Ethiopia Service Provision Assessment Plus Survey 2014
Ethiopian Public Health Institute (EPHI) Federal Ministry of Health ICF International
Ethiopia Service Provision Assessment Plus (ESPA+) Survey 2014
Final Report
Ethiopian Public Health Institute Addis Ababa, Ethiopia
Federal Ministry of Health Addis Ababa, Ethiopia ICF International Rockville, Maryland USA
October, 2014
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This report presents findings of the 2014 Ethiopia Service Provision Assessment Plus Survey (2014 ESPA+), which was implemented by the Ethiopian Public Health Institute in collaboration with the Ethiopian Ministry of Health. ICF International provided technical assistance. The 2014 ESPA+ is part of the worldwide MEASURE DHS project which assists countries in the collection of data to monitor and evaluate population, health, and nutrition programs. The survey was funded by the United States Agency for International Development (USAID), World Bank, Irish Aid, WHO and UNICEF. Additional information about the 2014 ESPA+ may be obtained from the Ethiopian Public Health Institute (EPHI), Gulele Arbegnoch Street, Gulele Sub City, Addis Ababa, Ethiopia. Telephone: +251.11.275.4647; Fax: +251.11.275.4744; website: http://www.ephi.gov.et. Information about the MEASURE DHS project can be obtained from ICF International, 530 Gaither Road, Suite 500, Rockville, MD 20850 USA. Telephone: 301.572.0200; Fax: 301.572.0999; E-mail:
[email protected]; website: http://www.DHSprogram.com.
CONTENTS List of Tables ................................................................................................................................................ iv List of Figures ............................................................................................................................................. viii FOREWORD ................................................................................................................................................... x ACKNOWLEDGEMENTS ................................................................................................................................ xi ACRONYMS AND ABBREVIATIONS .............................................................................................................. xii 1.
Overview of the health system in Ethiopia ........................................................................................... 1
2.
1.1 Key health indicators and trends ........................................................................................... 1 1.2 Major health policy and initiatives ......................................................................................... 2 1.3 The health care system .......................................................................................................... 3 ESPA+ background and methodology ................................................................................................... 5
3.
2.1 Institutional framework ......................................................................................................... 5 2.2 objectives of the ESPA+ .......................................................................................................... 6 2.3 2014 ESPA+ content and methods for data collection........................................................... 7 2.4 Sampling ................................................................................................................................. 9 2.5 Training and Data Collection ................................................................................................ 15 2.6 Data management and analysis ........................................................................................... 16 Facility-level infrastructure, resources, management and support system ....................................... 17
3.1 Background........................................................................................................................... 17 3.2 Availability of Services and Resources ................................................................................. 18 3.3 Management systems to support and maintain quality services ........................................ 31 3.4 Systems for Infection control ............................................................................................... 41 4. Child Health Services ............................................................................................................................... 50
5.
4.1 Background........................................................................................................................... 50 4.2 Availability of Child Health Services ..................................................................................... 51 4.3 Child Health Service Readiness ............................................................................................ 55 4.4 Adherence to Guidelines for Sick Child Service Provision .................................................... 66 4.5 Basic management and supportive system.......................................................................... 80 Family planning ................................................................................................................................... 84
6.
5.1. Background.......................................................................................................................... 84 5.2 Availability of family planning services ................................................................................ 86 5.3 Family Planning Service Readiness ....................................................................................... 94 5.4 Adherence to standards for quality family planning service.............................................. 100 5.5 Basic management and supportive system........................................................................ 109 Antenatal care services ..................................................................................................................... 115
7.
6.1. Background........................................................................................................................ 115 6.2. Availability of Antenatal care services .............................................................................. 116 6.3 Antenatal Care Service Readiness ...................................................................................... 118 6.4 Adherence to standards for quality ANC service provision ............................................... 124 6.5 Basic management and supportive system........................................................................ 145 6.6. Prevention of mother-to-child transmission of HIV .......................................................... 149 6.7. Malaria services in facilities offering antenatal care services ........................................... 151 Delivery and Newborn care .............................................................................................................. 155 7.1. Background........................................................................................................................ 155 7.2. Availability of delivery and new born care services .......................................................... 156 7.3. Delivery and Newborn Care Service Readiness................................................................. 162 ii
8.
7.4 Basic management and supportive system........................................................................ 168 HIV/AIDS services .............................................................................................................................. 173
9.
8.1 Background......................................................................................................................... 173 8.2. Availability of basic services for HIV/AIDS......................................................................... 174 8.3. Infection prevention and control ...................................................................................... 179 8.4 Basic management and supportive system........................................................................ 183 8.5 Care and support services for HIV/AIDS ............................................................................. 184 8.6 Advanced services for HIV/AIDS ......................................................................................... 190 8.7 Sexually transmitted infections service availability ........................................................... 193 Non- Communicable Diseases........................................................................................................... 197
9.1 Background......................................................................................................................... 197 9.2. Availability of Services for non-communicable diseases .................................................. 198 9.3. Readiness to provide quality NCD services ....................................................................... 201 10. Tuberculosis ...................................................................................................................................... 214 10.1. Background...................................................................................................................... 214 10.2 Availability of tuberculosis diagnosis and management services .................................... 214 10.3 Readiness to Provide Quality Tuberculosis Services ........................................................ 219 11. Malaria .............................................................................................................................................. 223 11.1. Background...................................................................................................................... 223 11.2. Availability of Services for Malaria .................................................................................. 223 11.3 Readiness to provide quality Malaria services ................................................................. 224 11.4 Malaria services in facilities offering curative care services for sick children.................. 229 12. Neglected Tropical Diseases ............................................................................................................. 235 12.1 Background....................................................................................................................... 235 12.1 Neglected Tropical diseases in Ethiopia ........................................................................... 235 12.2 Availability of services for neglected tropical diseases .................................................... 236 12.3 Readiness to provide quality NTD services ...................................................................... 238 13. Health provider clinical knowledge and attendance ........................................................................ 242 13.1 ESPA+ approach to assess provider’s clinical knowledge and attendance ...................... 242 13.2 Health provider clinical knowledge .................................................................................. 243 13.3 Health provider attendance ............................................................................................. 247 Reference .................................................................................................................................................. 250 ADDITIONAL TABLES WEIGHTING OF FACILITIES IN ESPA+ SURVEY PERSONNEL SURVEY INSTRUMENTS
Appendix A ................................................................... 253 Appendix B ...................................................................... 292 Appendix C ................................................................... 293 Appendix D .................................................................... 300
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List of Tables Table 2.1 Result of facility contact, by background characteristics ..................................................................... 10 Table 2.2 Distribution of surveyed facilities, by background characteristics ....................................................... 10 Table 2.3 Distribution of interviewed providers, by background characteristics and provider qualification...... 12 Table 2.4 Distribution of observed consultations, ESPA+ 2014............................................................................ 13 Table 2.5 Distribution of observed and interviewed clients (unweighted), ESPA+ 2014 ..................................... 14 Table 3.1-A Availability of specific services, ESPA+ 2014 ..................................................................................... 18 Table 3.1-B Availability of specific services in Health posts, ESPA+ 2014 ............................................................ 20 Table 3.2 Availability of basic client services, ESPA+ 2014 ................................................................................... 21 Table 3.3-A Availability of basic amenities for client services, ESPA+ 2014 ......................................................... 23 Table 3.3-B Availability of basic amenities for client services in Health Posts, ESPA+ 2014 ................................ 25 Table 3.4 Availability of basic equipment in health facilities, ESPA+ 2014 .......................................................... 26 Table 3.7.1-A Laboratory diagnostic capacity, ESPA+ 2014.................................................................................. 27 Table 3.7.2-B Laboratory diagnostic capacity, ESPA+ 2014 .................................................................................. 29 Table 3.8.1-A Availability of essential medicines, ESPA+ 2014 ............................................................................ 29 Table 3.8.1-B Availability of essential medicines in Health Posts, ESPA+ 2014 ................................................... 30 Table 3.9-A Management, quality assurance, and health management information systems, ESPA+ 2014 ...... 31 Table 3.9-B Management, quality assurance, and health management information systems in Health Posts, ESPA+ 2014 ........................................................................................................................................................... 33 Table 3.10 Supportive management practices at the facility level, ESPA+ 2014 ................................................. 35 Table 3.11-A Staffing pattern in surveyed facilities, ESPA+ 2014 ......................................................................... 37 Table 3.11-B Staffing pattern in surveyed facilities in Health Posts, ESPA+ 2014 ................................................ 38 Table 3.13-A User fee or charge for different services, ESPA+ 2014.................................................................... 40 Table 3.6-A Capacity for processing of equipment for reuse, ESPA+ 2014 .......................................................... 41 Table 3.6-B Capacity for processing of equipment for reuse in Health Posts, ESPA+ 2014 ................................. 42 Table 3.5.1 Standard precautions for infection control, ESPA+ 2014 .................................................................. 44 Table 3.12 Waste management in Health Facilities, ESPA+ 2014 ........................................................................ 46 Table 3.16 Waste disposal methods for sharps waste, ESPA+ 2014 .................................................................... 47 Table 4.1 Availability of child health services, ESPA+ 2014 .................................................................................. 52 Table 4.2 Availability of child health services - curative care and growth monitoring, ESPA+ 2014 ................... 53 Table 4.3 Availability of child health services - vaccination services, ESPA+ 2014............................................... 54 Table 4.4 Guidelines, trained staff, and equipment for child curative care services, ESPA+ 2014 ...................... 56 Table 4.5-A Infection control and laboratory diagnostic capacity, ESPA+ 2014 .................................................. 58 Table 4.5-B Infection control and laboratory diagnostic capacity in Health Posts, ESPA+ 2014 ......................... 59 Table 4.6-A Availability of essential and priority medicines and commodities, ESPA+ 2014............................... 60 Table 4.6-B Availability of essential and priority medicines and commodities in Health Posts, ESPA+ 2014...... 61 Table 4.7 Availability of Guidelines, trained staff, and equipment for vaccination services, ESPA+ 2014 .......... 62 Table 4.8 Availability of vaccines in health facilities, ESPA+ 2014........................................................................ 64 Table 4.9 Infection control for vaccination services, ESPA+ 2014 ........................................................................ 65 Table 4.10.1-A Assessments, examinations, and treatments for sick children, ESPA+2014 ................................ 66 Table 4.10.1-B Assessments, examinations, and treatments for sick children in Health Posts, ESPA+ 2014 ...... 69 Table 4.10.2-A Assessments, examinations, and treatments for sick children, ESPA+ 2014 ............................... 72 Table 4.10.2-B Assessments, examinations, and treatments for sick children, ESPA+ 2014 ............................... 74 Table 4.11-A Assessments, examinations, and treatment for sick children, classified by diagnosis or major symptoms, ESPA+ 2014......................................................................................................................................... 77 Table 4.11-B Assessments, examinations, and treatment for sick children, classified by diagnosis or major symptoms in Health Posts, ESPA+ 2014 ............................................................................................................... 78 iv
Table 4.12.1 Feedback from caretakers of observed sick children on service problems, ESPA+ 2014................ 79 Table 4.13 Supportive management for providers of child health services, ESPA+ 2014.................................... 80 Table 4.14-B Training for child health service providers in Health Posts, ESPA+ 2014 ........................................ 82 Table 5.1-A Availability of family planning services, ESPA+ 2014 ........................................................................ 87 Table 5.2.1-A Methods of family planning offered, ESPA+ 2014 ......................................................................... 88 Table 5.2.2-B Methods of family planning offered in Health Posts by Background Characteristics, ESPA+ 201489 Table 5.3.1-A Methods of family planning provided, ESPA+ 2014 ....................................................................... 89 Table 5.3.2-B Methods of family planning provided in Health Posts, ESPA+ 2014 .............................................. 90 Table 5.4-B Frequency of availability of family planning services in Health Posts, ESPA+ 2014 ...................... 91 Table 5.5.1-A Availability of family planning commodities, ESPA+ 2014 ............................................................. 92 Table 5.5.2-B Availability of family planning commodities in Health Posts, ESPA+ 2014 .................................... 93 Table 5.6-A Guidelines, trained staff, and basic equipment for family planning services, ESPA+ ....................... 94 Table 5.6-B Guidelines, trained staff, and basic equipment for family planning services, ESPA+ 2014 .............. 95 Table 5.7-A Items for infection control during provision of family planning, ESPA+ 2014 .................................. 98 Table 5.7-B Items for infection control during provision of family planning, ESPA+ 2014 .................................. 99 Table 5.8.2-A Client history and physical examinations for first-visit female FP clients, ESPA+ 2014 ............... 100 Table 5.8.1-B Client history and physical examinations for first-visit female FP clients, ESPA+ 2014, at HP .... 101 Table 5.9.1-A Components of counselling and discussions during consultations for female first-visit family planning clients, ESPA+ 2014 .............................................................................................................................. 103 Table 5.9.1-B Components of counselling and discussions during consultations for female first-visit family planning clients in health posts, ESPA+ 2014 ..................................................................................................... 105 Table 5.10.1-A Components of counselling and discussions during consultations for all female family planning clients, ESPA+ 2014 ............................................................................................................................................. 105 Table 5.10.1-B Components of counselling and discussions during consultations for all female family planning clients in health posts, ESPA+ 2014 .................................................................................................................... 107 Table 5.11.2-A Feedback from family planning clients on service problems, ESPA+2014 ................................. 107 Table 5.12-A Client knowledge about contraceptive method, ESPA+ 2014....................................................... 108 Table 5.13-A Supportive management for providers of family planning services, ESPA+ 2014 ........................ 110 Table 5.13-B Supportive management for providers of family planning services, ESPA+ 2014 ........................ 111 Table 5.14-A Training for family planning service providers, ESPA+ 2014 ......................................................... 111 Table 5.14-B Training for family planning service providers in health posts, ESPA+2014 ................................. 112 Table 6.1 Availability of antenatal care services, ESPA+ 2014 ........................................................................... 117 Table 6.2 Guidelines, trained staff, and basic equipment for antenatal care services, ESPA+ 2014 ................. 119 Table 6.3 Items for infection control during provision of antenatal care, ESPA+ 2014 ..................................... 120 Table 6.4-A Diagnostic capacity, ESPA+ 2014 ..................................................................................................... 121 Table 6.4-B Diagnostic capacity in health posts, ESPA+ 2014 ............................................................................ 122 Table 6.5 Availability of medicines and supplies for routine antenatal care, ESPA+ 2014 ................................ 124 Table 6.6 Characteristics of observed antenatal care clients, ESPA+ 2014 ........................................................ 125 Table 6.7.1-A General assessment and client history for observed first-visit antenatal care clients, ESPA+ 2014 ............................................................................................................................................................................. 127 Table 6.7.1-B General assessment and client history for observed first-visit antenatal care clients in health posts, ESPA+ 2014 ............................................................................................................................................... 129 Table 6.8.1-A Basic physical examinations and preventive interventions for antenatal care clients, ESPA+ 2014 ............................................................................................................................................................................. 131 Table 6.8.1-B Basic physical examinations and preventive interventions for antenatal care clients in health posts, ESPA+ 2014 ............................................................................................................................................... 134 Table 6.9.1 Content of antenatal care counselling related to risk symptoms, ESPA+ 2014 .............................. 136 Table 6.9.2 Content of antenatal care counselling related to risk symptoms, ESPA+ 2014 .............................. 138 Table 6.10.1-A Content of antenatal care counselling related to nutrition, breastfeeding, and family planning, v
ESPA+ 2014 ......................................................................................................................................................... 139 Table 6.10.1-B Content of antenatal care counselling related to nutrition, breastfeeding, and family planning in health posts, ESPA+2014 .................................................................................................................................... 141 Table 6.11.1-A Antenatal care clients' reported health education received and knowledge of pregnancy-related warning signs, ESPA+ 2014 ................................................................................................................................. 143 Table 6.12.1-A Feedback from antenatal care clients, ESPA+ 2014 ................................................................... 144 Table 6.13 Supportive management for providers of antenatal care services, ESPA+ 2014 ............................. 146 Table 6.14-A Training for antenatal care service providers, ESPA+ 2014 .......................................................... 146 Table 6.14-B Training for antenatal care service providers in health posts, ESPA+ 2014 .................................. 147 Table 6.15-A Availability of services for prevention of mother-to-child transmission of HIV in facilities offering antenatal care services, ESPA+ 2014 .................................................................................................................. 149 Table 6.16-A Guidelines, trained staff, equipment, diagnostic capacity, and medicines for prevention of mother-to-child transmission of HIV, ESPA+ 2014 ............................................................................................. 150 Table 6.17-A Malaria services in facilities offering antenatal care services, ESPA+ 2014 .................................. 152 Table 6.17-B Malaria services in facilities offering antenatal care services in health posts, ESPA+ 2014 ......... 153 Table 6.18.1-A Malaria prevention interventions for antenatal care clients: insecticide-treated bed nets and intermittent preventive treatment during pregnancy, ESPA+ 2014 .................................................................. 154 Table 7.1-A Availability of maternal health services, ESPA+ 2014 ..................................................................... 156 Table 7.2-A Signal functions for emergency obstetric care, ESPA+ 2014........................................................... 158 Table 7.3.1-A Newborn care practices, ESPA+ 2014........................................................................................... 160 Table 7.3.2-B Newborn care practices in health posts, ESPA+ 2014 .................................................................. 161 Table 7.4-A Guidelines, trained staff, and equipment for delivery services, ESPA+ 2014 ................................. 162 Table 7.5.1-A Medicines for delivery and newborn care, ESPA+ 2014 .............................................................. 164 Table 7.5.2-B Medicines for delivery and newborn care in health posts, ESPA+ 2014 ...................................... 166 Table 7.6 Items for infection control during provision of delivery care, ESPA+ 2014 ........................................ 167 Table 7.7 Supportive management for providers of delivery care, ESPA+ 2014................................................ 168 Table 7.8-A Training for providers of normal delivery services: delivery care, ESPA+ 2014 .............................. 169 Table 7.9-B Training for providers of normal delivery services: immediate newborn care in health post, ESPA+ 2014 .................................................................................................................................................................... 171 Table 8.1 Availability of HIV testing and counselling services, ESPA+ 2014 ....................................................... 176 Table 8.1.1-A HIV testing integration in facilities, ESPA+ 2014 .......................................................................... 178 Table 8.2 Items for infection control during provision of HIV testing services, ESPA+ 2014 ............................. 180 Table 8.2.1 Items for infection control during provision of HIV testing services in the laboratory, ESPA+ 2014 ............................................................................................................................................................................. 181 Table 8.2.2 Items for infection control during provision of HIV testing services at service site, ESPA+ 2014 ... 182 Table 8.2.2 Items for infection control during provision of HIV testing services at service site, ESPA+ 2014 ... 183 Table 8.4-A Guidelines, trained staff, medicines, and items for HIV/AIDS care and support services, ESPA+ 2014 ............................................................................................................................................................................. 187 Table 8.4.1-A HIV Care and Support Services offered, ESPA+ 2014 ................................................................... 189 Table 8.5-A Guidelines, trained staff, and Laboratory diagnostic capacity for antiretroviral therapy services, ESPA+ 2014 ......................................................................................................................................................... 192 Table 8.6-A Guidelines, trained staff, and medicines, for sexually transmitted infection services, ESPA+ 2014 ............................................................................................................................................................................. 194 Table 8.6.1-A Diagnosis and partner notification for sexually transmitted infection services, ESPA+ 2014 ..... 195 Table 9.1-A Service availability for non-communicable diseases, ESPA+ 2014 .................................................. 199 Table 9.1-B Diagnostic Service availability for non-communicable diseases, ESPA+ 2014 ................................ 197 Table 9.1-C Treatment Service availability for non-communicable diseases, ESPA+ 2014 ................................ 197 Table 9.2-A Guidelines, trained staff, and equipment for diabetes services, ESPA+ 2014 ................................ 202 Table 9.3-A Diagnostic capacity and essential medicines for diabetes, ESPA+ 2014 ......................................... 203 vi
Table 9.4-A Guidelines, trained staff, and equipment for cardiovascular diseases, ESPA+ 2014 ...................... 205 Table 9.5-A Availability of essential medicines and commodities for cardiovascular diseases, ESPA+ 2014 .... 206 Table 9.6-A Guidelines, trained staff, and equipment for chronic respiratory diseases, ESPA+ 2014............... 207 Table 9.7-A Availability of essential medicines and commodities for chronic respiratory diseases, ESPA+ 2014 ............................................................................................................................................................................. 209 Table 9.9-A Guidelines, trained staff, and equipment for cancer diseases, ESPA+ 2014................................... 210 Table 9.9-A Guidelines, trained staff, and equipment for cancer diseases, ESPA+ 2014................................... 211 Table 9.10-A Guidelines and trained staff for chronic renal diseases, ESPA+ 2014 ........................................... 213 Table 10.1-A Availability of tuberculosis services, guidelines, and trained staff for tuberculosis services, ESPA+ 2014 .................................................................................................................................................................... 215 Table 10.1-B Availability of tuberculosis services, guidelines, and trained staff for tuberculosis services in health posts, ESPA+ 2014 ................................................................................................................................... 216 Table 10.1a-A The most common method used for diagnosing pulmonary TB, ESPA+ 2014 ............................ 218 Table 10.2-A Diagnostic capacity and availability of medicines for tuberculosis treatment, ESPA+ 2014 ........ 219 Table 10.3 Standard precautions and conditions for client examination for tuberculosis treatment, ESPA+ 2014 ............................................................................................................................................................................. 221 Table 11.1-A Availability of malaria services and availability of guidelines, trained staff, and diagnostic capacity in facilities offering malaria services, ESPA+ 2014 ............................................................................................. 224 Table 11.1-B Availability of malaria services and availability of guidelines, trained staff, and diagnostic capacity in facilities offering malaria services, ESPA+ 2014 ............................................................................................. 225 Table 11.2-A Availability of malaria medicines and commodities in facilities offering malaria services, ESPA+ 2014 .................................................................................................................................................................... 227 Table 11.2-B Availability of malaria medicines and commodities in facilities offering malaria services in health posts, ESPA+ 2014 ............................................................................................................................................... 228 Table 11.4 Malaria treatment in facilities offering curative care for sick children, ESPA+ 2014 ....................... 229 Table 11.3-A Malaria diagnostic capacity in facilities offering curative care for sick children, ESPA+ 2014 ..... 230 Table 11.3-B Malaria diagnostic capacity in facilities offering curative care for sick children in health posts, ESPA+ 2014 ......................................................................................................................................................... 231 Table 11.5-A Treatment of malaria in children, ESPA+ 2014.............................................................................. 232 Table 11.5-B Treatment of malaria in children in health posts, ESPA+ 2014 ..................................................... 233 Table 12.1-A Service availability for neglected tropical diseases, ESPA+ 2014 .................................................. 237 Table 12.2-A Availability of neglected tropical disease medicines in facilities offering neglected tropical disease services, ESPA+ 2014........................................................................................................................................... 238 Table 12.3-A Availability of neglected tropical disease guidelines and training staff in facilities offering neglected tropical disease services, ESPA+ 2014 ............................................................................................... 240 Table 13.1 Diagnostic accuracy, ESPA+2014....................................................................................................... 243 Table 13.2 Adherence to clinical guidelines [EXAMINITION], ESPA+ 2014 ........................................................ 246 Table 13.3 Reason for absent, ESPA+ 2014 ........................................................................................................ 248
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List of Figures Figure 1.1 Trends in Health Impact Indicators........................................................................................................ 2 Figure 3.1 Percent of facilities having incinerators and placenta pit to manage wastes by Region, ESPA+ 2014 46 Figure 3.2 Percent of facilities with methods of medical waste management, ESPA+ 2014 ............................... 49 Figure 4.1 Availability of equipment for assessing health status of the sick child among facilities offering child curative care services, ESPA+ 2014....................................................................................................................... 56 Figure 4.2 Availability of essential medicines for treating sick children among facilities offering child curative care, ESPA+ 2014 .................................................................................................................................................. 61 Figure 4.3 Availability of vaccines among facilities offering child vaccination services and storing vaccines, ESPA+ 2014 ........................................................................................................................................................... 64 Figure 4.4 Danger signs assessed during observed sick child consultations among all facilities excluding Health Post, ESPA+ 2014 .................................................................................................................................................. 71 Figure 4.5 Main symptoms assessed during observed sick child consultations among all facilities excluding health Post, ESPA+ 2014 ....................................................................................................................................... 71 Figure 4.6 Training Received by Interviewed Child Health Service Providers in Facilities Excluding Health Posts, by Topic and Timing of Most Recent Training, ESPA+ 2014 ................................................................................. 82 Figure 5.1 Availability of Family Planning commodities on the day of survey in facilities excluding health posts, ESPA+ 2014 ........................................................................................................................................................... 93 Figure 5.2. Percent of facilities with items to Support Quality Counseling for Family planning, ESPA+, 2014.... 97 Figure 5.3 Availability of items for Infection Control for Examination of Family Planning Clients in Facilities Excluding Health Posts, ESPA+ 2014. .................................................................................................................... 98 Figure 5.4 Observed Elements of Client History-taking for First-visit Family Planning Clients in Facilities Excluding Health Posts, ESPA+, 2014 .................................................................................................................. 100 Figure 5.5 Percentage of observed family planning consultations on Conditions and Content of Family Planning Counselling in Facilities Excluding Health Posts, ESPA +2014, Ethiopia. ............................................................ 103 Figure 6.1 Availability of items and resources to support quality ANC services among facilities offering ANC service, ESPA+ 2014 ............................................................................................................................................ 118 Figure 6.2 Availability of medicines and supplies for routine ANC services among facilities providing ANC services, ESPA+ 2014........................................................................................................................................... 123 Figure 6.3 Client history for observed first-visit ANC clients in facilities excluding health posts, ESPA+ 2014 . 126 Figure 6.4 Routine tests performed for observed first-visit ANC clients in facilities excluding health posts, ESPA+ 2014. ........................................................................................................................................................ 127 Figure 6.5 Basic physical examinations for observed first-visit ANC clients in facilities excluding health posts, ESPA+ 2014 ......................................................................................................................................................... 130 Figure 6.6 Preventive interventions for ANC clients in facilities excluding health posts, ESPA+ 2014 .............. 130 Figure 6.7 Counselling topics on risk symptoms during ANC consultation among observed ANC clients, ESPA+ 2014 .................................................................................................................................................................... 136 Figure 6.8 Counselling topics on Nutrition, exclusive breast feeding and postpartum FP during ANC consultation, ESPA+ 2014. .................................................................................................................................. 139 Figure 6.9 Pregnancy related warning signs discussed during ANC consultations in health posts and other facility types, ESPA+ 2014. .................................................................................................................................. 143 Figure 6.10 Reported Percentage of Training and Supervisions Received by ANC Providers by Region, ESPA+ 2014 .................................................................................................................................................................... 149 Figure 7.1 Availability of Signal functions in facilities excluding health posts, ESPA+, 2014 ............................. 158 Figure 7.2 Topics of training received by providers of normal delivery service among facilities excluding health posts, ESPA+ 2014 ............................................................................................................................................... 169 Figure 7.3 Training topics on immediate newborn care received by delivery service providers in facilities viii
excluding health posts, ESPA+ 2014 ................................................................................................................... 171 Figure 8.1 Integration of HIV testing and counselling in different service sites in facilities excluding health posts, ESPA+ 2011 ............................................................................................................................................... 177 Figure 8.2 Availability of HIV care and services among health posts by region, ESPA+ 2014. ........................... 185 Figure 8.3 Availability of medicines for HIV care and support service in facilities offering HIV care and support services excluding health posts, ESPA+ 2014. .................................................................................................... 186 Figure 9.1 Availability of services for non communicable disease among facilities excluding health posts, ESPA+ 2014 .................................................................................................................................................................... 198 Figure 10.1 Common methods used for diagnosis of pulmonary TB among facilities, excluding health posts, offering any TB services, ESPA+2014 .................................................................................................................. 218 Figure 11.1 Availability of malaria medicines in facilities offering malaria services excluding health posts, ESPA+ 2014. ................................................................................................................................................................... 227 Figure 12.1 Availability of services for Neglected tropical diseases among facilities excluding health posts, ESPA+ 2014. ........................................................................................................................................................ 237 Figure 13.1 Diagnostic accuracy of interviewed health care providers on specified disease conditions among facilities excluding health posts, ESPA+ 2014. .................................................................................................... 243 Figure 13.2 Health providers absenteeism by facility type, ESPA+ 2014. .......................................................... 248
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FOREWORD The 2014 Ethiopian Service Provision Assessment Plus (ESPA+) survey is the first nationally representative facilitybased survey that is conducted to generate information on the general performance of facilities. The facilities services include maternal, child, and reproductive health services as well as services for specific infectious diseases, including sexually transmitted infections (STIs), HIV/AIDS, tuberculosis (TB), and malaria. In addition, the functioning of the various components of the health system that may affect the quality of services is also covered in this assessment. The 2014 ESPA+ was also designed to generate detailed information on the availability and quality of facility infrastructure, resources, and management systems. The survey also provides information on the clinical knowledge of selected diseases and staff attendance of health providers to provide quality HIV/AIDS services. The 2014 ESPA+ was designed to provide national and sub-national information on the availability and quality of services from a representative sample of 1,327 health facilities. These facilities include hospitals, health centres, health posts, and clinics, which is managed by government, other governmental (military, prison, federal police), nongovernmental organisations (NGOs), and private for profit. The survey included interviews of service providers, observations on sample consultations between the health care providers and clients and interviews with clients after they receive services. According to the finding of this survey, most of the facilities are equipped with the necessary equipment that allow them to provide primary health care and have essential commodity supplies and drugs. However, the survey identified that there is a major gap that require immediate remedy in order to improve the quality of health care service delivery. This 2014 ESPA+ report, therefore, is believed to be an important tool to the nation’s efforts towards the identification and addressing of issues that inhibit provision of and access to quality health care. It is with this regard that the Ethiopian Public Health Institute (EPHI), together with the Ministry of Health conducted this survey and takes pleasure in presenting the results of this survey. I hope that policy and programme managers will focus on the problems that are identified with the ESPA+ surveys to ensure that implementation of activities in the proposed areas of intervention is done in a coordinated manner. To this end, we urge all stakeholders to play active role in addressing the gaps and assist the sector to deliver high quality health services to the Ethiopian population.
