data (Study 2 and 3). More specifically, for Study 2, a multilevel mixed-effects modelling was conducted using the Ethiopian Services Provision Assessment (ESPA+) 2014 data to identify the client and facility-level determinants of quality of care in FP services as measured by client satisfaction in Ethiopia. In the analysis, while client and facility-level variables were considered as independent variables, client satisfaction was considered as an outcome variable. Client satisfaction was measured using clients’ exit interview responses to questions about the health service quality, assessed by the problems encountered by clients during their visit to health facilities for FP services. Clients’ responses on eleven questions that reflect clients’ perceptions of the quality of FP services were aggregated into an index using principal component analysis. Then, the aggregated index was dichotomised using the median score as cutoff point. Finally, a binary outcome of client satisfaction was devised as “more satisfied” if a score was greater or equal to the median cutoff point, and as “less satisfied” if a score was less than the median cutoff point. For Study 3, a combination of facility-based data from the ESPA+ 2014 dataset and community-based data from the Ethiopian Demographic and Health Survey (EDHS) 2016 dataset were employed. In the analysis, structural variables that reflected the material structure such as facility’s infrastructure (basic amenities) and availability of equipment and supplies and human resources such as health provider availability and trained provider availability were compared in public versus private primary health care facilities. The structural variables that reflected organisational structure such as presence of a quality assurance system and supervision in the past six months, availability of FP guidelines/protocols, and availability of a range of modern contraceptive methods were also compared in public versus private primary health care facilities. Survey logistic regression analysis was conducted to compare the structural quality of services, and a chi-square test was used to compare the characteristics of clients’/users’ who accessed FP services from these facilities. In Study 4, qualitative method was used to understand health providers’ perspectives on the use of FP guidelines in FP services. This study used in-depth interviews guided by a semi-structured interview guide. Twenty one participants were recruited from nine health facilities including two hospitals, five health centres, and two health posts in Gondar and Bahir Dar City administrations, Amhara region, Northwest Ethiopia. The audio-recorded interviews and notes taken were translated and transcribed into English by the lead author and entered into NVivo 11TM for data analysis and management. Thematic analysis according to the approach described by Braun and Clarke was employed for data analysis. Results In Study 1, the systematic review found few studies (eight quantitative studies and three qualitative studies) had been undertaken in a small proportion of African countries. While the quantitative studies were undertaken in Egypt, Kenya, Senegal, Ethiopia, Ghana, Tanzania, Namibia, the qualitative studies were undertaken in Kenya and Uganda. The studies were performed between 1995 and 2016. The limited evidence, assessed as being moderate to high quality suggested that quality of care in FP services was influenced by a range of client, provider and facility factors, as well as structural and process aspects of the facilities. Amongst the process factors, shorter client waiting time, presence of competent healthcare providers, provision/prescription of injectable methods, maintenance of privacy, and confidentiality were the most commonly identified factors positively associated with quality of care in FP services. For factors related to structure, good quality of stock was the most commonly identified factor positively associated with quality of care in FP services. In terms of the facility related factors, quality of care was associated with facility ownership in that privately-owned facilities and availability of FP guidelines were positively associated with better quality of care. The qualitative component of the systematic review pointed to additional factors associated with quality of care in FP services including access related factors such as ‘pre-requisites to be fulfilled by the clients and cost of services, provider workload, and providers’ behaviour. In Study 2, while both client and facility-level factors were shown to be associated with quality of care in FP services in Ethiopia, nearly one-third (32.8%) of the differences in the quality of care were attributed to the health facility level factors. At the client-level; provision of information on potential side effects of contraceptive method and number of history and physical assessments performed were positively associated with client satisfaction, long client waiting times (between 30 minutes to two hours) was negatively