QuEST Ethiopia

BACKGROUND: Due to low care utilization, a complex intervention was done for two years to optimize the Ethiopian Health Extension Program. Improved quality of the integrated community case management services was an intermediate outcome of this intervention through community education and mobilization, capacity building of health workers, and strengthening of district ownership and accountability of sick child services. We evaluated the association between the intervention and the health extension workers' ability to correctly classify common childhood illnesses in four regions of Ethiopia. METHODS: Baseline and endline assessments were done in 2016 and 2018 in intervention and comparison areas in four regions of Ethiopia. Ill children aged 2 to 59 months were mobilized to visit health posts for an assessment that was followed by re-examination. We analyzed sensitivity, specificity, and difference-in-difference of correct classification with multilevel mixed logistic regression in intervention and comparison areas at baseline and endline. RESULTS: Health extensions workers' consultations with ill children were observed in intervention (n = 710) and comparison areas (n = 615). At baseline, re-examination of the children showed that in intervention areas, health extension workers' sensitivity for fever or malaria was 54%, 68% for respiratory infections, 90% for diarrheal diseases, and 34% for malnutrition. At endline, it was 40% for fever or malaria, 49% for respiratory infections, 85% for diarrheal diseases, and 48% for malnutrition. Specificity was higher (89-100%) for all childhood illnesses. Difference-in-differences was 6% for correct classification of fever or malaria [aOR = 1.45 95% CI: 0.81-2.60], 4% for respiratory tract infection [aOR = 1.49 95% CI: 0.81-2.74], and 5% for diarrheal diseases [aOR = 1.74 95% CI: 0.77-3.92]. CONCLUSION: This study revealed that the Optimization of Health Extension Program intervention, which included training, supportive supervision, and performance reviews of health extension workers, was not associated with an improved classification of childhood illnesses by these Ethiopian primary health care workers. TRIAL REGISTRATION: ISRCTN12040912, http://www.isrctn.com/ISRCTN12040912.

CONTEXT AND OBJECTIVES: Non-communicable diseases and injuries (NCDIs) comprise a large share of mortality and morbidity in low-income countries (LICs), many of which occur earlier in life and with greater severity than in higher income settings. Our objective was to assess availability of essential equipment and medications required for a broad range of acute and chronic NCDI conditions. DESIGN: Secondary analysis of existing cross-sectional survey data. SETTING: We used data from Service Provision Assessment surveys in Bangladesh, the Democratic Republic of the Congo, Ethiopia, Haiti, Malawi, Nepal, Senegal and Tanzania, focusing on public first-referral level hospitals in each country. OUTCOME MEASURES: We defined sets of equipment and medications required for diagnosis and management of four acute and nine chronic NCDI conditions and determined availability of these items at the health facilities. RESULTS: Overall, 797 hospitals were included. Medication and equipment availability was highest for acute epilepsy (country estimates ranging from 40% to 95%) and stage 1-2 hypertension (28%-83%). Availability was low for type 1 diabetes (1%-70%), type 2 diabetes (3%-57%), asthma (0%-7%) and acute presentations of diabetes (0%-26%) and asthma (0%-4%). Few hospitals had equipment or medications for heart failure (0%-32%), rheumatic heart disease (0%-23%), hypertensive emergencies (0%-64%) or acute minor surgical conditions (0%-5%). Data for chronic pain were limited to only two countries. Availability of essential medications and equipment was lower than previous facility-reported service availability. CONCLUSIONS: Our findings demonstrate low availability of essential equipment and medications for diverse NCDIs at first-referral level hospitals in eight LICs. There is a need for decentralisation and integration of NCDI services in existing care platforms and improved assessment and monitoring to fully achieve universal health coverage.

Objective: To estimate the use of hospitals for four essential primary care services offered in health centres in low- and middle-income countries and to explore differences in quality between hospitals and health centres. Methods: We extracted data from all demographic and health surveys conducted since 2010 on the type of facilities used for obtaining contraceptives, routine antenatal care and care for minor childhood diarrhoea and cough or fever. Using mixed-effects logistic regression models we assessed associations between hospital use and individual and country-level covariates. We assessed competence of care based on the receipt of essential clinical actions during visits. We also analysed three indicators of user experience from countries with available service provision assessment survey data. Findings: On average across 56 countries, public hospitals were used as the sole source of care by 16.9% of 126 012 women who obtained contraceptives, 23.1% of 418 236 women who received routine antenatal care, 19.9% of 47 677 children with diarrhoea and 18.5% of 82 082 children with fever or cough. Hospital use was more common in richer countries with higher expenditures on health per capita and among urban residents and wealthier, better-educated women. Antenatal care quality was higher in hospitals in 44 countries. In a subset of eight countries, people using hospitals tended to spend more, report more problems and be somewhat less satisfied with the care received. Conclusion: As countries work towards achieving ambitious health goals, they will need to assess care quality and user preferences to deliver effective primary care services that people want to use.