Amha Kebede, PhD
Director General,
Ethiopian Public Health Institute
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ACKNOWLEDGEMENTS The following persons contributed to the preparation of this report: Mr. Theodros Getachew, Ethiopian Public Health Institute Mr. Atkure Defar, Ethiopian Public Health Institute Mr. Mekonnen Tadesse, Ethiopian Public Health Institute Mr. Kassahun Amenu, Ethiopian Public Health Institute Mr. Habtamu Teklie, Ethiopian Public Health Institute Mr. Terefe Gelibo, Ethiopian Public Health Institute Mr. Ibrahim Kedir, Ethiopian Public Health Institute Ms. Tigist Shumet, Ethiopian Public Health Institute Ms. Eden Getachew, Ethiopian Public Health Institute Dr. Belete Tafesse, Ethiopian Public Health Institute Mr. Yoseph G/Yohannes, Ethiopian Public Health Institute Mr. Asfaw Kelbessa, Federal Ministry of Health Mr. Solomon Abay, Federal Ministry of Health Mr. Lewi Tibebe, Social Health Insurance Dr. Alemayehu Ambel, World Bank Mr. Agazi Amha, UNICEF Mr. Abebe Bekele, Ethiopian Public Health Institute
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ACRONYMS AND ABBREVIATIONS ACE Angiotensin Converting Enzyme ACT Artemisinin Combination Therapy AIDS Acquired Immune Deficiency Syndrome ALU/AL Artemeter-Lumefantrine ANC Antenatal Care ARI Acute Respiratory Infection ARM Annual Review Meeting ART Antiretroviral Therapy ARV Antiretroviral BCG Bacillus Calmette-Guerin BEmOC Basic Emergency Obstetric Care BF Blood Film BP Blood Pressure BPR Business Process Reengineering BSc Bachlor of Science CAC Comprehensive Abortion Care CAFE Computer Assisted Field Editing CAPI Computer Assisted Personal Interviewing CBHI Community-Based Health Insurance CEmOC Comprehensive Emergency Obstetric Care CHERG Child Health Epidemiology Reference Group CL Cutaneous Leshimeniasis CPR Contraceptive Prevalence Rate CPT Cotrimoxazole Preventive Treatment CSA Central Statistics Agency CSS Care and Support Services DACA Drug Administration and Control Agency DBS Dried Blood Spot DHS Demographic and Health Survey DOTS Directly Observed Therapy Short course EDHS Ethiopian Demographic and Health Survey e-HMIS Electronic Health Management Information System ELISA Enzyme Linked Immunosorbent Assay EPHI Ethiopian Public Health Institute ESPA+ Ethiopia service provision assessment plus ETB Ethiopian Birr FANC Focused Antenatal Care FDRE Federal Democratic Republic of Ethiopia FGAE Family Guidance Association of Ethiopia FHAPCO Federal HIV/AIDS Prevention and Control Office FMoH Federal Ministry of Health FP Family Planning GDP Gross Domestic Product GoE Government of Ethiopia GTP Growth and Transformation Plan HBB Helping Baby Breath HBCs High Burden Countries HC Health Center HE Health Education HEP Health Extension Program HEW Health Extension Workers HIV Human Immunodeficiency Virus HMIS Health Management Information System HP Health Posts HSDP Health Sector Development Program ICCM Integrated Community Case Management ICPD International Conference on Population and Development IESO Integrated Emergency Surgical Officers IMCI Integrated Management of Childhood Illnesses IMNCI Integrated Management of Newborn and Childhood illness IMPAC Integrated Management of Pregnancy and Child birth IMR Infant Mortality Ratio
IRS Indoor Residual Spray ITN Insecticide-Treated Net IUCD Intrauterine Contraceptive devise Ix Investigations JCCC Joint Core Coordinating Committee JFA Joint Financing Arrangement JRM Joint Review Meeting LAM Lactation Amenorrhea Method LLIN Long-Lasting Insecticidal Nets MCH Maternal and Child Health MDA Mass Drug Administration MDG Millennium Development Goal MDR-TB Multidrug resistant TB MhGAP Mental Health Gap Action Program MLHPs Mid-Level Health Professionals MMR Maternal Mortality Ratio MOFED Ministry of Finance and Economic Development MOH Ministry of Health MVA Manual Vacuum Aspiration Mx Management NCD Non Communicable Disease NGO Nongovernmental Organization NHA National Health Account NTD Neglected Tropical Diseases ORS Oral Rehydration Salt PCR Polymerase Chain Reaction PE Physical Examination PEP Post Exposure Prophylaxis PFS Pharmaceutical Fund and Supply Agency PHCU Primary Health Care Unit PMTCT Prevention of Mother-to-Child Transmission of HIV Human Immunodeficiency Virus PPH Post-Partum Haemorrhage PPM Public Private Mix PTB Pulmonary tuberculosis QA Quality Assurance RDT Rapid Diagnostic Test RH Reproductive Health RHBs Regional Health Bureaus RPR Rapid Plasma Reagin SARA Service Availability and Readiness Assessment SDI Service Delivery Indicator SHI Social Health Insurance SNNP Southern Nations, Nationalities and Peoples SSA Sub-Saharan Africa SSG Sodium Stibo Gluconate STI Sexually Transmitted Infection SUFI Scaling up for Impact TB Tuberculosis TBAs Traditional Birth Attendants TFR Total Fertility Rate TGE Transitional Government of Ethiopia TSR Treatment Success Rate TT Tetanus Toxoid TWG Technical Working Group UNFPA United Nations United Nations Population Fund UNICEF United Nations Children’s Fund USAID United States Agency for International Development VCT Voluntary Counselling and Testing VDRL Venereal Disease Research Laboratory VL Visceral Leshimeniasis WHO World Health Organization
xii
WoHO
Woreda Health Office
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1. Overview of the health system in Ethiopia General description of the country Ethiopia is the tenth largest country in Africa, covering 1,104,300 square kilometres (with 1 million sq. km land area and 104,300 sq. km water) and is the major constituent of the landmass known as the Horn of Africa. It is a country with great geographical diversity and its topography shows a variety of contrasts ranging from high peaks of 4,550 m above sea level to a low depression of 110 m below sea level. It is bordered on the north-northeast by Eritrea, on the east by Djibouti and Somalia, on the south by Kenya, and on the west-southwest by Sudan. Its geographical coordinates are between 8 00 N and 38 00 E. Projections from the 2007 population and housing census estimate the total population for the year 2014 to be 87.9 million (CSA, 2013). The country is among the least urbanized country in the world with 83.6 percent living in rural areas. The pyramidal age structure reflects the large number of children under age 15. Children under age of 15 account for nearly half (47 percent) of the total population, a feature of populations with high fertility levels, while only about 4 percent of Ethiopians are over age 65. This population distribution is similar to that observed in the 2000 and 2005 surveys (EDHS, 2011). Ethiopia is a Federal Democratic Republic government under the 1994 constitution. It is composed of nine Regional States and two City Administrations. The regional states and city administrations are subdivided into 817 administrative Woredas (districts). A Woreda/District is the basic decentralized administrative unit and has an administrative council composed of elected members. The 817 Woredas are further divided into about 16,253 Kebeles, the smallest administrative unit in the governance. The decentralization of power to regional governments and local communities (Woredas) is the principal deviation in governance between the current government and the previous ones. It begun with the ratification of the constitution and has been continuously strengthened since then. The decentralization allowed regions and woredas to plan, implement and monitor all socioeconomic activities in their respective administrative levels. The role of Federal Governments and Federal Ministries has been limited to providing support in terms of budgets, policy formulations and capacity building. This approach is believed to have improved access to services and strengthen community participation and ownership at the grass-roots level.
1.1 Key health indicators and trends The major health problems of the country remain largely preventable communicable diseases, reproductive health related problems and nutritional disorders. Despite major progresses have been made to improve the health status of the population in the last two decades, Ethiopia’s population still face a high rate of morbidity and mortality and the health status remains relatively poor (Fig 1.1). Figures on vital health indicators from EDHS 2011 show a life expectancy of 54 years (53.4 years for male and 55.4 for female), and an IMR of 59/1000 (EDHS, 2011). There are multiple components that will influence this: available infrastructure; staff deployment and presence; and availability and quality of services provided. Although routine reporting will contribute to this understanding, at this stage of the implementation of routine reporting, national surveys are required to further complement the available routine reporting.
1
Deaths per 100,000 live births
900
871
800 700
676
673
600 500 400 300 200
166 97 48
100 0 2000
123 77 39
88 59 37
2005
2011
80 59 34 2014
EDHS IMR
NMR
MMR
U5MR
Figure 1.1 Trends in Health Impact Indicators in Ethiopia
1.2 Major health policy and initiatives Ethiopia had no health policy until the early 1960s, when a health policy initiated by the World Health Organization (WHO) was adopted. In the mid-1970s, during the Dergue regime, a health policy was formulated with emphasis on disease prevention and control. This policy gave priority to rural areas and advocated community involvement (TGE, 1993). The current health policy, promulgated by the Transitional Government, takes into account broader issues such as population dynamics, food availability, acceptable living conditions, and other essentials of better health (TGE, 1993). To realize the objectives of the health policy, the government established the Health Sector Development Programme (HSDP), which is a 20-year health development strategy implemented through a series of four consecutive 5year investment programmes (FMOH, 2010). The first phase (HSDP I) was initiated in 1996/97. The core elements of the HSDP include: democratisation and decentralisation of the health care system; development of the preventive and curative components of health care; ensuring accessibility of health care for all segments of the population; and, promotion of private sector and NGO participation in the health sector. Ethiopia’s Growth and Transformation Plan (GTP) 2011-2015 has been designed to maintain the rapid and broadbased economic growth enjoyed by Ethiopia in the recent past and eventually to end poverty (MOFED, 2010). The Health Sector Development Program (HSDP) is a key component of the GTP and its primary objective is to improve the health of the population through the promotion of preventive, curative and rehabilitative health services by: • Improving access to affordable health services; and • Improving the quality of health services The health policy in Ethiopia also takes into account broader issues such as population dynamics, food availability, acceptable living conditions, and other essentials of better health. The HSDP prioritizes maternal and newborn care, and child health, and aims to halt and reverse the spread of major communicable diseases such as HIV/AIDS, TB, and malaria. The Health Extension Programme (HEP) serves as the primary vehicle for the prevention, health promotion, behavioural change communication, and basic curative care. The HEP is an innovative health service delivery programme that aims at universal coverage of primary health care. The programme is based on expanding physical health infrastructure and developing Health Extension Workers (HEWs) who provide basic preventive and curative health services in the rural community. The first phase of the HSDP (HSDP I) was initiated in 1996/97. Thus far, the country has implemented the HSDP in three cycles and is in its fourth phase, HSDP IV (2010/11-2014/15). Assessment of HSDP III shows remarkable 2
achievements in the expansion and construction of health facilities, and improvement in the quality of health service provision. HSDP IV is designed to provide massive training of health workers to improve the provision of quality health services and the development of a community health insurance strategy for the country (FMOH, 2010). In addition, HSDP IV prioritizes maternal and newborn care, and child health. In line with the government’s current five-year national plan, the health sector continues to emphasize primary health care and preventive services; with focus on extending services to those who have not yet been reached and on improving the effectiveness of services, especially addressing difficulties in staffing and the flow of drugs.
1.3 The health care system The recently implemented Business Process Reengineering (BPR) of the health sector has introduced a three-tier health care delivery system: level one is a Woreda/District health system comprised of a primary hospital (to cover 60,000100,000 people), health centres (1/15,000-25,000 population) and their satellite Health Posts (1/3,000-5,000 population) connected to each other by a referral system. The primary hospital, health centre and health posts form a Primary Health Care Unit (PHCU). Level two is a General Hospital covering a population of 1-1.5 million people; and level three is a Specialised Hospital covering a population of 3.5-5 million people. (FMOH, 2010). The devolution of power to regional governments has resulted in largely shifting the decision making for public service delivery from the centre to being under the authority of the regions and down to the district level. Offices at different levels from the Federal Ministry of Health to Regional Health Bureaus (RHBs) and Woreda Health Offices share in decision making processes, powers, duties and responsibilities. The Ministry and the RHBs focus more on policy matters and technical support while Woreda Health Offices manage and coordinate the operation of the district health system under their jurisdiction. Rapid expansion of the private for profit and NGO sectors is augmenting the public | private | NGO partnership for health and boosting health service coverage and utilization (FMOH, 2010). The government has taken a wide range of measures to improve the health status of the population. A number of health sector policies and programs have been developed and aggressively implemented. National health policy was adopted in the early 1990s (FMOH, 1993) and strategies such as nutrition strategy, child survival strategy and infant and young child feeding strategies were endorsed subsequently. A number of innovative programs and interventions have been developed and implemented to translate the policies and strategies in to action. The health sector development programs and the health extension programs can be considered as the centrepieces in this accord. Changes in health care governance and health system management have been introduced. Decentralization in health care governance and management has been adopted. Relentless efforts have been made in expanding health facilities, human resource development and health care financing. Health sector reform - health reforms have been intensified through the application of Business Process Reengineering (BPR), leading to a set of new approaches including benchmarking best practices, designing new processes, revising organisational structures and a selection of key processes (8 core and 5 support processes). The BPR has been progressively implemented at all levels followed by changes in staff deployment, specific job assignments and the recruitment of new staff. Health facility construction and expansion - Progress in facility construction, upgrading and equipping under HSDP III has been remarkable. The numbers have reached 14,416 HPs (88.7percent of the target); 2,689 HCs (84 percent of target); and 111 Public Hospitals (125 percent of target).
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Human resource development - Overall, targets have been met for the community level and most of the MidLevel Health Professionals (MLHPs). However, there are still major gaps for medical doctors, midwives and anaesthesia professionals, especially when considering the long lead time and limited involvement of the private sector in training these professionals. Pharmaceutical services - In order to improve efficiency in the supply chain of pharmaceuticals and medical supplies, PHARMID has been transformed into the Pharmaceutical Fund and Supply Agency (PFSA) and key measures taken to strengthen the capacity of the new agency. The PFSA has been able to develop a pharmaceutical forecasting plan in consultation with health facilities about what would be required for need-based procurement. Health and health related services and product regulation - A key principle of the health sector BPR is improving the quality of health services through institutionalising accountability and transparency. As a part of this, the former Drug Administration and Control Agency (DACA) has been transformed into the Health and Health related Services and Product Regulatory Agency with a mandate to undertake inspection and quality control of health and health related products; premises, professionals and health delivery processes in an integrated manner. Harmonisation and alignment - Under harmonisation and alignment, the major objective is to have the One-Plan, One-Budget and One-Report approach at all levels of the health system. Ethiopia is a signatory of the Global IHP+ Compact and the first to develop and sign a Country-based IHP+ Compact. One Plan: The health sector wide strategic plan (HSDP) is the product of substantial consultations between the Ministry of Health and the Health Development Partners. One of the most important refinements in HSDP III was the inclusion of “Woreda-Based Health Sector Planning”; this planning system created a platform for joint planning by all stakeholders at all levels of the health system including health development partners. One Budget: Subsequent to signing the IHP+ Compact in 2008, the FMoH and health development partners jointly commissioned an independent health system assessment that led to establishment of the MDG Performance Fund and a Joint Financing Arrangement (JFA) for the Fund that signed by Development Partners, and enabling the FMoH to access and make use of pooled funds. One Report/One M&E: As part of the BPR, integrated supportive supervision, operational research, performance reviews and quality assurance and inspections are now complementing M&E to inform strategic planning of the health sector. Joint Performance reviews such as the annual review meeting (ARM) and joint review meeting (JRM) are being undertaken according to the plan; the Annual Review Meeting (ARM) has been conducted every year. Governance of HSDP: Key coordinating and steering committees are performing well, including the FMoH-RHBs Joint Steering Committee, FMoH-HPN Joint Consultative Forum and the Joint Core Coordinating Committee (JCCC). The Joint Consultative Forum and JCCC meetings have also been regularly functional, with the JCCC focusing on technical and operational issues. Health care financing - Over the course of the HSDPs, various background studies on health care financing issues have contributed to the design and introduction of health financing reforms. The reform components include: retention and utilisation of revenue, administration of the fee waiver system and establishment of functioning facility governance bodies. Other parts of the reforms have included outsourcing of nonclinical services, establishing private wings in health facilities and the exemption of certain services. Retention and utilisation of revenue - The performance report for health care financing up to the end of fiscal year 2008/2009 showed that 73 hospitals and 823 health centres have started retaining revenue. Encouragingly, 95 percent of these units collecting user fees had used the revenue at their level. Health insurance: To date, a draft law and regulation have been revised and presented for policy and technical discussions. A series of consultative discussions have been conducted in Addis Ababa and the regions. The legal framework has been improved and the social health insurance (SHI) Proclamation was approved by the Council of Ministers and by Parliament in July 2010. Parallel to the work on social health insurance, various activities have been undertaken to develop and pilot community-based health insurance (CBHI). Trend of expenditure in the health sector: Ethiopia’s fourth National Health Accounts study (NHA, 2010) showed that national health expenditures have grown significantly, increasing the per capita health expenditure has increased from USD 7.14 (in 2004/05) to USD 16.09 (in 2007/08). 4
Pastoralist health service - Pastoralist peoples in Ethiopia constitute about 10 percent of the national population, and they have many special health needs that are not completely met by the largely static facility-based health system present in the rest of the country. This gap prompted FMoH to adapt the 16 health Extension program (HEP) packages to pastoralists’ needs and translate them into local languages. There is also now a Pastoralist Health Promotion and Disease Prevention Directorate to focus attention on health of the pastoralist populations. Operational research - In HSDP III, the BPR resulted in redesigning Research and Technology Transfer as a core process of the FMoH. There was a surge in the number of operational studies during HSDP III that covered a wide range of areas: Child health, Communicable diseases, Public health, Reproductive health, and health services.
2. ESPA+ background and methodology The 2014 ESPA+ was designed to be a cross-sectional study, which combine MEASURE DHS SPA, World Health Organization’s service Availability and Readiness Assessment (SARA) and the World Bank’s Service Delivery Indicator (SDI). The sample size for the ESPA+ was determined by a combination of census and random samples. The public health care sector in Ethiopia is organized into a three-tier system: tier one (district health system) is comprised of a primary hospital and health centres with their satellite health posts. Health posts are manned by Health Extension Workers (HEWs), and provide mainly essential promotive and preventive services and limited curative services. Tier one (primary hospital, health centre and their satellite health posts) constitute the Primary Health Care Unit (PHCU). Tier two is composed of general hospitals, while tier three is made up of specialized hospitals. The private-for-profit and NGO health sectors in Ethiopia have seen rapid expansion in recent years, which is augmenting the public – private – NGO partnership for health. The ESPA+ is an assessment of health facilities, designed to provide information on the general performance of facilities that offer maternal, child, and reproductive health services as well as services for specific infectious diseases, including sexually transmitted infections (STIs), HIV/AIDS, tuberculosis (TB), and malaria; and the functioning of the various components of the health system that may affect the quality of services. The 2014 ESPA+ is the first survey of its kind to be conducted in Ethiopia. Information to provide a comprehensive picture of the strengths and weaknesses of the service delivery environment for each assessed service was collected from a representative sample of facilities managed by the government, non-governmental organisations (NGOs), and private for-profit organisations, in all 9 regions and 2 city administrations of the country. The 2014 ESPA+ provide indicators at national level for the different facility types and managing authority as well as aggregate indicators at the regional level.
2.1 Institutional framework The 2014 Ethiopia Service Provision Assessment Plus (2014 ESPA+) survey was undertaken by the Ethiopian Public Health Institute (EPHI). Technical support for the survey was provided by World Bank and ICF International under the MEASURE DHS Project. The United States Agency for International Development (USAID), World Bank, UNICEF, Irish Aid, and World Health Organization provided the financial support. A technical committee was constituted to oversee all policy and technical issues related to the survey. The purpose of the 2014 ESPA+ survey was to collect information on the delivery of health care services in Ethiopia and to examine the preparedness of facilities for provision of quality health services in the areas of: child health, maternal and newborn care, family planning, sexually transmitted infections, HIV and AIDS, and tuberculosis.
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This report presents provisional results on facility infrastructure and service delivery based on information collected from the health facilities. This information will help health programme managers and policy makers to prioritise interventions that will enhance the provision of quality health services.
2.2 objectives of the ESPA+ The objectives of the 2014 ESPA+ is to:
Assess the preparedness of health facilities in Ethiopia to provide quality child and maternal health and family planning services.
Provide a comprehensive body of information on the performance of different types of facilities that provide essential health care services.
Identify gaps in the support services, resources, and processes that are used to provide health services and that may negatively affect the ability of facilities to provide quality services.
Describe the processes used to provide essential health care services and the extent to which accepted standards for quality service provision are adhered to.
Compare the findings by facility type, management authority, and region.
Describe the extent to which clients understand the advice given on the service received so that the best health outcome is achieved.
Institutionalize capacity to carry out nationwide surveys and use data for further analyses and future survey planning, with diminishing external support, as a longterm objective
Data collection instruments were adapted and developed for ESPA+ to respond to the following basic questions:
1. What is the availability of different health services in the country? Specifically, what proportions of the different facility types offer specific health services?
2. To what extent are facilities prepared to provide quality health services? For each high-priority service, the 2014 ESPA+ used Facility Inventory Questionnaires and Provider Interviews to collect information on whether a facility has the capacity to provide the service at acceptable standards or not. The capacity is measured by the presence of essential equipment and supplies in a location reasonably accessible when providing a service. Quality of services, which is one aspect of capacity, is measured by the following characteristics of facilities: training and supervision of staff, availability of service delivery protocols and client education materials, availability and use of health information records, the service delivery environment, and facility systems for maintaining equipment and supplies. The survey assessed support systems for general management, quality assurance, logistics for medicines, infection control, and systems for monitoring activities (such as tracking service coverage rates and referrals). Interviewers asked whether a facility had these support systems in place and noted whether those systems were functioning. A facility’s basic infrastructure can affect the standard of health services provided and influence clients’ willingness to use the facility. The 2014 ESPA+ collected data on whether facilities had electricity, water, and client amenities and on whether the facility kept records of services provided and on which days of the week. The 2014 ESPA+ also assessed staffing levels. 6
3. To what extent does the service delivery process follow generally accepted standards of care? ESPA+ interviewers observed interactions between clients and providers to assess whether the process followed in service delivery meets standards for acceptable content and quality. Interviewer observed consultations for sick children, family planning services, and antenatal care (ANC). They recorded what information is shared between the client and the provider and what processes the provider follows when assessing the client, conducting procedures, and providing treatment.
4. What issues affect clients’ and service providers’ satisfaction with the service delivery environment? Each observed client was subsequently asked to participate in an exit interview to ascertain the client’s perception of information shared and services received. This information provides further insight on the quality of the client-provider interaction. Also, providers were interviewed about their satisfaction with the work environment.
5. To what extent are the staff available to give the service to client? The ESPA+ checked the availability of staff during their working hour. Staff roaster was checked in two visits. One was unannounced visit and the other was announced visit. The availability of staff on duty was checked in the facility against the staff roaster.
6. What is the level of clinical knowledge among health service provider in diagnosing and managing selected disease conditions? For few selected services, the 2014 ESPA+ used Provider Interviews to collect information on whether the health care provider has disease specific knowledge to provide the service at acceptable standards or not.