associated with client satisfaction. At the facility-level; facilities being in an urban location, and having FP guidelines/protocols for their providers were positively associated with client satisfaction. In Study 3, private health facilities appear relatively more deficient in terms of some important aspects of structural aspects of quality of services such as availability of trained staff, access to FP guidelines/protocols and access to a range of contraceptives than public health facilities. Private health facilities are better equipped with basic infrastructure component of the structural quality of services such as functional cell phones and water supply and equipment than public health facilities. Women who accessed FP services from private facilities were different from those who accessed these services in public facilities. They were more likely to reside in an urban area, to be Muslim, have a job, and have no or fewer number of children than women accessing FP services from public health facilities. In Study 4, healthcare providers identified a number of barriers affecting use of FP guideline. These included: lack of knowledge and lack of or inadequate access to guideline; lack of up-to-date information in the guideline, providers’ behaviour including limited reading of literature including clinical guidelines and religious beliefs/values against FP services provision; lack of support and supervision from managers; insufficient health workforce; and lack of or inadequate training about FP guideline. Healthcare providers also identified a few facilitators to FP guideline use including ease of access; managers who championed their use; and provision of training about FP guideline. Conclusion Overall, the findings showed that quality of care in FP services was influenced by multiple factors related to FP services clients, healthcare providers, and the health facility characteristics. In Ethiopia, the factors affecting quality of care in FP services were related to structure and process of care provision. The findings have also indicated that the structural quality of services in FP services were different between public and private health facilities. Moreover, the findings demonstrated the characteristics of women accessing FP services in private facilities were different from the characteristics of women accessing FP services in public facilities. The findings have also pointed to a set of factors affecting use of FP guidelines including lack of knowledge and lack of or insufficient access to the guidelines, providers’ personal religious beliefs, relying on prior knowledge and tradition rather than protocols and guidelines, insufficient health workforce, and lack of support from managers, and inadequate training on use of guidelines. These results provide important evidence for policy makers and stakeholders to develop effective strategies to help to further improve the quality of care in FP services in Ethiopia and thereby improve the uptake of FP services in that country. Moreover, the results showed that actions are needed at different levels targeting health systems and health facilities. Further studies are also required to explore the healthcare providers’ and managers’ views of factors affecting quality of care in FP services. Strengths of the study The thesis has a number of strengths. The thesis employed multiple but interrelated study deigns including systematic reviews, secondary data analysis, and qualitative interviews. The thesis examines determinants of quality of care from broader (Africa-level) to specific geographic locations (Amhara region). The thesis uses nationally representative datasets obtained from surveys conducted using standardised methodologies and data collection instruments. The qualitative study explored the barriers and facilitators of FP guidelines use for the first time in Ethiopia. Unique contributions of the thesis The findings of thesis has several contributions for policy and further research. In terms of policy implications, the thesis suggests that improving quality of care in FP services in Ethiopia and other LMIC requires improving structural and process components of quality of care. Moreover, it was found that structural components of quality of care could influence not only the outcome of quality of care but also the process of care provision in FP services. The thesis also suggests that, with its limitations, the Donabedian model of quality of care can serve as a lens through which quality of care in FP services could be measured. In terms of further research, the thesis indicates that: 1) exploring factors affecting quality of care from health providers and health managers’ viewpoint as it is useful to identify additional factors related to the healthcare system, 2) further studies are needed to explore how structural and process components of quality of care affecting long term outcomes of quality of care such as reduction in fertility and maternal mortality.Thesis (Ph.D.) -- University of Adelaide, School of Public Health, 201