BACKGROUND: Triangulating findings from MDSR with other sources can better inform maternal health programs. A national Emergency Obstetric and Newborn Care (EmONC) assessment and the Maternal Death Surveillance and Response (MDSR) system provided data to determine the coverage of MDSR implementation in health facilities, the leading causes and contributing factors to death, and the extent to which life-saving interventions were provided to deceased women. METHODS: This paper is based on triangulation of findings from a descriptive analysis of secondary data extracted from the 2016 EmONC assessment and the MDSR system databases. EmONC assessment was conducted in 3804 health facilities. Data from interview of each facility leader on MDSR implementation, review of 1305 registered maternal deaths and 679 chart reviews of maternal deaths that happened form May 16, 2015 to December 15, 2016 were included from the EmONC assessment. Case summary reports of 601 reviewed maternal deaths were included from the MDSR system. RESULTS: A maternal death review committee was established in 64% of health facilities. 5.5% of facilities had submitted at least one maternal death summary report to the national MDSR database. Postpartum hemorrhage (10-27%) and severe preeclampsia/eclampsia (10-24.1%) were the leading primary causes of maternal death. In MDSR, delay-1 factors contributed to 7-33% of maternal deaths. Delay-2, related to reaching a facility, contributed to 32% & 40% of maternal deaths in the EmONC assessment and MDSR, respectively. Similarly, delay-3 factor due to delayed transfer of mothers to appropriate level of care contributed for 29 and 22% of maternal deaths. From the EmONC data, 72% of the women who died due to severe pre-eclampsia or eclampsia were given anticonvulsants while 48% of those dying of postpartum haemorrhage received uterotonics. CONCLUSION: The facility level implementation coverage of MDSR was sub-optimal. Obstetric hemorrhage and severe preeclampsia or eclampsia were the leading causes of maternal death. Delayed arrival to facility (Delay 2) was the predominant contributing factor to facility-based maternal deaths. The limited EmONC provision should be the focus of quality improvement in health facilities.

BACKGROUND: Shortages and imbalances in physician workforce distribution between urban and rural and among the different regions in Ethiopia are enormous. However, with the recent rapid expansion in medical education training, it is expected that the country can make progress in physician workforce supply. Therefore, the aim of this study was to examine the distribution of physician workforce in Ethiopia and assess the role of retention mechanisms in the reduction of physician migration from the public health sector of Ethiopia. METHODS: This organizational survey examined physician workforce data from 119 hospitals from 5 regions (Amhara, Oromia, Southern Nations Nationalities and Peoples Region [SNNPR], Tigray, and Harari) and 2 city administrations (Addis Ababa and Dire Dawa City). Training opportunity, distribution, and turnover between September 2009 and July 2015 were analyzed descriptively. Poisson regression model was used to find the association of different covariates with physician turnover. RESULTS: There were 2,300 medical doctors in 5 regions and 2 city administrations in ~6 years of observations. Of these, 553 (24.04%) medical doctors moved out of their duty stations and the remaining 1,747 (75.96%) were working actively. Of the actively working, the majority of the medical doctors, 1,407 (80.5%), were males, in which 889 (50.9%) were born after the year 1985, 997 (57%) had work experience of <3 years, and most, 1,471 (84.2%), were general practitioners. Within the observation period, physician turnover among specialists ranged from 21.4% in Dire Dawa to 43.3% in Amhara region. The capital, Addis Ababa, was the place of destination for 32 (82%) of the physicians who moved out to other regions from elsewhere in the country. The Poisson regression model revealed a decreased incidence of turnover among physicians born between the years 1975 and 1985 (incident rate ratio [IRR]: 0.63; 95% confidence interval [CI]: 0.51, 0.79) and among those who were born prior to 1975 (IRR: 0.24; 95% CI: 0.17, 0.34) compared to those who were born after 1985. Female physicians were 1.4 times (IRR: 1.44; 95% CI: 1.14, 1.81) more likely to move out from their duty stations compared to males. In addition, physicians working in district hospitals were 2 times (IRR: 2.14; 95% CI: 1.59, 2.89) more likely to move out and those working in general hospitals had 1.39 times (IRR: 1.39; 95% CI: 1.08, 1.78) increased rate of turnover in comparison with those who were working in referral hospitals. Physicians working in the Amhara region had 2 times (IRR: 2.01; 95% CI: 1.49, 2.73) increased risk of turnover in comparison with those who were working in the capital, Addis Ababa. The probability of migration did not show a statistically significant difference in all other regions (>0.05). CONCLUSION: The public health sector physician workforce largely constituted of male physicians, young and less experienced. High turnover rate among females, the young and less experienced physicians, and those working in distant places (district hospitals) indicate the need for special attention in devising human resources management and retention strategies.