2.3 2014 ESPA+ content and methods for data collection 2.3.1 Content of the 2014 ESPA+ The Ethiopia Service Provision Assessment plus (ESPA+) consists of two major activities. These are: (1) a national level sample survey of formal sector public and private functional health facilities including all hospitals, sampled health centres, private clinics and health posts, and (2) a census of hospitals and health centres in all 9 regions and 2 city administrations of the country. Pharmacies, diagnostic centres, regional laboratories, and individual doctors’ offices are typically not included in this ESPA+ survey. The Survey covers more themes and questions than the Census. All the Census questions are the subset of the Survey questions. Therefore, the Census team did not go to those facilities where the SPA+ Survey took place. For example, the Census teams did not go to hospitals as all the hospitals are included in the Survey. However, the Census data have information from all government hospitals. Likewise, the Census teams did not collect information from those health centres that the survey covers. Again, the parts of the information from these health centres are in the Census dataset. Therefore, after the survey was completed, the relevant data from the Survey was transferred to the Census; so that, the Census had a complete dataset coming from all government hospitals and health centres. The report for census of hospitals and health centers is available in a separate document. The survey assessed the availability of staff at health facility when they are supposed to be available. This was done by two visits to the health facility. The first was announced visit and the second one was unannounced. The data collectors checked on who should be present in the facility at specified time and who actually was present. This help to measure the staff absenteeism at facility level which affects the quality of service. 7
Four high-priority health services, all interrelated to some extent, were assessed: child health, family planning, maternal health, and specific infectious diseases (STIs, HIV/AIDS, TB, and malaria). In each of these four areas, the survey assessed whether components considered essential for quality health services are present and functioning. The components assessed were those commonly promoted in different programs supported by the government and development partners. The ESPA+ also assessed whether more sophisticated components were present, such as higherlevel diagnostic and treatment modalities or support systems for health services that are usually introduced after basiclevel services have been put in place. The child health component of the survey was designed to assess the availability of preventive services (immunization and growth monitoring) and outpatient curative care for sick children, with a focus on the process followed in providing services to sick children. Service provision was compared with the standards set in the guidelines for the World Health Organization’s Integrated Management of Neonatal and Childhood Illness (IMNCI). The family planning component focused on the process followed in counselling and providing contraceptive methods to family planning clients. The maternal health component assessed, counselling and screening during ANC visits, delivery service environment, and care during the postpartum period. The infectious disease component assessed the availability of services for diagnosing and treating of STIs as well as HIV/AIDS, TB, and malaria diagnostic and treatment programs. 2.3.2 Data Collection Instruments To achieve the objectives of the assessment and to capture information from the different categories, data were collected using the following instruments: A facility inventory questionnaire was used to obtain information on how the facilities are prepared to provide each of the priority services. The facility inventory questionnaire collects information on the availability of specific items (including their location and functional status), components of support systems (e.g., logistics, maintenance, and management), and facility infrastructure, including the service delivery environment. Hence, the most knowledgeable person about the organisation of the facility and/or the most knowledgeable provider of each service was interviewed by the data collectors. If another provider needed to give some specific information, that provider was invited (or visited, if appropriate) and questioned about that information. The inventory questionnaire is organised into the following three modules: (1) Module 1 elicits information on service availability. (2) Module 2 collects information on general facility readiness. Seven sections cover topics such as facility infrastructure (sources of water, electricity, etc.), staffing, health management information systems, health statistics, processing of instruments for re-use, health care waste management, availability of basic supplies and equipment, laboratory diagnostic capacity, and medicines and commodities. (3) Module 3 solicits information on service-specific readiness. Sections cover child health (child vaccination, growth monitoring, and curative care), family planning, antenatal care, prevention of mother-to-child transmission of HIV (PMTCT), delivery and newborn care, noncommunicable disease and infectious diseases such as tuberculosis, malaria, and HIV/AIDS. A health provider questionnaire was used to solicit information from a sample of health service providers on their qualifications (training, experience, and continuing education), supervision they 8
had received, and their perceptions of the service delivery environment. The Health worker interview questionnaire was modified to include a set of service specific “knowledge” questions based on World Bank’s SDI clinical knowledge assessment modules, to assess individual health providers’ knowledge in managing common health conditions. Observation protocols captured key components of consultations and examinations of sick children, antenatal care, and family planning. Once in a facility, interviewers attempted to observe a sample of consultations for their respective service component (antenatal care, family planning, or sick child) as they occurred. The observations, which were recorded in a checklist, covered
the process used in conducting specific procedures and examinations and also the content of information exchanged between the provider and the client (including history, symptoms, and advice). Client exit interview questionnaires were designed to assess each client’s understanding of the consultation and/or examination as part of their visit to the facility. Client exit interviews were conducted with clients whose consultations had been observed. 2.3.3 Data Collection Approaches After preparation of definitive questionnaires in English, the questionnaires were translated into three major languages: Amharigna, Oromiffa, and Tigrigna. English and Amharigna translation of the inventory questionnaire were loaded onto tablet computers, which were used during interviews to ask questions and also record responses (computer assisted personal interviewing–CAPI). All other types of questionnaires were paper based, but responses were entered into computers and edited in the field (computer assisted field editing–CAFE).
2.4 Sampling 2.4.1 Sampled Health Facilities A list of 23,102 formal sector health facilities in Ethiopia was obtained from the Federal Ministry of Health. The list included: 202 hospitals, 3,292 health centres, 15, 618 health posts, and 3,990 private clinics (higher clinics, Medium clinics and lower clinics). These facilities were managed by the following authorities: the government, other governmental (military, prison, federal police), private for profit, and nongovernmental organisation (NGOs (mission/faith based, non profit)). Because of their importance and their limited numbers, all hospitals were included in the survey and allowing for inclusion of newly identified hospital in the survey. A representative sample of health centres and clinics were selected and included in the survey. A total sample size of 1,327 health facilities were selected, including 321 health posts and 10 newly identified hospitals. Health posts were independently selected, analysed, and reported. The sample includes all hospitals, sample of health centres, private clinics, and health posts. In order to respond to the data needs of the FMOH, to get key information on facility infrastructure, services offered, and GPS information from all public hospitals and sampled health centres, the survey is designed such that all the remaining health centres were visited by a separate set of teams concurrently, using a simplified version (a subset) of the inventory questionnaire. This component of the assessment is referred to as the Census. Table 2.1 presents the percent distribution of the facilities on the master list and the results following attempts to visit those facilities. Some facilities on the list were closed or not yet operational (11 percent); in about 1 percent of facilities were not interviewed for various reasons including: security reason, inaccessible for various reasons, duplication, inability to obtain consent, and facility type change (e.g. changed to a special dental clinic). As a result, data were successfully collected from a total of 1,165 facilities, representing 88 percent of those on the sampled list. 9
Table 2.1 Result of facility contact, by background characteristics Table 2.1
Result of facility contact, by background characteristics
Percent distribution of sampled facilities according to result of visit of the survey team to the facility, by background characteristics, Ethiopia SPA+ 2014
Background characteristics
Completed
Facility type Referral Hospital General Hospital Primary Hospital Health Center Health Post Higher Clinic Medium Clinic Lower Clinic
Respondent not available
Refused
Closed/not yet operational
Other
Total percent
Number of facilities surveyed
97 97 93 98 91 81 79 72
0 0 0 0 1 0 0 0
0 1 0 0 0 1 0 0
3 1 7 2 7 17 20 28
0 1 0 0 1 0 2 0
100 100 100 100 100 100 100 100
33 134 56 298 321 70 168 247
95
1
0
4
1
100
768
83 77
0 0
0 0
0 22
17 1
100 100
12 515
97
0
0
3
0
100
32
Region Tigray Afar Amhara Oromia Somali Benishangul Gumuz SNNP Gambella Harari Addis Ababa Dire Dawa
88 82 89 88 80 84 91 84 92 87 96
1 4 0 1 0 0 0 0 0 0 0
1 0 0 0 0 0 0 0 0 1 0
9 14 11 11 15 16 9 15 5 13 4
2 0 0 0 5 0 0 1 3 0 0
100 100 100 100 100 100 100 100 100 100 100
132 78 184 236 84 77 183 80 61 128 84
Urban/rural Urban Rural Unknown
88 90 0
0 1 5
0 0 0
11 9 68
0 0 26
100 100 100
624 684 19
88
0
0
11
1
100
1,327
Managing authority Government/ public Other governmental (military, prison, federal police) Private for profit NGO (mission/ faith-based, nonprofit)
Total
Note: some of the rows may not add up to 100 percent due to rounding
Table 2.2 presents the percent distribution by background characteristics of the facilities that were successfully assessed. The majority of facilities in the country (using adjusted/weighted proportions to reflect actual facility distribution in Ethiopia) are health posts (69 percent) and health centres (16 percent). Private clinics (14 percent) and Hospitals (1 percent) are the fewest in number. The majority of the facilities (85 percent) are managed by the government, facilities managed by private for profit (14 percent), and NGO (mission/faith-based, non profit) (1 percent) are small in proportion. Oromia region contains the largest proportion of the facilities (37 percent) followed by SNNP and Amhara regions which contain about one-fourth of the facilities each (24 percent and 23 percent respectively).The majority of health facilities are located in rural area (85 percent) of the country. Table 2.2 Distribution of surveyed facilities, by background characteristics Table 2.2
Distribution of surveyed facilities, by background characteristics
10
Percent distribution and number of surveyed facilities, by background characteristics, Ethiopia SPA+ 2014 Number of facilities surveyed
Background characteristics Facility type Referral Hospital General Hospital Primary Hospital Health Center Health Post Higher Clinic Medium Clinic Lower Clinic
Weighted percent distribution of surveyed facilities
Weighted
Unweighted
0 1 0 16 69 1 3 10
2 7 3 182 802 13 37 119
32 130 52 292 292 57 132 178
85
990
728
0 14
4 163
10 396
1
8
31
Region Tigray Afar Amhara Oromia Somali Benishangul Gumuz SNNP Gambella Harari Addis Ababa Dire Dawa
5 1 23 37 3 2 24 1 0 3 0
54 14 269 432 39 21 285 10 3 31 5
116 64 163 208 67 65 167 67 56 111 81
Urban/rural Urban Rural
15 85
176 989
551 614
100
1,165
1,165
Managing authority Government/ public Other governmental (military, prison, federal police) Private for profit NGO (mission/ faith-based, nonprofit)
Total
2.4.2 Sampled Health care Providers Health service provider is defined as one who provides consultation service, counselling or education, and laboratory service to clients. For example health workers are not illegible for observation or interview, if they only take measurement or complete registration. The sample of health service providers was selected from those who were present in the facility on day of visit and who provided services. A maximum of fifteen providers were interviewed in each facilit. In facilities where fifteen or fewer health care providers are available, all of the providers present on the day of visit are interviewed. In facilities where more than fifteen providers are available, they were selected for interview, if their work was observed and the remaining health care providers were randomly selected by their qualification, departments where they work, and the service that they provide. Table 2.3 shows the number and percent distribution of health providers who were interviewed with the health provider questionnaire. A total of 6,125 providers were interviewed, mainly from government managed health facilities (87 percent) most often in health centres (44 percent) and in health posts (33 percent) made frequently of diploma nurses (34 percent) and health extension workers (30 percent).
11
Table 2.3 Distribution of interviewed providers, by background characteristics and provider qualification Table 2.3 Distribution of interviewed providers, by background characteristics and provider qualification Percent distribution and number of interviewed providers, by background characteristics and provider qualification, Ethiopia SPA+ 2014 Number of interviewed providers
Background characteristics Facility type Referral Hospital General Hospital Primary Hospital Health Center Health Post Higher Clinic Medium Clinic Lower Clinic Total Managing authority Government/ public Other governmental (military, prison, federal police) Private for profit NGO (mission/ faith-based, nonprofit) Total Region Tigray Afar Amhara Oromia Somali Benishangul Gumuz SNNP Gambella Harari Addis Ababa Dire Dawa Total Urban/rural Urban Rural Total Provider type General practitioner MD specialist1 Health officer Nurse (diploma) Nurse (Bsc) Midwifes (Bsc) Midwifes (diploma) Specialist nurse Integrated emergency surgical officer (IESO) Msc in medical laboratory Lab technologist
Weighted percent distribution of interviewed providers
Weighted
Unweighted
3 8 2 44 33 2 4 5
176 464 145 2,676 2,013 123 237 291
435 1,555 581 2,145 459 266 413 271
100
6,125
6,125
87
5,306
4,474
0 12
24 705
54 1,402
1
89
195
100
6,125
6,125
7 1 20 33 3 2 22 1 0 9 1
436 81 1,242 2,018 194 121 1,363 49 27 547 48
647 257 854 1,267 352 297 831 188 196 873 363
100
6,125
6,125
34 66
2,054 4,071
3,922 2,203
100
6,125
6,125
2 1 7 34 5 2 9 0
140 55 414 2,101 298 113 528 5
436 208 516 2,422 507 76 660 20
0 0 2
7 0 148
30 1 271
12
Laboratory technician Health extension worker Total
7 30
442 1,859
603 355
100
6,125
6,125
2.4.3 Sampled observation and Client Exit interview Samples of observation and Exit Clients were systematically selected based on the number of clients expected for each service on the day of the survey. The rule to observe is a maximum of five clients per each provider of a specific service with a maximum of fifteen observations for each service per facility. Where several eligible Antenatal care and family planning clients were waiting, interviewers tried to select two new clients for every follow up client. For child health consultations, children younger than five years old who presented with an illness rather than an injury or accident were selected for observation. The exit interview was conducted only for clients whose consultation is observed before leaving the facility. Table 2.4 presents the number and percent distribution of observations of consultations (actual and weighted). Most of the observations, in order of frequency, were of sick children (1,908), antenatal care clients (1,853), and family planning clients (1,247). Table 2.4 Distribution of observed consultations, ESPA+ 2014 Table 2.4
Distribution of observed consultations
Percent distribution and number of observed consultations for, outpatient curative care for sick children, family planning, and antenatal care, by type of facility, Ethiopia SPA+ 2014 Number of observed consultations
Facility type
Percent distribution of observed consultations
Weighted
Unweighted
OUTPATIENT CURATIVE CARE FOR SICK CHILDREN Referral Hospital General Hospital Primary Hospital Health Center Health Post Higher Clinic Medium Clinic Lower Clinic Total
20 18 5 43 7 1 3 3
382 334 86 825 142 22 59 57
109 537 230 720 65 54 134 59
100
1,908
1,908
3 13 4 71 6 0 2 2
40 160 52 880 73 1 21 21
86 252 139 628 44 16 57 25
100
1,247
1,247
218 389 96 1,050 71 3 25
179 618 225 736 25 29 36
FAMILY PLANNING Referral Hospital General Hospital Primary Hospital Health Center Health Post Higher Clinic Medium Clinic Lower Clinic Total
ANTENATAL CARE Referral Hospital General Hospital Primary Hospital Health Center Health Post Higher Clinic Medium Clinic
12 21 5 57 4 0 1
13
Lower Clinic Total
0
2
5
100
1,853
1,853
Table 2.5 shows, the number of clients attending facility on the day of the survey eligible for observation, number whose consultations were observed and who were interviewed, and the percentages of eligible clients who were observed and interviewed by type of service and type of facility. Most of eligible clients present on the day of the survey, in order of frequency, were of sick children (1,980), antenatal care clients (1,902), and family planning clients (1,265). Almost all (between 96 and 99 percent) clients present on the day of the survey were observed and interviewed. Table 2.5 Distribution of observed and interviewed clients (unweighted), ESPA+ 2014 Table 2.5
Distribution of observed and interviewed clients (unweighted)
Number of clients attending facility on the day of the survey eligible for observation, number whose consultations were observed and who were interviewed, and the percentages of eligible clients who were observed and interviewed, by type of service and type of facility, Ethiopia SPA+ 2014
Facility type
Total number of Percentage of clients present on Actual number of clients who were the day of the clients observed observed and survey and interviewed interviewed OUTPATIENT CURATIVE CARE FOR SICK CHILDREN
Referral Hospital General Hospital Primary Hospital Health Center Health Post Higher Clinic Medium Clinic Lower Clinic Total
115 568 235 743 66 55 139 59
109 537 230 720 65 54 134 59
95 95 98 97 98 98 96 100
1,980
1,908
96
88 256 141 638 44 16 57 25
86 252 139 628 44 16 57 25
98 98 99 98 100 100 100 100
1,265
1,247
99
186 636 230 752 25 30 38 5
179 618 225 736 25 29 36 5
96 97 98 98 100 97 95 100
1,902
1,853
97
FAMILY PLANNING Referral Hospital General Hospital Primary Hospital Health Center Health Post Higher Clinic Medium Clinic Lower Clinic Total
ANTENATAL CARE Referral Hospital General Hospital Primary Hospital Health Center Health Post Higher Clinic Medium Clinic Lower Clinic Total
14
2.5 Training and Data Collection Pre-Test The questionnaires were pretested to detect any possible problems in the flow of the questionnaires, gauge the length of time required for interviews, as well as any problems in the translations. The pretest also helped to detect any problems with the data entry programs. The pre-test for the 2014 ESPA+ took place from October 15, 2013 – November 13, 2013, Ethiopia. Sixteen regional coordinators, four team leader, and ten interviewers all mostly health providers hired by EPHI were trained as interviewers in the application of the questionnaires and computer programmes and also lead the main training. During pre-test data collection, health facilities within Oromia region which were not sampled in the main survey were surveyed for three days to test and refine the survey instruments and the computer programmes. After the pre-test, the questionnaires and computer programmes were finalised for the main data assessment. ICF personnel lead the training and staffs from EPHI, FMOH, and World Bank were also involve in the training in the area of their expertise. Main Assessment The main training for the 2014 ESPA+ took place from February 06, 2014 – March 09, 2014. Eight of the sixteen regional coordinators, master level health workers with prior survey experience conducted the main assessment in Amharic. The four team leader and ten interviewers from the pre-test remained with EPHI to assist in preparation for and during main training as well. EPHI personnel along with ICF international and World Bank personnel oversaw the training. One hundred Eighty-nine, mostly health providers (nurses, nurse midwives, and clinicians) were trained in the application of survey instruments and computer programmes. The training included classroom lectures and discussion, practical demonstrations, mock interviews, role plays, and field practices. The participants were also given daily homework—to conduct mock interviews among themselves using the survey tools. The first two weeks of training were dedicated exclusively to training interviewers on use of paper questionnaires, and also to field practice. The three days of field practice was to ensure that the participants understood the content of the (paper) questionnaires, as well as how to organise themselves once in a health facility. During the third week of training, participants were first introduced to tablet computers, and then transitioned to the use of the tablet computers for data collection (CAPI) and for data entry and editing (CAFE); this was done using completed paper questionnaires from the facilities visited during the pre-test. During the fourth week, participants practiced all questionnaire types and CAPI/CAFE approaches in teams and in pairs. The first three days of the fifth week were dedicated to field practice using computers followed by a two days discussion on concerns raised from the field practice. Following the training, 36 teams were formed, each consisting of a team leader, four interviewers, and a driver. Extra interviewers were dispersed throughout teams. Main data collection took place from March 10, 2014, to July 25, 2014. The team leader had responsibility of checking all questionnaires before leaving the facility. Each team was given a list of facility to visit, list of facilities name, type, and location. On average, the data collection took two days per facility. Each interviewer ensures that the respondent for each component of the facility inventory is the most knowledgeable person for the particular service or system being assessed. Informed consent is obtained from the person in charge in the facility for inventory questionnaire, from providers for provider interview and observation, and from clients for client observation and exit.
15
Fieldwork supervision was coordinated by EPHI. TWG members, FMOH staff, EPHI staff, World Bank and ICF personnel participated in supportive fieldwork supervision. Eight regional coordinators were each assigned to supervise four to five teams. They made periodic visits to their teams to review work and monitor data quality. Four of the regional coordinators assumed the role of data managers and coordinators in the survey central office. Field check table generated by the data entry program were also used to check the quality of collected data, and, where necessary the central office staff communicated to the regional coordinators and sorted out any problems. Six data encoders were engaged to support the survey central office.
2.6 Data management and analysis The information entered in the PC-tablets by each interviewer was downloaded daily by the team supervisor into his/her computer, and sent regularly to the central office, preferably when data collection was completed in a health facility. The data from field were zipped and sent to the Central Office using internet connection via configured Outlook mail. These zipped files were extracted, reviewed and checked for any errors and inconsistencies. Double entry of the paper questionnaire by the data encoders and verification is also done. Secondary editing was done by the data managers and if any error or inconsistency is found teams were informed to correct and resend the data. The data managers finalize and back up the data in EPHI server with password protection. The data was secured and could not be accessed by unauthorized person. Data cleaning included the checking of range, structure and a selected set of checks for internal consistency. All errors detected during machine editing were corrected. Technical assistance for the data editing programs were furnished by ICF International. All data entry and editing programs were written using CSPro. Several conventions were observed during the analysis of the 2014 ESPA+ data.
First, unless otherwise indicated, the 2014ESPA+ considered only those items observed by the interviewers themselves to be available.
Second, in a majority of facilities, multiple health workers contribute to the services received by clients. The health worker, who ultimately assesses the client, makes the final diagnosis and prescribes any treatment, if necessary, and is identified as the primary provider for the particular service. This health worker is the provider who the interviewer observed using the observation protocols.
Third, quite often, certain measurements (e.g., measuring blood pressure and temperature) are routinely done by health workers other than the primary provider, and separate from the actual consultation. Where this system is used, and all clients receive these measurements as part of their visit, then clients who are selected for observation are assumed to have received these measurements, even if the primary provider does not take these measurements.
16
3. Facility-level infrastructure, resources, management and support system 3.1 Background This chapter reports on resources, management, and support systems at the facility level. Although health care services can be offered under a variety of conditions, some common elements of the health system ensure their quality, acceptability, and utilization. The first part of this chapter looks at the extent to which health care facilities in Ethiopia have the following resources:
A basic package of services and staff qualified to deliver them Facility infrastructure to support service delivery and utilization Basic equipment availability Standard infection prevention supplies Essential medicines Laboratory service capacity The second part of the chapter considers whether the facilities have management systems in place to: Address management issues Quality assurance system Develop staff capability through training and supervision Encourage community participation and mechanisms to decrease financial barriers to care. Finally, the chapter considers whether Ethiopian health care facilities provide the basic support systems so critical to the quality of services, including:
Logistics systems to support the ongoing maintenance of equipment and infrastructure Medication delivery systems to ensure medicines, vaccines, and contraceptives are available when needed Infection control systems to ensure safe practices in the prevention of infection and illness.
Key Findings
About one-fifth (22 percent) of all facilities offer all basic client services. In general, between six to seven of ten hospitals and eight of ten health centres offer all basic services.
About half of the facilities have regular, uninterrupted electricity (i.e., the facility is connected to a central power grid, or has solar power or both, and power is routinely available during regular service hours), or has a functioning generator with fuel.
Over three quarter of all facilities have an improved water source in the facility (i.e., water is piped into the facility or onto facility grounds, or else water is from a public tap or standpipe, a tube well or borehole, a protected dug well, or protected spring, or rain water, or bottle water), and the outlet from this source is within 500 metres of the facility.
Fewer than three of every four facilities, excluding health posts (74 percent) have a functioning client latrine, but a little over half of health posts have a functioning client latrine.
Transport for emergencies is available in two third of all facilities (i.e., the facility has a functioning ambulance or other vehicle for emergency transport that is stationed at the facility and had fuel available on the day of the survey), or else the facility has access to an ambulance or other vehicle stationed at or operating from another facility.
Among all facilities, a little over forty minutes is the average travel time from the health facility to the ambulance station. 17
Among the 14 essential medicines, paracetamol oral suspension and diclofenac tablet/capsule (each 55 percent) and amoxicillin tablets/capsules (54 percent) are more likely available medicines in facilities excluding health posts.
Only one of five (19 percent) of health facilities excluding health posts report by using e-HMIS.
Over all, none of the facilities charge for vaccination, however 8 percent of general hospitals and 3 percent of referral hospitals have user fee for vaccination services.
Only 16 and 26 percent of all facilities had incinerator and placenta pit respectively.
3.2 Availability of Services and Resources 3.2.1 Availability of all services The availability of a basic package of health services, and the overall ease of access to the health care system all contribute to client utilisation of services in a health facility. The Ethiopian health care service delivery system comprises a network of facilities that provide both preventive and curative health services. Most hospitals and health centres are expected to offer a full range of basic services, including outpatient services for all age groups; maternal and child health care services (antenatal, delivery, and postnatal care); family planning; treatment of sexually transmitted infections (STIs); immunisation; and child growth monitoring. However, some specialised facilities may not offer all services and they are excluded from this study. Because, if a facility does not offer all services, it should not be assumed that the facility is substandard. Clients may have to visit several facilities, however, to meet all of their family’s basic health care needs. Tables 3.1-A and 3.1-B present information on the overall availability of individual services. The comprehensive inventory of the available individual services contributes to use of service. Among all health facilities, excluding health posts, the most available service is emergency service (97 percent) followed by curative care services for sick children, diagnostic or treatment of malaria, and diagnostic or treatment of STIs excluding of HIV services (93 percent each). Intensive care unit (ICU) services are available only in 1 percent of all facilities excluding health posts. Table 3.1-A Availability of specific services, ESPA+ 2014 Table 3.1-A
Availability of specific services
Among all facilities, excluding health posts, the percentages and numbers that offer specific services, Ethiopia SPA+ 2014 Number of facilities offering service
Service provided
Percentage of facilities offering service (weighted)
Weighted
Unweighted
49
177
449
51
185
448
93
337
795
89 77
324 281
742 660
48 65 93
175 237 338
468 571 828
Child vaccination services (EPI), either at the facility or as outreach1 Growth monitoring services, either at the facility or as outreach2 Curative care services for children under age 5, either at the facility or as outreach Any family planning services, including modern methods, fertility awareness methods, male or female surgical sterilization3 Antenatal care services Service for the prevention of motherto-child transmission of HIV (PMTCT)4 Normal delivery5 Diagnosis or treatment of malaria6
18
Diagnosis or treatment of STIs, excluding HIV7 Diagnosis, treatment prescription or follow-up for TB8 HIV testing and counselling (HTC) services9 HIV/AIDS antiretroviral prescription or treatment follow-up services10 HIV/AIDS care and support services11 Diagnosis or management of noncommunicable diseases12 Minor surgical services13 Laboratory diagnostic services Neglected tropical diseases Emergency services Inpatient services Total
93
338
823
69
252
659
59
216
590
17 27
61 96
285 347
81 73 57 68 97 33
293 264 208 247 354 119
747 666 645 632 833 428
-
363
873
1 Routine series of DPT/Pentavalent, polio, and measles vaccinations offered from the facility, excluding any outreach services 2 Child Growth Monitoring services: Growth monitoring is the regular monitoring of a "well" child, to see how s/he is developing. It usually involves measurement of a child's weight and height from birth through age 5 years. The rate of growth is checked against a chart to assure they were within an acceptable range. These services are usually offered from "well baby" clinics. We are interested in whether the facility offers these services, either in the facility or as outreach. 3 Facility provides, prescribes, or counsels clients on any of the following: contraceptive pills (combined or progestin-only), injectables (progestin-only), implants, IUCDs, male condoms, female condoms, female sterilization (tubal ligation), male sterilization (vasectomy), or periodic abstinence method. 4 Facility reports that it provides any of the following services for the prevention of motherto-child transmission (PMTCT) of HIV: HIV testing and counselling for pregnant women or children born to HIV-positive women, provision of antiretroviral (ARV) prophylaxis to HIVpositive pregnant women or to newborns of HIV-positive women, provision of infant and young child feeding for PMTCT, provision of nutritional counselling for HIV-positive pregnant women and their infants, provision of family planning counselling to HIV-positive pregnant women, or provision of ART to HIV-positive pregnant women. 5 Normal delivery refers to a birth that is vaginal, spontaneous in onset, low-risk at the start of labor, and remaining so through labor and delivery. Delivery services are almost always with newborn care services, which refer to treatment received by a newborn child from the date of birth and for the first four weeks of life. 6 Facility reports that it offers malaria diagnosis and/or treatment services. Also, facilities offering curative care for sick children where providers of sick child services were found on the day of the survey to be making diagnosis of malaria or offering treatment for malaria were counted as offering malaria diagnosis and/or treatment services. 7 These include any service to diagnose or treat sexually transmitted infections, infections, excluding HIV infection. 8 Facility reports that providers assigned to the facility diagnose TB, prescribe treatment for TB, or provide TB treatment follow-up services for clients put on treatment elsewhere. 9 Facility reports that is has the capacity to conduct HIV testing in the facility, either by rapid diagnostic testing or ELISA, and an unexpired HIV rapid diagnostic test kit is available in the facility on the day of the survey, or other test capability is available. 10 Facility reports that providers in the facility prescribe antiretroviral (ARV) treatment and/or provide clinical follow-up for clients on ARV treatment. Outreach ART facilities are included in this definition. 11 Facility reports that providers in the facility prescribe or provide any of the following: · Treatment for any opportunistic infections or for symptoms related to HIV/AIDS, including treatment for topical fungal infections; · Systematic intravenous treatment for specific fungal infections such as cryptococcal meningitis; · Treatment for Kaposi's sarcoma; · Palliative care, such as symptom or pain management, or nursing care for terminally ill or severely debilitated patients; · Nutritional rehabilitation services, including client education, provision of nutritional or micronutrient supplementation; · Fortified protein supplementation; · Care for paediatric HIV/AIDS patients; · Preventive treatment for TB, i.e., isoniazid with pyridoxine; · Primary preventive treatment for opportunistic infections, such cotrimoxazole preventive treatment; · General family planning counselling and/or services for HIV-positive clients; · Condoms
19
12 Diagnosis and management of non-communicable diseases including diabetes, cardiovascular diseases, and chronic respiratory conditions in adults. 13 These are defined as any situation that requires suture, incision, excision, manipulation, or procedures that can be performed in the general OPD and not requiring the use of a surgical theatre. Examples include incision and drainage of an abscess, suturing of cuts, etc.