Condom utilization and sexual behavior of female sex workers in Northwest Ethiopia: A cross-sectional study

Introduction: Sexually transmitted infections are among the most important public health problems in the world. People who indulge in unsafe sex, such as female sex workers are the most at risk population groups due to multiple sexual partners and inconsistent condom use. The aim of this study was to assess condom utilization and sexual behavior of female sex workers in Gondar town, Northwest Ethiopia. Methods: A quantitative cross-sectional study triangulated with qualitative method was conducted from March 20 - April 10, 2014 in Gondar town. The quantitative data were collected through interviewing 488 female sex workers while in-depth interview was administered to collect qualitative data from 10 female sex workers. The collected data were entered into EPI-INFO version 3.5.3 and exported to SPSS version 20.0 software for analysis. Logistic regression analysis was done to determine the association between condom utilization and independent variables. Results: This study revealed that less than half (47.7%) of the respondents utilized condom with any type of client. Secondary education or above, perceiving themselves at risk of HIV/AIDS infection, having awareness that sexually transmitted infections could increase HIV infection, being tested for HIV/AIDS in the last 12 months, and having lower number of clients in a month were positively associated with condom utilization. Conclusion: This finding depicted that condom utilization was low among female sex workers. Thus, developing and implementing target oriented behavioral change and communication strategies are needed to prevent the risk of acquiring HIV/AIDS and other sexually transmitted infections in female sex workers.Keywords: Female sex worker, Condom utilization, AIDS, STIs, Ethiopi

Partograph utilization and associated factors among obstetric care providers in North Shoa Zone, Central Ethiopia: a cross sectional study

Background: Globally, prolonged and obstructed labor contributed to 8% of maternal deaths which can be reduced by proper utilization of partograph during labor. Methods: An Institution based cross-sectional study was conducted in June, 2013 on 403 obstetric care providers. A pre-tested and structured questionnaire was used to collect data. Data was entered to EpiInfo version 3.5.1 statistical package and exported to SPSS version 20.0 for further analysis. Logistic regression analyses were used to see the association of different variables. Results: Out of 403 obstetric care providers, 40.2% utilized partograph during labor.Those who were midwives by profession were about 8 times more likely to have a consistent utilization of the partograph than general practitioners (AOR=8. 13, 95% CI: 2.67, 24.78). Similarly, getting on job training (AOR=2. 86, 95% CI: 1.69, 4.86), being knowledgeable on partograph (AOR=3. 79, 95% CI: 2.05, 7.03) and having favorable attitude towards partograph (AOR=2. 35, 95% CI: 1.14, 4.87) were positively associated with partograph utilization. Conclusion: Partograph utilization in labor monitoring was found to be low. Being a midwife by profession, on job training, knowledge and attitude of obstetric care providers were factors affecting partograph utilization. Providing on job training for providers would improve partograph utilization. Keywords: ,

Knowledge of Pregnant Women on Mother-to-Child Transmission of HIV in Meket District, Northeast Ethiopia