Curative care for sick children services (96 percent), family planning services (94 percent) and Antenatal care services (92 percent) are the most available services at health post level but no laboratory diagnostic services were found as expected (Table 3.1-B). Table 3.1-B Availability of specific services in Health posts, ESPA+ 2014 Table 3.1-B
Availability of specific services
Among health posts, the percentages and numbers that offer specific services, Ethiopia SPA+ 2014 Number of facilities offering service
Service provided
Percentage of facilities offering service (weighted)
Weighted
Unweighted
82
658
235
83
668
221
96
766
280
94 92 45 76
757 736 358 612
265 259 146 260
21
172
106
29
233
64
14
109
69
5 13 0
37 103 1
7 35 1
-
802
292
Child vaccination services (EPI), either at the facility or as outreach1 Growth monitoring services, either at the facility or as outreach2 Curative care services for children under age 5, either at the facility or as outreach Any family planning services, including modern methods, fertility awareness methods, male or female surgical sterilization3 Antenatal care services Normal delivery4 Diagnosis or treatment of malaria Diagnosis or treatment of STIs, excluding HIV5 Diagnosis, treatment prescription or follow-up for TB HIV testing and counseling (HTC) services5 HIV/AIDS antiretroviral prescription or treatment follow-up services6 HIV/AIDS care and support services7 Laboratory diagnostic services Total
1 Routine series of DPT/Pentavalent, polio, and measles vaccinations offered from the facility, excluding any outreach services 2 Child Growth Monitoring services: Growth monitoring is the regular monitoring of a "well" child, to see how s/he is developing. It usually involves measurement of a child's weight and height from birth through age 5 years. The rate of growth is checked against a chart to assure they were within an acceptable range. These services are usually offered from "well baby" clinics. We are interested in whether the facility offers these services, either in the facility or as outreach. 3 Facility provides, prescribes, or counsels clients on any of the following: contraceptive pills (combined or progestin-only), injectables (progestin-only), implants, IUCDs, male condoms, female condoms, female sterilization (tubal ligation), male sterilization (vasectomy), or periodic abstinence method. 4 Normal delivery refers to a birth that is vaginal, spontaneous in onset, low-risk at the start of labour, and remaining so through labour and delivery. Delivery services are almost always with new-born care services, which refer to treatment received by a new-born child from the date of birth and for the first four weeks of life. 5 These include any service to diagnose or treat sexually transmitted infections, infections,
20
excluding HIV infection. 6 Facility reports that providers in the facility prescribe antiretroviral (ARV) treatment and/or provide clinical follow-up for clients on ARV treatment. Outreach ART facilities are included in this definition. 7 Facility reports that providers in the facility prescribe or provide any of the following: · Treatment for any opportunistic infections or for symptoms related to HIV/AIDS, including treatment for topical fungal infections; · Systematic intravenous treatment for specific fungal infections such as cryptococcal meningitis; · Treatment for Kaposi's sarcoma; · Palliative care, such as symptom or pain management, or nursing care for terminally ill or severely debilitated patients; · Nutritional rehabilitation services, including client education, provision of nutritional or micronutrient supplementation; · Fortified protein supplementation; · Care for paediatric HIV/AIDS patients; · Preventive treatment for TB, i.e., isoniazid with pyridoxine; · Primary preventive treatment for opportunistic infections, such cotrimoxazole preventive treatment; · General family planning counselling and/or services for HIV-positive clients; · Condoms
3.2.2 Availability of Basic Client Services Table 3.2 presents information on the availability of basic maternal and child health services, family planning services, and services for adult sexually transmitted diseases, both individually and as a package. Availability of a package of services contributes to ease of access and use of services. Table 3.2 Availability of basic client services, ESPA+ 2014 Table 3.2
Availability of basic client services
Among all facilities, the percentages offering indicated basic client services and all basic client services, by background characteristics, Ethiopia SPA+ 2014
Background characteristics Facility type Referral Hospital General Hospital Primary Hospital Health Center Health Post Higher Clinic Medium Clinic Lower Clinic Managing authority Government/ public Other governmental (military, prison, federal police) Private for profit NGO (mission/ faith-based, non-profit) Region Tigray Afar Amhara Oromia Somali Benishangul Gumuz SNNP Gambella Harari Addis Ababa
Child vaccination services
Child growth monitoring services
Curative care services for Any modern All basic client children under family planning Antenatal care age 5 services (ANC) services Services for STI services1
Number of facilities
78 74 81 89 82 8 7 2
72 78 81 89 83 19 15 5
88 97 100 99 96 74 88 86
88 89 90 98 90 51 74 78
91 94 94 99 92 55 55 52
100 98 100 99 21 97 97 82
63 67 71 82 13 4 3 0
2 7 3 182 802 13 37 119
84
85
96
92
93
36
26
990
3 1
0 7
86 86
6 78
33 53
100 86
0 1
4 163
67
74
96
31
80
94
23
8
81 52 67 78 62 83 74 47 59 17
87 34 75 75 50 64 80 21 63 22
91 100 96 94 95 97 96 91 86 82
90 73 94 86 60 98 98 77 77 58
88 83 89 87 74 91 95 49 70 45
48 69 39 45 92 45 31 62 71 95
35 19 20 27 25 33 15 10 32 14
54 14 269 432 39 21 285 10 3 31
21
Dire Dawa
63
67
84
80
72
93
60
5
Urban/rural Urban Rural
38 78
39 79
87 96
79 91
69 91
79 38
29 21
176 989
72
73
95
89
87
44
22
1,165
Total
1 Basic client services include outpatient curative care for sick children, child growth monitoring, facility-based child vaccination services, any modern methods of family planning, antenatal care, and services for sexually transmitted infections (STI).
The basic services assessed by the 2014 ESPA+ are each available, in 44 percent or more of all Ethiopian facilities. For example, curative care for sick children are available in 95 percent of all facilities; family planning services and antenatal care services are each available in 89 and 87 of all facilities; child growth monitoring and child vaccination services are each available in 73 and 72 percent. STI services are the least likely of the basic services to be available, in just 44 percent of all facilities. On average, about one-fifth (22 percent) of all facilities offer all basic services. Availability of basic client services at Tertiary Level of health care According to the Ethiopian Food, Medicine and Healthcare Administration and Control Agency proclamation No 661/2009, referral hospitals a health facility at tertiary level of healthcare which provides curative and rehabilitative services with a minimum capacity of 110 beds and provides at least gynaecology and obstetrics, paediatrics, internal medicine, surgery, orthopaedics, psychiatry, ophthalmology, ENT, dentistry, dermatology specialty services and emergency services that require advanced diagnostic facilities and therapeutic interventions and shall have a minimum of additional two sub-specialties. It shall also provide promotive and preventive services including medical laboratory, imaging and pharmacy services and other related services stated under this standard. In case of government owned comprehensive specialized hospitals, the minimum bed capacity shall be 300 beds with at least four subspecialty services. Accordingly the Ethiopian service provision assessment 2014 found that 63 percent of referral hospitals offer all basic client services. Offering basic client services at referral hospital ranges from 72 percent for growth monitoring to 100 percent for STI services (see table 3.2). Availability of basic client services at Secondary Level of health care The Ethiopian Food, Medicine and Healthcare Administration and Control Agency proclamation No 661/2009 defined a health facility at secondary level of healthcare which provides promotive, preventive, curative and rehabilitative service that requires diagnostic facilities and therapeutic interventions with a minimum capacity of 50 beds and at least shall provide gynaecology and obstetrics, paediatrics, internal medicine, surgery, psychiatry and emergency services. In addition, it shall provide laboratory, imaging and pharmacy services and other related services stated under this standard. Two-third of percent of general hospitals offer all basic client services. Offering basic client services at general hospital ranges from 74 percent for child vaccination to 98 percent for STI services (see table 3.2). Availability of basic client services at Primary Health Care Units Primary hospital Is a health facility at primary level of healthcare which provides promotive, preventive, curative and rehabilitative services with a minimum capacity of 35 beds and provides at least 24 hour emergency services, general medical services, treatment of basic acute and chronic medical problems, basic emergency surgical intervention and Comprehensive Emergency Obstetric Care (CEOC) including laboratory, imaging and pharmacy services and other related services stated under this standard. Health centre is a health facility at primary level of the healthcare system which provides promotive, preventive, curative and rehabilitative outpatient care including basic laboratory and pharmacy services with the capacity of 10 beds for emergency and delivery services. 22
Health post Is a health facility at the primary level of the healthcare that provides mainly essential promotive and preventive services and limited curative services Overall seven of every ten primary hospitals, eight of every ten health centres and only one tenth of health posts offer all basic client services. Clinics are much less likely to offer all basic services, at less than 5 percent. Higher clinic, medium clinic and lower clinic are also less likely to offer child growth monitoring services (19, 15 and 5 percent respectively), and child vaccination services (8, 7 and 2 percent respectively). In health posts, availability of these basic services varies widely; only one-fifth (21 percent) offer STIs services while majority offer curative care for sick children, antenatal care services and family planning services. Government and NGO (mission/faith-based, non-profit) facilities are generally most likely to offer each of the basic services. However, there is considerable variation among private for profit and other government facilities. For example, although nine of every ten private for profit facilities offer child curative care and STI services, only 1 percent offer child vaccination services. Six in ten facilities in Dire Dawa region offer all basic client services compared with only one in ten in Addis Ababa and Gambella region. 3.2.3 Basic Amenities for Client Services Although good services can be provided in minimal service delivery settings, both clients and providers are more likely to be satisfied with a facility that has basic amenities and infrastructure such as a regular source of electricity, supply of improved water, and basic sanitation. Table 3.3-A. and table3.3-B present information on availability of basic amenities for client services. Table 3.3-A Availability of basic amenities for client services, ESPA+ 2014 Table 3.3-A
Availability of basic amenities for client services
Among all facilities, excluding health posts, the percentages with indicated amenities considered basic for quality services, by background characteristics, Ethiopia SPA+ 2014 Amenities
Background characteristics Facility type Referral Hospital General Hospital Primary Hospital Health Center Higher Clinic Medium Clinic Lower Clinic Managing authority Government/ public Other governmental (military, prison, federal police)
Connected Improved Regular to Power water Piped electricity1 grid 9 source2 Water10
Visual and auditory privacy3
Client latrine4
Average travel time to the ambulance Number Communication Internet Emergency station in of equipment5 access6 transport7 minutes8 facilities
100 95 88 57 84 61 32
100 97 94 54 100 97 71
97 93 92 71 96 96 77
97 88 90 44 96 90 43
97 96 100 94 93 98 88
97 97 85 78 95 86 59
88 86 77 30 93 72 60
63 51 38 4 32 5 3
84 91 96 91 66 40 34
5 14 5 46 9 12 37
2 7 3 182 13 37 119
59
55
72
46
94
79
32
6
91
45
190
78
100
86
86
97
100
97
28
47
-
23
2
Private for profit NGO (mission/ faith-based, nonprofit) Region Tigray Afar Amhara Oromia Somali Benishangul Gumuz SNNP Gambella Harari Addis Ababa Dire Dawa Urban/rural Urban Rural Total
42
80
83
57
90
67
67
6
37
28
163
77
64
89
64
98
88
39
27
79
51
8
64 70 45 49 78
83 59 65 60 46
86 45 79 74 48
69 37 50 47 35
98 99 87 92 95
86 88 71 67 81
45 53 48 45 15
8 8 5 3 12
87 67 69 64 66
18 37 61 35 161
22 5 87 116 8
47 50 68 63 60 82
70 66 29 94 98 94
76 72 77 94 97 96
36 43 22 89 94 90
91 95 77 86 97 96
82 71 77 94 97 98
34 44 45 86 78 88
6 8 0 11 17 28
60 65 45 51 59 66
48 33 21 15 20 14
4 80 6 2 31 3
52 51
97 46
94 65
83 30
95 90
80 70
69 33
11 3
59 71
23 49
149 214
52
67
77
52
92
74
48
7
66
41
363
Note: The indicators presented in this table comprise the basic amenities domain for assessing general service readiness within the health facility assessment methodology proposed by WHO and USAID (WHO 2012). 1 Facility is connected to a central power grid and there has not been an interruption in power supply lasting for more than two hours at a time during normal working hours in the seven days before the survey, or facility has a functioning generator or invertor with fuel available on the day of the survey, or else facility has back-up solar power. 2 Water is piped into facility or piped onto facility grounds or bottled water is used, or else water from a public tap or standpipe, a tube well or borehole, a protected dug well, protected spring, or rain water, and the outlet from this source is within 500 meters of the facility. 3 A private room or screened-off space available in the general outpatient service area that is a sufficient distance from other clients so that a normal conversation could be held without the client being seen or heard by others. 4 The facility had a functioning flush or pour-flush toilet, a ventilated improved pit latrine, pit latrine with slab, or composting toilet. 5 The facility had a functioning land-line telephone, a functioning facility-owned cellular phone or wireless telephone, a private cellular phone that is supported by the facility, or a functioning short wave radio available in the facility. 6 The facility had a functioning computer with access to the internet that is not interrupted for more than two hours at a time during normal working hours, or facility has access to the internet via a cellular phone inside the facility. 7 The facility had a functioning ambulance or other vehicle for emergency transport that is stationed at the facility and had fuel available on the day of the survey, or facility has access to an ambulance or other vehicle for emergency transport that is stationed at another facility or that operates from another facility. 8 For facilities with access to an ambulance or other vehicle for emergency transport that is stationed at another facility or that operates from another facility, the time taken (in minutes) to travel from the facility to the ambulance station on different road types (all weather road, dry weather road, foot path/rail) by different mode of transport (car, cart, foot, or motorcycle). 9 Facility is connected to a central power grid 10 Water is piped into facility or piped onto facility grounds
In general, about half of the facilities have regular, uninterrupted electricity (i.e., the facility is connected to a central power grid, or has solar power or both, and power is routinely available during regular service hours), or has a functioning generator with fuel. As expected, all hospitals regardless of type (88 to 100 percent) and higher clinics (84 percent) are more likely than medium clinics and health centers (61 and 57 percent respectively) to have regular, uninterrupted electricity. Lower clinics are the least likely to have regular, uninterrupted electricity. Other government facilities and NGO facilities are also more likely than private and Government facilities to have regular, uninterrupted electricity. Fewer than 3 in ten health posts have regular, uninterrupted electricity. In general, over three quarter of all facilities have an improved water source in the facility (i.e., water is piped into the facility or onto facility grounds, or else water is from a public tap or standpipe, a tube well or borehole, a protected dug well, or protected spring, or rain water, or bottle water), and the outlet from this source is within 500 metres of the facility. However, health centers are less likely than other types of facilities to have an improved water source (71 percent). Forty five percent of health posts have an improved water source.
24
On average, fewer than three of every four facilities (74 percent) have a functioning client latrine. However lower clinics (59 percent) as well as health facilities managed by Private for profit (67 percent) are less likely to have a functioning client latrine. A little over half of health posts have a functioning client latrine. Overall, transport for emergencies is available in two third of all facilities (i.e., the facility has a functioning ambulance or other vehicle for emergency transport that is stationed at the facility and had fuel available on the day of the survey), or else the facility has access to an ambulance or other vehicle stationed at or operating from another facility. Medium clinics and lower clinics are the least likely to have emergency transport, at 40 percent and 34 percent respectively. Over seven of every ten health posts have emergency transport. Among all facilities excluding health posts, a little over forty minutes is the average travel time from the health facility to the ambulance station. It takes an average of 5 minutes for hospitals. In Somali region, an average of over two hours is required to reach an ambulance station (138 minutes for health posts and 161 minutes for all other health facilities). Table 3.3-B Availability of basic amenities for client services in Health Posts, ESPA+ 2014 Table 3.3-B
Availability of basic amenities for client services
Among health posts, the percentages with indicated amenities considered basic for quality services, by background characteristics, Ethiopia SPA+ 2014 Amenities Visual and Piped auditory Water10 privacy3
Background characteristics
Connected Regular to Power Improved electricity1 grid 9 water source2
Facility type Health Post
29
5
45
3
78
51
14
72
42
802
29
5 0
45
3 0
78
52
14
72
41
800
100
0
0
100
360
2
Managing authority Government/ public Other governmental (military, prison, federal police)
0
0
Client latrine4
Average travel time Communication Emergency to the ambulance Number of equipment5 transport6 station in minutes7 facilities
Region Tigray Afar Amhara Oromia Somali Benishangul Gumuz SNNP Gambella Harari Dire Dawa
44 50 54 18 15 10 24 15 24 42
16 5 11 2 0 7 3 0 38 26
40 55 63 39 40 52 39 67 52 65
4 14 6 2 5 0 0 0 10 42
96 95 63 75 85 83 92 74 100 94
76 86 49 55 65 66 39 67 100 90
12 50 14 14 10 0 13 30 38 0
84 77 71 61 75 86 84 52 81 97
33 50 28 51 138 41 32 23 22 21
33 10 182 316 31 17 205 4 1 2
Urban/rural Urban Rural
28 29
48 4
50 45
28 2
79 78
57 51
1 14
92 71
34 43
26 776
78
51
14
72
42
802
Total
29
5
45
3
Note: The indicators presented in this table comprise the basic amenities domain for assessing general service readiness within the health facility assessment methodology proposed by WHO and USAID (WHO 2012). 1 Facility is connected to a central power grid and there has not been an interruption in power supply lasting for more than two hours at a time during normal working hours in the seven days before the survey, or facility has a functioning generator or invertor with fuel available on the day of the survey, or else facility has back-up solar power. 2 Water is piped into facility or piped onto facility grounds or bottled water is used, or else water from a public tap or standpipe, a tube well or borehole, a protected dug well, protected spring, or rain water, and the outlet from this source is within 500 meters of the facility. 3 A private room or screened-off space available in the general outpatient service area that is a sufficient distance from other clients so that a normal conversation could be held without the client being seen or heard by others. 4 The facility had a functioning flush or pour-flush toilet, a ventilated improved pit latrine, pit latrine with slab, or composting toilet. 5 The facility had a functioning land-line telephone, a functioning facility-owned cellular phone or wireless telephone, a private cellular phone that is supported by
25
the facility, or a functioning short wave radio available in the facility. 6 The facility had a functioning computer with access to the internet that is not interrupted for more than two hours at a time during normal working hours, or facility has access to the internet via a cellular phone inside the facility. 7 The facility had a functioning ambulance or other vehicle for emergency transport that is stationed at the facility and had fuel available on the day of the survey, or facility has access to an ambulance or other vehicle for emergency transport that is stationed at another facility or that operates from another facility. 8 For facilities with access to an ambulance or other vehicle for emergency transport that is stationed at another facility or that operates from another facility, the time taken (in minutes) to travel from the facility to the ambulance station on different road types (all weather road, dry weather road, foot path/rail) by different mode of transport (car, cart, foot, or motorcycle). 9 Facility is connected to a central power grid 10 Water is piped into facility or piped onto facility grounds
3.2.4 Availability of basic equipment The 2014 ESPA+ also assessed the availability of equipment and supplies necessary for evaluating the status of general outpatient service area for providing preventive interventions. Table 3.5 summarises information on these items by background characteristics. Overall, 70, 48, and 32 percent of all facilities at general outpatient service area have adult, child, and infant scale respectively. Facilities managed by NGO are more likely to have adult scale (90 percent), child scale (59 percent) and infant scale (48 percent) than facilities managed by other authority. Three fourth of all facilities at general outpatient service area have thermometer and stethoscope. Almost all facility types have stethoscope except health posts (66 percent). Seven of every ten facilities at outpatient service area have blood pressure apparatus. All NGO facilities and private for profit facilities (more than 96 percent) are more likely to have blood pressure apparatus, and stethoscope than facilities managed by other authorities. Table 3.4 Availability of basic equipment in health facilities, ESPA+ 2014 Table 3.4
Availability of basic equipment
Among all facilities, the percentages with equipment considered basic to quality client services available in the general outpatient service area, by background characteristics, Ethiopia SPA+ 2014
Background characteristics Facility type Referral Hospital General Hospital Primary Hospital Health Center Health Post Higher Clinic Medium Clinic Lower Clinic Managing authority Government/ public Other governmental (military, prison, federal police) Private for profit NGO (mission/ faithbased, non-profit)
Adult scale
Child scale1
Equipment Stadio meter (or height Rod) for Measuring Blood measuring tape (for head pressure Number of Infant scale2 height circumference) Thermometer Stethoscope apparatus3 Light source4 facilities
78 77 75 70 70 82 87 66
34 44 35 39 58 34 23 7
28 36 31 32 37 18 12 6
66 60 46 51 30 70 49 29
38 39 40 25 24 45 31 19
84 82 77 75 72 92 96 83
100 98 100 97 66 94 99 98
100 93 96 89 57 93 98 96
41 56 46 37 32 91 89 74
2 7 3 182 802 13 37 119
70
54
36
34
24
73
72
63
33
990
54 71
3 12
0 7
51 36
30 22
45 86
56 98
56 96
53 80
4 163
90
59
48
55
64
94
100
100
50
8
Region
26
Tigray Afar Amhara Oromia Somali Benishangul Gumuz SNNP Gambella Harari Addis Ababa Dire Dawa Urban/rural Urban Rural Total
83 56 67 65 43 65 82 55 79 86 75
36 54 51 52 43 51 46 20 34 30 31
41 45 36 23 18 40 44 26 36 14 46
37 38 34 33 29 35 34 30 48 56 56
25 18 16 27 12 12 30 16 43 26 33
97 76 77 62 52 84 88 71 66 94 74
95 90 80 64 76 82 83 77 95 97 94
88 79 64 61 75 73 72 70 91 97 93
39 29 45 36 18 21 41 27 43 84 49
54 14 269 432 39 21 285 10 3 31 5
81 68
25 52
24 34
49 32
24 24
82 73
90 73
89 64
56 37
176 989
70
48
32
34
24
75
76
68
40
1,165
Note: The indicators presented in this table comprise the basic equipment domain for assessing general service readiness within the health facility assessment methodology proposed by WHO and USAID (WHO 2012). 1 A scale with gradation of 250 grams, or a digital standing scale with a gradation of 250 grams or lower where an adult can hold a child to be weighed, available somewhere in the general outpatient area 2 A scale with gradation of 100 grams, or a digital standing scale with a gradation of 100 grams where an adult can hold an infant to be weighed, available somewhere in the general outpatient area 3 A digital blood pressure machine or a manual sphygmomanometer with a stethoscope available somewhere in the general outpatient area 4 A spotlight source that can be used for client examination or a functioning flashlight available somewhere in the general outpatient area.
3.2.5 Laboratory Diagnostic Capacity The capacity of a health facility to conduct laboratory diagnostic test enhances greatly the level of service provision. Health facilities do not necessarily require the availability of a specific or designated laboratory building, but the mere presence of tests in the facility including the availability of reagents and equipment needed for each test depending on the level of the facility type. Tables 3.6.1 –A and 3.6.1-B present information on availability of basic and advanced level diagnostic test capacity in the facility Table 3.7.1-A Laboratory diagnostic capacity, ESPA+ 2014 Table 3.7.1-A
Laboratory diagnostic capacity
Among all facilities, excluding health posts, the percentages with capacity to conduct basic and advanced laboratory diagnostic tests in the facility, by facility type, managing authority and urban/rural, Ethiopia SPA+ 2014 Facility type
Laboratory tests
Referral General Primary Hospital Hospital Hospital
Health Center
Higher Medium Clinic Clinic
Lower Clinic
Managing authority Other NGO government (mission al (military, / faithprison, based, Governmen federal Private nonprofi t/ public police) for profit t)
Urban/rural
Urban
Rural
Total
Basic tests 10 Hemoglobin 0 Blood glucose 84 Malaria diagnostic test 78 Urine protein 97 Urine glucose 97 HIV diagnostic 10 test 0
8 5 9 0
6 7 7 5
8 5 9 5 9 5
8 8 9 8 9 6
9 8
9 6
6 5 8 2
5 1 7 7
51
8 2 8 9 8 9
7 1 8 1 8 0
94
7 2
4 5
24 20
82 59
4 0 4 6
0
27
9
17
3
22
75
25
6
82
78
25
4
61
75
29
6
53
75
29
5 0 3 4 3 3
6
94
94
19
5 8
27
37
13
23
44
11
24
56
56
56
58
37
46
56
32
42
54
63
59
DBS collection 47 TB microscopy 81 Syphilis rapid diagnostic test 81 General microscopy 84 Urine pregnancy 10 test 0 Liver or renal function test (ALT or Creatinine) 91
1 0 7 0
0 4 6
62
8 6 8 5
5 8 7 2
9 4
59
8 9
7 0
4 4
2
7 2
6 3
7 2
6 3
97 3
1 2 4 7 2 8 9 4 8 0 9 8 1
6 4 4 2 9 6 9 8 5 9 6 0
6
6
0
Equipment for diagnostic imaging X-ray machine 75 Ultrasonogra m 88 CT scan 13
7 3 7 2 7
4 8 5 2 0
7
3
Advanced level diagnostic tests Serum electrolytes (chemistry analyzer) 97 Full blood count with differentials 97 Blood typing and cross matching 19 CD4 count Syphilis serology
78
Gram stain Stool microscopy CSF/ body fluid counts TB culture TB rapid diagnostic test
94
Number of facilities
31
84
2
5 5 7 9
4 0 7 7
7 6 8 2
6 9 8 5
9 5
17
0
19
3
2
0
53
11
16
1
36
69
20
2
63
28
23
3 4 5 7
8 9
3
61
78
29
7 1
1 7
0
4
6
8
4 3
2 3
0
11
8
4 3
2 3
0
5
7
5
2
57 0
4 1 4 8 8 8 1 9 7 0
1
6
52
34
3 15 57
0 0
3 7 6 8 3
18 2
1 3
0
5 2 9
15
8
11
44
30
36
41
21
29
51
41
45
5 0
58
38
46
11
1 1
17
1
7
6
10
2 0
18
5
10
11
6
10
2 0
18
5
10
0
5
0
2
3
4
3
0
0
5
6
0
0 1 0
6
1
3
1 6 2 7 1 9 0 0
0
4
3
2
6
1
3
1
18
6
23
39
7
20
2
58
28
23
48
37
42
3 0
58 0
78 0
29 0
4 1 8 5 7 6 1 0
63 0
33 0
45 0
0
0
1
0
1
0
1
1
1
3
0
3
6
5
8
1
4
8 0
0 0
3 0
6 0
9 1
6 1 3 0
12 1
1 0
6 0
3 7
11 9
190
2
16 3
8
14 9
21 4
36 3
Note: The basic test indicators presented in this table comprise the diagnostic capacity domain for assessing general service readiness within the health facility assessment methodology proposed by WHO and USAID (WHO 2012). Note: DBS = dried blood spot; CSF = cerebrospinal fluid; CT = computed tomography
In general, the capacity of a health facility to conduct laboratory diagnostic test, even the basic tests, is very low. Except for the capacity in conducting malaria diagnostic test and HIV diagnostic test, for which fewer than 6 of ten facilities excluding health posts could conduct the tests, only less than half of all facilities are able to conduct the remaining basic tests. Over half of health posts are able to conduct malaria diagnostic test while only one of ten health posts could perform HIV diagnostic test.
28
Table 3.7.2-B Laboratory diagnostic capacity, ESPA+ 2014
1
Table 3.7.2-B
Laboratory diagnostic capacity
Among health posts, the percentages with capacity to conduct basic and advanced laboratory diagnostic tests in the facility by region, Ethiopia SPA+ 2014
Laboratory tests
Tigray
Basic tests Malaria diagnostic test HIV diagnostic test
96 60 33
Number of facilities
Amhara
Oromia
Region Benishangul Somali Gumuz
82 36
71 14
36 9
35 5
79 7
55 13
63 0
38 38
71 68
53 14
10
182
316
31
17
205
4
1
2
802
Afar
SNNP
Gambella
Harari
Dire Dawa
Total
Note: The basic test indicators presented in this table comprise the diagnostic capacity domain for assessing general service readiness within the health facility assessment methodology proposed by WHO and USAID (WHO 2012). Note: DBS = dried blood spot; CSF = cerebrospinal fluid; CT = computed tomography
3.2.6 Availability of essential medicines Essential medicines are those that satisfy the priority health care needs of the population. They are selected with due regard to public health relevance, evidence on efficacy and safety, and comparative cost-effectiveness. Essential medicines are intended to be available within the context of functioning health systems at all times in adequate amounts, in the appropriate dosage forms, with assured quality and adequate information, and at a price the individual and the community can afford. Among the 14 essential medicines, paracetamol oral suspension and diclofenac tablet/capsule (each 55 percent) and amoxicillin tablets/capsules (54 percent) are more likely available medicines (Table 3.1.8-A) in facilities excluding health posts. Moreover, among the 14 essential medicines in health posts, only 3 of them are found. Hence, paracetamol oral suspension and amoxicillin tablets/capsules are more likely existed than diclofenac tablet/capsule in health posts. (Table 3.7.1-B). Table 3.8.1-A Availability of essential medicines, ESPA+ 2014 Table 3.8.1-A
Availability of essential medicines
Percentages of facilities, excluding health posts, having the 14 essential medicines available, by background characteristics, Ethiopia SPA+ 2014 Facility type
Essential medicines Essential medicines Amitriptyline tablets/capsules 1
Amoxicillin tablests/capsules 2
Arthemisin Lumephrantrine * Atenolol tablets/capsules 3
General Primary Referral Hospita Hospita Health Hospital l l Center
6 6
7 1
7 3
1 9
9 4 6 3
9 6 6 6
9 4 8 1
8 4
7 5
5 8
Higher Mediu Clinic m Clinic
Lower Clinic
Managing authority Other governmen tal (military, prison, Governme federal Private nt/ public police) for profit
Urban/rural NGO (mission / faithbased, nonprofi t)
6
1 6
9
1 2
4 1 3 0
6 3 4 7
5 4 4 0
8
2
5
7
0
0
21
9
2
9 1 7 2
1 0
1 2
1 1
91
44
9
9
6
3
72
22
3
7 8 3 5
4
9
0
0
7
9
2
1 1
29
Urban
Rural
Total
Captopril tablets/capsules 4
Ceftriaxone injectable 5 Ciprofoxacin tablets/capsules 6
Cotrimoxazole oral suspension 7 Diazepam tablets/capsules 8
Diclofenac tablets/capsules 9
Glibenclamide tablets/capsules 10
5 3 7 8
4 1 8 4
4 6 8 3
4 6 2
5 1 3
0
0
6
6
1
6
3
63
9
6
9 7 8 8
9 2 8 8
9 6 9 2
8 8 8 9
1 0 1 0
1 0 1 1
8 1 1
89
25
8
89
41
9 7 1 0 0
8 8
8 5
5 6
6
3
3
57
9 1
9 0
7 8
1 7
2 6
3 0
9 1 8 4
8 5 9 3
7 1 8 7
3 2 8 8
9 1 1
2 1 4
0 1 9
8 3
8 8
9 3
3 1
5 9
6 1
9 2 8 6 7 4
9 6 9 2 7 9
8 2 8 5 3 4
1 3 1 0 1 4
1 3 1 7
2 7
1 5
0
3
1 8 2
Mebendazole tablets * Medroxyprogestero ne (depo) injection 8 * 4 Omeprazole/Cimeti dine tablets/capsules 9 11 4 Paracetamol oral 8 suspension 12 8 Salbutamol inhaler 8 13 4 Simvastatin/Atovast atin tablet/capsule 3 14 1
Number of facilities 2
7
4 2 7
6 2 9
2 4 1
4 3 6
9
6 6 9 0
3 8 3 6
6 1 6 4
5 1 5 2
19
5
1 8
2 8
3 5
3 2
79
22
2 7
7 9
4 5
6 2
5 5
34
6
88
44
2 1 6
2 2 7 2
2 5 4 0
1 6 6 6
1 9 5 5
93
11
6 0
3 0
6 9
8 2
7 7
3 2 4
83
22
85
9
6 2 1
7
2
36
25
3
4 6 6 3 4 8
3 7 4 3 2 2
5 5 6 4 2 1
4 7 5 5 2 2
6
0
0
1
3
1
8
3
0
1
1 3
3 7
1 1 9
2
1 6 3
8
1 4 9
2 1 4
3 6 3
190
Note: The indicators presented in this table comprise the essential medicines domain for assessing general service readiness within the health facility assessment methodology proposed by WHO and USAID (WHO 2012). Note: Medicines with * are not included among the 14 essential medicines. 1 For the management of depression in adults 2 First-line antibiotics for adults 3 Beta-blocker for management of angina/hypertension 4 Vaso-dilator, for management of hypertension 5 Second-line injectable antibiotic 6 Second-line oral antibiotic 7 Oral antibiotic for children 8 Muscle relaxant for management of anxiety, seizures 9 Oral analgesic 10 For management of type 2 diabetes 11 Proton pump inhibitor, for the treatment of peptic ulcer disease, dyspepsia, and gastro-esophageal reflux disease 12 Fever-reduction and analgesic for children 13 For the management and relief of bronchospasm in conditions such as asthma and chronic obstructive pulmonary disease 14 For the control of elevated cholesterol
According to the Ethiopian FMHACA health post requirements, the health post shall not maintain medicines, medical supplies or equipment which is not included in the health post medicines list. The 2014 ESPA+ assessed the availability of Amoxicillin tablets/capsules, Arthemisin Lumephrantrine, Diclofenac tablets/capsules, Mebendazole tablets, Medroxyprogesterone (depo) injection, and Paracetamol oral suspension to identify general service readiness. Table 3.8.1-B Availability of essential medicines in Health Posts, ESPA+ 2014 Table 3.8.1-B
Availability of essential medicines
Percentages of health posts, having the 14 essential medicines available, by background characteristics, Ethiopia SPA+ 2014 Facility type
Managing authority
30
Urban/rural
Essential medicines
Health Post
Government/ public
Other governmental (military, prison, federal police)
11 51 4 23
11 51 4 23
0 0 100 0
23 45 2 23
11 52 4 23
11 51 4 23
84 15
84 15
0 0
73 0
84 15
84 15
802
800
2
26
776
802
Essential medicines Amoxicillin tablets/capsules 1 Arthemisin Lumephrantrine * Diclofenac tablets/capsules 2 Mebendazole tablets * Medroxyprogesterone (depo) injection * Paracetamol oral suspension 3 Number of facilities
Urban
Rural
Total
Note: The indicators presented in this table comprise the essential medicines domain for assessing general service readiness within the health facility assessment methodology proposed by WHO and USAID (WHO 2012). Note: Medicines with * are not included among the 14 essential medicines. 1 First-line antibiotics for adults 2 Oral analgesic 3 Fever-reduction and analgesic for children
3.3 Management systems to support and maintain quality services Basic management and support systems are required to ensure that health services can consistently provide an acceptable level of quality. 3.3.1 Management Meetings, Quality Assurance, and Health Management Information System Information on the availability of functioning systems for each of the assessed components is shown in Table 3.8A Table 3.9-A Management, quality assurance, and health management information systems, ESPA+ 2014 Table 3.9-A Management, quality assurance, and health management information systems Among all facilities, excluding health posts, the percentages with regular management meetings and having documentation of a recent meeting, the percentages of facilities with quality assurance activities and having documentation of quality assurance activities, and the percentages of facilities with a system for eliciting client opinion, by background characteristics, Ethiopia SPA+ 2014 Percentage of facilities with Percentage of facilities with available place for data maintaining
Managemen t meeting Managemen with t meeting community monthly or participation more often, Monthl at least once with y or every 6 observed more months, with Having documentati often documentati Background routine on of a Board on of a characteristi manageme recent meetin recent cs nt meeting meeting g meeting
Facility type Referral Hospital General Hospital Primary Hospital Health
System for determini ng client opinion, procedure Regular for quality reviewing assurance client activities opinion with and observed report of documentati recent on of quality review of assurance client activity 1 opinion
Practice of compilin g report monthly or more Electronic often and Health health documen Manageme manageme ts the nt nt most Informatio informatio recent n System n system report
A designat ed person who is data manager Com or HMIS puter focal Shelf MPI for 2 3 person HMIS
Enoug h Back Comput sized Numb Up er and card er of Syste backup room faciliti 4 5 m system es
100
78
59
44
56
59
94
75
84
3
75
28
81
25
25
19
2
96
74
47
28
35
49
90
61
83
5
89
25
61
34
31
34
7
98
81
58
40
38
52
94
75
88
4
90
38
73
40
40
42
3
97
89
46
40
13
31
95
31
87
9
87
33
27
12
8
24
182
31
Center Higher Clinic Medium Clinic
52
19
3
1
3
23
62
18
51
1
96
5
18
4
3
9
13
55
11
3
5
4
5
54
4
55
5
74
9
1
7
0
23
37
3
0
1
1
2
23
1
18
5
73
3
1
10
1
18
119
97
88
47
40
15
33
95
33
87
9
87
33
29
14
9
24
190
100
94
0
22
25
72
33
6
78
0
97
3
25
3
3
6
2
38
5
1
0
2
4
33
3
28
4
75
4
2
8
1
19
163
65
47
3
35
5
11
68
27
54
12
94
19
27
28
16
23
8
Tigray
78
64
60
34
25
32
81
40
72
11
84
22
36
18
18
23
22
Afar
60
43
10
7
2
9
48
19
65
4
88
8
18
7
5
13
5
Amhara
63
53
33
17
7
16
74
17
66
8
75
11
17
12
4
19
87
Oromia
72
60
32
27
12
26
63
25
61
5
92
36
20
8
6
16
116
Somali 74 Benishangul Gumuz 64
38
7
11
4
2
71
27
39
6
81
17
23
14
9
9
8
47
35
14
3
6
72
11
70
8
83
19
14
0
0
11
4
Lower Clinic 32 Managing authority Governmen t/ public Other government al (military, prison, federal police) Private for profit NGO (mission/ faith-based, nonprofit) Region
SNNP
78
45
5
27
2
15
62
6
52
11
74
10
4
15
2
35
80
Gambella
41
9
2
0
2
0
40
1
23
0
97
4
2
1
1
6
6
Harari Addis Ababa
63
34
23
11
26
11
54
26
51
14
89
9
29
37
14
34
2
58
22
16
6
9
21
62
21
55
1
79
11
20
9
8
23
31
Dire Dawa
76
32
34
6
18
10
74
36
68
2
82
8
38
24
16
26
3
Urban
64
38
22
13
12
18
65
24
58
7
77
18
24
10
6
21
149
Rural
74
58
28
28
7
21
67
16
60
7
85
20
11
12
5
22
214
Total
70
50
25
22
9
19
66
19
59
7
82
19
17
11
6
22
363
Urban/rural
1
Facility reports that it routinely carries out quality assurance activities and had documentation of a recent quality assurance activity. This could be a report or minutes of a quality assurance meeting, a supervisory checklist, a mortality review or an audit of records or registers 2 Shelves with standard size height of 30cm, with of 50cm and depth of 35cm (in Supine position and each cell contains 50 cards). 3 A box used to keep master patient index card (MPI cards). 4.computer for HMIS and backup system 5 For hospitals greater or equal to 60m 6 Computers that are used for HMIS purpose only
Management Meetings To function well, a health facility must have an established system in place for identifying and addressing management and administrative issues. This system may involve meetings to discuss scheduling and day-to-day issues or meetings to discuss broader management issues, such as financing, utilisation, or plans for health-related campaigns. The meetings must be regularly scheduled, however, and specific staff must have defined areas of responsibility. The 2014 ESPA+ looked for evidence of functioning management committee meetings held monthly or more often and asked for official documentation of proceedings. The system is considered to be functioning if there is a record of committee meetings, with documented decisions and follow up on issues discussed.
32
Overall, 70 percent of health facilities excluding health posts and 58 percent of health posts reported having routine management committee meetings monthly or more often; however, 50 percent of facilities excluding health posts and 29 percent of health posts had actual documentation of a recent meeting (Tables 3.8-A and 3.8-B). About eight of ten facilities in Tigray and SNNP region are more likely than facilities in other regions to have routine management committee meetings and about six of ten facilities excluding health posts to have documentation of recent meetings. Quality Assurance Quality assurance (QA), an important component of service delivery, refers to a system for monitoring the quality of care, identifying problems, and instituting changes to resolve those problems. Quality assurance systems require an established standard against which quality is measured; there must also be systematic methods to assess results and develop interventions. The following are examples of QA activities and approaches: • A supervisory checklist for health systems, which looks for the presence of equipment and supplies, the completeness of Health Management Information System (HMIS) accounts, and other process indicators. • A supervisory checklist for health service provision, which verifies specific content in client assessments, treatments, or consultations. This list is often used to document the provision of care. • A facility-wide review of mortality, which is a structured system to review the records of each client who dies. There will normally be a committee established for this purpose. • Audits of medical records or registers, which check medical records for the presence of specific items or information and may assess if protocols were followed. • Quality assurance committee or staff reports. QA committee refers to an organized group that regularly meets to discuss about findings from QA activities. Table 3.8-A provide information on facilities reporting QA activities. Overall, only one of ten (9 percent) of health facilities excluding health posts report regular QA activities with observed documentation of QA activities. Referral Hospitals (56 percent), Primary Hospitals (38 percent), and General Hospitals (35 percent) are most likely to report regular QA activities with observed documentation compared with 13 percent of health centers and less than one of ten private clinics. Among all health posts, only 13 percent of them report regular QA activities with observed documentation of QA activities. Health Management Information System (HMIS) HMIS, is a system using new registers, and tools like reporting format and tally sheet, to regularly collect health services data. There are two systems (paper based and electronic) in the ground to organize, analyse and send report to higher level. If there is a computer with e-HMIS software installed and start to use, it will be considered as electronic based system. It is expected, but not all facilities have a system for collecting health services data that will eventually feed into the compilation of report.
Table 3.8-A provide information on facilities reporting to have e-HMIS. Overall, only one of five (19 percent) health facilities excluding health posts report having e-HMIS. Government managed facilities (33 percent) are most likely to have e-HMIS compared with 3 percent of private for profit facilities. Among all health posts, only 3 percent of them have eHMIS. Table 3.9-B Management, quality assurance, and health management information systems in Health Posts, ESPA+ 2014 33
Table 3.9-B
Management, quality assurance, and health management information systems
Among health posts, the percentages with regular management meetings and having documentation of a recent meeting, the percentages of facilities with quality assurance activities and having documentation of quality assurance activities, and the percentages of facilities with a system for eliciting client opinion, by background characteristics, Ethiopia SPA+ 2014
Background characteristics Facility type Health Post
Percentage of facilities with System for determining client opinion, Management procedure meeting with for Management community Regular quality reviewing meeting participation at assurance client monthly or least once activities with opinion and more often, every 6 observed report of Having with observed Monthly or months, with documentation recent routine documentation more often documentation of quality review of management of a recent Board of a recent assurance client meeting meeting meeting meeting activity 1 opinion
58
Managing authority Government/ public 58 Other governmental (military, prison, federal police) 100
Practice of compiling report monthly or more often Community Electronic and Health health documents Information management the most Management information recent Number of System(CHIS) system report facilities
29
0
24
13
6
76
3
90
802
29
0
25
13
6
76
3
91
800
0
0
0
0
0
0
0
0
2
Region Tigray Afar Amhara Oromia Somali Benishangul Gumuz SNNP Gambella Harari Dire Dawa
64 41 57 52 35 55 71 56 57 58
36 5 34 20 5 21 42 0 14 13
0 5 0 0 0 0 0 0 0 0
64 9 6 32 5 10 29 0 14 29
32 5 17 7 10 0 18 0 19 19
12 5 6 7 0 0 5 0 0 3
88 27 97 73 25 100 68 30 100 77
4 5 9 0 0 0 3 0 52 0
92 59 97 98 30 90 84 56 90 74
33 10 182 316 31 17 205 4 1 2
Urban/rural Urban Rural
72 57
48 28
0 0
21 25
21 13
48 4
92 75
0 3
93 90
26 776
58
29
0
24
13
6
3
90
802
Total
76
1
Facility reports that it routinely carries out quality assurance activities and had documentation of a recent quality assurance activity. This could be a report or minutes of a quality assurance meeting, a supervisory checklist, a mortality review or an audit of records or registers
3.3.2 Management Practices Supporting Community Involvement Encouraging community input into a facility’s functions makes the facility more accountable to the community it serves; it also helps the facility to better understand the community’s needs. This increases the probability of better health-seeking behaviour, which in turn may improve the health of the population. Government policy recommends an interface with the community. Community Representation Overall, one in every five (22 percent) facilities, excluding health posts and quarter (24 percent) of health posts have routine management meeting with community participation at least once every six month, with documentation of a recent meeting (Tables 3.8-A and 3.8-B). Community participation in management meetings is most likely to have in Referral Hospitals (44 percent), Primary Hospitals (40 percent), and health centres (40 percent). At the regional level, 34
facilities in Tigray (34 percent), Oromia (27 percent), and SNNP (27 percent) regions are most likely to have routine community participation in management meetings. Client Feedback The 2014 ESPA+ also assessed whether facilities have a system to elicit and review client opinion. Of all facilities excluding health posts, only 19 percent of facilities excluding health posts have a system for determining client opinion, procedure for reviewing client opinion and report of recent review of client opinion (Table 3.8-A). Referral Hospitals (59 percent) and primary hospitals (52 percent) are more likely than other types of facilities to have systems to elicit client feedback. Only 6 percent of health posts have a system for determining client opinion, procedure for reviewing client opinion and report of recent review of client opinion (Table 3.8-B). Among the different management authorities excluding health posts, other governmental (military, prison, federal police) (72 percent) and government (33 percent) are more likely than NGO facilities (11 percent) or private for profit (4 percent) to elicit and review client opinion. Client feedback systems, although uncommon across all regions excluding health posts, are almost nonexistent in Gambella and in Somali regions. 3.3.3 Supportive Management Practices at Facility Level The 2014 ESPA+ collected information on whether facilities have supervisory and staff development activities, which are important for supporting quality health care. Summary information on supportive management practices at the facility level is provided in Table 3.10. Table 3.10 Supportive management practices at the facility level, ESPA+ 2014 Table 3.10
Supportive management practices at the facility level
Among all facilities, the percentages that had an external supervisory visit during the six months before the survey, and the percentages of facilities where at least half of the interviewed providers reported receiving routine work-related training and personal supervision recently, by background characteristics, Ethiopia SPA+ 2014 Percentage of facilities having routine:
Background characteristics Facility type Referral Hospital General Hospital Primary Hospital Health Center Health Post Higher Clinic Medium Clinic Lower Clinic Managing authority Government/ public Other governmental (military, prison, federal police) Private for profit NGO (mission/ faith-based, non-profit) Region Tigray Afar Amhara Oromia Somali
Percentage of facilities with supervisory visit during the six months before the survey 1
Number of facilities
72 34 33 12 5 23 8 1
Number of facilities where at least two eligible providers were Percentage with interviewed with supportive health worker management interview practices4 questionnaire5
Staff training2
Personal supervision3
Training and personal supervision
2 7 3 182 802 13 37 119
63 73 73 82 97 56 46 43
38 40 56 73 83 50 55 73
13 11 33 40 78 32 26 28
6 5 13 6 3 3 2 1
2 7 3 181 337 12 36 43
7
990
92
79
64
4
526
9 5
4 163
100 45
7 64
7 27
0 1
2 86
5
8
50
42
25
4
7
6 33 5 4 33
54 14 269 432 39
86 83 89 86 71
95 73 89 70 75
78 55 75 48 52
7 24 1 5 30
37 8 123 244 12
35
Benishangul Gumuz SNNP Gambella Harari Addis Ababa Dire Dawa Urban/rural Urban Rural Total
5 4 14 20 16 22
21 285 10 3 31 5
91 87 79 73 49 89
81 77 57 70 52 64
67 64 41 50 25 52
0 2 8 9 3 13
15 143 4 2 28 3
12 5
176 989
65 90
65 79
32 65
5 4
121 500
6
1,165
85
76
58
4
621
1
Facility reports that it received at least one external supervisory visit from the district, regional or national office during the six months period before the survey. At least half of all interviewed providers reported that they had received any in-service training as part of their work in the facility during the 24 months before the survey. This refers to structured sessions and does not include individual instructions a provider might receive during routine supervision. 3 At least half of all interviewed providers reported that they had been personally supervised at least once during the six months before the survey. Personal supervision refers to any form of technical support or supervision from a facility-based supervisor or from a visiting supervisor. It may include, but is not limited to, review of records and observation of work, with or without any feedback to the health worker. 4 Facility had an external supervisory visit during the six months before the survey, and staff has received routine training and supervision. 5 Interviewed providers who did not personally provide any clinical services assessed by the survey, for example, administrators who might have been interviewed, are excluded. 2
External Supervision Supervision by external bodies has many benefits. It can help to ensure that system-wide standards and protocols are followed at the facility level and promote an organisational culture that expects such standards and protocols to be implemented. It provides an opportunity to expose staff to a wider scope of ideas and relevant experiences, including onthe-job training for some providers. It can also motivate service providers, especially if the supervisor is supportive. In the 2014 ESPA+, a facility that reports at least one supervisory visit by external supervisors during the six months that precede the survey is defined as having routine external supervision. Overall, only 6 percent of all facilities have routine external supervision (Table 3.9). Referral hospitals (72 percent), are more likely than other facility types to have routine external supervision. Private and NGO facilities are relatively less likely than facilities managed by other authorities to have external supervision (each 5 percent), compared with between 7 percent and 9 percent of facilities managed by other authorities. Facilities in Afar and Somali (each 33 percent) regions are more likely to have routine external supervision. Training To maintain levels of knowledge and technical competence, health service providers must continually be exposed to new information. The 2014 ESPA+ assessed whether, during the 24 months preceding the survey, providers had received any formal or structured in-service training related to the services they offer. Although it is recognised that providers may receive new information and individual instruction related to their work during routine supervisory visits, the 2014 ESPA+ assessed only structured, ‘classroom-type’ training. If at least half of the health service providers interviewed at a facility report receiving in-service training relevant to their jobs within the 24 months that precede the survey, that facility is defined by the ESPA+ as having routine staff development activities. Overall, 85 percent facilities satisfy these criteria for routine staff training (Table 3.9). Health posts (97 percent) and health centres (82 percent) are much more likely than the other facility types to have routine staff training. Private facilities are less likely than facilities managed by other authorities to meet the criteria for routine staff training (45 percent), compared with 100 percent of facilities managed by other governmental (military, prison, federal police) facilities and 92 percent of facilities managed by government. Supervision of Health Service Providers In addition to general facility-level supervision, the work of individual staff must be assessed so that each person’s strengths and weaknesses can be identified and appropriate support can be Facility-level Infrastructure, Resources, and Systems provided. If at least half of the interviewed health service providers in a facility reported being personally 36
supervised at least once during the six months preceding the survey, the ESPA+ defines the facility as providing routine staff supervision. About eight of every ten facilities meet the criteria for routine staff supervision (Table 3.9). Health posts (83 percent) and health centres and lower clinics (each 73 percent) are most likely to have routine staff supervision. Other governmental (military, prison, federal police) facilities are less likely than other facilities to have routine staff supervision (7 percent) compared with 42 to 79 percent) of facilities managed by other authorities. At the regional level, the weakest level of supervision is among facilities in Addis Ababa and Gambella regions, where 52 percent and 57 percent, respectively of facilities meet the criteria for personal supervision. 3.3.4 Staffing Pattern in Surveyed Facilities During the survey, the 2014 ESPA+ collected data from facilities in-charge about personnel assigned to, employed by or seconded to their facility, whether part time or full time. Tables 3.10-A and 3.10-B present the median number of providers assigned to, employed by or seconded to facility by type of providers and background characteristics. Staffing pattern at Tertiary level of Health care According to EFMHACA standard, the specialized hospital shall have at least 26 MD specialist, 26 general practitioner, 81 BSc nurse, 89 diploma nurse, and 24 Midwifes etc… Based on this standard the referral hospitals in Ethiopia fall below the standard in many of the staffing patterns. For instance fifty percent of referral hospitals have 14 MD specialist including General Surgeon, Anesthesiologist, Obstetrician and gynecologist, Internist, Pediatrician, psychiatrist, Radiologist, and other Service Specialist (Table 3.11-A). Staffing pattern at secondary level of Health care According to EFMHACA standard, the specialized hospital shall have at least 16 MD specialist, 14 general practitioner, 48 BSc nurse, 49 diploma nurse, and 13 Midwifes etc… Based on this standard findings from ESPA + survey indicated that the general hospitals in Ethiopia fall below the standard in all of the staffing patterns. Fifty percent of general hospitals have 4 MD specialist including General Surgeon, Anesthesiologist, Obstetrician and gynecologist, Internist, Pediatrician, psychiatrist, Radiologist, and other Service Specialist, 6 general practitioner, 5 BSc nurse , 33 Diploma nurse, and 7 midwifes (Table 3.11-A). Staffing pattern at Primary Health care Unit According to EFMHACA standard, the Primary hospital shall have at least 3 medical doctors, 3 Health officers / Integrated Emergency Surgical Officers (IESO), 5 BSc nurse, 20 diploma nurse, and 4 Midwifes etc. Health centers shall have at least 1 medical doctor, 2Health officers / Integrated Emergency Surgical Officers (IESO), 5 BSc or diploma nurse, and 3 Midwifes etc. And health posts shall have at least 2 health extension workers. The result of the 2014 ESPA+ show that fifty percent of primary hospitals have fulfilled more than the standard with having a median number of 5 medical doctors, 4 Health officers / Integrated Emergency Surgical Officers (IESO), 20 nurses and 6 midwifes. Fifty percent of health centres have 2 Health officers / Integrated Emergency Surgical Officers (IESO, 6 nurses, and 2 midwifes (Table 3.11-A). Fifty percent of health posts have 2 health extension workers which means that health posts fulfilled the minimum human resource standards (Table 3.11-B). Table 3.11-A Staffing pattern in surveyed facilities, ESPA+ 2014 Table 3.11-A
Staffing pattern in surveyed facilities
Median number of providers1, assigned to, employed by, or seconded to facilities, excluding health post, by type of provider and type of facility, Ethiopia SPA+ 2014 Background characteristics
Medical General Health specialist2 Practitione officer /
Median number of providers assigned to/ employed by/ seconded to facility Diploma Specialize BSc or Pharmacy Med Lab Other Health Supportiv Number of BSc nurse nurse d nurse3 Diploma Professional Professional Paramedic extensio e Staff 7 facilities
37
r
Facility type Referral Hospital 14 General Hospital 4 Primary Hospital Health Center Higher Clinic 2 Medium Clinic Lower Clinic Managing authority Government/ public Other government al (military, prison, federal police) Private for profit NGO (mission/ faith-based, nonprofit)
Integrate d Emergenc y Surgical Officer (IESO)
4
midwife
5
s6
n worker
22
7
48
74
4
16
18
19
13
-
91
2
6
2
5
33
1
7
6
7
4
-
44
7
5 1
4 2 -
3 1
17 6 3
1 -
6 2 -
6 2 -
6 2 3
3 -
-
25 6 6
3 182 13
-
1 -
-
2 2
-
-
-
2 -
-
-
3 1
37 119
-
-
2
1
6
-
2
2
2
-
-
6
190
-
-
-
-
3
-
-
1
1
-
-
7
2
-
-
-
-
2
-
-
-
-
-
-
2
163
-
-
-
-
4
-
-
-
1
-
-
4
8
Region Tigray Afar Amhara Oromia Somali Benishangul Gumuz SNNP Gambella Harari Addis Ababa Dire Dawa
-
-
2 1 1
1 1
6 3 4 4 5
-
2 1 1 2 2
2 1 1 1
2 2 1 1
1 -
1 -
5 5 3 4 3
22 5 87 116 8
1 -
-
1 1 1
1
4 4 3 2 2 4
-
2 -
1 1
2 1 2 3 2
-
-
4 3 2 4 4 7
4 80 6 2 31 3
Urban/rural Urban Rural
-
-
1 -
-
3 5
-
2
1
2 1
-
-
3 4
149 214
-
-
1
-
4
-
1
-
1
-
-
4
363
Total 1
Numbers provided by facility in-charge MD specialist includes General Surgeon, Anesthesiologist, Obstetrician and gynecologist, Internist, Pediatrician, psychiatrist, Radiologist, and other Service Specialist. 3 includes neonatology nurse, ophthalmic nurse, public health nurse etc… 4 Includes BSc or Diploma pharmacy 5 Includes MSC, BSc or diploma laboratory technicians and Microbiologists 6 includes environmental health, health informatics/information technician, biomedical engineer, radiology technician/technologist, physiotherapy professional and dietician 7 includes Administration and finance, cleaners, compliance handling officer, maintenance personnel, morgue attendant, reception, social worker etc... 2
The result of the 2014 ESPA+ show that general practitioner and medical specialists are more in referral hospitals than in other facility type. Moreover, health facilities managed by the government provided the most median number of providers. Table 3.11-B Staffing pattern in surveyed facilities in Health Posts, ESPA+ 2014 38
Table 3.11-B
Staffing pattern in surveyed facilities
Median number of providers1, assigned to, employed by, or seconded to a health post, by type of provider and type of facility, Ethiopia SPA+ 2014
Background characteristics Facility type Health Post
Median number of providers assigned to/ employed by/ seconded to facility Diploma nurse / Health extension midwife worker Number of facilities
-
2
802
-
2
800
-
-
2
Region Tigray Afar Amhara Oromia Somali Benishangul Gumuz SNNP Gambella Harari Dire Dawa
1 1 -
2 1 2 2 2 2 2 2 2 3
33 10 182 316 31 17 205 4 1 2
Urban/rural Urban Rural
1 -
1 2
26 776
-
2
802
Managing authority Government/ public Other governmental (military, prison, federal police)
Total 1
Numbers provided by facility in-charge
3.3.5 User Fees That Decrease Financial Barriers to Utilisation of Health Services User fees may have a positive effect on the use of health facilities by increasing the funds available to the facility; they may also have a negative effect by deterring poor clients from using services. User fees with exemption schemes for vulnerable people often help to augment inadequate facility budgets. However, providing exemptions or discounts for poor clients can result in budget shortages if there is no system for reimbursing the facility for these exempted or discounted costs. Some other approaches also encourage appropriate use by poor clients and reimburse facilities for client services. These approaches include insurance plans, credit plans (delayed payment for services received), and charity or equity funds that reimburse the costs of certain clients (thus increasing access to care by reducing out-of-pocket payments at the time of service utilisation). In any case, health facilities should clearly display their fees for service, if they charge for any services. This improves accountability, reduces the likelihood of corruption, and helps clients calculate the costs they will incur in seeking services. Table 3.11 summarises information on facilities that charge routine user fees for client services. Ninety six percent of facilities routinely charge some form of user fees for client services. Ninety-four percent of private facilities charge for client services; the same is true for NGO and government facilities (90 and 99 percent respectively). Over all, none of the facilities charge for vaccination, however 8 percent of general hospitals and 3 percent of referral hospitals have user fee for vaccination services. Facilities in Gambella, Addis Ababa, and Somali regions (3 percent, 39
2 percent and 1 percent respectively) are charging the users for vaccination. Hospitals, regardless of the level (ranging from 2 percent to 6 percent) have user fees for ARV treatment, and anti-tuberculosis medicines each except referral hospitals which excludes charge for anti-tuberculosis medicines. Nine and eighteen percent of the facilities charge for HIV diagnostic test and malaria rapid diagnostic test, 32 percent and 11 percent charge for family planning service and normal delivery respectively. Table 3.13-A User fee or charge for different services, ESPA+ 2014 Table 3.13-A
User fee or charge for different services
Among all facilities, excluding health posts, the percentages that implement routine user fees or charges for client services, the percentage with fixed or separate fees, the percentage with fees for major activities, and the percentage with procedures available for patients and clients who are unable to pay by background characteristics, Ethiopia SPA 2014
Background characteristics
Percentage of facilities that have a fee for the following services: Percentage of facilities with routine Family user-fees Percentage planning Malaria or charges Number of facilities services, HIV rapid for client of with fixed including FP Normal diagnostic diagnostic ARV for ARV for services1 facilities fees Vaccines commodities deliveries test test treatment PMTCT
Facility type Referral Hospital General Hospital Primary Hospital Health Center Higher Clinic Medium Clinic Lower Clinic
100 98 100 99 100 95 92
2 7 3 182 13 37 119
6 4 0 3 6 8 10
3 8 0 0 0 0 0
3 22 4 1 40 64 74
22 40 10 1 27 28 16
3 24 6 1 64 43 3
25 43 15 15 51 46 10
3 6 2 0 1 0 0
0 6 4 1 10 8 0
0 6 2 0 0 0 0
2 7 3 180 13 35 109
99
190
3
0
1
1
1
15
0
1
0
187
6 94
2 163
0 9
0 0
0 71
50 22
0 18
50 22
0 0
0 3
0 0
0 154
90
8
16
0
9
4
4
24
1
0
0
7
Region Tigray Afar Amhara Oromia Somali Benishangul Gumuz SNNP Gambella Harari Addis Ababa Dire Dawa
97 86 99 95 97 97 99 74 94 92 82
22 5 87 116 8 4 80 6 2 31 3
1 3 0 11 10 6 3 2 0 11 0
0 0 0 0 1 0 0 3 0 2 0
19 17 40 22 10 37 40 54 21 45 10
5 10 17 4 10 3 11 10 12 21 15
17 8 8 1 5 0 7 0 15 38 12
26 32 15 11 8 31 13 60 45 57 37
1 3 0 0 1 0 0 0 0 2 0
0 0 4 1 0 0 1 0 0 5 2
0 0 0 0 0 2 0 0 3 0 0
21 4 86 110 8 4 79 5 2 29 2
Urban/rural Urban Rural
94 98
149 214
6 5
1 0
40 27
15 8
19 2
28 12
1 0
4 1
0 0
140 209
96
363
6
0
32
11
9
18
0
2
0
349
Managing authority Government/ public Other governmental (military, prison, federal police) Private for profit NGO (mission/ faith-based, nonprofit)
Total 1
Fixed fee that covers all services that a client receives and separate fee for different components of the services provided by the facility.