Knowledge of pregnant women on the three periods of mother-to-child transmission (MTCT) of HIV has implication for child HIV acquisition. This study aims to assess the knowledge of pregnant women on mother-to-child transmission of HIV and to identify associated factors in Meket district, northeast Ethiopia. Logistic regression models were fitted to identify associated factors. Adjusted odds ratios (AOR) with 95% confidence intervals (CI) were used to determine the presence and strength of association. About onefifth (19%) of women were knowledgeable on mother-to-child transmission of HIV (95% CI: 15.5%, 22.4%). Being urban resident (AOR: 2.69, 95% CI: 1.48, 4.87), having primary education (AOR: 2.41, 95% CI: 1.03, 5.60), reporting receiving information on HIV from health care providers (AOR: 3.24, 95% CI: 1.53, 6.83), having discussion with partner about mother-to-child transmission of HIV (AOR: 2.64, 95% CI: 1.59, 4.39), and attending antenatal care (AOR: 5.80, 95% CI: 2.63, 12.77) were positively associated with increased maternal knowledge of mother-to-child transmission of HIV. Knowledge of mother-to-child transmission of HIV among pregnant women was low. Providing information, especially for rural women and their partners, is highly recommended. Background Vertical transmission of Human Immunodeficiency Virus (HIV) is still a major challenge in the world, especially in developing countries Without any intervention, the risk of a baby getting HIV infection from an infected mother ranges from 15% to 25% in the developed nations and from 25% to 35% in developing countries. HIV transmission rate and timing are estimated to be 5% to 10% during pregnancy, 10% to 15% during delivery and 5% to 20% through breast-feeding. In general mother to child transmission contributes 15-45% of HIV acquisition for children The national adult HIV prevalence in Ethiopia is 1.2% It is estimated that 138, 906 children less than 15 years are living with HIV in 2014. There are an estimated 3,886 new infections each year due to mother-to-child transmission According to Ethiopian Demographic and Health Survey (EDHS) report, about three-quarters of reproductive aged women know that HIV can be transmitted to a baby through breastfeeding Maternal knowledge on MTCT is a corner stone of effective implementation of the World Health Organization (WHO) recommendation of the four-pronged approach to reduce mother-to-child transmission of HIV Despite the large challenge of vertical transmission of HIV, there were also limited community-based studies on women knowledge on mother-to-child transmission of HIV. Hence, this study attempts to fill the gap through assessing the level of knowledge of MTCT of HIV and its associated factors at Meket district, Northeast Ethiopia. Methods Study Design, Population, and Setting. A communitybased cross-sectional study design was conducted in Meket district, northeast Ethiopia, from March 8 to 21, 2014. Meket district is located 665 km north of Addis Ababa, the Ethiopian capital city. The district has an estimated population size of 254,520 of which 59,939 are reproductive aged women, and an estimated 8,246 were pregnant women. Those pregnant women are living in Meket district were constituted our study population. Sample Size and Sampling Procedure. Sample size was determined using single population proportion formula with the assumptions of 95% level of confidence, 12% proportion of knowledgeable women on MTCT of HIV Operational Definitions. In the present study, pregnant woman was regarded as being knowledgeable on MTCT if she correctly identified the three different modes/periods of MTCT of HIV; otherwise she was classified as nonknowledgeable. Comprehensive knowledge of HIV was also measured if a pregnant woman correctly identified three modes of transmission of HIV (unsafe sexual practice, blood transfusion, and MTCT) and recognized two common misconceptions. Comprehensive knowledge about HIV/AIDS was measured after posing the following questions: (1) knowing that condom use and limiting sex partners to one uninfected partner are HIV prevention methods, (2) being aware that a healthy-looking person can have HIV, and (3) rejecting the two most common local misconceptions, that is, HIV/AIDS can be transmitted through mosquito bites and by supernatural means in Ethiopia Data Collection Procedures. Data were collected using pretested, structured, and interviewer administered questionnaire. The questionnaire was prepared after reviewing relevant literatures. Five female nurses supervised by two BSc health professionals collected the data. For eligible women who were not at home during our first attempt, the interviewers revisited the participant's home at least two times before excluding the participant. Training was given to the data collectors about informed consent, techniques of interviewing, data collection procedures, and different sections of the questionnaire. Supervisors and principal investigators checked the questionnaire on its completeness and consistency on the daily basis. Data Processing and Analysis. The data were entered into EPI info version 3.5.3 statistical software and then sorted, cleaned, and analyzed by using SPSS version 20 statistical package. Descriptive statistics were done to describe the study participants in relation to relevant variables. Both bivariate and multiple logistic regression analyses were carried out to see the effect of sociodemographic factors, maternal condition factors, and other factors on the knowledge of MTCT of HIV and to control cofounding. Odds ratios with 95% CI were computed to identify factors associated with mothers' MTCT knowledge. Ethical Consideration. Ethical