40
Antituberculosis medicines
Number of facilities having routine user fee
3.4 Systems for Infection control Universal precautions refer to infection control measures that can prevent cross-infection from blood and other body fluids. All health workers who may come into contact with body fluids should exercise these universal precautions, working under the assumption that anyone may have an infectious condition (CDC, 1987; JHPIEGO, 2003). The 2014 ESPA+ assessed conditions for infection control in all service delivery areas covered by the survey. The survey examined conditions to see whether providers could reasonably be expected to wash their hands between seeing different clients. It also checked for the presence of a box for secure disposal of sharp items such as disposable needles, which may be contaminated with HIV or other blood borne infections. Summary information on facilities’ capacity to process equipment for reuse is presented in Tables 3.12-A and 3.12-B 3.4.1 Capacity for Processing of Equipment for Reuse For most equipment that is used for client examination, either sterilisation or high-level disinfection (HLD) procedures are sufficient to prevent the spread of infection. However, to effectively kill the spores that cause illnesses such as tetanus, either dry-heat sterilisation or an autoclave system (or the less frequently used chemical sterilisation) is required. This type of system is necessary for processing surgical equipment that will be reused, such as blade handles and scissors used to cut the umbilical cord. Depending on the size of the facility, different types of equipment may be processed using different methods or at more than one site in the facility. The information presented in this chapter refers to the primary site in the facility where equipment is processed.
Table 3.6-A Capacity for processing of equipment for reuse, ESPA+ 2014 Table 3.6-A
Capacity for processing of equipment for reuse
Among all facilities, excluding health post, percentage of facilities with the equipment and other items to support the final processing of instruments for reuse, by background characteristics, Ethiopia SPA+ 2014
Background characteristics Facility type Referral Hospital General Hospital Primary Hospital Health Center Higher Clinic Medium Clinic Lower Clinic Managing authority Government/ public Other governmental (military, prison, federal police) Private for profit NGO (mission/ faith-based, nonprofit) Region Tigray Afar Amhara Oromia Somali Benishangul Gumuz
Equipment 1
Percentage of facilities having: Equipment, Equipment and knowledge of knowledge of process time, and process time2 automatic timer 3
Written guidelines for sterilization or HLD 4
Number of facilities
100 100 100 91 99 95 85
94 88 88 58 84 76 57
81 71 81 27 66 55 24
34 33 40 12 15 21 7
2 7 3 182 13 37 119
91
59
28
13
190
100 88
75 64
62 35
25 10
2 163
89
74
39
26
8
97 61 88 88 68 79
72 36 56 59 47 39
51 24 27 22 23 19
31 4 10 5 1 7
22 5 87 116 8 4
41
SNNP Gambella Harari Addis Ababa Dire Dawa Urban/rural Urban Rural Total
94 87 83 99 98
65 45 74 81 66
34 9 54 66 62
20 2 14 17 24
80 6 2 31 3
94 87
68 57
45 22
17 9
149 214
90
62
32
12
363
1 Facility reports that some equipment is processed in the facility and facility has a functioning electric dry heat sterilizer, a functioning electric autoclave, a non-electric autoclave with a functioning heat source, an electric boiler or steamer, or a non-electric boiler or steamer with a functioning heat source available anywhere in the facility or high level disinfectant that are used for sterilization or high level disinfection of equipment for reuse 2 Processing area has functioning equipment and power source for processing method and the responsible worker reports the correct processing time (or equipment automatically sets the time) and processing temperature (if applicable) for at least one method. Definitions for capacity for each method assessed were a functioning equipment and the following processing conditions: · Dry heat sterilization: Temperature at 160°C and processed for at least 120 minutes, or temperature at least 170°C and processed for at least 60 minutes. · Autoclave: Temperature at 121°C under 106KPas pressure; wrapped items processed for at least 30 minutes; unwrapped items processed for at least 20 minutes · Boiling or steaming: Items processed for at least 20 minutes. · Chemical high-level disinfection: Items processed in chlorine-based or glutaraldehyde or formaldehyde solution and soaked for at least 20 minutes 3 An automatic timer here refers to a passive timer that can be set to indicate when a specified time has passed. It may be part of the sterilization process or the HLD equipment. 4 Hand-written instructions that are pasted on walls and which clearly outline the procedures to follow for processing of equipment are acceptable Note: According to FMoH National Infection Prevention guidelines the temperature and time relationship for dry heat sterilization is set to be as follows: · Temperature at 160°C and processed for at least 120 minutes. · Temperature at 170°C and processed for at least 60 minutes. Autoclave: · Temperature at 121°C under 106KPas pressure wrapped items processed at least for 30 minutes. · Temperature at 121°C under 106KPas pressure unwrapped items processed at least for 20 minutes.
Nine of every ten facilities excluding health posts and four of every ten health posts have functioning equipment (including the necessary chemicals for HLD) for the processing method used (see Table 3.12-A). All hospitals (100 percent), higher clinics (99 percent), medium clinics (95 percent) and health centres (91 percent) have functioning equipment. All other governmental (military, prison, federal police) and government (91 percent) facilities are more likely to have functioning equipment than NGO facilities (89 percent) or private for profit (88 percent). At the regional level, the availability of functioning equipment ranges from 99 percent of facilities in Addis Ababa region to 61 percent in Afar region. Sixty two percent of facilities excluding health posts and 16 percent of health posts have functioning equipment as well as the correct knowledge of the processing time and temperature for the method (see Table 3.6). When the presence of an automatic timer is added to the assessment (where applicable) the proportion declines to 32 percent of facilities, excluding health posts, and 2 percent of health posts. Written guidelines for sterilisation or HLD processing in any service area were found in only 12 percent of all facilities excluding health posts and 1 percent of health posts. Table 3.6-B Capacity for processing of equipment for reuse in Health Posts, ESPA+ 2014 Table 3.6-B
Capacity for processing of equipment for reuse
Percentage of health posts with the equipment and other items to support the final processing of instruments for reuse, by background characteristics, Ethiopia SPA+ 2014
Background characteristics
Equipment 1
Percentage of facilities having: Equipment, Equipment and knowledge of knowledge of process time, and process time2 automatic timer 3
Facility type
42
Written guidelines for sterilization or HLD 4
Number of facilities
Health Post
39
16
2
1
802
39
16
2
1
800
0
0
0
0
2
Region Tigray Afar Amhara Oromia Somali Benishangul Gumuz SNNP Gambella Harari Dire Dawa
40 14 51 34 15 62 37 19 48 52
32 14 29 11 0 17 13 4 29 35
20 9 0 0 0 7 5 4 5 13
0 0 3 0 0 0 0 0 0 6
33 10 182 316 31 17 205 4 1 2
Urban/rural Urban Rural
2 40
0 17
0 3
0 1
26 776
39
16
2
1
802
Managing authority Government/ public Other governmental (military, prison, federal police)
Total
1 Facility reports that some equipment is processed in the facility and facility has a functioning electric dry heat sterilizer, a functioning electric autoclave, a non-electric autoclave with a functioning heat source, an electric boiler or steamer, or a non-electric boiler or steamer with a functioning heat source available anywhere in the facility or high level disinfectant that are used for sterilization or high level disinfection of equipment for reuse 2 Processing area has functioning equipment and power source for processing method and the responsible worker reports the correct processing time (or equipment automatically sets the time) and processing temperature (if applicable) for at least one method. Definitions for capacity for each method assessed were a functioning equipment and the following processing conditions: · Dry heat sterilization: Temperature at 160°C and processed for at least 120 minutes, or temperature at least 170°C and processed for at least 60 minutes. · Autoclave: Temperature at 121°C under 106KPas pressure; wrapped items processed for at least 30 minutes; unwrapped items processed for at least 20 minutes · Boiling or steaming: Items processed for at least 20 minutes. · Chemical high-level disinfection: Items processed in chlorine-based or glutaraldehyde or formaldehyde solution and soaked for at least 20 minutes 3 An automatic timer here refers to a passive timer that can be set to indicate when a specified time has passed. It may be part of the sterilization process or the HLD equipment. 4 Hand-written instructions that are pasted on walls and which clearly outline the procedures to follow for processing of equipment are acceptable Note: According to FMoH National Infection Prevention guidelines the temperature and time relationship for dry heat sterilization is set to be as follows: · Temperature at 160°C and processed for at least 120 minutes. · Temperature at 170°C and processed for at least 60 minutes. Autoclave: · Temperature at 121°C under 106KPas pressure wrapped items processed at least for 30 minutes. · Temperature at 121°C under 106KPas pressure unwrapped items processed at least for 20 minutes.
3.4.2 Standard precautions for infection prevention Infection control is crucial to quality care during examining patients at outpatient area. Among all facilities, 18 percent had sterilization equipment (Table 3.13.1). Almost all hospitals are more likely to have these sterilization equipment than other facility types. Among the various managing authorities, government facilities (12 percent) are less likely to have these items. Looking at individual infection control items, 43 percent of the health facilities had soap and running water or else alcohol based hand disinfectant. This suggests that service providers in around six of ten facilities either use other sources of water to wash their hands (such as water in a basin, which is usually used multiple times) or simply do not wash their hands while providing outpatient service. Individually, an average of 41 percent had soap, 45 percent had running water, and only three of ten facilities had alcohol-based hand disinfectant. 43
Table 3.5.1 Standard precautions for infection control, ESPA+ 2014 Table 3.5.1
Standard precautions for infection control
Percentages of facilities with sterilization equipment somewhere in the facility and other items for standard precautions available in the general outpatient area of the facility on the day of the survey, by facility type, managing authority and urban/rural, Ethiopia SPA+ 2014 Facility type
Items
General Primary Referral Hospita Hospita Health Hospital l l Center
Sterilizatio n equipment 10 1 0 Equipment for highlevel disinfectio n2 63 Safe final disposal of sharps waste3 66 Safe final disposal of infectious waste 4 75 Appropriat e storage of sharps waste 5 84 Appropriat e storage of infectious waste 6 9 Disinfectan t7 91 Syringes and needles 8 75 Soap Running water 9 Soap and running water Alcoholbased hand disinfectan t Soap and running water or else alcoholbased hand disinfectan t Latex gloves 10 Medical masks Gowns
Health Post
Higher Mediu Lower Clinic m Clinic Clinic
Managing authority Other government al (military, prison, Governmen federal Private t/ public police) for profit
Urban/rural NGO (mission / faithbased, nonprofi t)
Urban
Rural
Total
9 9
9 6
53
2
8 7
8 8
41
12
56
55
65
67
10
18
7 9
8 7
77
34
6 3
6 6
62
42
51
63
63
57
43
45
8 1
7 5
76
51
7 4
6 0
65
56
42
64
73
65
55
57
8 2
7 3
68
52
8 0
6 2
57
55
42
60
72
61
55
56
7 7
8 1
67
93
4 8
5 8
64
88
69
60
88
67
88
84
3 2 8 5
1 0 7 9
14
13
14
14
30
28
26
14
16
50
3 5 8 2
27
51
3 7 8 7
90
50
48
88
88
74
53
56
3 8 5 6 6 3
44
88
17
85
82
72
82
80
36
71
36
48
72
84
62
37
41
44
38
8 0 7 6 7 9
80
31
7 5 7 5 7 1
87
84
7 0 7 4 7 9
76
39
47
75
94
66
41
45
75
6 8
5 0
25
22
6 8
7 1
65
23
47
66
82
56
25
30
91
8 2
7 1
30
17
7 9
7 1
61
20
45
65
65
54
22
27
8 9 9 4 5 2 8
8 1 9 0 2 7 9
39
35
36
48
82
88
68
39
43
78
92
75
100
91
92
83
77
78
12 83
3 43
8 8 8 7 4 0 8
79
62
9 1 9 6 5 9 9
12 78
5 51
2 58
22 81
45 91
26 76
4 52
7 55
81
94 97 63 94
44
Eye protection 19 Guidelines for standard precaution s 11 28 Number of facilities
2
6 2 6
0 1 2
1
2 2 5
5 2 2
7
6
2
0
11
25
13
2
4
1 8
1 7
10
5
1 7
1 4
5
6
0
8
8
14
5
6
7
3
18 2
80 2
1 3
3 7
11 9
990
4
16 3
8
17 6
98 9
1,16 5
Note: The indicators presented in this table comprise the standard precautions domain for assessing general service readiness within the health facility assessment methodology proposed by WHO and USAID (WHO 2012). 1 Facility reports that some instruments are processed in the facility and the facility has a functioning electric dry heat sterilizer, a functioning electric autoclave, or a non-electric autoclave with a functioning heat source available somewhere in the facility. 2 Facility reports that some instruments are processed in the facility and the facility has an electric pot or other pot with heat source for high-level disinfection by boiling or high-level disinfection by steaming, or else facility has chlorine, formaldehyde, CIDEX, or glutaraldehyde for chemical high-level disinfection available somewhere in the facility on the day of the survey. 3 The process of sharps waste disposal is incineration and the facility has a functioning incinerator with fuel on the day of survey, or else the facility disposes of sharps waste by means of open burning in a protected area, dumping without burning in a protected area, or removal offsite with storage in a protected area prior to removal offsite. 4 The process of infectious waste disposal is incineration, and the facility has a functioning incinerator with fuel on the day of survey, or else the facility disposes of infectious waste by means of open burning in a protected area, dumping without burning in a protected area, or removal offsite with storage in a protected area prior to removal offsite. 5 Sharps container observed in general outpatient service area, in area where HIV testing is done if facility does HIV testing, as well as in area where minor surgery is done, if facility does minor surgeries 6 Waste receptacles observed in general outpatient service area, in area where HIV testing is done if facility does HIV testing, as well as in area where minor surgery is done, if facility does minor surgeries 7 Chlorine-based or other country-specific disinfectants used for environmental disinfection available in the general outpatient area 8 Single-use standard disposable syringes with needles or else auto-disable syringes with needles available in the general outpatient area 9 Piped water, water in bucket with specially fitted tap, or water in pour pitcher available in the general outpatient area 10 Non-latex equivalent gloves are acceptable. 11 Any guideline for infection control in health facilities available in the general outpatient area
3.4.3 Waste Management Hazardous waste includes infectious waste (such as bandages and cotton balls that may be contaminated by blood or other bodily fluids) and sharps waste (such as needles and syringes, blades and ampoules). Appropriate final disposal of hazardous waste is another important aspect of infection control. The most effective means for hazardous waste disposal is incineration and subsequent burial of the residue. Burying items in deep pits is also an effective means of disposal. When assessing whether facilities have adequate waste disposal systems, the most important issue is verifying that there is a disposal process that eliminates the possibility of contamination through contact. If the waste is visible and not protected from animals or people, either before or after being removed, burned, or buried, there is an increased chance that people might inadvertently come in contact with it, risking infection. A detail on waste management is provided in Table 3.14. Overall, only 16 and 26 percent of all facilities had incinerator and placenta pit respectively. General hospitals (77 percent) and primary hospitals (75 percent) are more likely to have incinerator than referral hospitals, higher clinics, and health centers (63 percent, 62 percent and 63 percent respectively). Health posts are the least likely (4 percent) to have an incinerator compared with other facilities. NGO-managed facilities are the most likely (59 percent) to have an incinerator than facilities authorized by government and private.
45
Facilities having incinerator and placenta pit by region (N=349) 60
50
49
50
Percent
40
30
37
28
30
28
27
27
26 23
31
22
26
21
Incinerator
20 14
15
1011
9
10
Placenta Pit
16
15
14
11 7
0
Region
Figure 3.1 Percent of facilities having incinerators and placenta pit to manage wastes by Region, ESPA+ 2014 Hospitals, regardless of their level (ranging from 78 to 100 percent) and health centers (87 percent) are the most likely to have a placenta pit than other facilities. Table 3.12 Waste management in Health Facilities, ESPA+ 2014 Table 3.12
Waste management
Among all facilities, the percentages with facilities to manage liquid wastes, by background characteristics Ethiopia SPA 2014
Background characteristics Facility type Referral Hospital General Hospital Primary Hospital Health Center Health Post
Percentage of facilities having: Septic tank, soak away pit, percolation ditch or collection Written tank for guidelines management Dilution / for health of liquid neutralizing care waste Incinerator Placenta pit waste Sewage line tank management Trained staff
63 77 75 62 4
78 84 100 87 13
78 88 83 45 7
78 82 81 40 3
3 9 0 1 0
46
63 48 48 13 4
22 25 29 7 11
Municipal line
25 21 6 6 1
Sucking car
63 55 40 9 2
Number of facilities
2 7 3 182 802
Higher Clinic Medium Clinic Lower Clinic
63 43 13
16 31 10
64 51 24
78 51 9
6 3 1
19 12 2
10 5 0
38 25 4
67 48 9
13 37 119
15
28
15
10
0
6
11
2
3
990
5 24
2 15
14 33
56 23
2 2
2 5
3 2
28 11
53 21
4 163
59
48
66
51
7
23
3
4
36
8
Region Tigray Afar Amhara Oromia Somali Benishangul Gumuz SNNP Gambella Harari Addis Ababa Dire Dawa
28 9 14 15 22 10 15 7 27 49 37
50 27 28 23 14 11 26 11 21 30 31
28 12 19 12 9 10 20 16 38 57 59
27 9 16 7 7 8 8 10 39 77 56
2 0 0 0 0 0 0 0 0 8 2
26 4 3 7 2 3 3 2 18 17 21
12 7 3 13 6 8 10 11 11 11 17
2 0 3 2 1 0 1 0 13 50 10
20 3 5 4 2 1 2 5 46 68 53
54 14 269 432 39 21 285 10 3 31 5
Urban/rural Urban Rural
39 12
38 24
43 13
39 8
2 0
14 5
13 9
15 1
28 2
176 989
16
26
18
13
1
6
9
3
6
1,165
Managing authority Government/ public Other governmental (military, prison, federal police) Private for profit NGO (mission/ faithbased, non-profit)
Total
Sharps Waste and Infectious Waste After determining which system each facility used, data collectors went either to the location where waste is stored prior to disposal or to the disposal site itself to assess whether there was potentially hazardous waste that was not protected. The disposal system for sharps waste is considered to be safe if sharps waste disposal is incinerated and the facility has a functioning incinerator with fuel on the day of survey, or else the facility disposes of sharps waste by means of open burning in a protected area, dumping without burning in a protected area, or removal offsite with storage in a protected area prior to removal offsite. Fifty-seven percent of facilities have safe sharps waste disposal system. Health posts (51 percent) are less likely to have safe sharps waste disposal system than other facility types (Table 3.5.1).
The disposal system for infectious waste is considered to be safe if infectious waste disposal is incinerated, and the facility has a functioning incinerator with fuel on the day of survey, or else the facility disposes infectious waste by means of open burning in a protected area, dumping without burning in a protected area, or removal offsite with storage in a protected area prior to removal offsite. Fifty-six percent of facilities have safe infectious waste disposal system. Health posts (52 percent) and lower clinics (57 percent) are less likely to have safe infectious waste disposal system than other facility types (Table 3.5.1). General hospitals are more likely to have safe final disposal of sharp waste and infectious waste than other facility types. Table 3.16 Waste disposal methods for sharps waste, ESPA+ 2014 Table 3.16
Waste disposal methods for sharps waste
Percentage of facilities for waste disposal methods with sharp waste, by background characteristics, Ethiopia SPA 2014 Background characteristics
Removed
Removed
Percentage of facilities disposing of sharps waste: Burned in Burned Burned on Unprotected
47
Protected area
Number of
offsite, unprotected storage Facility type Referral Hospital General Hospital Primary Hospital Health Center Health Post Higher Clinic Medium Clinic Lower Clinic
offsite, protected storage
incinerator in facility
unprotected on flat ground in facility
protected ground or in pit in facility
area in facility without burning
in facility without burning
facilities
3 0 0 0 1 0 0 0
0 0 0 1 17 5 12 6
91 93 96 80 9 85 75 21
3 2 0 4 22 0 4 14
3 4 0 12 27 6 5 43
0 0 0 1 4 2 1 8
0 2 2 1 2 1 0 4
2 7 3 182 802 13 37 119
1
14
22
18
24
4
2
990
0 0
0 7
15 38
47 10
37 32
0 6
0 3
4 163
0
2
70
13
12
0
1
8
Region Tigray Afar Amhara Oromia Somali Benishangul Gumuz SNNP Gambella Harari Addis Ababa Dire Dawa
0 3 0 2 4 3 0 2 4 0 0
14 0 7 17 1 0 17 2 25 8 28
46 35 24 20 36 27 18 36 29 91 46
8 22 21 18 33 22 13 25 4 0 9
20 32 35 23 13 42 26 28 9 0 5
2 1 4 4 4 6 4 5 2 0 0
0 6 4 0 5 0 3 2 2 1 0
54 14 269 432 39 21 285 10 3 31 5
Urban/rural Urban Rural
0 1
13 13
58 19
9 19
13 28
2 4
1 2
176 989
1
13
25
17
25
4
2
1,165
Managing authority Government/ public Other governmental (military, prison, federal police) Private for profit NGO (mission/ faith-based, non-profit)
Total
Overall, among facilities which have adequate medical waste other than sharp waste disposal system, 16 percent of facilities have incinerator in the facility and 38 percent of facilities have a protected ground or pit in the facility to dispose medical wastes.