clearance was obtained from the Research and Ethical Review Committee (REC) at the Institute of Public Health, College of Medicine and Health Science of University of Gondar. Permission letter was secured from Meket District Health Office. Written informed consent was taken from each study participant after reading the consent form. The purpose and benefit of the study and their right to withdraw at any time were also delivered to each participant prior to the interview. Confidentiality of the information was maintained throughout by using anonymity identifiers, keeping their privacy by interviewing them individually. Results Sociodemographic Characteristics of Pregnant Women. Five hundred forty-two pregnant women participated in the study (97.5% response rate). The majority (85.4%) were rural dwellers. The mean age of the study participants was 29.45 years (SD = 5.4). Four hundred and sixty (84.9%) were married, 196 (36.2%) were able to read and write, and nearly four-fifths (80.1%) were homemaker ( Journal of Pregnancy 3 Knowledge of Pregnant Women on MTCT. One hundred three (19%) (95% CI: 15.5%, 22.4%) were knowledgeable on MTCT of HIV. Most (84.5%) heard about mother to child transmission of HIV. Among those who heard MTCT, more than two-thirds (70.7%) mentioned labor/delivery as a time of HIV transition from mother to child. 225 (41.5%) pregnant women identified at least two periods of motherto-child transmission of HIV. Nearly two-thirds (63.8%) had comprehensive knowledge on HIV/AIDS, and another equivalent proportion of women heard about PITC Factors Associated with Knowledge of Pregnant Women on MTCT of HIV. In multivariable analysis, higher levels of maternal education status, having received information about HIV from health professionals, and reported discussion of MTCT and ANC with their partners were positively associated with knowledge of mother-to-child transmission of HIV. Those women who live in the urban settings were about three more like to be knowledgeable than their rural counterparts (AOR: 2.69, CI (1.48, 4.87)). Those literate mothers were about three times more likely to be knowledgeable than who did not read and write (AOR: 3.25, CI (1.55, 6.78)). Likewise, a woman was 2.41 times more likely to be knowledgeable if she had completed primary school as compared to those who did not read and write (AOR: 2.41, CI (1.04, 5.60)). Pregnant women who received information on HIV from health care providers were about three times more likely to be knowledgeable than women who had not received information (AOR: 3.24, CI (1.54, 6.83)). Women who had discussions with their partner were more likely to be knowledgeable than those who had not (AOR: 5.80, CI (2.63, 12.78)). Correspondingly, mothers who discussed MTCT with their partners were more likely to be knowledgeable than those who had not (AOR: 2.64, CI (1.59, 4.39)) Discussion Being knowledgeable on MTCT of HIV and the fact that the risk of transmission can be reduced by using antiretroviral drugs are critical in reducing MTCT of HIV. This can contribute greatly towards the achievement of the Millennium Development Goals related to HIV. This study revealed that 19% (95% CI: 15.5%, 22.4%) of respondents were knowledgeable on MTCT of HIV. This result is in line with a cross-sectional study conducted at Temeke District Hospital, Dar Es Salaam (15.7%) In the present study, nearly two-thirds of pregnant women had comprehensive knowledge on HIV/AIDS which is higher than studies in Yaoundé (23%) Knowledge of pregnant women on MTCT of HIV among pregnant women was significantly varied based on their place of residence. Those pregnant women residing in urban areas were more likely to be knowledgeable when compared to the rural residents. This finding is in line with studies conducted at Gondar and Hawassa towns in Ethiopia In this study, pregnant women who discussed and received information about HIV/AIDS from health care providers were more knowledgeable. They were found to be three times more likely to be knowledgeable than those who had not. Spouse discussion on antenatal care follow-up was also positively associated with knowledge of MTCT. Those pregnant women who had discussions with their partners were six times more likely to be knowledgeable than those who had not discussed the issue. This is similar to reports from other studies Pregnant women may receive information from a variety of sources about health services. Spouses having delivered information and participated in discussions about MTCT of HIV with their wives (40.6%) were associated with good knowledge of the subject. Accordingly, pregnant women who had discussion with their partners were more than two times more likely to have good knowledge of MTCT. This might be because partner discussion in this regard could enhance their knowledge. This study tried to assess pregnant women who did not attend health care facilities for ANC and HIV concerning their knowledge about MTCT of HIV. However, because of financial and time constraints, this study did not include the knowledge part of prevention of mother-to-child transmission of HIV. Conclusions Despite many efforts, the knowledge of pregnant women on mother-to-child transmission of HIV is low. If pregnant woman resides in urban environment, she attends school, if she receives information on HIV from health care providers, and if she attends antenatal care, she is more likely to be knowledgeable on MTCT of HIV. Strengthening women education and by reaching previously inaccessible parts of the community, integration of HIV, prevention of MTCT, and ANC service, is highly recommended. Moreover, strengthening discussion of MTCT with spouses is important

Trends and causes of maternal mortality in Ethiopia during 1990-2013:Findings from the Global Burden of Diseases study 2013

Background: Maternal mortality is noticeably high in sub-Saharan African countries including Ethiopia. Continuous nationwide systematic evaluation and assessment of the problem helps to design appropriate policy and strategy in Ethiopia. This study aimed to investigate the trends and causes of maternal mortality in Ethiopia between 1990 and 2013. Methods: We used the Global Burden of Diseases and Risk factors (GBD) Study 2013 data that was collected from multiple sources at national and subnational levels. Spatio-temporal Gaussian Process Regression (ST-GPR) was applied to generate best estimates of maternal mortality with 95% Uncertainty Intervals (UI). Causes of death were measured using Cause of Death Ensemble modelling (CODEm). The modified UNAIDS EPP/SPECTRUM suite model was used to estimate HIV related maternal deaths. Results: In Ethiopia, a total of 16,740 (95% UI: 14,197, 19,271) maternal deaths occurred in 1990 whereas there were 15,234 (95% UI: 11,378, 19,871) maternal deaths occurred in 2013. This finding shows that Maternal Mortality Ratio (MMR) in Ethiopia was still high in the study period. There was a minimal but insignificant change of MMR over the last 23 years. The results revealed Ethiopia is below the target of Millennium Development Goals (MGDs) related to MMR. The top five causes of maternal mortality in 2013 were other direct maternal causes such as complications of anaesthesia, embolism (air, amniotic fluid, and blood clot), and the condition of peripartum cardiomyopathy (25.7%), complications of abortions (19.6%), maternal haemorrhage (12.2%), hypertensive disorders (10.3%), and maternal sepsis and other maternal infections such as influenza, malaria, tuberculosis, and hepatitis (9.6%). Most of the maternal mortality happened during the postpartum period and majority of the deaths occurred at the age group of 20-29 years. Overall trend showed that there was a decline from 708 per 100,000 live births in 1990 to 497 per 100,000 in 2013. The annual rate of change over these years was-1.6 (95% UI:-2.8 to-0.3). Conclusion: The findings of the study highlight the need for comprehensive efforts using multisectoral collaborations from stakeholders for reducing maternal mortality in Ethiopia. It is worthwhile for policies to focus on postpartum period

The burden of HIV/AIDS in Ethiopia from 1990 to 2016: evidence from the Global Burden of Diseases 2016 Study

BACKGROUND: The burden of HIV/AIDS in Ethiopia has not been comprehensively assessed over the last two decades. In this study, we used the 2016 Global Burden of Diseases, Injuries and Risk factors (GBD) data to analyze the incidence, prevalence, mortality and Disability-adjusted Life Years Lost (DALY) rates of Human Immunodeficiency Virus / Acquired Immune Deficiency Syndrome (HIV/AIDS) in Ethiopia over the last 26 years. METHODS: The GBD 2016 used a wide range of data source for Ethiopia such as verbal autopsy (VA), surveys, reports of the Federal Ministry of Health and the United Nations (UN) and published scientific articles. The modified United Nations Programme on HIV/AIDS (UNAIDS) Spectrum model was used to estimate the incidence and mortality rates for HIV/AIDS. RESULTS: In 2016, an estimated 36,990 new HIV infections (95% uncertainty interval [UI]: 8775-80262), 670,906 prevalent HIV cases (95% UI: 568,268-798,970) and 19,999 HIV deaths (95% UI: 16426-24412) occurred in Ethiopia. The HIV/AIDS incidence rate peaked in 1995 and declined by 6.3% annually for both sexes with a total reduction of 77% between 1990 and 2016. The annualized HIV/AIDS mortality rate reduction during 1990 to 2016 for both sexes was 0.4%

The COVID-19 pandemic and healthcare systems in Africa:A scoping review of preparedness, impact and response