48
Percent of Facilities with having medical waste management methods (N= 1,165) 40
38
35 30
28
Percent
25 20 16 15 10 6 5
6
2
2
0 Removed offsite, unprotected storage
Removed offsite, protected storage
Burned in Burned incinerator in unprotected facility on flat ground in facility
Burned on Unprotected Protected protected area in facility area in facility ground or in without without pit in facility burning burning
Medical waste disposal Methods
Figure 3.2 Percent of facilities with methods of medical waste management, ESPA+ 2014
49
4. Child Health Services 4.1 Background World Health Organization (WHO) and also United Nations Children’s Fund (UNICEF) have estimated that about 10 million children under five years of age die each year, largely from preventable causes. Many sick children who are brought to health care providers do not receive adequate assessment and treatment (WHO, 1999). 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 preventable or treatable diseases (WHO/CHERG 2010). In an effort to improve standard of child health services, WHO and other agencies developed the Integrated Management of Childhood Illness (IMCI) strategy (WHO, 1997). This strategy advocates using every visit to a health care provider as an opportunity, not only to conduct a full assessment of the child’s current health and possible underlying problems, but also to provide interventions, such as vaccination that can prevent illness or minimise its progression. The IMCI strategy aims to reduce morbidity and mortality among children under age five years through improving health workers’ skills through training and supportive supervision; improving health systems, including equipment, supplies, organisation of work, and referral systems and improving child care at the community and household levels in line with key family practices. Training and supportive supervision, through a holistic approach, help health workers assess and appropriately treat major childhood illnesses (including acute respiratory infections, diarrhoea, malaria, measles, and other severe infections). WHO recommends that at least 60 percent of providers need to be trained in IMCI case management to ensure a critical mass for proper management of sick children. IMCI has already been introduced in more than 75 countries around the world. In Ethiopia, Integrated Management of New born and Childhood Illness (IMNCI) is currently being delivered through health centres and some hospitals. At Health post level it is referred as integrated community case management (ICCM), mainly focusing on community management of pneumonia, diarrhoea, malaria, and sever acute uncomplicated malnutrition and referral of sever case. By employing the IMNCI/ICCM framework, the 2014 ESPA+ endeavours to provide useful information that can be used to fathom progress in implementing the child health services across all continuum of health facilities. This chapter explores the following areas relating to the provision of quality child health services at health facilities in Ethiopia: Availability of services: Section 4.2 including Tables 4.1-4.3, examines the availability of child health services and how often these services are available. Service readiness: Section 4.3 including Tables 4.4-4.9, addresses the readiness of facilities to provide good-quality client services, including the availability of basic amenities and equipment, infection prevention and control processes, laboratory diagnostic capacity, and essential medicines. Adherence to standards: Section 4.4, including Tables 4.10.1-4.12.2, examines the content of observed sick child consultations and feedback from caretakers of observed sick children. Basic management and administrative systems: Section 4.5 including Tables 4.13 and 4.14, considers the extent to which essential management and administrative systems, including in-service training, and supervision are in place to support quality services.
Key Findings
Sixty-two percent of facilities provide all three basic child health services (Outpatient Curative Care, Child Vaccination, and Child Growth Monitoring).
Nighty-six, eighty-three, and eighty-one percent of health posts provide out-patient curative care for sick children, growth monitoring, and all child vaccination services respectively.
50
Governmental managing facilities are more likely to demonstrate service readiness in terms of Guideline, trained staff and equipment
Fifty-six percent of facilities offering child vaccination services have all the five basic child vaccines available in the facility.
Only 5 percent of providers assessed all the three general danger signs of sick children.
Providers assessed all three main symptoms in 43 percent of the observed consultations in all facilities excluding health posts.
Caretakers of sick child repeatedly mentioned long waiting time (10 percent) to see provider as a major problem related to service specific issues.
Forty-eight percent of child health service providers received training related to child health during the 24 months preceding the survey.
Seventy percent of child health service providers received personal supervision during the 6 months preceding the survey.
4.2 Availability of Child Health Services Outpatient Curative Care, Child Vaccination, and Child Growth Monitoring The Ethiopian Demographic and Health Survey 2011 indicated that Seven percent of children under age five showed symptoms of acute respiratory infection (ARI) in the two weeks prior to the survey and for 27 percent of them advice or treatment was sought from a health care facility or provider. Seventeen percent of children under age 5 had a fever, thirteen percent had diarrhoea, and 3 percent had diarrhoea with blood in the two weeks prior to the survey. One in every four children age 12-23 months (24 percent) were fully vaccinated at the time of the survey, a 19 percent increase from the level reported in the 2005 EDHS (EDHS, 2011). The 2014 ESPA+ assessed the availability of three basic child health services: out-patient curative care for sick children, routine childhood vaccination services under EPI, and routine growth monitoring services. Table 4.1 provides information on the availability of these services. Tables 4.2 and 4.3 provide further details on the frequency of availability of child health services. Among all facilities, Sixty-two percent of facilities provide all three basic child health services including all five child vaccines as a package (Table 4.1). Availability and Frequency of child health services at Tertiary Level of health care Sixty three percent of referral hospitals offer all three basic child health services including all five child vaccines (outpatient curative care for sick children, growth monitoring, and all five child vaccinations). The most offered child health service at referral hospital is Outpatient curative care for sick children (88 percent) whereas the least offered child health service is Routine vitamin A supplementation (47 percent) (Table 4.1). Among referral hospitals offering outpatient curative care for sick children and growth monitoring, the percentages providing curative care for sick children and growth monitoring at a frequency of 5 or more days per week accounted 100 percent and 96 percent respectively (Table 4.2). Availability and Frequency of child health services at Secondary Level of health care Two-third of general hospitals offer all three basic child health services including all five child vaccines (outpatient curative care for sick children, growth monitoring, and all five child vaccinations) (Table 4.1). Among general hospitals offering outpatient curative care for sick children and growth monitoring, the percentages providing curative care for sick children and growth monitoring at a frequency of 5 or more days per week accounted 98 percent and 90 percent respectively (Table 4.2). 51
Availability and Frequency of child health services at Primary health care unit Three-fourth of primary hospitals, eight in every ten health centres and seven in ten health posts offer all three basic child health services including all five child vaccines (outpatient curative care for sick children, growth monitoring, and all five child vaccinations) (Table 4.1). Among general hospitals, health centres and health posts offering outpatient curative care for sick children, the percentages providing curative care for sick children at a frequency of 5 or more days per week were 100 percent , 98 percent and 69 percent respectively (Table 4.2). Lower clinics are the type of facility least likely to provide all three basic services (1 percent), and Health centres are more likely to provide all the services (82 percent). Government facilities are more likely to provide all three basic child health services (73 percent) than other managing authorities. Facilities in rural areas are more likely (68 percent) to provide all the services than facilities in urban areas (32 percent). At regional level, facilities in Tigray are more likely to offer all three basic child health services (78 percent), while facilities in Addis Ababa are less likely to offer all three services as a package (15 percent) and facilities in rural areas are more likely (68 percent) to offer the services than facilities in urban areas (32 percent). Table 4.1 Availability of child health services, ESPA+ 2014 Table 4.1
Availability of child health services
Among all facilities, the percentages offering specific child health services at the facility, by background characteristics, Ethiopia SPA+ 2014 Percentage of facilities that offer:
Background characteristics Facility type Referral Hospital General Hospital Primary Hospital Health Center Health Post Higher Clinic Medium Clinic Lower Clinic Managing authority Government/ public Other governmental (military, prison, federal police) Private for profit NGO (mission/ faithbased, nonprofit) Region Tigray Afar Amhara Oromia Somali Benishangul Gumuz SNNP Gambella Harari Addis Ababa Dire Dawa Urban/rural Urban Rural
Outpatient curative care for sick children
Growth monitoring
Child vaccination1
All three basic child health services
Child vacc+2
All three basic child health services, including all Routine vitamin A vaccines3 supplementation
Number of facilities
88 97 100 99 96 74 88 86
72 78 81 89 83 19 15 5
78 74 81 89 82 8 7 2
63 68 75 82 72 7 6 1
78 74 81 88 81 8 7 2
63 68 75 82 71 7 6 1
47 67 73 85 83 5 8 3
2 7 3 182 802 13 37 119
96
85
84
74
82
73
83
990
86 86
0 7
3 1
0 1
3 1
0 1
2 3
4 163
96
74
67
60
67
60
68
8
91 100 96 94 95 97 96 91 86 82 84
87 34 75 75 50 64 80 21 63 22 67
81 52 67 78 62 83 74 47 59 17 63
78 25 64 65 38 53 70 21 55 15 60
81 49 67 78 61 83 70 41 59 16 63
78 25 64 65 37 53 67 20 55 15 60
79 73 80 70 72 15 78 21 61 14 63
54 14 269 432 39 21 285 10 3 31 5
87 96
39 79
38 78
35 68
35 77
32 68
37 78
176 989
52
Total
95
73
72
63
71
62
72
1,165
1
Routine provision of pentavalent (DPT+HepB+HiB), polio, and measles vaccination in the facility to children. Routine provision of pentavalent (DPT+HepB+HiB), polio, measles, BCG, and pneumococcal vaccination in the facility 3 Includes outpatient curative care for sick children, growth monitoring, and all five child vaccinations. 2
Out-patient curative care for sick children (95 percent) is the most commonly provided service of all the three basic services. These services are almost universally available across all facility types, except in higher clinics which is less than 80 percent. Although on average 71 percent of all facilities offer child vaccination services, majority of health centres (88 percent) and health posts (81 percent) offer the service, compared with only 2 percent of lower clinics. Government facilities (82 percent) are the most likely to offer childhood vaccination services and facilities in rural areas are more likely (77 percent) to offer the services than facilities in urban areas (35 percent) (table 4.1). Seventy-two percent of facilities provide routine vitamin A supplementation. Health centres (85 percent) and health post (83 percent) are more likely to provide vitamin A supplementation than other facility types. Facilities in Amhara region (80 percent), Tigray (79 percent), SNNP (78 percent) and in rural areas (78 percent) are more likely to provide the service than other regions and residence respectively. The ESPA+ 2014 assessed frequency of availability of child health services among facilities offering the services (table 4.2). Among all facilities offering outpatient curative care for sick children, majority (78 percent) of them offer the service 5 or more days per week at the facility. While among all facilities offering growth monitoring service, 37 percent of them offer the service 5 or more days per week and health posts are least likely (23 percent) to provide the service 5 or more days per week at the facility. Table 4.2 Frequency of availability of child health services - curative care and growth monitoring, ESPA+ 2014 Table 4.2
Frequency of availability of child health services - curative care and growth monitoring
Among all facilities offering outpatient curative care for sick children and growth monitoring, the percentages providing the service at the facility at specific frequencies, by background characteristics, Ethiopia SPA+ 2014
Background characteristics Facility type Referral Hospital General Hospital Primary Hospital Health Center Health Post Higher Clinic Medium Clinic Lower Clinic Managing authority Government/ public Other governmental (military, prison, federal police) Private for profit NGO (mission/ faith-based, nonprofit) Region Tigray Afar Amhara Oromia Somali Benishangul Gumuz SNNP
Outpatient curative care for sick children Number of 1-2 3-4 5 or more days facilities
Growth monitoring 1-2
3-4
5 or more days
Number of facilities
0 0 0 0 20 0 0 0
0 1 0 0 11 4 0 0
100 98 100 98 69 94 96 99
2 7 3 180 766 10 33 103
0 7 5 8 18 0 0 0
4 0 2 0 4 0 0 0
96 90 93 86 23 100 100 84
1 6 2 162 668 3 6 6
16
9
74
952
16
3
36
837
0 0
0 0
100 98
3 140
1
0
98
0 11
0
1
99
8
1
2
81
6
3 3 10 26 4 3 6
3 3 4 9 4 0 12
92 94 85 65 92 94 81
50 14 257 407 37 20 275
3 55 6 17 27 10 24
0 0 3 4 9 0 2
53 40 52 33 54 50 21
47 5 202 323 20 13 229
53
Gambella Harari Addis Ababa Dire Dawa Urban/rural Urban Rural Total
8 2 2 0
5 10 2 0
85 88 93 97
9 3 26 4
9 20 2 24
19 3 0 4
40 63 96 65
2 2 7 3
9 15
4 8
86 76
153 950
11 16
0 3
78 33
69 784
14
8
78
1,103
16
3
37
853
Note: Some facilities provide the service less than one day per week; therefore, the total percentages may not add to 100 percent.
Facilities providing child vaccination services were assessed for frequency of routine child vaccination services and it was found that, 20, 19, 18, 8, 7 percent of them provide polio, pentavalent, pneumococcal, measles, and BCG vaccination services respectively for 5 or more days at the facility(Table 4.3). Table 4.3 Frequency of availability of child health services - vaccination services, ESPA+ 2014 Table 4.3
Frequency of availability of child health services - vaccination services
Among facilities offering routine child vaccination services, the percentages providing the service at the facility at specific frequencies, by background characteristics, Ethiopia SPA+ 2014 Routine polio vaccination
Background characteristics Facility type Referral Hospital General Hospital Primary Hospital
1-2
Numbe 5 or r of more facilitie 3-4 days s
9 2 8 8 8 8 7 7
4
4
9
1
12
0
Health Center 13
0
Health Post
12
5
Higher Clinic Medium Clinic
0
0
59
0
Lower Clinic
52
0
5 8 8 4 1 3 9
4
2 0
Managing authority Government/ public 12 Other government al (military, prison, federal 10 police) 0 Private for profit 9 NGO (mission/ faith-based, nonprofit) 47
0 2
0 7 7
0
5 2
Routine pentavalent Routine measles Routine BCG vaccination vaccination vaccination Numbe Numbe Numbe 5 or r of 5 or r of 5 or r of more facilitie more facilitie more facilitie 1-2 3-4 days s 1-2 3-4 days s 1-2 3-4 days s
9 2 8 8 8 1 7 4
1
4
4
6
8
1
2
19
0
165
13
1
660
12
1
0
5 3 8
3
56
0
2
52
0
4 5 1 4 4 3 9
831
12
4
1 9
0
10 0
3
4
0 1 8
0 6 6
5
47
0
5 2
2
7 6 6 3 4 0 4 7 1 0 3 8 5 8 6 6
850
1 8
1 6 2 165 679 1 3
3
5 0 6 7
5
5 7
0
667
0
3 5 1 3 7 2 5
2
5 4 6 2 4 0 4 9 1 0 8 1 5 8 9 1
4
8
836
1 8
0
0
3
0 1 2
0
4 2
4 0 2 0 5 0 3
Region
54
2 0 3 3 2 4 2 6
1 5 2 162
1 3
2
5 0 7 1
5
7 3
1 2
0
3 5 3 3 1 9 2 1
2 0
Pneumococcal vaccination
1-2
Numbe 5 or r of more facilitie 3-4 days s
9 2 8 7 8 1 7 1
1
4
4
6
10
1
2
19
0
162
15
2
4
662
11
1
0
0
8 4 0
5 3 8
3
56
0
0
0
2
52
0
4 5 1 4 4 3 9
2
7
830
12
4
1 8
0
0
10 0
0
0 1 7
3
4
0 1 8
0 6 5
1
2 0
5
47
0
5 2
1 0
1 6 2 164 655 1 3 2
827
0 3
5
Tigray
0
0
Afar
19
0
Amhara
10
6
Oromia
13
Somali Benishangul Gumuz
24
4 2 7
4
0
SNNP
16
0
9
0
27
3
4
0
10
2
Urban
13
3
Rural
12
Total
12
Gambella Harari Addis Ababa Dire Dawa
2 5 4 5 2 3 1 8 4 3 1 1 1 5 2 4 5 5 9 6 7 1
46
0
0
7
24
0
181
9
6
336
12
25
24
5 2 7
18
4
0
212
16
0
5
11
0
2
27
3
5
3
8
3
15
2
2 6 3 7 2 1 1 7 4 3 1 1 1 3 2 2 5 5 8 9 6 6
44 8 181 350 25 17 217 5 2 5 3
0
1 6 2 8
6
6
181
4 2 7
6 3 7
343
0
8
18
0
210
0
6 1 0
0
9
2
0
5
0
6 1 0
3
2 0
67
4
7
777
6 2 1 5
4
8
844
1 8
5 3 3 1 4 2 2 2 7
0
3 1 6 1 8 6 4 7 8 4 1
45 7
25
5
3
0
1 0 2 8
0
3
180
10
6
2 2 7
5 3 4
343
12
24
24
5 2 7
0
18
4
0
206
15
0
0
8 1 0 1 5
5
8
0
0
6
2
30
3
5
5
7
8
0
8 1 0
3
12
0
3
1 4
67
14
3
2
7
772
12
2
7
838
12
6 2 8 2 1 2 0 3 0
0
3 1 4 1 7 7 0 6 1 3 5
0
45
0
0
7
20
0
2 5 4 1 2 0 1 7 4 2 1 1 1 1 2 7 5 2 8 6 6 7
46 7 181 343 24 18 201 5 2 5 3
Urban/rural 67
13
3
4
7 5 1 5
4
7 4 1 4
791
6 0 1 5
772
12
4
2 0
840
12
4
1 9
858
1 8
67
4
7 9 1 3
773
4
1 8
835
61
Note: Pentavalent = DPT (diphtheria, pertussis and tetanus) + HiB + HepB ; BCG = bacillus CalmetteûGuTrin Note: Some facilities provide the service less than one day per week; therefore, the total percentages may not add to 100 percent.
4.3 Child Health Service Readiness 4.3.1 Readiness for Curative Care Service for Sick Children To improve the diagnosis of illnesses and to minimise missed opportunities to provide preventive interventions, IMNCI standards recommend that any consultation for a sick child also include:
Assessing vaccination status and providing vaccines that are due Assessing nutritional status and counselling caretakers on identified problems Assessing overall health status Ensuring that the child receives the first dose of any prescribed medicine, including antibiotics, at the facility and leaves the facility with the necessary medications Ensuring that caretakers know how to administer medications and treatments, know about appropriate foods, and know how much food the child needs both during this illness and when not sick Ensuring that caretakers know when to return, either because signs indicate that the child must be seen immediately or because of scheduled follow-up
The 2014 ESPA+ assessed the readiness through availability of equipment, supplies, guidelines and health system components necessary to adhere to IMNCI guidelines and to support quality out-patient care for sick children. Assessed elements are as follows:
Guidelines, trained staff, and equipment for adhering to IMNCI guidelines for assessment of the sick child Infection prevention items and laboratory diagnostic capacity Essential medicines for treating sick children in accordance with IMNCI guidelines IMNCI job aids, including the chart booklet, recording form, and mother/caretaker cards
55
4.3.1.1 Guidelines, trained staff and equipment for assessment of the sick child In Ethiopia, 69 percent of facilities offering outpatient curative care for sick children have IMCI guideline and 41percent have Growth monitoring service. Forty-eight and 47 percent have at least one staff member who received training in IMCI and growth monitoring respectively during 24 months before the survey (Table 4.4). Moreover, more than 50 percent of facilities have physical examination related equipments with the exception of infant scale (39 percent) and length for height or board (44 percent). Figure 4.1 summarises information on these items. Table 4.4 provides details by background characteristics.
Percentage of facilities offering child curative care services
Availability of equipment for assessing health status of the sick child (N=1,103) 91 79 58
74 60
51
44
39
78
Equioment
Figure 4.1 Availability of equipment for assessing health status of the sick child among facilities offering child curative care services, ESPA+ 2014 Government managed facilities have greatest service readiness in terms of availability of guidelines and trained staff. For example, among all governmental facilities offering outpatient curative care service for sick children, 79 percent have IMCI guideline and 55 percent have at least one trained child health service provider in IMCI during the 24 months preceding the survey (Table 4.4). Table 4.4 Guidelines, trained staff, and equipment for child curative care services, ESPA+ 2014 Table 4.4
Guidelines, trained staff, and equipment for child curative care services
Among all facilities offering outpatient curative care for sick children, the percentages having indicated guidelines, trained staff, and equipment, by background characteristics, Ethiopia SPA+ 2014 Guidelines
Background characteristics Facility type Referral Hospital General Hospital Primary
IMCI
1 8 3 8 6
Trained staff
Growth monitorin g IMCI1
25 31 42
1 8 2 8 3
Growth monitorin g2
14 43 48
Equipment
Child scale3
8 6 7 7 7
Infant scale4
7 1 7 2 7
Tape for Length measuring or head height circumferenc Stethoscop Thermomet Growth board e e er chart
8 9 9 0 9
56
82
96
100
82 81
90 94
100 100
6 8 6 0 7
Timer
Number of facilities offering outpatient curative Tape for care for measurin sick g MUAC children
10 0
61
2
97 94
57 65
7 3
Hospital Health Center
50
49
5 3 9 5 9
Higher Clinic 7 Medium 1 Clinic 4
5
5
2
3
8
7
Lower Clinic 5
0
3
48
Health Post
5 8 1 7 8
Managing authority Government/ 7 public 9 Other government al (military, prison, federal police) 2 Private for profit 7 NGO (mission/ faith-based, 2 nonprofit) 7
5 5 8 4 0 2 9 1 7
2
7 6 5 6 4 6 1 2 5 1 0
6
0 7 2 3 6 8 7 6 3 3 5
5 5
54
6 4
4 3
4 3
0
0
0
2
0
4
3
4 1 5
9
4 3 4 5
27
1 8
25
7 2
7 0
5 9
5 7 6 2 6 3 6 0 5 1 5 2 5 4 2 7 5 2 4 5 4 4
6 3 5 2 4 7 2 4 2 7 4 5 5 1 3 4 5 2 2 7 6 9
5 8 4 8 4 4 4 1 3 8 3 8 4 1 3 1 6 5 7 9 7 5
52
4 6 6 0
4 0 3 9
6 4 4 0
47
5 8
3 9
4 4
42
55
62
88
98
50
76
69
70
96
100
1 6 6 6 9 2 0
66
97
99
33
86
52
93
77
180
89
87
766
94
5
10
6
97
7
33
100
0
95
3
103
78
75
6 9
90
85
952
34
40
49
0
10 0
0
3
42
89
100
2
95
2
140
78
95
100
3 8
99
68
8
53
100
97
96
90
50
42
83
96
90
34
14
39
86
83
91
81
257
57
66
68
95
74
407
22
64
79
91
41
37
35
86
85
92
57
20
58
90
82
82
80
275
37
72
78
93
24
9
71
67
96
98
58
3
68
97
100
96
13
26
60
84
99
97
60
4
57
87
94
97
34
153
50
78
76
3 1 6 4
89
80
950
51
79
78
6 0
91
74
1,10 3
Region Tigray Afar Amhara Oromia
8 9 3 3 8 3 6 6
Somali 6 Benishangul 6 Gumuz 9 7 SNNP 4 3 Gambella 0 1 Harari 5 2 Addis Ababa 4 4 Dire Dawa 1
73 8 39 41 6 31 52 9 19 8 35
4 1 3 1 5 5 4 9 1 9 6 4 4 9 3 6 1 9 1 5 5 3
44 42 50 52 16 55 47 36 48 11 57
8 9 2 0 5 9 6 4 2 2 3 3 6 5 1 0 2 9 1 9 5 6
Urban/rural
Rural
3 9 7 4
Total
6 9
Urban
45
2 0 5 2
41
4 8
21
21
Note: The indicators presented in this table comprise staff and training and equipment domains for assessing readiness to provide preventative and curative child health services within the health facility assessment methodology proposed by WHO and USAID (WHO 2012). Note: MUAC = Mid-Upper Arm Circumference Note: In health posts IMCI should be understood as Integrated Community Case Management (ICCM) for common child hood illness 1 At least one interviewed provider of child health services in the facility reported receiving in-service training in Integrated Management of Childhood Illness (IMCI) during the 24 months preceding the survey. Training refers only to in-service training. The training must have involved structured sessions; it does not include individual instruction that a provider might have received during routine supervision. 2 At least one interviewed provider of child health services in the facility reported receiving in-service training in growth monitoring during the 24 months preceding the survey. Training refers only to in-service training. The training must have involved structured sessions; it does not include individual instruction that a provider might have received during routine supervision. 3 A scale with gradation of 250 grams, or a digital standing scale with gradation of 250 grams or less where an adult can hold a child to be weighed
57
4
A scale with gradation of 100 grams, or a digital standing scale with gradation of 100 grams where an adult can hold an infant to be weighed
4.3.1.2 Infection prevention items and laboratory diagnostic capacity Ensuring infection prevention and control items, and laboratory diagnostic equipment are critical to prevent facility acquired infections and effectively provide child health services. Items assessed for infection prevention and control include; soap, running water, hand disinfectant, latex glove, sharps containers, and receptacles. In addition, equipment assessed for Laboratory diagnostic services are haemoglobin test, malaria test, and stool microscopy. Among all facilities, excluding Health posts offering outpatient curative care services for sick children, only 43 percent have soap and running water at the service site on the day of the survey and only 44 percent of them have alcoholbased hand antiseptic, but 56 percent of them have either soap and running water, or alcohol-based hand antiseptic. More than 70 percent of health facilities, excluding health posts have latex glove, while seventy-four percent of these facilities have sharp containers, only 30 percent of them have waste receptacles. Regarding diagnostic service capacity, fifty-eight percent of facilities have laboratory diagnostic capacity for malaria. Health centres, Somali region, and rural facilities are least likely to have infection prevention items listed above (table 4.5-A). Haemoglobin test (23 percent) is the least provided laboratory service in contrast with malaria test or stool microscopy. Lower clinics (6 percent), private for profit facilities (25 percent), and facilities in Gambella region (42 percent) are least likely to provide malaria test. Similar pattern is exhibited in stool microscopy (Table 4.5-A). Table 4.5-A Infection control and laboratory diagnostic capacity, ESPA+ 2014 Table 4.5-A
Infection control and laboratory diagnostic capacity
Among facilities, excluding health post, offering outpatient curative care services for sick children, the percentages with indicated items for infection control observed to be available at the service site on the day of the survey and the percentages having the indicated laboratory diagnostic capacity in the facility, by background characteristics, Ethiopia SPA+ 2014 Items for infection control
Background characteristics Facility type Referral Hospital General Hospital Primary Hospital Health Center Higher Clinic Medium Clinic Lower Clinic Managing authority Government/ public Other governmental (military, prison, federal police) Private for profit NGO (mission/ faithbased, nonprofit) Region Tigray Afar
Laboratory diagnostic capacity Number of facilities offering outpatient curative care for sick children
Running water1
Soap and running water or else AlcoholalcoholSoap and based based running hand hand water antiseptic antiseptic
Latex gloves2
Sharps Waste container receptacle3
82 68 56 29 86 75 70
89 74 65 39 83 78 76
79 64 50 21 81 71 65
86 79 71 26 81 70 59
93 85 81 35 91 87 76
96 93 88 54 95 86 91
93 89 88 81 65 73 61
50 53 38 24 67 53 27
100 85 67 25 75 53 1
82 85 88 83 83 71 6
89 79 85 57 80 74 1
2 7 3 180 10 33 103
30
40
23
28
37
55
82
25
27
83
58
188
82 72
78 76
78 67
74 64
82 80
100 90
26 64
11 35
11 18
100 25
33 22
1 140
84
95
82
63
87
91
84
53
40
51
57
8
70 33
77 33
65 19
61 55
74 60
70 80
84 75
47 20
37 24
81 92
71 50
18 5
Soap
58
Hemoglobin4
Malaria5
Stool microscopy6
Amhara Oromia Somali Benishangul Gumuz SNNP Gambella Harari Addis Ababa Dire Dawa Urban/rural Urban Rural Total
51 46 13 32 37 51 59 87 61
50 58 23 39 51 43 59 89 71
42 40 8 26 35 31 52 83 58
43 44 28 34 31 47 59 73 58
55 55 30 49 44 58 66 93 76
82 66 58 59 59 86 86 87 92
82 68 67 72 75 49 83 72 76
26 34 16 16 15 13 21 61 42
17 22 20 16 17 3 52 58 68
55 54 80 51 53 42 76 78 82
34 38 46 37 44 11 66 75 74
80 112 7 4 75 5 2 26 2
61 41
70 47
57 33
60 34
72 46
78 66
72 76
40 23
39 13
59 58
50 39
132 205
49
56
43
44
56
71
74
30
23
58
43
337
Note: The laboratory diagnostic capacity indicator measures presented in this table comprise the indicators in the diagnostics domain for assessing readiness to provide preventative and curative child health services within the health facility assessment methodology proposed by WHO and USAID (WHO 2012). 1 Piped water, water in bucket with specially fitted tap, or water in pour pitcher 2 Non-latex equivalent gloves are acceptable. 3 Waste receptacle with plastic bin liner 4 Facility had functioning equipment and reagents for colorimeter, hemoglobinometer, or HemoCue. 5 Facility had unexpired malaria rapid diagnostic test kit available somewhere in the facility or a functioning microscope with necessary stains and glass slides to perform malaria microscopy. 6 Facility had a functioning microscope with glass slides and formal saline (for concentration method) or normal saline (for direct method) or LugolÆs iodine solution.