BACKGROUND: The COVID-19 pandemic has overwhelmed health systems in both developed and developing nations alike. Africa has one of the weakest health systems globally, but there is limited evidence on how the region is prepared for, impacted by and responded to the pandemic. METHODS: We conducted a scoping review of PubMed, Scopus, CINAHL to search peer-reviewed articles and Google, Google Scholar and preprint sites for grey literature. The scoping review captured studies on either preparedness or impacts or responses associated with COVID-19 or covering one or more of the three topics and guided by Arksey and O’Malley’s methodological framework. The extracted information was documented following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension checklist for scoping reviews. Finally, the resulting data were thematically analysed. RESULTS: Twenty-two eligible studies, of which 6 reported on health system preparedness, 19 described the impacts of COVID-19 on access to general and essential health services and 7 focused on responses taken by the healthcare systems were included. The main setbacks in health system preparation included lack of available health services needed for the pandemic, inadequate resources and equipment, and limited testing ability and surge capacity for COVID-19. Reduced flow of patients and missing scheduled appointments were among the most common impacts of the COVID-19 pandemic. Health system responses identified in this review included the availability of telephone consultations, re-purposing of available services and establishment of isolation centres, and provisions of COVID-19 guidelines in some settings. CONCLUSIONS: The health systems in Africa were inadequately prepared for the pandemic, and its impact was substantial. Responses were slow and did not match the magnitude of the problem. Interventions that will improve and strengthen health system resilience and financing through local, national and global engagement should be prioritised

The COVID-19 pandemic and healthcare systems in Africa : a scoping review of preparedness, impact and response

Funding Information: Funding GAT was supported with funding from the Australia National Health and Medical Research Council (NHMRC) Investigator Grant #1195716.Peer reviewedPublisher PD

National disability-adjusted life years(DALYs) for 257 diseases and injuries in Ethiopia, 1990–2015: findings from the global burden of disease study 2015

Background: Disability-adjusted life years (DALYs) provide a summary measure of health and can be a critical input to guide health systems, investments, and priority-setting in Ethiopia. We aimed to determine the leading causes of premature mortality and disability using DALYs and describe the relative burden of disease and injuries in Ethiopia. Methods: We used results from the Global Burden of Diseases, Injuries, and Risk Factors Study 2015 (GBD 2015) for non-fatal disease burden, cause-specific mortality, and all-cause mortality to derive age-standardized DALYs by sex for Ethiopia for each year. We calculated DALYs by summing years of life lost due to premature mortality (YLLs) and years lived with disability (YLDs) for each age group and sex. Causes of death by age, sex, and year were measured mainly using Causes of Death Ensemble modeling. To estimate YLDs, a Bayesian meta-regression method was used. We reported DALY rates per 100,000 for communicable, maternal, neonatal, and nutritional (CMNN) disorders, non-communicable diseases, and injuries, with 95% uncertainty intervals (UI) for Ethiopia. Results: Non-communicable diseases caused 23,118.1 (95% UI, 17,124.4–30,579.6), CMNN disorders resulted in 20,200.7 (95% UI, 16,532.2–24,917.9), and injuries caused 3781 (95% UI, 2642.9–5500.6) age-standardized DALYs per 100,000 in Ethiopia in 2015. Lower respiratory infections, diarrheal diseases, and tuberculosis were the top three leading causes of DALYs in 2015, accounting for 2998 (95% UI, 2173.7–4029), 2592.5 (95% UI, 1850.7–3495.1), and 2562.9 (95% UI, 1466.1–4220.7) DALYs per 100,000, respectively. Ischemic heart disease and cerebrovascular disease were the fourth and fifth leading causes of age-standardized DALYs, with rates of 2535.7 (95% UI, 1603.7–3843.2) and 2159.9 (95% UI, 1369.7–3216.3) per 100,000, respectively. The following causes showed a reduction of 60% or more over the last 25 years: lower respiratory infections, diarrheal diseases, tuberculosis, neonatal encephalopathy, preterm birth complications, meningitis, malaria, protein-energy malnutrition, iron-deficiency anemia, measles, war and legal intervention, and maternal hemorrhage