Similar assessments on infection prevention items and laboratory diagnostic capacity to health posts were done and the finding shows that only 23 percent of Health posts offering outpatient curative care services for sick children have soap and running water and 37 percent of them have either soap and running water or alcohol-based hand antiseptic at the service site. Great majority of these health posts (95 percent) have sharp containers but only 14 percent have waste receptacles. Health posts in Gambella region (8 percent) and Somali region (11 percent) are the least likely to have soap and running water or else alcohol-based hand antiseptic at the service site. Fifty-five percent of these Health posts have a laboratory diagnostic capacity for malaria. Table 4.5-B Infection control and laboratory diagnostic capacity in Health Posts, ESPA+ 2014 Table 4.5-B
Infection control and laboratory diagnostic capacity
Among health posts offering outpatient curative care services for sick children, the percentages with indicated items for infection control observed to be available at the service site on the day of the survey and the percentages having the indicated laboratory diagnostic capacity in the facility, by background characteristics, Ethiopia SPA+ 2014 Items for infection control
Background characteristics Facility type Health Post Managing authority Government/ public Other governmental (military, prison, federal police) Region Tigray Afar Amhara Oromia Somali
Soap
Running water1
Soap and running water
Soap and running water or else alcoholAlcohol-based based hand hand antiseptic antiseptic
Laboratory diagnostic capacity
Latex gloves2
Sharps container
Waste receptacle3
Malaria5
Number of facilities offering outpatient curative care for sick children
38
39
23
18
37
81
95
14
55
766
38
39
23
18
37
81
95
14
56
764
0
0
0
0
0
100
100
0
0
2
71 23 53 37 11
58 32 47 34 16
50 23 35 20 5
58 36 21 17 11
79 45 50 34 11
92 91 85 76 63
100 86 97 90 84
21 18 12 12 5
96 82 74 39 37
31 10 177 295 30
59
Benishangul Gumuz SNNP Gambella Harari Dire Dawa Urban/rural Urban Rural Total
14 30 12 53 40
18 43 8 42 33
7 19 4 37 17
29 8 4 63 47
36 27 8 68 53
86 86 62 100 100
96 100 85 95 100
7 19 15 11 33
79 57 65 42 70
17 200 4 1 2
62 38
27 40
27 23
3 18
30 37
91 81
99 94
1 14
56 55
21 745
38
39
23
18
37
81
95
14
55
766
Note: The laboratory diagnostic capacity indicator measures presented in this table comprise the indicators in the diagnostics domain for assessing readiness to provide preventative and curative child health services within the health facility assessment methodology proposed by WHO and USAID (WHO 2012). 1 Piped water, water in bucket with specially fitted tap, or water in pour pitcher 2 Non-latex equivalent gloves are acceptable. 3 Waste receptacle with plastic bin liner 4 Facility had functioning equipment and reagents for colorimeter, hemoglobinometer, or HemoCue. 5 Facility had unexpired malaria rapid diagnostic test kit available somewhere in the facility. 6 Facility had a functioning microscope with glass slides and formal saline (for concentration method) or normal saline (for direct method) or LugolÆs iodine solution.
4.3.1.3 Essential medicines for treating sick children The 2014 ESPA+ have also assessed the availability of essential and priority medicines for management of common childhood illness among facilities offering outpatient curative care for sick child. As Table 4.6-A indicates, Amoxicillinsyrup/suspension/dispersible (91 percent) is the most available antibiotic among all facilities excluding health posts. ORS is available in 82 percent of the facilities. The availability is less for Zinc tablets (34 percent) and Vitamin A capsules (40 percent) than other essential medicines (Table 4.6-A). Table 4.6-A Availability of essential and priority medicines and commodities, ESPA+ 2014 Table 4.6-A
Availability of essential and priority medicines and commodities
Among facilities, excluding health posts, offering outpatient curative care services for sick children, the percentages where indicated essential and priority medicines to support care for the sick child were observed to be available in the facility on the day of the survey, by background characteristics, Ethiopia SPA+ 2014 Essential medicines
Background characteristics Facility type Referral Hospital General Hospital Primary Hospital Health Center Higher Clinic Medium Clinic Lower Clinic Managing authority Government/ public Other governmental (military, prison, federal police) Private for profit NGO (mission/ faith-based,
Priority medicines Number of facilities offering ArteAmpiCeftrioutpatient misinin cillin axone Benzathine curative compowder powder Genta- penicillin care for bination for for mycin for sick therapy injection injection injection injection children
CotrimoxAmoxicillin azole syrup, syrup, suspen- suspension or sion or disperdispersible 1 sible
Paracetamol Mebensyrup or dazole/ suspen- Vitamin A Albension1 capsules1 dazole
96 95 98 97 33 53 68
100 99 100 100 63 83 81
96 90 92 88 13 12 11
89 88 92 84 14 19 28
43 47 48 67 12 12 3
93 96 96 94 14 16 22
36 27 50 60 1 6 2
64 67 81 72 11 7 3
68 45 63 34 2 0 2
79 83 83 63 14 6 4
89 89 92 73 11 12 14
86 72 83 85 13 12 6
2 7 3 180 10 33 103
97
100
89
85
66
94
59
73
35
64
74
85
188
96 62
33 80
29 9
11 25
0 4
26 18
0 3
29 4
4 2
11 6
22 13
29 7
1 140
74
96
94
65
53
91
12
34
13
25
68
54
8
ORS1
60
Zinc tablets
nonprofit) Region Tigray Afar Amhara Oromia Somali Benishangul Gumuz SNNP Gambella Harari Addis Ababa Dire Dawa
87 89 81 87 86 93 85 89 59 48 74
90 97 91 92 96 83 98 97 79 67 92
73 62 57 63 57 49 51 25 41 24 63
78 63 58 69 61 49 52 50 41 26 66
67 41 44 41 61 24 40 6 7 10 24
76 78 66 69 89 52 54 68 48 28 61
60 34 40 40 48 36 23 20 24 7 24
75 81 50 45 74 46 32 27 24 11 58
35 7 27 22 34 24 12 22 10 9 11
57 57 46 42 55 33 29 17 28 16 42
70 59 55 52 69 46 39 44 38 19 47
66 45 48 62 60 49 48 44 10 21 47
18 5 80 112 7 4 75 5 2 26 2
Urban/rural Urban Rural
71 89
86 95
40 66
48 66
27 48
45 73
27 40
34 49
16 23
33 43
34 58
39 59
132 205
82
91
55
59
40
62
34
43
20
39
48
52
337
Total
Note: The essential medicines comprise the medicines and commodities indicators for assessing readiness to provide preventative and curative child health services within the health facility assessment methodology proposed by WHO and USAID (WHO 2012). Note: ORS = oral rehydration salts 1 These medicines and commodities are also in the group of priority medicines for children.
Majority of government health facilities (greater than 80 percent) have all essential medicines with the exception of zinc tablets and vitamin A capsule (Figure 4.2).
Percentage of facilities offering child curative care services
Availability of Essential Medicines for Treating Sick Children (N=337 for others , N= 766 for HP). 82
90
91 70 59
55
40 23
62 66 34 37
16 0 Facilities Excluding health post Health post
Essential Medcines Figure 4.2 Availability of essential medicines for treating sick children among facilities offering child curative care, ESPA+ 2014 Among all health posts offering outpatient curative care service for sick children, majority (90 percent) have ORS followed by Vitamin A (70 percent), mebendazole/albendazole (66 percent), and Artemisinin combination therapy. However, only 23 and 37 percent have Amoxicillin Syrup/dispersible and Zinc tablet. Table 4.6-B Availability of essential and priority medicines and commodities in Health Posts, ESPA+ 2014 Table 4.6-B
Availability of essential and priority medicines and commodities
61
Among health posts offering outpatient curative care services for sick children, the percentages where indicated essential and priority medicines to support care for the sick child were observed to be available in the facility on the day of the survey, by background characteristics, Ethiopia SPA+ 2014 Essential medicines
Amoxicillin syrup, suspen- Para- cetamol sion or dispersyrup or sible 1 suspen- sion1
Vitamin A capsules1
Mebendazole/ Albendazole
Zinc tablets
Arte- misinin com- bination therapy
Number of facilities offering outpatient curative care for sick children
Background characteristics
ORS1
Facility type Health Post
90
23
16
70
66
37
53
766
91
23
16
70
66
37
54
764
0
0
0
0
0
0
0
2
100 86 94 90 84 96 86 92 79 80
46 45 32 15 26 43 22 12 16 80
8 45 18 12 37 32 14 23 26 70
88 45 85 66 42 4 73 4 89 67
88 59 82 56 63 68 65 35 89 77
71 5 41 24 16 86 46 46 42 23
83 59 71 32 53 93 62 50 26 93
31 10 177 295 30 17 200 4 1 2
65 91
29 23
0 16
87 70
64 66
30 37
57 53
21 745
90
23
16
70
66
37
53
766
Managing authority Government/ public Other governmental (military, prison, federal police) Region Tigray Afar Amhara Oromia Somali Benishangul Gumuz SNNP Gambella Harari Dire Dawa Urban/rural Urban Rural Total
Note: The essential medicines comprise the medicines and commodities indicators for assessing readiness to provide preventative and curative child health services within the health facility assessment methodology proposed by WHO and USAID (WHO 2012). Note: ORS = oral rehydration salts 1 These medicines and commodities are also in the group of priority medicines for children.
4.3.2 Readiness for Child Vaccination Services This sub section addresses the following elements, which are important for quality vaccination services:
Availability of guidelines, trained staff, equipment and supplies for vaccination sessions Capacity to maintain the quality of vaccines Availability of vaccines Infection prevention for vaccination services 4.3.2.1 Availability of Guidelines, Trained staff, Equipment and Supplies for Vaccination Sessions
Table 4.7 provides information on the availability of all the components assessed for quality vaccination services by background characteristics. Overall, the study findings revealed 53 percent of facilities that offer child immunization services have guidelines and 47 percent of them have at least one staff member trained on child immunization service. A great majority of these facilities have equipment for vaccination services with the exception of vaccine refrigerator (18 percent) with a great disparity between government facilities (18 percent) and private facilities (72). Table 4.7 Availability of Guidelines, trained staff, and equipment for vaccination services, ESPA+ 2014 62
Table 4.7
Guidelines, trained staff, and equipment for vaccination services
Among facilities offering child vaccination services, the percentages having EPI guidelines, trained staff, and basic equipment necessary for vaccination services, by background characteristics, Ethiopia SPA+ 2014 Equipment
Guidelines1
Trained staff2
Vaccine refrigerator3
88 53 62 51 54 43 35 48
16 19 19 35 51 49 59 0
68 79 86 77 3 88 23 76
92 93 95 97 86 100 100 100
100 99 100 92 95 100 93 48
100 90 88 87 91 100 60 48
1 5 2 162 658 1 3 2
53
47
18
88
95
90
827
50 41
50 40
50 72
100 93
50 95
50 90
0 2
50
32
61
99
81
64
5
Region Tigray Afar Amhara Oromia Somali Benishangul Gumuz SNNP Gambella Harari Addis Ababa Dire Dawa
86 56 58 43 13 42 65 20 55 81 55
42 43 39 49 37 58 53 39 70 35 71
35 31 22 16 29 9 11 29 39 86 57
81 79 94 82 99 100 91 74 91 97 94
99 89 96 92 92 95 98 92 94 96 96
91 92 94 84 96 99 94 59 100 93 88
44 7 181 336 25 17 210 5 2 5 3
Urban/rural Urban Rural
49 54
34 48
72 14
98 87
95 95
93 90
67 768
53
47
18
88
95
90
835
Background characteristics Facility type Referral Hospital General Hospital Primary Hospital Health Center Health Post Higher Clinic Medium Clinic Lower Clinic Managing authority Government/ public Other governmental (military, prison, federal police) Private for profit NGO (mission/ faith-based, nonprofit)
Total
Vaccine carrier with ice pack4
Sharps container
Syringes and needles5
Number of facilities offering child vaccination services
Note: The indicators presented in this table comprise the indicators included as part of the staff and training and equipment domains for assessing readiness to provide routine child vaccination services within the health facility assessment methodology proposed by WHO and USAID (WHO 2012). 1 National guidelines for the Expanded Program on Immunization (EPI) or other guidelines for immunizations 2 At least one interviewed provider of child vaccination services in the facility reported receiving in-service training in EPI during the 24 months preceding the survey. Training refers only to in-service training. The training must have involved structured sessions; it does not include individual instruction that a provider might have received during routine supervision. 3 If refrigerator is observed in the facility and have a temperature between +2 and +8 degrees. 4 If facility reports that it purchases ice for use with the vaccine carriers, this was accepted in place of ice packs. 5 Single-use standard disposable syringes with needles or auto-disable syringes with needles
4.3.2.2 Capacity to maintain the quality of vaccines A lack of vaccine refrigerators, electricity, or other fuel (such as liquefied petroleum gas) to run electric generators for refrigerators are common reasons why facilities cannot or do not store vaccines. If a facility cannot maintain the cold chain and safely store vaccines, it must collect vaccines from a central location or a nearby facility with a refrigerator on the day(s) of service and then use mobile vaccine carriers and ice packs to maintain their temperature. The logistical challenges of maintaining the cold chain frequently result in limited availability of vaccination services. Overall, 88 percent of facilities offering child vaccination services have a vaccine carrier with ice pack. Only 3 percent of health posts have a 63
vaccine refrigerator (refrigerator is observed in the facility and temperature is between +2 and +8 degree Celsius). Information on vaccine storage conditions with details on elements assessed is provided in Chapter 3. 4.3.2.3 Availability of Vaccines The availability of child vaccines was assessed at facilities that provide vaccination services and also store vaccines. Figure 4.3 summarise these findings and Table 4.8 provides additional information on vaccine availability by facility type, managing authority, and region. Individually, pentavalent, polio, measles, and BCG vaccines were available on the day of the survey in more than 75 percent of the facilities that offer child vaccination services. However, collectively, more than five in ten facilities (56 percent) had all the five basic child vaccines available in the facility on the day of the survey.
Percentage of facilities storing vaccines
Availability of vaccines among facilities offering child vaccination services and storing vaccines (N = 186) 94
93
89
79
75
56
BCG
OPV
Pentavalent
Measles
PCV
All basic vaccines
Vaccines
Figure 4.3 Availability of vaccines among facilities offering child vaccination services and storing vaccines, ESPA+ 2014 Health posts were the least likely to have all the basic child vaccines in stock (24 percent) compared with other facility types. Health facilities in Gambella region are the least likely to have all basic vaccines (39 percent) among facilities in other regions. Table 4.8 Availability of vaccines in health facilities, ESPA+ 2014 Table 4.8
Availability of vaccines
Among facilities that offer child vaccination services and routinely store vaccines at the facility, the percentages having unexpired indicated vaccines observed on the day of the survey, by background characteristics, Ethiopia SPA+ 2014 Percentage of facilities offering child vaccination services and storing vaccines where the following vaccines were observed:
Background characteristics Facility type Referral Hospital General Hospital
Pentavalent1
100 98
Oral polio vaccine
91 91
Measles vaccine
All three vaccines Penta + Polio + Measles2
95 95
86 90
64
BCG vaccine
86 85
Pneumococcal conjugate vaccine
91 93
All basic child vaccines3
73 80
Number of facilities offering child vaccination services and storing vaccines
1 5
Primary Hospital Health Center Health Post Higher Clinic Medium Clinic Lower Clinic Managing authority Government/ public Other governmental (military, prison, federal police) Private for profit NGO (mission/ faith-based, nonprofit) Region Tigray Afar Amhara Oromia Somali Benishangul Gumuz SNNP Gambella Harari Addis Ababa Dire Dawa Urban/rural Urban Rural Total
100 95 88 100 100 100
93 85 31 100 40 100
93 94 87 100 100 100
88 81 30 100 40 100
83 75 73 100 40 100
95 89 88 100 100 100
71 58 24 100 40 100
2 152 22 1 1 2
94
79
93
75
75
89
55
180
100 94
100 89
100 89
100 86
100 89
100 92
100 80
0 2
100
80
100
80
78
99
77
4
100 80 98 98 79 91 85 74 76 100 84
98 56 65 89 65 95 76 65 71 99 81
98 72 96 96 81 86 91 63 82 97 78
95 56 61 84 63 81 73 53 71 97 73
86 61 88 73 56 91 60 45 76 86 62
98 80 94 87 76 86 91 68 65 95 86
81 48 49 57 48 81 45 39 59 84 57
18 3 50 64 11 2 29 2 1 5 2
97 93
95 73
98 91
92 69
90 70
94 88
79 47
52 135
94
79
93
75
75
89
56
186
Note: The measures presented in this table comprise the indicators included as part of the medicines and commodities domain for assessing readiness to provide routine child vaccination services within the health facility assessment methodology proposed by WHO and USAID (WHO 2012). 1 Pentavalent = DPT + hepatitis B + haemophilus influenza B. 2 At least one unexpired vial or ampoule each of pentavalent (DPT+HepB+HiB) vaccine, oral polio vaccine, and measles vaccine with relevant diluents available. 3 At least one unexpired vial or ampoule each of pentavalent vaccine, oral polio vaccine, measles vaccine, BCG vaccine and pneumococcal conjugate vaccine with relevant diluents.
4.3.2.4 Infection prevention for vaccination services Infection control is vital to the overall quality of services, and it requires certain supplies. As evident in Table 4.9, great majority (95 percent) of facilities offering child vaccination services have sharp containers while a minority (18 percent) have a waste receptacle with a plastic bin liner. Health centres (less than 35 percent) have all the items for infection control with the exception of sharp containers (92 percent) and latex glove (57 percent). Having clean hand is a crucial infection prevention measure. Therefore, all facilities offering child vaccination services should have some means of hand cleaning. Only 37 percent of facilities offering child vaccination service in Ethiopia have either soap and running water or alcohol-based hand disinfectant available at the service site on the day of the survey. Table 4.9 Infection control for vaccination services, ESPA+ 2014 Table 4.9
Infection control for vaccination services
Among facilities offering child vaccination services, the percentages with indicated items for infection control observed to be available at the service site on the day of the survey, by background characteristics, Ethiopia SPA+ 2014
Background characteristics
Percentage of facilities offering child vaccination services that have indicated items for infection control Soap and running water Alcohol-based or else Running Soap and hand alcohol-based Sharps Waste Soap water1 running water disinfectant hand Latex gloves2 container receptacle3
65
Number of facilities offering child vaccination services
disinfectant Facility type Referral Hospital General Hospital Primary Hospital Health Center Health Post Higher Clinic Medium Clinic Lower Clinic
80 59 55 27 35 55 90 39
64 62 62 35 40 55 97 48
64 54 52 19 24 55 90 39
76 69 74 26 17 51 90 48
88 77 76 34 36 62 93 48
92 85 79 57 80 19 100 48
100 99 100 92 95 100 93 48
48 45 26 28 15 100 93 14
1 5 2 162 658 1 3 2
33
39
23
19
36
75
95
18
827
50 44
100 54
50 39
50 46
50 58
50 71
50 95
0 59
0 2
78
78
77
79
80
72
81
67
5
Region Tigray Afar Amhara Oromia Somali Benishangul Gumuz SNNP Gambella Harari Addis Ababa Dire Dawa
55 37 43 31 12 18 29 15 42 55 35
54 42 43 36 19 19 44 16 45 54 37
43 32 28 21 11 12 21 7 30 49 22
48 40 21 19 17 26 10 16 55 60 31
65 49 41 36 20 36 29 19 64 72 47
81 86 81 71 54 83 78 68 91 70 92
99 89 96 92 92 95 98 92 94 96 96
24 13 13 19 12 5 21 9 18 48 33
44 7 181 336 25 17 210 5 2 5 3
Urban/rural Urban Rural
42 33
47 39
36 22
34 18
50 35
70 76
95 95
28 17
67 768
34
40
23
20
37
75
95
18
835
Managing authority Government/ public Other governmental (military, prison, federal police) Private for profit NGO (mission/ faithbased, nonprofit)
Total 1
Piped water, water in bucket with specially fitted tap, or water in pour pitcher Non-latex equivalent gloves are acceptable 3 Waste receptacle with plastic bin liner. 2
4.4 Adherence to Guidelines for Sick Child Service Provision To assess whether providers adhere to standards for providing good-quality services, the interviewers observed sick child consultations using observation checklists based on IMCI guidelines. The observers noted whether recommended procedures were carried out and what information the provider shared. However, the study did not assess whether the information shared was correct and whether findings were appropriately interpreted. Table 4.10.1-A and 4.10.1-B summarise providers’ assessments, examinations, and essential advice given to caretaker by facility type, managing authority and residence. Tables 4.10.2-A and 4.10.2-B show providers’ assessments, examinations, and essential advice given to caretaker by region. Table 4.10.1-A Assessments, examinations, and treatments for sick children, ESPA+2014 Table 4.10.1-A
Assessments, examinations, and treatments for sick children
Among sick children whose consultations with a provider were observed in facilities excluding health posts, the percentages for whom the indicated assessment, examination, or intervention was a component of the consultation, by facility type, managing authority and rural/urban, Ethiopia SPA+ 2014 Facility type Primary Components of Referral General Hospita Health consultation Hospital Hospital l Center
Managing authority Other NGO governmenta Private (mission/ Higher Mediu Lower Government l (military, for faithClinic m Clinic Clinic / public prison, profit based,
66
Urban/rural
Urban
Rural
Total
federal police) Qualification of provider Generalist general practitioner, medical specialist 98 Health officer, integrated emergency surgical officer (IESO) 1 Nurse or midwife (BSc, public health or specialized) 1 Nurse of midwife (diploma) 0
nonprofit )
44
44
0
9 6
8
0
32
71
47
10
47
3
33
21
19
21
4
53
5
17
0
19
32
17
18
17
8
12
13
0
3
3
9
0
1
2
7
11
8
20
22
66
0
36
9 2
41
29
33
56
27
69
40
53
48
56
57
0
46
59
53
60
55
50
49
48
48
14
55
48
48
50
49
4
7
13
11
9
14
10
16
7
13
9
2
4
6
6
4
0
4
16
4
7
5
25
27
28
26
26
86
27
30
28
21
26
History: assessment of main symptom Cough or difficulty breathing 51
67
72
70
65
28
65
77
61
73
65
50
64
68
73
66
44
65
66
61
75
66
Fever 72 All three main symptoms1 30 Ear pain or discharge from ear 0 All 3 main symptoms plus ear pain/ discharge 0 None of the symptoms 23
86
87
83
82
100
83
76
80
84
82
42
49
48
7 4 7 0 8 7 4 4
43
14
39
43
39
52
43
14
20
34
7
13
4
4
History: assessment of general danger signs Inability to eat or drink or breastfeed 60 Vomiting everything 47 Convulsions All general danger signs None of the above
Diarrhea
History: other assessment Asked about mother's HIV status Asked about TB disease in any parent in last 5 years Asked about 2 or more
4 9 7 7 2 1 9 2 0
58 50 16 11 24
4 3 5 7 1 1 5 2 8
40
5 8 7 4 8 1 4 2
2 1
15
9
21
28
15
22
17
28
20
25
9
12
3
15
0
9
12
11
21
14
3
4
0
2
2
9
0
4
3
11
3
8
9
28
23
0
0
2
16
0
2
8
12
21
15
4
2
5
3
0
0
1
3
0
1
1
3
3
3
0
3
5
4
1
1
1
3
0
1
2
2
4
3
67 66 86
67
episodes of diarrhea in child Asked about severe pneumonia2 Asked about severe malnutrition3 Asked about severe disease4
0
1
2
2
4
0
3
2
0
2
1
1
3
2
1
4
8
16
0
4
0
10
0
0
9
5
16
9
0
2
2
2
1 2
2
1
1
0
3
0
1
2
1
40
67
63
60
6 7
42
4 5
56
71
54
74
54
62
56
27
48
41
44
4 8
58
6 1
41
72
53
43
38
51
42
32
30
31
29
1 8
30
1 3
30
0
21
28
29
31
29
58
61
47
27
7 6
53
7 1
40
58
74
52
47
36
44
17
22
28
27
2 8
23
5
24
28
17
17
22
26
23
14
16
13
21
2 1
12
3
18
14
9
10
15
21
17
11
21
33
19
18
28
28
28
18
23
19
16
34
28
20
20
14
52
36
27
17
23
5
9
5
3
1
17
7
7
3 1 4 4 1 7 3 0
1
11
11
5
24
26
29
2
8
Physical examination Took child's temperature with thermometer 5
Felt the child for fever or body hotness Counted respiration (breaths) for 60 seconds Listened to chest with stethoscope or counted pulse Checked skin turgor for dehydration Checked for pallor by looking at palms Checked for pallor by looking at conjunctiva Looked into child's mouth Checked for neck stiffness Looked in child's ear Felt behind child's ears for tenderness Undressed child for examination Pressed both feet to check for edema
Essential advice to caretaker Give extra fluids to child 15 Continue feeding child 18 Symptoms requiring immediate return 16 Number of sick child
38 2
39
3 0 3 9
6
3
4
0
8
3
5
4
5
17
6
5
42
28
21
8
8
8
2 1
13
3
4
14
13
32
5
8
6
19
5 0
40
3 3
22
28
38
30
24
23
24
6
7
5
7
2
6
0
5
3
4
10
6
24
20
34
27
0
28
18
24
33
27
21
16
37
3 3 2 6
29
0
26
26
26
33
28
17
15
21
33 4
86
82 5
32
34
2 5 2 0
1 5
15
2 1
19
14
15
13
19
19
19
2 2
59
5 7
1,542
5
18 1
38
1,21 9
54 7
1,76 6
29
68
observations Note Five children were provided services by a Health Surveillance Assistant and are excluded from that panel of the table. 1 Cough or difficulty breathing, diarrhea, and fever 2 Cough with chest indrawing or convulsion or comma or history of convulsion and irritability. 3 MUAC
